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. At our last assessment we rated this key question requires improvement. At this assessment, the rating has improved too good.

Clinical areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks for patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Information on incident reporting, complaints and duty of candour was clearly displayed for staff and families. Staff demonstrated a good understanding of these processes and knew how to access guidance and escalate concerns. Duty of candour was understood as the requirement to be open and transparent with people when things went wrong.

The duty of candour process had been appropriately applied to seven incidents, with one incident ongoing at the time of inspection. The trust had systems in place to monitor compliance, including adherence to its 10-day response timescale. Compliance with the verbal duty of candour process was 100%. However, four written responses were issued outside of the trust’s expected time frame to allow for multidisciplinary input. Learning from this resulted in improvements including the introduction of a standardised tracking system, strengthened documentation and decision-making processes, and enhanced oversight and escalation.

There had been no serious incidents reported in the previous 12 months. The most recent incident occurred in January 2025, with the final report approved in October 2025. The investigation concluded that the care pathway was appropriate, although four areas for improvement were identified. Progress against three recommendations was monitored through audit processes. Learning was shared through divisional governance structures and patient safety forums.

Staff consistently received feedback from incidents and complaints through a range of mechanisms, including one-to-one discussions, governance meetings, newsletters and visual learning tools such as ‘learning on a page’ and ‘lightning learning’ posters. Two band 6 governance facilitators supported the sharing of learning and audit outcomes across both hospital sites.

Multidisciplinary team (MDT) meetings held weekly, including Monday review meetings, provided a structured forum to discuss incidents, complaints, ongoing investigations and emerging themes. This supported shared learning and the implementation of changes to practice to reduce the risk of recurrence.

Leaders facilitated regular mortality and morbidity meetings and shared findings from audit activity, including the paediatric sepsis audit. Reviews of complex cases, including a paediatric death, demonstrated reflective practice. Discussions considered the clinical, ethical and emotional aspects of care, including the importance of advance care planning and effective communication between tertiary and local services.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Systems were in place to support safe referral, admission and discharge pathways. Referral and admission processes captured essential patient information, and some patient groups received follow-up contact after discharge, such as post-operative check calls for tonsillectomy patients. Discharge planning was supported through the integrated pathway of care (IPOC) documentation, which ensured appropriate referrals and follow-up arrangements were made. Discharge information was shared with families and relevant professionals, including GPs and health visitors, to support continuity of care.

Different triage systems were used within the children’s emergency department and inpatient areas. Staff received training to ensure they were competent in applying both systems, which supported safe and effective patient flow across the service.

The service had policies in place to manage patient flow and capacity, including a children’s bed management policy and seasonal staffing plans agreed at care group and executive level.

A transition strategy (2026–2030) was in place to support young people moving from children to adult services. This included clear objectives and a dedicated transition team, which supported continuity of care for children with long-term conditions.

However, oversight of external recommendations required improvement. A regional review of children’s surgical services identified six recommendations, and although an action plan included 11 areas, there had been no progress against five of these at the time of inspection.

Medical support was available 24 hours a day, with clear escalation routes to the consultant on call. Structured communication tools, such as SBAR, were used to support safe handover between staff. Consultant-led handovers took place twice daily, with appropriate nursing input. Where consultants were not present, handovers were maintained through registrar-to-registrar communication.

Senior nursing support was available 24 hours a day through band 6 and band 7 staff, with additional support from a band 8a matron during daytime hours. Out-of-hours support was provided by the adult site team. We observed examples of visible leadership within clinical areas.

Multidisciplinary teams contributed to patient safety through attendance at critical care forums and regular clinical discussions.

Arrangements were in place for the transfer of critically ill children, including access to a specialist regional transport service. However, the trust was unable to provide assurance that a current, signed transfer agreement was in place following the inspection.

Transfer processes were supported by policies and tools, including those for time-critical transfers and the Safe transfer of the paediatric patient (STOPP) tool. Compliance with the STOPP tool varied between 60% and 90%, and there was no clear analysis or action plan to address areas of non-compliance. This limited assurance that all elements of safe transfer processes were consistently completed.

