Doncaster Royal Infirmary

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs This key question has been rated good. This meant people’s needs were met through good organisation and delivery.

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

We have not awarded this service a score for Responsive.

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

We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff delivered care using a person-centred approach that incorporated the views of children, young people and their parents or carers. Care delivery was respectful, inclusive and tailored to individual needs. Children and young people were supported to become familiar with the environment, which helped to reduce anxiety and build trust with staff.

Reasonable adjustments were made in line with the Equality Act 2010. Staff had completed relevant training, including safeguarding and learning disability and autism mandatory e-learning, which supported them to meet the needs of children and young people with complex conditions.

Children and young people with autism spectrum disorder and other additional needs were identified early in the care pathway. This enabled staff to adapt care to meet individual communication needs, sensory preferences and established routines. Adjustments included the use of flexible appointment times, quieter environments and tailored communication approaches to improve engagement and reduce distress.

Learning disability and mental health support was available to staff and patients when required, which supported inclusive and responsive care delivery.

We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service planned and delivered care in a way that considered the diverse needs and preferences of children, young people and their families, including those with protected characteristics and those at risk of poorer outcomes. Care was coordinated to support continuity and reduce inequalities in access and experience.

The service worked collaboratively with external partners through the Children and Young People’s Strategic Partnership (CYPSP). This multi-agency approach supported shared learning and coordinated care across organisations. Information was shared effectively between partners to improve outcomes, address health inequalities and enhance the experiences of children and families. Evidence from partnership meetings demonstrated active engagement with key priorities, including children and young people’s voice, health inequalities and wider system planning.

Practical arrangements supported access to services. While on-site parking was limited, the availability of a park and ride service provided an alternative for staff, children and families, supporting access to the hospital.

We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

We scored the service as 3. The evidence was of a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service complied with the Accessible Information Standard and ensured that information was available in formats that met the needs of children, young people and their families. This included translated materials and accessible formats, which supported people to understand their care, rights and how to raise concerns.

Information governance arrangements ensured the secure handling of patient information. Key roles, including the Caldicott Guardian, senior information risk owner and data protection officer, were clearly identified. Staff followed processes for making notifications to external bodies when required.

The service recorded eight General Data Protection Regulation (GDPR) related incidents within children’s services. Themes included missing, incomplete or incorrect information and data breaches. While incidents were identified and managed, these issues indicated that information governance processes were not always consistently applied.

Staff ensured that children, young people and their families received appropriate information about care, treatment, services and their rights. Families told us they were kept informed about progress and treatment plans. Information was provided in ways that were accessible and appropriate to individual needs.

We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support. They involved people in decisions about their care and told them what had changed as a result.

The service had systems in place to manage complaints and feedback effectively. Staff had access to the trust’s complaints handling policy and demonstrated an understanding of how to respond to concerns appropriately. Systems ensured that people who raised concerns were protected from discrimination or disadvantage. Staff received feedback from complaint investigations, and learning was shared widely through governance meetings, ward forums, drop-in sessions and newsletters.

Children, young people and their families were aware of how to raise concerns and told us they felt comfortable doing so. When concerns were raised, people received feedback, which supported a transparent and open approach to complaint handling.

Complaints were reviewed regularly by senior leaders. Weekly reviews monitored progress against timescales, and themes and trends were discussed at trust-level committees. Data for January to December 2025 identified 44 complaints and 32 contacts. Most concerns related to clinical care, including diagnosis and treatment, while a smaller proportion related to communication, staff attitudes and behaviours.

Learning from complaints resulted in improvements to the service. Actions included the introduction of age-appropriate welcome guides, bedside communication boards, daily check-in huddles, improved discharge information and the use of SEND resource boxes. The service also implemented wider improvements through the CYP voice initiative launched in September 2025. In addition, the introduction of Phase 1 of Martha’s Rule ‘wellness questions’ further strengthened opportunities for families to raise concerns and escalate issues.

These actions demonstrated that the service listened to feedback and used it to drive improvements in care and patient experience.

We make sure that everyone can access the care, support and treatment they need when they need it.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service ensured children and young people could access care when they needed it. Services remained open throughout 2025, and staff followed the trust’s capacity and escalation plans to manage periods of increased demand and acuity.

