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.

This meant the service was consistently managed and well-led. Leaders recognised aspects of the culture required improvement and as such had taken action to improve it. Leaders mitigated risks to ensure that person-centred care was received by all children and young people using the service.

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 checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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.

We scored the service as 2. The evidence showed some shortfalls. The service had adopted trust vision and values. The service did not have a children’s and young people’s strategy but planned to develop one. Work was ongoing to improve the culture amongst staff groups within the service.

The work the service was doing showed they understood the challenges and the needs of people and their communities.

Cultural and behavioural concerns had previously been identified within paediatric services across Doncaster Royal Infirmary and Bassetlaw Hospital. These concerns had been escalated appropriately, including engagement with the CQC, and prompted a comprehensive internal review. This resulted in a targeted action plan with five strategic priorities focused on improving culture, leadership and patient safety.

Leaders had taken action to address these concerns through strengthened executive oversight, benchmarking against external standards and ongoing monitoring of improvement actions. While progress was made, work to embed positive cultural change was ongoing.

An external ‘A Kinder Life’ cultural review had been commissioned to further explore behaviors and staff experience within the service. This included a structured 16-week programme involving senior nurses, medical staff and advanced practitioners. Early engagement had taken place with consultant staff. The need for this external review indicated that cultural challenges remained, and sustained effort was required to embed improvements across all staff groups.

The organisational vision was ‘Healthier together – Delivering exceptional Care for All.’ The trust vision was “To be the safest Trust in England, outstanding in all we do.” The vision was supported by the core values of being kind, inclusive, person-centred, empowering, accountable and collaborative. Expected behaviours associated with these values included: attentive listening, integrity, honesty, courage and positivity. We saw these values and behaviours applied within children’s services, particularly in relation to work addressing health inequalities and improving patient experience.’

However, the service did not have a dedicated children and young people’s strategy. While plans were in place to develop this, including a structured three-stage engagement programme involving children and young people, the absence of a current strategy limited assurance of a clear, service-specific vision and direction.

Early progress towards developing this strategy included the recruitment of a youth worker and the introduction of a youth group to gather feedback and lived experience. The longer-term ambition was to develop a Children and Young People Charter by 2027 to guide future priorities and service development.

The service’s current quality priorities were aligned with wider trust objectives. Development of developmentally appropriate healthcare (DAH) had been identified as a key area for future focus, with planned progression during 2026.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Leaders had the skills, knowledge and experience to carry out their roles effectively. They demonstrated a clear understanding of the services they managed and were able to describe how teams worked together to deliver high-quality care.

Leaders were visible within clinical areas and were approachable to both staff and patients. Staff told us they felt supported by local leaders and valued their presence within the service.

Leadership development opportunities were available across the organisation, supporting both current and future leaders to develop their skills and capabilities.

While leadership was generally effective and supportive, ongoing cultural improvement work within the service meant leaders needed to continue to embed consistent behaviors and expectations across all staff groups. (See shared direction and culture section for further detail.)

We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. The evidence showed a good standard. The service fostered a culture where people could speak up, and their voice would be heard.

The trust had systems in place to support a culture where staff could raise concerns. Regular Freedom to Speak Up (FTSU) reports were presented to the board, with the most recent detailed update provided in March 2026. This report demonstrated oversight of progress against previously identified actions and supported the development of the trust’s ‘Speaking Up Strategic Plan’ (2026–2028).

Actions had been taken to strengthen the FTSU function, including improvements to leadership support and learning processes. Staff could access the trust’s Speaking Up policy and were supported through tools such as the ‘Being Fair’ framework following patient safety incidents.

Staff engagement mechanisms were in place, including monthly ‘candid conversation’ sessions where staff could discuss concerns, share learning and contribute to service improvement. Training compliance for FTSU awareness was generally strong across staff groups.

Feedback mechanisms were also in place for children, young people and their families, with information about raising concerns displayed in clinical areas. Leaders and staff used feedback from patients and staff to inform improvements.

