Doncaster Royal Infirmary

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

The service did not always manage medicines or the risk of infection, nor did they adhere to the principles of infection prevention and control. The service did not consistently manage or monitor people’s safety. Whilst the training provided was comprehensive, the service did not ensure that all staff completed it.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Evidence shows some shortfalls. The service aspired to have a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety, but there was limited assurance that lessons were learnt to continually identify and embed good practice.

Sharing of incidents was intended to take place during daily safety huddles. However, during the inspection we did not observe any safety huddles, and staff told us these occurred infrequently.

We reviewed a sample of 10 incidents and the subsequent shared learning and saw issues being repeatedly reported such as equipment issues, record keeping and skin integrity assessments. This did not provide assurance that once themes had been identified that they were actioned in a timely manner.

We reviewed the most recent 5 complaints received by the department prior to inspection and found issues in the management of four responses. We saw that they had not been managed appropriately as they had not been responded to within the appropriate timescale which may have delayed any learning.

All staff we spoke with could articulate what constituted an incident and how they would report it. Staff were encouraged by senior leaders to report incidents as the department promoted a no blame culture and told us that reporting incidents were essential for learning.

The evidence shows significant shortfalls. The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. Following inspection, we issued a Section 31 letter of intent due to significant concerns regarding patient safety.

On arrival to the emergency department, patients who self-attended were first directed to an electronic tablet computer. Patients inputted their own details and reason for attendance and then would be directed by the computer to the clinical area most appropriate for their presenting complaint. This was a new system that had only recently been introduced.

We spoke with 5 patients who told us that they could not record all of their reasons for presentation on the tablet. This created a risk to prioritisation and management of their care, including being referred to an inappropriate clinical area. We saw an example of one patient who had a fall, hurt their arm and hit their head, the system only allowed one injury to be recorded. This meant that there was an increased risk of issues not being assessed.

We saw 10 examples of patients being directed by clinical staff or from the electronic booking-in system to minor injuries and the urgent treatment centre (UTC) with no record of their presentation. This meant that the other areas were unaware of the patient as they would not appear on their systems. Consequently, there was no oversight of those patients as they moved to other clinical areas.

We saw 5 examples of unwell patients who had not been clinically prioritised and were subject to long waits of more than 4 hours for assessment at the UTC. We immediately escalated one patient who should not have been directed to the UTC due to the nature of their presentation. This posed a significant risk as there was no oversight or ownership of those patients as they moved between clinical areas.

We were informed that following initial allocation to minor injuries or the UTC on arrival, this would not generate a record of the patient on the department computer system and would direct patients away from the main department. We saw 5 examples of patients waiting for UTC that staff were not aware of, this increased the risk of harm due to a lack of clinical oversight. This was escalated to reception staff at the UTC but we were told that patients who had attended with a prearranged appointment were prioritised over patients who attended from the emergency department.

We saw 15 patients in the waiting room who had not received a full clinical assessment of their presenting condition. We were told that due to a lack of flow through the department and into the hospital, patients were delayed in reaching the appropriate clinical area and could be left waiting multiple hours without receiving any full clinical assessment.

During our inspection staff told us there was no formalised or documented plan on how to manage patients waiting within the main waiting room of the department.

We noted that no member of clinical staff was allocated to provide oversight of patients in the main waiting room. There was a risk that patients could deteriorate in this area, and this would not be identified by staff. There was no process in place to assess and effectively monitor those patients. Following our second visit we saw that a health care assistant had been allocated to this area. Some staff told us that they felt they did not have the right level of training or experience to manage this role.

Patients waiting did not have their basic needs met. We saw and were told by 15 patients we spoke with that they had not had their pain assessed. We saw one example of a patient with a significant limb injury who had waited 6 hours for appropriate pain relief. We raised significant concerns with senior leaders regarding the level of risk, and we were provided with assurances regarding this. At the second inspection visit, we were told that additional measures had been introduced to increase opportunities for patients to be asked if they required pain relief.

There were pathways to stream patients directly to speciality surgical assessment areas but due to issues within other clinical areas these were inconsistently used which meant patients could be waiting excessively long periods for specialist assessment.