Staff had access to clear escalation guidance for deteriorating patients. Where risks were identified, these were recorded on the risk register. For example, compliance with European paediatric advanced life support training was 73%. Mitigation was in place, which included monitoring of skill mix, redeployment of staff and booking staff onto training, this meant the service could not fully assure that all staff had the required competencies to always respond to deteriorating children.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

The trust had robust safeguarding governance arrangements in place. The chief nurse was the executive lead for safeguarding, with oversight provided through the strategic safeguarding group (SSG). The SSG provided leadership and strategic direction for safeguarding systems and processes, with representation from integrated care board partners.

The trust’s 2024/25 safeguarding annual report provided assurance to the board on safeguarding activity. A safeguarding work plan and audit schedule were in place and monitored through the SSG. The report identified weaknesses in Child Protection Information Sharing (CP-IS) processes. This had been recognised as a trust-level risk, with an action plan implemented across maternity, paediatric and emergency services. Named leads were identified, standard operating procedures introduced, and performance was now monitored through the SSG, providing improved oversight.

Safeguarding systems included appropriate pre-employment checks. Audit data confirmed all staff had enhanced Disclosure and Barring Service (DBS) checks in place.

Leadership for safeguarding within children’s services was clearly defined, with two consultant paediatricians and two named nurses providing oversight and support. Safeguarding liaison meetings were embedded in practice, taking place daily within inpatient areas and weekly within outpatient services to ensure timely information sharing and risk management.

Comprehensive safeguarding policies and guidance were available to staff, covering key areas such as child exploitation, PREVENT, female genital mutilation (FGM), chaperoning and restraint. Clear procedures were in place to respond to safeguarding concerns, including suspected child abduction.

Staff demonstrated a good understanding of safeguarding responsibilities, including how to identify and escalate concerns. Trust data showed 508 safeguarding referrals had been made for children and young people. Staff described effective partnership working with external agencies and provided examples of protecting vulnerable children, including those with protected characteristics. At Doncaster Royal Infirmary, 976 safeguarding liaison meetings had taken place in 2025/26, supporting coordinated multi-agency working. Learning from case reviews was shared through the SSG.

The trust had invested in safeguarding supervision, with 15 trained supervisors supporting staff. All level 3 trained staff were offered six-monthly supervision, and records confirmed full compliance within children’s services during quarter one.

Training compliance for safeguarding, Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was generally high, ranging from 94% to 100%. However, attendance at face-to-face level 2 safeguarding training for nursing staff was lower at 67%. This meant the service could not fully assure that all nursing staff had up-to-date practical safeguarding training. Two consultant paediatricians had completed level 4 safeguarding training.

Additional training initiatives, including ‘Martha’s Rule’, were delivered through the practice development team to support staff capability.

Martha's Rule is a critical patient safety initiative in the NHS that gives hospital inpatients, their families, and carers the right to request an urgent, independent review if they are worried the patient's condition is deteriorating and feel their concerns are not being addressed.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence was generally of a good standard and where shortfalls these were monitored. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff interacted with children, young people (CYP) and their families in a friendly and respectful way. They encouraged questions and provided information to support understanding of care and treatment. Staff used age-appropriate approaches, including play and distraction techniques, to communicate effectively with children, particularly those with communication needs.

Records we reviewed demonstrated that children and families were involved in care planning. Five records showed clear evidence of the child’s voice and parental or carer involvement in decision-making. Advocacy support was available, and families were encouraged to provide feedback about their experiences.

Staff followed standard operating procedures to assess and manage risks. Risk assessments were completed on or prior to admission and included consideration of additional needs such as mental health conditions, learning disabilities and other vulnerabilities. Care was adapted to meet individual needs, including allowing additional time for assessments where required. A review of seven records confirmed risk assessments were completed, including pressure area assessments, surgical safety processes and pre- and post-operative checks.