However, there were some gaps in assurance. No Freedom to Speak Up champions were identified within children’s services, which limited local visibility and access to support. Staff feedback themes included worker safety, well-being and inappropriate behaviors, as well as concerns relating to systems, processes and leadership. While some staff reported they would feel confident to speak up again, the number of responses was limited, which reduced assurance that all staff felt consistently confident to raise concerns.

Overall, while systems to support speaking up were established and functioning, further work was required to strengthen local engagement and provide assurance that all staff felt confident and supported to raise concerns.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The evidence showed a good standard. 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.

The trust had a comprehensive equality, diversity and inclusion (EDI) improvement plan in place, which outlined a wide range of actions to improve workforce equality. Progress had been made against the actions aligned to the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES). Ongoing work was evident across most of the trust’s five of the high-impact priorities. However, this information was not clearly broken down at service level, which limited assurance of how improvements specifically impacted children’s services.

The trust demonstrated a commitment to promoting an inclusive culture. It had achieved ‘Bronze status’ in recognition of its anti-racism work, with executive leadership supporting this agenda. Initiatives such as corporate induction events, which included content on allyship and anti-racism, supported staff awareness and engagement.

Training compliance in equality, diversity and health inequalities was strong across most staff groups, supporting staff to recognise and respond to discrimination and inequalities in the workplace. Staff completion of equality, diversity and human rights training was generally high, although there was some variation across staff groups.

The trust promoted an inclusive culture through a range of initiatives, including staff recognition events, awareness campaigns and support for international staff. These activities helped to strengthen belonging and staff engagement.

Staff were supported through flexible working arrangements and reasonable adjustments to meet individual needs. Managers demonstrated an understanding of their responsibilities in supporting staff well-being and inclusion. Local initiatives, such as the paediatric ‘Star’ nomination programme, encouraged staff recognition and positive team culture.

Overall, the trust had strong systems and initiatives in place to support equality, diversity and inclusion. However, the lack of service-level data and evaluation meant the service could not fully assure that all EDI improvements were consistently embedded across children’s services.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance, and outcomes, and share this securely with others when appropriate.

The service had clear governance arrangements, with defined roles, responsibilities and accountability structures. Nursing and medical governance leads were in place, supported by governance facilitators. Staff demonstrated an understanding of governance processes, and there were clear ward-to-board reporting pathways.

Regular governance meetings were well established. Monthly clinical governance meetings were attended by multidisciplinary teams and included discussion of incidents, complaints, mortality, sepsis and medicines management. Learning was shared with staff through team meetings, newsletters and ‘soundbite’ communications, which helped ensure lessons from incidents were disseminated and embedded in practice.

Systems were in place to monitor quality and safety. Infection prevention and control was effectively managed, with oversight through specialist committees reporting to the trust board. The service had identified sepsis management as an area for improvement and had implemented targeted actions, including the introduction of a paediatric sepsis nurse role, training programmes and sepsis grab boxes. Ongoing audit and benchmarking activity demonstrated a proactive approach to improvement, although work in this area was still in progress.

Mortality and morbidity processes were established, with cases reviewed regularly and learning shared through performance and governance meetings. This supported reflective practice and quality improvement.

Managers could access information to support their management role, including service performance, staffing, and patient care. Please refer to ‘safe and effective staffing’ in the safe domain for further detail on how the service has managed staffing.

Staff had access to appropriate equipment and information systems. Data used to monitor performance was timely and supported oversight of patient care, staffing and service delivery. Performance was reviewed monthly, with key indicators including patient experience, sepsis, pain and audit compliance. While most audit areas demonstrated high compliance, some areas, such as pain and tendable audits, fell below expected thresholds at times, indicating variability in performance.

Audit processes were generally robust, supported by regular local and trust-wide activity. However, the documentation audit process had been identified as ineffective and was paused. A new digital audit tool was being developed and was due to be implemented in June 2026. Until this was established, the service could not fully assure the quality and consistency of clinical documentation.

