Doncaster Royal Infirmary

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We looked for evidence that people and communities had the best possible outcomes because their needs were assessed.

We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, well-being and communication needs with them.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, well-being, and communication needs with them.

The service assessed and responded to the individual needs of children and young people, including those with special educational needs and disabilities (SEND). SEND resources, such as sensory boxes and communication aids, were available across the service to support engagement and understanding. A SEND lead oversaw quality improvement work in this area, working in partnership with families, and plans were in place to establish a dedicated SEND working group. A sensory room was available within children’s outpatients to provide additional support.

Children and young people were further supported by a youth worker and hospital school team, which contributed to a holistic approach to care.

Following the inspection the trust confirmed a pain management team was in place to support children and young people. Staff said a multidisciplinary pain working group had recently been established. A paediatric pain policy was in place, although this was due for review. Staff used appropriate pain assessment tools, and records confirmed ongoing monitoring and review of pain.

However, pain audit results were variable across the service. Performance had declined in some areas, including the children’s ward and observation unit, while improvements were seen in the surgical unit. Although audit results were reviewed through governance processes and actions were identified, inconsistent performance meant the service could not fully assure effective and consistent pain management for all patients.

Staff completed comprehensive and timely assessments of patients’ health, care and communication needs. Assessments were undertaken in appropriate settings, including the emergency department and inpatient areas, with additional support provided for children with complex needs. Pre-clerking processes ensured that children with additional needs, including SEND, were identified early and appropriate adjustments were made.

A review of patient records demonstrated that care was personalised, risks were identified and regularly reviewed, and consent was obtained where required. Children who required additional support were given more time for assessments and treatment, supporting a person-centred approach.

Nutritional and hydration needs were assessed and monitored appropriately. Risks were identified during pre-assessment, and ongoing monitoring of intake and output was evident in-patient records. Most records reviewed included appropriate documentation of weight and height.

Facilities were available to support children and families during their stay. These included shared dining areas and a parents’ room with access to refreshments. Food provision met a range of dietary requirements, including cultural and medical needs, supporting inclusive and individualised care.

We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

We scored the service as 3. The evidence generally showed a good standard and where improvements were required the service recognised these areas and had taken action to improve them. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff actively participated in clinical audit and quality improvement activity to support evidence-based care. Ward accreditation audits were completed annually across the trust, and the service had addressed all actions identified in the previous cycle. Recent accreditation results were positive, with the children’s ward achieving 97.5% compliance.

Ongoing monitoring was in place through weekly and monthly audit activity, including audits undertaken by matrons and ward managers. Findings from these audits informed the care and excellence quality dashboard and were discussed regularly at leadership processes.

Clinical guidelines were largely up to date and supported evidence-based practice. A multidisciplinary paediatric guideline group was responsible for reviewing and approving guidelines. Of 141 guidelines, 10 were identified as overdue or requiring review. While most guidelines we reviewed were current, one did not include a review date. This meant the service could not fully assure that all clinical guidance was consistently reviewed and maintained in line with best practice.

Compliance with National Institute for Health and Care Excellence (NICE) guidance was monitored through executive assurance processes. At the effective assurance group in May 2026, compliance was reported as 96%, demonstrating good alignment with national standards.

Staff used a range of evidence-based tools to support clinical decision-making, including those for pain assessment, recognition of the deteriorating child, and sepsis management. These tools supported consistent delivery of care in line with current clinical standards.

We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

We scored the service as 2. The evidence showed shortfalls. The service worked well across teams and services to support people. They made sure children only needed to tell their story once by sharing their assessment of needs when children moved between different services. However, consultant staff did not always see or review children and young people in recommended time frames.

Staff shared patient information effectively during handovers, which supported continuity of care between shifts. Teams worked collaboratively with other departments and services, including discharge teams, consultants and specialist services, to coordinate care delivery.

Daily consultant-led multidisciplinary team (MDT) handovers were in place seven days a week. Safety huddles took place daily to review patient risks and priorities. However, ward rounds were not consistently consultant-led twice daily, which meant senior clinical oversight was variable.

Consultant support was available out of hours through the on-call system, and consultants attended when clinically required. However, the service was unable to consistently achieve consultant review within expected time frames, particularly at weekends. This meant children were not always reviewed by a consultant within 14 hours of admission, in line with national standards. Although middle-grade doctors reviewed patients within four hours of admission, the lack of consistent timely consultant input limited assurance that all patients received early senior decision-making.