The service had assessed itself against the Paediatric Critical Care Society (PCCS) standards in 2024 and was compliant with 12 out of 38 standards. The remaining standards were rated as requiring further development. Although an action plan was in place and risks were recorded on the service risk register, this indicated the service did not yet fully meet national expectations for paediatric critical care provision.

The service was able to provide level 1 high dependency care within designated side rooms and staff were trained to stabilise patients prior to transfer. There was 24-hour access to a specialist retrieval team and appropriate pathways were in place for escalation to regional intensive care units. Children with severe trauma were transferred directly to specialist trauma centres.

Staff could access sepsis policies, guidance and escalation pathways. Sepsis discharge information was provided to families. Audit data identified areas for improvement, including completion of sepsis screening tools and staff education. Although actions had been identified and progress was being made, not all actions had been completed, which meant improvements in sepsis management were still ongoing.

At the time of inspection, the deteriorating patient policy was under development and had not yet been fully implemented. The planned introduction of the national paediatric early warning score (PEWS) and Martha’s Rule aimed to strengthen this area; however, until implementation, the service could not fully assure alignment with national standards.

Patient deterioration was monitored using the paediatric advanced warning system (PAWS), with audit compliance ranging from 70% to 90%. This variation meant monitoring was not consistently reliable across the service.

Staff were trained and prepared to respond to emergencies. Nursing staff-maintained competency through critical care passports, life support training and simulation exercises.

Staff were allocated clear roles during shifts to ensure preparedness in emergency situations. Thirty simulation sessions had been undertaken over the previous two years to enhance skills in managing complex and high-risk scenarios.

The service used the NHS surgical safety checklist; however, compliance was not consistently achieved. Between October 2025 and April 2026, there were instances of non-compliance with national safety standards for invasive procedures (NatSSIPs), including 46 missed ‘time out’ checks and 24 missed ‘sign out’ checks. Although monitoring and additional training had been introduced, these gaps meant the service could not fully assure consistent adherence to national safety standards.

We observed good communication between staff, children and families during surgical pathways. Preoperative assessments, baseline observations and safety checks were completed appropriately, and children were supported through the process using distraction techniques and clear communication.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The trust had clear governance arrangements for information management and technology security. Overall responsibility sat with the Chief Executive, with delegated responsibility to the chief information officer as senior information risk owner and the Caldicott Guardian. Policies and guidance, including data protection and safe haven procedures, supported practice. Systems were in place to monitor cyber security, including regular reporting on penetration testing and incidents.

Security systems-controlled access to clinical areas, including swipe card entry, doorbell systems and CCTV. However, these were not always effective in practice. We observed that the camera in the children’s outpatient clinic (COPD) was not working. In addition, doors to some areas, including the children’s observation unit (CHOU) dirty utility room and the COPD main entrance, were left open. This was not in line with the trust’s access control policy. Although staff took immediate action when concerns were raised, the service later advised this practice was locally accepted, which did not align with trust policy and reduced assurance of a consistently secure environment.

Clinical environments were clean, generally well maintained and appropriately equipped. However, some environmental risks were identified. These included damage to flooring in the COPD cleaners’ room and instances of equipment requiring maintenance review. Records showed that 27 out of 308 pieces of equipment were overdue for servicing, which meant the service could not fully assure that all equipment was safe and fit for use.

Staff were trained and assessed as competent in the use of equipment relevant to their roles, with training completed during induction and monitored through performance processes. Staff confirmed this was reviewed through monthly governance arrangements.

The physical environment supported the delivery of care, including designated bed capacity and provision of high dependency care within side rooms. Children requiring mental health support were cared for in appropriate side rooms; however, these rooms were not ligature free. Although staff undertook risk assessments and removed potential hazards; the service was unable to provide a completed ligature risk audit. This meant the service could not fully assure that environmental risks for vulnerable patients had been systematically assessed and mitigated.

Facilities to support children’s experience were appropriate. Play areas were clean, well-organised and maintained, with equipment safely secured. Toys were managed by the play team and appeared clean and suitable for use.