We were told about a new national initiative that had been introduced as part of the 2025/2026 national plan that detailed that crews would wait a maximum of 45 minutes to handover a patient so that the crews would be able to respond to other emergency calls in a timely way. Whilst this had been introduced within the department, there was limited available space which resulted in significant overcrowding in ambulance handover areas. At one point we saw 18 patients in an area designed for 10 patients. This was a risk because staff allocated to this area would not be able to provide safe care and treatment due to overcrowding.

Following feedback, the trust took immediate steps to create additional capacity within the department which included opening further beds spaces in the trust and a specifically designated escalation space adjacent to the emergency department. At the time of the second inspection visit we still saw overcrowding within the department.

Clinical responsibility for patients within the department was not clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialities. We noted the emergency department staff retained medical oversight and nursing care for those patients who were waiting for admission. This caused increased demand on the staff and space available for patients.

Bed management meetings were held throughout the day. The purpose of these meetings was to maintain oversight of patient flow across the hospital and to escalate any issues within the emergency department. During inspection we attended these meetings and saw no effective escalation or discussion of issues. It was observed that whilst issues were raised, such as high levels of demand within the department there was no further discussion or timely escalation. Information provided following inspection showed actions had been created from these meetings.

We reviewed all actions provided to us by the trust related to concerns we raised during our first inspection at a follow up site visit in January. Whilst we saw that plans had been made, we were not assured that these had been fully introduced with full consultation and action by staff. Senior staff we spoke with in the emergency department could not articulate any changes in how they managed safe systems, pathways and transitions.

Evidence shows some shortfalls. The service shared concerns quickly and appropriately but did not ensure that all staff had the required level of training for their role.

We saw that medical staff had not received the correct level of safeguarding training for their role as recommended by the intercollegiate safeguarding guidance. Training compliance for safeguarding children level two and three were 64% and 50% respectively and 70% for safeguarding adults level two. This did not provide assurance that all medical staff would be able to identify safeguarding issues.

All staff we spoke with knew how to make a safeguarding referral and would do so when appropriate. We were told that feedback wasn’t always received following a safeguarding referral which meant opportunities for reflection and development were lost.

We were told that safeguarding would be discussed in daily safety huddles, but we saw no safety huddles during inspection, this did not provide assurance that safeguarding was discussed every day.

We were not provided with any audits around safeguarding which meant any errors or omissions could not be used as learning to prevent future occurrence.

All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. However, due to poor safeguarding training compliance and no bespoke training in the Mental Capacity Act or Deprivation of Liberty Safeguards we could not be assured that all staff would be competent in the assessment of capacity.

All staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

We reviewed the assessment template which included asking patients about any relevant safeguarding details. We also noted staff asking about family members who the patient may have caring responsibilities for.

We saw that the hospital safeguarding team provided a visible presence within the department. This allowed for greater levels of support and guidance for department staff.

We did not observe any interactions that required restraint or restrictive practice, but we observed junior medical staff requesting advice and support from senior colleagues.

Evidence shows significant shortfalls. The service did not demonstrate how they work with people to understand and manage risks by thinking holistically. Staff did not always feel able to provide care to meet people’s needs nor could they consistently demonstrate that it was safe, supportive and enabled people to do the things that mattered to them. Following inspection, we issued a Section 31 letter of intent due to significant concerns regarding patient safety.

Staff were expected to use a nationally recognised tool to identify deteriorating patients and escalate concerns appropriately. Although vital signs were recorded and National Early Warning Score (NEWS2) calculated, we found inconsistent use of the system when reviewing recorded observations.

We reviewed observations for 10 patients and identified five examples of incomplete escalation where records did not demonstrate that appropriate action had been taken. While an escalation policy was in place, inconsistent implementation increased the risk of harm to patients.

Following the inspection, we requested completed NEWS2 audits. However, we were not assured that auditing was effective due to the small sample size provided.

Staff did not always complete risk assessments for each patient on admission / arrival. We reviewed 15 patient records of patients within the department at the time of inspection. We saw repeated omissions or errors regarding risk assessments in 13 records. Audits provided after inspection showed that risk assessments were not always completed in a timely manner.

We saw that completed audits consistently highlighted repeated issues and we saw no evidence of effective action being taken to address these. For example, we saw that pain assessment was regularly audited but remained an issue, most patients we spoke with reported issues with the assessment and treatment of pain.

