Doncaster Royal Infirmary

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We saw that work had recently been undertaken but this was yet to be fully embedded.

We have not awarded this service a score for Well-led.

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

Evidence shows some shortfalls. We noted improvements were in progress, but they required time to become fully embedded and sustained.

The culture and team working showed a deteriorating position. This was evidenced from staff we spoke with and staff survey results. Staff survey results from 2024 showed a deteriorating picture in how senior leaders listened to staff and how they lacked confidence that their voice would be heard. During inspection we were told that the senior management structure had changed and that there was work ongoing to address the issues raised and to increase staff uptake. The most recent staff survey had not been published at the time of inspection and therefore the results were not available to discuss with senior leaders.

Staff survey results showed a worsening response for how staff were listened to. However, work was ongoing to improve staff engagement and that staff would be given the opportunity to contribute to discussions about the strategy for their service.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Senior leaders were able to articulate how their role aligned with the trust values of ‘We Care’.

Staff could explain how they were working to deliver high quality care. All staff could articulate the trust values and how they fitted into delivering high levels of patient care.

Evidence shows a good standard which showed planned improvements needed to be fully embedded and sustained. Inclusive leaders at all levels understood the care context and reflected the organisation’s culture and values. Newly appointed leaders within the triumvirate demonstrated the skills, knowledge, experience, and integrity to lead effectively.

Nursing and medical staff across the emergency department understood the key risks to patients within the department. Staff told us the emergency departmental leads and newly appointed senior managers were approachable, visible, and provided them with good support.

Staff understood the reporting structures and leaders understood their key roles and responsibilities. Leaders also fully understood the key risks and challenges faced by the emergency department. Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they collaborated with partners such as the local NHS ambulance trust.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. There was a triumvirate leadership structure at departmental and divisional level with medical, nursing, and operational leads.

Leaders had effective support and opportunities to develop and maintain their credibility and skills. All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

Evidence shows some shortfalls and that improvements needed to be made and to become fully embedded and sustained over time. The service had commenced work towards a positive culture where people felt they could speak up and their voice would be heard but this was not fully embedded.

Staff survey results from 2024 showed a deteriorating picture in how senior leaders listened to staff and how staff lacked confidence that their voice would be heard. During inspection we were told that the management structure at triumvirate level had changed and that work was being undertaken to address this but was not yet fully embedded.

Leaders were working towards a positive culture where people felt that they could speak up and that their voice would be heard. They were able to describe how staff reported concerns and how these were investigated, then feedback was given to staff, via various forums. Leaders described an open-door policy and had an eagerness to want to help and support staff. Uptake from this was poor but senior leaders were committed to ensuring staff had the freedom to speak up.

Staff were aware of the freedom to speak up policy (FTSU) and how to use it. A poster was on display in the staff room to alert staff of FTSU and how they could act on concerns.

The department had introduced increased numbers of professional nurse advocates and freedom to speak up champions. Drop in sessions had been arranged and advertised for all staff.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

Managers and staff had access to the feedback from patients, carers and staff but required more time to use feedback to drive improvements.

Evidence shows some shortfalls. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders monitored staff experience through the NHS Staff Survey and the NHS Workforce Race Equality Standard. The most recent results showed declines in staff engagement and morale compared with the previous year. Staff from ethnic minority backgrounds were more likely than white staff to report harassment, bullying or abuse from patients, relatives or the public.

In urgent and emergency care, staff described high pressure and workload. While leaders had some initiatives in place, it was not always clear how findings were translated into consistent, measurable actions. This highlighted the need for continued focus on fostering an inclusive, safe, and supportive culture for all staff.

Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work.

Evidence shows significant shortfalls. Governance structures were in place but inconsistently applied and was not always used effectively. New leadership had introduced a stronger focus on governance, management and sustainability but this was yet to be fully embedded.

Staff did not always have sufficient time and resources for effective governance and risk management. We saw that data collection was inconsistent, and that completed audits were not consistently of a high standard, nor did they demonstrate where actions had been taken to address negative findings. As a result, there was limited assurance that information was consistently available to monitor performance, quality, and to drive improvement.

There was a slow pace of change with issues highlighted at previous inspections such as training compliance, staffing, medicine optimisation and equipment cleanliness. We saw the same issues at this inspection which did not provide assurance that when issues had been identified that they were actioned in an appropriate timeframe.

The department held a significant amount of risk for the organisation and that there was inconsistent support across the hospital to improve flow and outcomes for patients. We did note that senior leaders were aware of this and had attempted new cross care group working to address this, but this was not yet fully embedded.

We were not assured that at times of high patient demand that there was effective escalation of patient risks, capacity and resource issues. We observed no consistent approach to the discussion of risks at safety huddles, board rounds and bed management meetings.

There were regular meetings for safety, audit, quality, and governance. These discussed and addressed key areas of performance, risk, audit and workforce. Minutes recorded recognition of the areas of concern, but we were not assured that the pace of change was sufficient.

We were told about a twice-weekly Divisional Patient Safety Panel to review incidents, drive learning, implement process improvements, and escalate where required. A clear governance structure is in place, with defined specialty and divisional leads (supported by senior nursing deputies), alongside a Quality Assurance Lead and dedicated audit facilitator to maintain oversight and support continuous improvement.

Risks were captured on a divisional risk register and were rated in terms of likelihood and consequence. The trust had risk management processes which meant that risks were escalated appropriately from the emergency department up to board level when required but we were not assured that when risks were identified that they were actioned in a timely manner.

Staff and leaders at both department and trust level demonstrated a good understanding of the risks within the emergency department and the action being taken to mitigate or remove risks. We discussed the top risks for the service with the leadership team and reviewed the emergency department risk register. We saw that the main risk was that of capacity and demand.

We saw computers unlocked when not in use and we saw examples of paper records with patient information being left in plain sight which did not provide assurance that confidential information was kept secure.

All staff were able to describe how they made notifications to external bodies such as the local authority for safeguarding issues and to the UK Health Security Agency for notifiable illnesses.

Evidence shows a good standard. The service shared information and learning with partners and collaborate for improvement.

Leaders understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The leadership team understood how their staff felt about delivering care that met both the physical and mental health needs of patients.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care, such as the local NHS ambulance trust. Partners we spoke with informed us although communication between services was challenging there were no performance issues, and the teams worked well together.

The trust’s strategy aligned to local plans in the wider health and social care economy, and services were planned to meet the needs of the relevant population.

Evidence shows some shortfalls. New leadership had introduced a stronger focus on continuous learning, innovation, and improvement but this was yet to be fully embedded.

All senior leaders were aware of the issues that faced the department and the areas that required improvement. We noted that it was only after the recent change in the triumvirate management system that the pace of change had improved.

Staff felt that there wasn’t the time or opportunity to develop opportunities for improvements and innovation. A new self-directed booking system was in place; initial assurance regarding oversight and ownership was not evident at inspection, however post-inspection confirmation was provided that appropriate oversight and ownership arrangements were established.

Good practice was recognised and celebrated.