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Doncaster Royal Infirmary Requires improvement

We are carrying out a review of quality at Doncaster Royal Infirmary. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 July 2018

Our rating of the hospital stayed the same. We rated the hospital as requires improvement because overall the domains of safe, effective and well led required improvement whilst caring and responsive we rated as good.

Inspection areas

Safe

Requires improvement

Updated 23 October 2015

Effective

Requires improvement

Updated 23 October 2015

Caring

Good

Updated 23 October 2015

Responsive

Requires improvement

Updated 23 October 2015

Well-led

Good

Updated 23 October 2015

Checks on specific services

Medical care (including older people’s care)

Good

Updated 10 July 2018

Our rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well- led as good.
  • Staff were aware of how and when to report incidents including safeguarding concerns. We saw that staff received feedback and lessons learned were shared.
  • All areas we visited were clean and well- maintained. Staff practiced safe infection control techniques and we saw predominantly positive audit results.
  • Staff assessed patients for risk of deterioration and escalated their care when necessary.
  • We saw safe medical and nurse staffing levels in place.
  • We saw good examples of multidisciplinary working. The trust performed better than the England average in a number of national audits.
  • Staff told us they were encouraged and supported to professionally develop.
  • We saw staff seeking patient consent before providing care and treatment. We saw that capacity assessments were completed for some, but not all, patients.
  • Patients, relatives and carers we spoke with gave consistently positive feedback: patients told us they felt safe on the wards and that staff were caring and compassionate.
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff were emotionally supportive to patients and their loved ones. Friends and family test responses were predominantly positive.
  • Services were planned to meet the needs of local people. Consultants were available seven days per week.
  • Care and treatment for vulnerable patients, such as those living with dementia or a learning disability, were seen as a priority. We saw numerous positive examples of initiatives in place for these patients.
  • There was a clear leadership structure. Staff told us that their line managers were visible, approachable and supportive. We saw positive leadership at ward and team level.
  • Staff were aware of the trust’s vision and values, Local governance arrangements were robust. Ward managers attended care group governance meetings. Ward managers were aware of the risks to their service.
  • We saw numerous examples of improvements and innovation.

However:

  • There was low compliance in some mandatory training modules for medical staff.
  • There was a high percentage of nurse bank and agency use on some wards and not all patients were seen by a consultant within 14 hours of being admitted to the hospital in line with national guidance.
  • The service did not ensure VTE assessments were routinely reviewed within 24 hours in line with NICE guidelines.
  • We found that some patient pathways were out-of-date for review and did not have any references to nationally recognised, evidence-based, best-practice guidance.
  • The trusts performance was worse than the England average for the national heart failure audit and the national lung cancer audit.
  • Appraisal rates had improved since our inspection in 2015, however they remained lower than the trust target on some wards.
  • Consent to care and treatment was not always obtained in line with legislation for patients who lacked capacity.
  • The trust reported high numbers of delayed discharges and was not monitoring patient bed moves at night.

Services for children & young people

Good

Updated 10 July 2018

Our ratings of this service stayed the same. We rated it as good because:

  • We rated effective, caring, responsive and well led as good. Safe was rated as requires improvement.
  • Sepsis screening tools were used and all the records of patients we saw with suspected sepsis were managed appropriately.
  • Care and treatment was based on national guidance and the service monitored the effectiveness of care and treatment.
  • Staff cared for patients with kindness and compassion, ensuring they involved patients and their families. Feedback we received about the services from patients and their families was positive.
  • The service was responsive to the needs of the individual children and young people who used it.
  • Children’s services were actively involved with the Integrated Care System (ICS) to plan care to reflect the needs of the local population.
  • There were effective governance systems and processes in place. Regular review of the risk register took place.

However:

  • Safeguarding training rates were below the trust target.
  • There were no individual risk assessment tools to ensure the effective management of children and young people with mental health needs. Not all staff had received training in caring for children and adolescents with mental health conditions, but this had started to be addressed.
  • Actual staffing levels did not meet planned levels and the nurse to patient ratio exceeded the Royal College of Nursing (RCN) guidance (2013).
  • We observed that staff were not always using personal protective equipment or following appropriate hand hygiene practices.
  • There were environment issues, such as out of order shower cubicles on the children’s unit, water damaged ceiling tiles and protruding wires on the neonatal unit and condemned televisions were being stored in the adolescent room on the children’s ward.
  • We observed medicines left unattended.