We identified a small number of environmental risks during the inspection, including exposed twine hanging from ceiling vents and a broken storage trolley drawer. These were escalated and addressed immediately by staff, demonstrating a responsive approach to risk management.

Systems were in place to safely store hazardous substances and medical gases, with high levels of compliance reported through monthly audits. Legionella monitoring was undertaken regularly, with actions completed as required, providing assurance of water safety processes.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 2. The evidence showed some shortfalls. The service had some staffing shortfalls in qualified, skilled, and experienced staff. The evidence showed that the service had reviewed and mitigated risks when nursing and medical staffing shortfalls were identified. Ongoing recruitment was taking place to fill vacancies. The service made sure staff received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

The service had systems in place to review workforce capacity and skill mix. A bi-annual workforce review (November 2025), approved in April 2026, identified the need to increase registered nursing staff and reduce unregistered staff. The chief nurse had agreed these recommendations, and some actions had been implemented, including additional band 7 site practitioner roles to support out-of-hours cover.

Staff described low turnover within paediatric services, and recruitment above establishment had been used to mitigate maternity leave. Staffing arrangements included rotation across sites and services, with flexibility to respond to demand. Planned staffing levels generally included appropriate registered nursing cover, with band 6 and band 7 nurses providing leadership on each shift.

However, staff reported that staffing levels had not always felt safe. Incident data confirmed six staffing-related incidents over a 12-month period which were recorded as no harm. Workforce tools, including the Safer Nursing Care Tool and Safe Care system, were used to monitor acuity, dependency and staffing levels. Daily reviews and twice-daily trust-wide staffing meetings supported escalation and oversight of staffing risks.

The service provided 24-hour nursing cover, with band 6 and 7 nurses acting as bleep holders. However, the service was not consistently aligned with Royal College of Nursing (RCN) 2025 guidance, which recommends access to a band 8a nurse over a 24-hour period. Band 8a support was available during the day but relied on the adult site team overnight. This meant the service could not always assure access to senior paediatric nursing leadership.

Additional roles supported service delivery, including play specialists, a youth worker, transition nurses and a mental health champion. Specialist nursing roles and an education lead supported staff development and patient care.

Medical staffing was generally sufficient to maintain safe care, with rotas compliant with the European Working Time Directive. Gaps were managed through locum cover and recruitment. However, the service did not fully meet the Facing the Future standards which outlined how to provide a safe, sustainable and high-quality service that met the health needs of children and young people Compliance was reported at 80%, with gaps in consultant availability and review timescales. Children were not consistently reviewed by a consultant within 14 hours of admission, and there was no clear time frame for achieving compliance. A shortfall of three whole-time equivalent consultants had been identified, with a business case in development. This limited assurance that children consistently received timely senior clinical review.

Workforce metrics indicated ongoing staffing pressures. Fill rates for registered nurses ranged from 87.6% (day) to 91.4% (night), with lower fill rates for unregistered staff. The service used bank and agency staff to maintain safe staffing levels, including over 3,900 hours of registered nurse bank usage over a six-month period. Medical agency usage totalled 1,143 hours, primarily at specialty trainee level. While mitigation was in place, reliance on temporary staffing indicated gaps in substantive workforce capacity.

Training compliance did not consistently meet trust targets. Statutory and essential training compliance ranged from 84% (nursing) to 88% (medical), below the 90% target. Compliance for locally mandated training varied between 75% and 97%.

Of particular concern was low compliance in L2 paediatric life support training for nursing staff, which ranged from 44% to 71% across training levels. This meant the service could not fully assure that all nursing staff had the required skills to recognise and respond to deteriorating children. In contrast, medical staff compliance in life support training was 100%.

Staff were supported through structured induction, preceptorship programmes and access to ongoing training and development. Appraisal rates were high across all staff groups, and staff reported access to supervision and team meetings, which supported professional development and safe practice.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection prevention and control (IPC) arrangements were well coordinated. Executive oversight was provided by the Chief Nurse, with operational leadership from the Director of Infection Prevention and Control (DIPC) and the IPC team. Systems were in place to monitor compliance, with board-to-ward oversight, routine surveillance and all infection incidents reported through the trust’s incident reporting system.