Senior staff told us they were expected to undertake audits of patient care during their shifts to ensure all risk assessments had been completed and appropriate actions taken. However, they told us that increasing workloads meant they were not always able to complete these audits in a timely way. This meant there was not always assurance that patient care within the department was being monitored effectively.

We also saw that where an issue had been escalated and actions been taken that they were still ineffective. We saw that pressure area care had been highlighted as an ongoing issue, information was shared with staff but training compliance across all nursing groups was 21% at time of inspection which did not provide assurance that an escalated issue was managed appropriately. Following inspection, we were told that there was additional training and support available to staff. But due to a lack of completed risk assessments we were not assured that this was effective.

Intentional rounding was introduced following the initial inspection visit and was being embedded into practice at the time of the second inspection. It had been noted that an action plan had been introduced to improve the use of the intentional rounding.

There was a flag on the electronic patient record system that alerted staff if a patient had a safeguarding or mental health concern. We saw examples of patient passports being available within the emergency department to enable awareness to staff of specific patient need but we were told that these were not always used.

Evidence shows significant shortfalls. The service did not detect and control potential risks in the care environment. Staff did not make sure equipment, facilities and technology supported the delivery of safe care. The service was previously in breach of the legal regulation in relation to safe environments. Improvements were not found at this assessment, and the service remained in breach of this regulation.

We saw multiple patients being managed in temporary escalation spaces or in non-clinical areas such as areas outside of patient cubicles. This meant patients were waiting in areas close to external doors or with high footfall. We also noted these areas did not have adequate facilities for personal care.

The treatment and waiting room areas in the minor injuries service were located within a modular building and were not suitable for safely managing patients who may present with challenging behaviour due to the size and layout, including limited exit points. This meant staff and other patients may not have been able to safely access exits in an emergency. The provider was unable to provide a risk assessment to show how these risks were identified and managed.

We were told by staff that some equipment was not readily available due to maintenance issues. We noted that this issue had been raised to senior management and had been referenced in a recent departmental newsletter. Information following inspection provided assurance that there was sufficient equipment to provide safe care.

The emergency department was not visibly clean with no evidence of cleaning being regularly undertaken. We saw areas covered in considerable amounts of dust and other debris. Following our first onsite inspection, we were provided with audits that had been undertaken following the inspection visit, we were also provided with plans for cleaning schedules and audits to ensure ongoing compliance. During our follow up visit we saw some improvement in cleanliness of the department, but some areas were still visibly dirty with accumulated dust and other debris.

The designated mental health assessment room was fully Psychiatric Liaison Accreditation Network (PLAN) compliant. We also noted that there were two allocated cubicles that could be made ligature free if required. We reviewed the risk assessments of all clinical areas and found them complete and without omission. However, there was no ligature risk assessments for temporary escalation spaces.

Not all clinical and non-clinical waste was managed appropriately. Information provided following inspection detailed multiple examples of incorrect waste management, the main issue reported was a lack of adherence to the colour coding of waste.

Evidence shows significant shortfalls. The service did not always make sure there were enough qualified, skilled, and experienced staff. They did not consistently make sure staff received effective development. Staff also failed to work together to provide safe care that met people’s individual needs. The service was previously in breach of the legal regulation in relation to safe and effective staffing. Improvements were not found at this assessment, and the service remained in breach of this regulation.

The service had a clearly defined and appropriate planned staffing model, with consistent establishment levels in place, but actual staffing did not reliably meet these plans. There were recurrent shortfalls in registered nursing staff, with multiple shifts operating with fewer registered staff than planned, resulting in reduced clinical capacity during parts of the shifts. This meant the service could not consistently demonstrate that it always had enough suitably qualified staff available to keep people safe.

At the time of our assessment, mandatory training compliance for nursing staff was 73% and this was noted to be a deteriorating trend. The mandatory training compliance for medical staff was 52% and below the trust target of 85%.

Nursing staff life support training was 55% overall and beneath trust target in all areas. Paediatric resuscitation showed 41% overall compliance across two modules. Medical staff training compliance for life support training was 51% over two modules.

However, the mandatory training for staff was comprehensive and when completed met the needs of patients and staff. The training covered topics such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety and information governance.