A business case was in development to strengthen consultant presence during periods of peak activity and improve compliance with national standards.

Diagnostic and pharmacy services were available seven days a week, supporting timely access to investigations and treatment.

The service worked collaboratively with the Child and Adolescent Mental Health Service (CAMHS), with weekly meetings in place to support joined-up care for inpatients. However, access to mental health support did not meet full 24/7 liaison expectations, which meant children requiring urgent mental health input may not always receive a timely specialist response.

We support people to manage their health and well-being so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and well-being to maximize their independence, choice, and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service adopted a holistic and preventative approach to the care of children and young people across inpatient and outpatient settings. Assessments routinely included growth monitoring, with weight and height recorded and plotted on age-appropriate centile charts. This supported early identification of concerns and informed timely clinical decision-making.

Nutritional risks were systematically assessed on admission using the Paediatric Yorkhill Malnutrition Score (PYMS). Where risks were identified, children were referred to specialist dietetic services for assessment and intervention. This supported effective management of nutritional needs and reduced the risk of deterioration during admission.

Comprehensive assessments included consideration of wider health and well-being factors, such as lifestyle and activities of daily living. Sensitive discussions relating to smoking and alcohol use were undertaken in line with national guidance, and appropriate support pathways were in place. These assessments were reviewed through multidisciplinary team (MDT) processes, ensuring a coordinated and person-centred approach to care.

The service had established evidence-based pathways for long-term conditions, including childhood obesity and type 2 diabetes. These pathways included clear referral routes to community services, enabling children and families to access ongoing education, lifestyle support and multidisciplinary input beyond the acute setting.

We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff had access to policies, guidelines and escalation pathways to support the management of deteriorating and septic patients. Clinical tools, included the paediatric early warning system (PEWS) and sepsis screening tools. Audit data demonstrated improvements in sepsis management compared with the previous year. Access to electronic systems enabled staff to review test results and imaging promptly, supporting timely clinical decision-making.

The service had an established audit and quality improvement programme. A forward plan included 36 projects for 2025/26, of which eight were deferred, with further audits planned for 2026/27. While this demonstrated a structured approach to quality improvement, the number of deferred audits limited assurance that all planned improvements were progressed within expected timescales.

The service participated in national audits to benchmark performance. Results from the National Children and Young People Asthma Audit showed performance above the England average across all five indicators. For example, support for addressing parental or carer tobacco dependency was significantly higher than the national average. However, although areas for improvement were identified through audit findings, the service was unable to demonstrate clear action plans or monitoring arrangements for all key performance indicators. This limited assurance that learning from audit outcomes was consistently translated into measurable improvement.

Similarly, comparative asthma audit data over two years identified variation against national benchmarks; however, the service could not demonstrate agreed actions where performance fell below expected standards.

Participation in the Epilepsy12 audit demonstrated improvement aligned with the National Epilepsy Bundle of Care. This work was undertaken collaboratively with regional partners, and quality improvement priorities identified for future development.

Local audit processes identified areas requiring improvement. For example, fluid balance audits identified poor compliance in recording and total calculations. The service responded with a quality improvement programme involving multidisciplinary staff, benchmarking with other organisations and redesign of documentation. A revised fluid balance chart was developed and further refined following testing. However, audit findings from intravenous fluid therapy reviews indicated ongoing gaps in documentation, which meant improvements were still being embedded into practice.

Outcomes and performance were monitored through monthly review meetings, which included patient experience feedback. Feedback from children, young people and families was captured through surveys and the friends and family test, with generally positive results. Ward-level audit data, including audits, demonstrated high compliance in most areas, providing assurance of generally good quality care.

We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Policies and procedures were in place to support staff in obtaining consent in line with best practice. The consent policy was aligned to the trust’s statutory and essential training framework, which set out training requirements for staff.

Where children and young people lacked capacity, staff assessed and documented capacity on a decision-specific basis. Staff demonstrated an understanding of the principles of the Mental Capacity Act and took appropriate steps to support children and young people to be involved in decisions about their care wherever possible.

Patients and families reported they were involved in decision-making. We observed examples of appropriate consent being obtained, including confirmation from a parent who had consented to their child’s surgical procedure.

However, the service did not undertake audits of consent practice. While the service recognised this gap and had plans to consider introducing consent audits, the absence of formal monitoring meant the service could not fully assure that consent processes were consistently applied and documented in line with policy.