Critical care

Good

Updated 23 October 2015

Overall critical care services at Doncaster Royal Infirmary were judged as good.

There were many positive aspects to the unit. Caring was good: patients stated they were well cared for and surveys supported this. Care was effectively delivered by the multidisciplinary team utilising best practice. The service was well led overall, though as a relatively new care group unit further focus was required on the development of the unit in terms of space and facilities.

The service met the individual needs of patients whilst they were on the unit. Early discharges and out-of-hours discharges were similar to other units, and out of hours discharges to the ward were slightly above that of other similar units. There were some concerns regarding patients being discharged from the critical care unit delayed by over four hours.

Within safety, concerns were identified with regard to the environment and the risks associated with evacuation in the event of a fire and distance from other services that were required for the effective functioning of the unit. The poor use of storage and the impact this had on infection prevention risks and the practices for nursing patients with infections.

End of life care

Good

Updated 23 October 2015

We saw that end of life care services were safe, caring, responsive and well led. However, we saw that improvements were required in order for services to be effective. Hotel services staff were not adequately trained or supported in the receipt of bodies to the mortuary and we were not assured by the trust’s arrangements for the storage of bodies in the mortuary in a way that respected the dignity of patient’s after death. The trust needed to have a more systematic approach to recording mental capacity assessments in relation to DNACPR decisions where patients were unable to be involved in these discussions.

We observed specialist nurses and medical staff providing specialist support in a timely way that was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. Specialist palliative care nurses provided a seven day face to face assessment service. We were told that staff were caring and compassionate and we saw the service was responsive to patients’ needs. There were prompt referral responses from the specialist palliative care team and a good focus on preferred place of care and fast track discharge for patients at the end of life wishing to be at home.

Action had been taken against the issues identified in audits including the National Care of the Dying Audit. The implementation of the last days of life individual plan of care (IPOC) had been closely monitored by the end of life care coordinator with continuous reviews and feedback in place to develop this. The development of an electronic referral/alert system had seen an increase in referrals to the end of life care team in a timely manner. A business case had been developed as a result and the trust board had committed investment in expanding the end of life service as a result. The trust had a clear vision and strategy for end of life care services and participated in regional discussions and collaboration in relation to strategic planning and delivery of services to improve end of life care in the region.

Outpatients and diagnostic imaging

Requires improvement

Updated 23 October 2015

We rated outpatients and diagnostic and imaging as requires improvement. Safe and well-led required improvement; effective was inspected but not rated and caring and responsive were good.

There is a legal requirement to protect the public from unnecessary radiation exposure. We saw that there were doors with no signage that had unrestricted entry to x-ray controlled areas. This was raised with the trust and referred to the Health and Safety Executive. Not all areas had been addressed when we revisited as part of an unannounced inspection 10 days later. There were effective systems to report incidents. However, in some areas we were unable to identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents. Imaging and nursing staff reported that a safety handover of the patients from the wards did not occur. Inpatients were left waiting in beds on the main corridor of the department with no escort. This practice potentially created safety risks.

Records showed the number of staff that had received mandatory training and an annual appraisal was below the trust compliance target of 85%, particularly in outpatients. We saw patient personal information and medical records were mostly managed safely and securely. However there was limited evidence of audit to demonstrate effectiveness. This included IR(ME)R related audits. Radiation Exposure/ DRLs were not audited regularly. Patient’s records were not routinely audited.

All of the patients we spoke with across the department told us they were very happy with the services provided. The management team were in the process of reviewing capacity and demand for outpatient clinics. Most referral to treatment targets were met including all cancer related targets. There was no centrally held list of all patients requiring a review or follow-up appointment. Medical imaging was not meeting the 6 week target referral to treatment target; however improvements had been made.