Children and young people accessed the service through a range of referral routes, including the emergency department, GP referrals and planned pathways. Activity levels were high, with over 8,700 inpatient admissions and 14,700 outpatient attendances recorded over a 12-month period. Referral-to-treatment performance was strong, with the service achieving 87.4%, exceeding the national target.

The service monitored attendance and recognised missed appointments could present safeguarding risks. Non-attendance rates were reported at 13%, and appropriate processes were in place, including escalation through safeguarding procedures where children were repeatedly not brought to appointments.

Total occupied bed days from the 1 April 2025 – 1 March 2026 in the children’s areas ranged from 49% to 79.7%.

Length of stay was generally short across the service, supporting timely patient flow. However, readmission rates varied across the year, reaching up to 22.2%. While this data was monitored, it was based on a model that excluded some admissions, which limited a full understanding of performance and outcomes.

Access to urgent and follow-up care was supported through urgent and next-day clinics, as well as open access arrangements following discharge. These pathways enabled families to seek timely advice or review if a child’s condition deteriorated.

However, there were some gaps in assurance. The service was unable to confirm whether all children admitted with an acute condition were reviewed by a consultant within 14 hours, as this information was not captured electronically. This limited the ability to monitor compliance with national standards.

A range of outpatient services and specialist clinics were available, supporting access to care across different needs. However, staff reported that most children undergoing blood tests did not receive local anaesthetic cream prior to the procedure, which may impact patient experience and comfort.

The surgical unit operated flexible opening hours based on demand, and discharge planning involved multidisciplinary input to support continuity of care. Short-term open access to the service following discharge further supported timely review and continuity for children and families.

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support, and treatment in response to this.

Tackling health inequalities was a key strategic priority for the trust, reflected within its “Healthier Together” strategy. A dedicated health inequalities enabling plan (2023–2028) set out priority areas, including prevention, urgent and emergency care and children and young people. The service aligned its work with the national Core20PLUS5 framework, focusing on key areas such as asthma, diabetes, epilepsy, oral health and mental health, to reduce inequalities and improve outcomes.

The service worked collaboratively with system partners, including the children and young people’s (CYP) alliance, integrated care board and local authorities, to address health inequalities and develop coordinated approaches to care.

The trust used population data to understand inequalities. For example, analysis of children awaiting tooth extraction identified higher waiting numbers among those living in the most deprived areas. This demonstrated that the service was identifying and responding to inequalities within its population.

Equality impact assessments and policies supported the delivery of equitable care. Staff used these to ensure that care and services did not disadvantage people with protected characteristics. Initial assessments considered factors such as language barriers, cultural beliefs and wider social determinants of health, which informed personalised care planning.

Care was adapted to meet individual needs. This included the use of hospital passports, tailored communication methods, quiet environments and active involvement of parents and carers. Staff worked to reduce distress and improve engagement, particularly for children with additional needs.

We saw examples where the service had adapted care to meet the needs of individuals with protected characteristics, including providing tailored emotional support and creating safe spaces for discussion. This demonstrated a person-centred and inclusive approach to care.

Staff training supported this approach. Compliance with training in equality, diversity and human rights, health inequalities and mental health awareness was generally high, which helped ensure staff had the knowledge to recognise and respond to inequality and deliver equitable care.

We scored the service as 3. The evidence showed a good standard. We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

The service supported children, young people and their families during significant life events, including end-of-life care and bereavement. Bereavement support was tailored to the needs of families depending on the age of the child. Specialist bereavement midwives supported families of premature babies or those who died within the neonatal period. For older children, a named child death key worker provided ongoing support and facilitated access to external bereavement services, including local counselling and national charities.

Support was sensitive to individual needs, including emotional, cultural and spiritual requirements. Families were offered access to chaplaincy services or their own faith leaders, and arrangements were made, where possible, to support timely burial in line with cultural beliefs. For sudden deaths, referrals to counselling services were available to support parents and siblings through the bereavement process.

Staff were supported by clear policies and guidance, including the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) policy, which included specific guidance for children and young people. This supported staff in planning care and treatment decisions appropriately, including end-of-life care.

The service participated in regional audit activity, including the DNACPR and ReSPECT audit, to benchmark practice and identify areas for improvement. At the time of inspection, the service was awaiting the outcomes of the most recent audit cycle. This demonstrated engagement with external assurance processes to support continuous improvement in end-of-life care.