Staff had access to comprehensive IPC policies and guidance, including protocols for MRSA screening and management. Clear visual information was displayed across clinical areas, including hand hygiene guidance, ‘bare below the elbows’ standards, appropriate use of personal protective equipment (PPE) and how to contact the IPC team.

Clinical areas were visibly clean, well maintained and appropriately equipped. Cleaning schedules were up to date and demonstrated regular cleaning of all areas. Equipment was clean and appropriately labelled, and toys were cleaned after use and as part of daily and weekly routines within play areas. Environmental audit results for 2025/26 demonstrated high compliance across inpatient areas, ranging from 94.9% to 100%, including full compliance for commode cleaning.

Staff adhered to IPC principles, including effective hand hygiene and appropriate use of PPE. Hand hygiene training compliance was high, ranging from 89.7% to 100% across clinical areas.

Training compliance for IPC was mixed. Level 1 IPC training compliance was strong across staff groups (90–100%). However, level 2 IPC training compliance was variable and as low as 20% for some staff groups. This meant the service could not fully assure that all staff had up-to-date knowledge and skills to manage infection risks effectively.

The service monitored infection rates and reported low levels of healthcare-associated infections. One case of Pseudomonas infection was identified between April 2025 and March 2026, which was managed through established reporting processes.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happen.

There was a safe system in place for the safe handling of medicines. The pharmacy clinical team lead described systems in place to ensure medicines was applied across different stages of the medicines pathway, including prescribing, dispensing, administration and monitoring.

There were systems in place to minimise the risk of medicines-related harm. There were clear processes for checking prescriptions, including verification of dose, route, allergies and potential interactions. Weight-based dosing was routinely used for paediatric patients, and high-risk medicines were subject to independent double-checking by two trained staff. Patient identification checks were consistently undertaken prior to medicines administration. Systems were in place to reduce dispensing errors, including separate prescription baskets and QR code tracking of staff involved in preparation. The service was in the process of transitioning to electronic prescribing, which staff anticipated would further reduce risks associated with transcription errors. The pharmacy clinical team lead described how they would proactively challenge any prescriptions that were incorrect or unclear to ensure patient safety.

Medicines reconciliation processes were in place at admission, transfer and discharge. This included verification of medicines, doses, routes, allergies and current weight, with clear documentation of any changes. A review of 4 patient charts confirmed allergies, height, and weight were documented. We were told families were involved in discussions about medicines and received verbal and written information to support safe administration at home. Translation services and tailored communication approaches were used to meet individual needs. Pharmacists provided support on ward rounds and were accessible both during working hours and via an on-call system, ensuring consistent clinical oversight.

Antimicrobial stewardship, which is described as, only use antibiotics when needed, was well embedded, with audit data showing appropriate cultures were taken prior to treatment, antibiotics prescribed in line with guidance, and significant improvement in documentation of review or stop dates. Performance was favourable when benchmarked regionally, with effective intravenous to oral switch practices in place.

The trust demonstrated a safety culture. Staff reported incidents and near misses through the trust’s electronic reporting system (Datix), which were reviewed and investigated. Learning from incidents was shared through team meetings, safety briefings, emails and pharmacist forums. Medicines were stored safely and securely. Policies and procedures supported safe practice. The trust had an up-to-date medicines management policy that clearly outlined staff roles, prescribing standards, administration processes, storage requirements, incident reporting, and training expectations.

Audit systems were established and used to monitor compliance with medicines management standards. Recent audit results showed good compliance levels, with identified issues relating to fridge temperature monitoring and escalation, which were addressed and shared for learning.

We reviewed medicine related incidents for the last 12 months, including prescribing omissions, dosing errors and delays in dispensing. Appropriate action had been taken in response, including application of duty of candour and shared learning.

Medicines, including controlled drugs (CDs), were stored securely, with daily stock checks completed. FP10 prescription forms were used appropriately, and logs confirmed compliance.