Staff we spoke with were aware of the trust overall vision and strategy and were positive about the recent and future management of medical imaging and outpatients. An outpatient’s services strategy had been drafted however, this lacked detail. A review of outpatient services had started to audit the current outpatient service delivery and clinical work streams but this was not yet completed. There were limited key performance indicators for outpatients. Radiology discrepancy and peer review meetings were inconsistent with the Royal College of Radiology (RCR) Standards.

Surgery

Good

Updated 23 October 2015

Incidents were reported and effectively investigated, and lessons were learned. The wards and departments were mostly clean and well maintained. However, there were worn floors and dust and dirt on trolleys and autoclaves in the theatre sterile supply unit. We found medicines and records were managed appropriately. The service responded appropriately to clinical risk in patients, although not all staff had received safeguarding training. There were some shortages of nursing and surgical staff; the trust were aware of this and were actively recruiting to fill the vacancies.

We found evidence-based care and treatment which was audited in the wards and departments. There was a system for the provision of pain relief to patients although it had been identified there were delays in the provision of analgesia to patients referred to the surgical assessment ward by their GPs. We found effective systems for the provision of nutrition and hydration to patients. Patient outcomes data did not show the trust to be an outlier in any area of practice.

Mandatory training records showed compliance with the 85% target for achievement of this was poor. However, the majority of staff we spoke with told us they were up-to-date with their mandatory training. There were systems in place for yearly appraisal. We found that the surgery services were caring and that patients received compassionate care. We found evidence of service planning and delivery to meet the needs of local people.

The percentage of patients waiting to start treatment (incomplete pathway) within 18 weeks from point of referral to treatment was better than the national target, however the number of patients who had to wait longer than 18 weeks from referral to treatment (admitted) breached the operational standard.

We found that the trust had systems in place that assisted in meeting the needs of people who used the service.

The surgical care groups at Doncaster were well-led with a vision and strategy for the service and systems of governance, risk management and quality measurement in place.

Urgent and emergency services

Requires improvement

Updated 14 March 2019

We rated this service as requires improvement. Safe was rated as inadequate. Effective, responsive and well led were rated as requires improvement. Caring was rated as good.

Maternity

Requires improvement

Updated 10 July 2018

We rated the service as requires improvement because:

  • We rated safe and effective as requires improvement. We rated caring, responsive and well led as good.
  • The service was not meeting their target of 90% for women receiving one to one care in labour.
  • At the previous inspection, a large number of staff had not received mandatory training in a number of subjects. At this inspection, we found medical staff continued to be non-compliant for mandatory training.
  • Both medical and midwifery staff were not meeting the target for safeguarding training.
  • Nursing staff we spoke with told us that the induction of labour procedures varied depending on the doctor who saw the patient, this meant the induction of labour policy was not followed consistently on both sites at the time of our inspection. Following our inspection the trust introduced an audit process. Several trust policies were past their date of review. However, the trust was aware of this and a policy review group was in place. We were assured by the management team that the out of date policies would be updated quickly.
  • When we inspected in 2015, staff told us they had not had an appraisal in the preceding 12 months. At this inspection, we found the trust continued not to meet its appraisal target of 90% compliance for nursing and medical staff.
  • Some staff told us there was disconnect between ward level staff and the service leads. They said morale was low and some staff felt senior managers had not engaged with them sufficiently about proposed changes; including staffing, ward and location rotation.

However:

  • There were robust incident management processes. Learning from incidents and investigations were shared with staff at team meetings and individually with their managers. The trust produced a monthly staff update, which included learning from incidents and good practice.
  • Consultant cover on labour ward was in line with current guidance and the ratio of midwife to birth ratio was slightly better than the national average.
  • To meet women’s needs specialist midwives were employed by the service. This included specialists for teenage pregnancies, antenatal screening, safeguarding, bereavement, diabetes and infant feeding. Specialist support was also available through the learning disabilities specialist nurses and perinatal mental health consultant.
  • External audits took place and these included the National Maternity and Perinatal audit. Action plans were produced and working groups were set up to address the actions identified.
  • Procedures were in place to refer and safeguard adults and children from abuse and staff were aware of the procedures to follow. This included referral to the mental health team.