We identified some concerns relating to record keeping and information governance. Patient records were observed stored in an unsecured area in outpatients. In addition, not all medical records reviewed were fully completed, with some lacking signatures or clear documentation of timing and consultant review. This reduced assurance that records were consistently accurate, complete and secure.

Risks were identified, recorded and escalated through appropriate governance structures. The service maintained a risk register, which included several high-rated risks. Actions and progress against risks were monitored through divisional governance processes. For example, risks relating to transition services were being progressed through review of staffing models and development of a business case.

The trust had policies in place to manage escalation and major incidents, including business continuity arrangements to ensure services could be maintained during disruptions. Staff described effective partnership working within and beyond the organisation to support safe and sustainable care delivery.

Overall, governance systems were established and supported the delivery of safe and effective care. However, some gaps in assurance remained, particularly in relation to documentation, audit effectiveness and consistency of performance monitoring.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The trust was developing its approach to engaging with people and communities whose voices are seldom heard. A health inequalities forum, established over 18 months ago, brought together internal teams and external partners, including voluntary and community sector organisations, to identify and address inequalities within the local population. Children’s services were actively involved in this forum, contributing to system-wide approaches to improving outcomes for children and young people.

The service used lived experience to inform improvements. Families of children with special educational needs and disabilities (SEND) were invited into clinical areas to provide feedback on how the environment and services could better meet their needs. This approach supported meaningful engagement and helped shape service developments.

Targeted initiatives demonstrated how feedback was translated into practice. For example, the ‘Little Voices, Little Steps’ project involved children from a local deaf school, who visited the hospital and shared their experiences. This led to tangible improvements, including the development of resource boxes to support communication and reasonable adjustments. Further work was planned to improve transition arrangements and access to interpreters in emergency situations.

Children, young people and their families had opportunities to engage directly with senior leaders and commissioners. Regular youth engagement events were held, offering young people opportunities to share feedback, contribute to service design and influence the development of more youth-friendly environments.

Overall, the service demonstrated a commitment to partnership working and community engagement. While this work was still developing in some areas, there was clear evidence that feedback from children, young people and families was being used to inform service improvements.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice and research.

The service demonstrated a commitment to continuous learning and improvement through a range of quality improvement initiatives. These included the introduction of specialist roles, such as transition nurses, sepsis nurses, practice development nurses, audit nurses and a mental health champion. Additional roles, including youth workers, site practitioners and professional nurse advocates, supported service development and staff wellbeing.

Quality improvement processes were responsive to identified risks and feedback. For example, following concerns regarding fluid balance documentation and compliance with national guidance, the service introduced a revised fluid balance chart in March 2026. This aimed to improve accuracy and reduce the risk of errors associated with intravenous fluid management.

Governance arrangements had been strengthened through the implementation of the Patient Safety Incident Response Framework (PSIRF), the introduction of patient safety panels, and joint governance meetings between paediatric and emergency department teams. These changes supported a more coordinated and learning-focused approach to patient safety.

The service responded to national safety learning and patient feedback. The introduction of Martha’s Rule ‘wellness questions’ enabled families to escalate concerns and supported early identification of deterioration. In addition, improvements to mental health risk assessments were made following incident reviews, which enhanced care planning and patient safety.

Work to address health inequalities was ongoing, including collaboration with the SEND working group, outreach initiatives with local schools and improvements to communication and wayfinding within clinical areas. Projects such as ‘Little Voices’ and the introduction of translation tools supported more inclusive care.

Staff were actively involved in innovation and service development. For example, fundraising initiatives had been undertaken to support the development of a dedicated sensory room within the children’s ward and assessment unit. While this demonstrated staff engagement and commitment, the absence of a fully established sensory space meant that further improvements to the environment were still required to fully meet the needs of children with sensory needs.

Overall, the service showed a proactive approach to learning and improvement. However, some initiatives were still in development, and the impact of these changes was not yet fully embedded across the service.