The department could not meet the standard for registered nurses (children) as referenced in Facing the Future standards for paediatric care. Adult trained nurses who had completed paediatric competencies were used to fill some gaps in rotas. Information provided following inspection showed that only 10 registered adult nurses had completed the paediatric competency training which did not provide assurance that all staffing shortfalls could be met.

All agency staff we spoke with told us they had a limited orientation on their first shift in the emergency department. Due to patient volume during inspection, we saw staff being allocated to the department from other areas of the hospital, but it was noted that they were not all trained in patient observations or the use of the department’s computer systems.

All staff told us that working relationships had deteriorated with limited communication and no teamwork. There was limited teamwork observed during the inspection. We did not see nor were we told about any work to improve this.

Managers supported all staff to develop through yearly, constructive appraisals of their work. The data provided showed that medical staff appraisal completion was 100%. The nursing staff appraisal completion rate was 90% in the last 12 months.

Evidence shows significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of infection spreading. The service was previously in breach of the legal regulation in relation to infection prevention and control. Improvements were not found at this assessment, and the service remained in breach of this regulation. Following inspection, we issued a Section 31 letter of intent due to significant concerns regarding staff and patient safety.
We saw no adherence to the principles of infection prevention and control (IPC) when managing patients with confirmed infectious diseases. We saw no adherence to additional management requirements for patients with confirmed infectious diseases.
We saw staff failing to use personal protective equipment (PPE) correctly and saw staff coming out of cubicles and not removing their PPE before commencing additional tasks. We also noted a lack of handwashing from all grades of staff within the department. During our follow up visit we saw limited improvement in the appropriate use of PPE or in basic hand hygiene.
We also noted a failure to effectively decontaminate cubicles after patients with a confirmed infectious disease had been moved. This meant that any subsequent patients in those areas were at an increased risk of infection. During our follow up visit we saw no improvement in the effective cleaning of cubicles, we observed cleaning that took 2 minutes to complete which did not provide assurance that cleaning was effective.
We noted an inconsistent use of ‘I am clean’ stickers which showed when a piece of equipment was last cleaned. The stickers were either missing or incomplete on most equipment we saw.
We did not observe any staff cleaning equipment between use which meant there was an increased possibility of cross contamination. During our follow up visit we saw no improvement in the cleaning of equipment between use.
We reviewed audit results following inspection but were not assured of the quality due to low sample sizes and the limited information provided. Following the first onsite inspection, the service confirmed that a new IPC process would be implemented. During our follow up visit, staff informed us that this new process had been introduced; however, due to the limited progress evident at the time of review, we were not assured that it was functioning effectively.
Following the first onsite inspection, we reviewed action plans provided by the trust to address the concerns raised. Whilst the trust had made plans, at our follow up inspection, we were not assured that these had been fully introduced as we saw no improvement.

Evidence shows some shortfalls; the service did not consistently follow safe systems and processes for prescribing and administering medicines.

Patient records reviewed during the inspection did not always contain full medicines histories, and medicines were not consistently prescribed in a timely manner. Of the 5 records we reviewed, 3 did not include a comprehensive medicines history.

We saw multiple examples of delays in patients being assessed, prescribed, and being given pain relief. We were told that there were plans to increase the range of pain relief that could be given to patients by senior nursing staff without prescription, but this process was still ongoing.

We reviewed 5 examples during inspection of incomplete sepsis recognition and treatment records. This included delays in the prescription and administration of antibiotics. We noted there was an emergency medicine consultant lead for sepsis and a sepsis nurse supporting sepsis management.

We were told that an audit was undertaken by the sepsis lead nurse and best practice and results and learning shared in the sepsis ED group and the Trust wide sepsis group, but this audit was not provided

Medicines reconciliation was not consistently undertaken; we were told that medical doctors would only undertake this once a patient had been referred to the medical team. This increased the risk of patients not receiving critical time and other prescribed medication.

We also noted that there was no designated pharmacist supporting the emergency department, which was not in line with current guidance from the Royal College of Emergency Medicine.

Medicines were stored safely and securely in most areas visited. Temperature monitoring was completed to ensure medicines remained safe for use. Controlled drugs were stored securely, and records were accurate. Any discrepancies were identified and reported promptly.