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Provider: Rotherham Doncaster and South Humber NHS Foundation Trust Good

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary

Overall summary & rating


Updated 28 June 2018

  • We rated caring, effective, responsive and well led as good and the overall rating for Community inpatient services went up to good at this inspection.
  • With the exception of mental health rehabilitation services, patients’ physical and mental health risk assessments were comprehensive. Appropriate management plans were in place and patients had up to date and comprehensive care plans, which reflected national guidance and best practice and met their individual needs.
  • The trust board and senior leadership team had the appropriate range of skills, knowledge and experience to perform its role and the non-executive directors had the appropriate skills and knowledge in order to provide relevant challenge to the trust board. The senior leadership team and senior managers understood the key priorities within the services.
  • We rated one adult social care location, 88 Travis Gardens, as outstanding in the caring domain.
  • The trust had an excellent staff, patient and public engagement strategy which followed a recognised methodology. Staff throughout the trust had access to specialist training and development and had been empowered to implement quality improvements.
  • Leaders were visible in the service and approachable for patients and staff. Staff felt supported by their managers and felt they could raise concerns or approach their managers for support.
  • A physical health and wellbeing strategy was in place under the executive lead of the medical director. We saw in all core services we inspected that patients had good access to physical health care; physical health checks were undertaken and staff promoted healthier lifestyles.


  • We rated safe as requires improvement in four of the 14 core services. The overall rating for acute wards for adults of working age and psychiatric intensive care wards had gone down to requires improvement.
  • Although the trust had improved its overall mandatory training compliance, staff in some wards and teams were not up to date with their mandatory training requirements. Training for prevention and management of violence and aggression, a key component of enabling safe care was below 75% in acute wards for adults of working age and psychiatric intensive care units. Compliance was only 15% in one ward.
  • There were medicines management issues in three core services at this inspection. At our last inspection we found that patients allergy status was not completed on some prescription charts in the community based mental health services for adults of working age. At this inspection we found that this had not been rectified across all teams.
  • Not all staff had received an up-to-date appraisal of their performance.
  • Patients in some services had limited access to psychological therapies and occupational therapy.

Inspection areas


Requires improvement

Updated 28 June 2018

Our rating of safe went down. We rated it as requires improvement because:

  • Nurse call alarm systems were not in place in all of the bedrooms on the acute wards for adults of working age. Staff on one ward in Doncaster were unaware that they weren’t present.
  • Seclusion facilities lacked some of the necessary equipment, clocks were not visible to patients in two seclusion facilities.
  • Staff in some wards and teams were not up to date with their mandatory training requirements. Training for prevention and management of violence and aggression, a key component of enabling safe care was below 75% in acute wards for adults of working age and psychiatric intensive care units. Compliance was only 15% in one ward.
  • We found blanket restrictions were in place in two core services we visited on this inspection.
  • There were prescribing and transcribing errors in the medicines administration charts including missing signatures. In community mental health services for adults of working age staff did not always record the allergy status of the patient on the medicine chart, something which we also found at the last inspection.
  • We found syringes which were not in sealed packages and were out of date and medicine which had passed its expiry date and staff had not identified this. There were gaps and inconsistencies in the recordings of fridge and clinic room temperatures.
  • Staff did not always follow the trust’s lone working procedures and in a community based service there was no alarm system in any of the interview rooms.
  • We rated four of the 14 core services as requires improvement for the safe domain, this takes account the ratings of core services which were not inspected this time.


  • Staff knew how to report incidents. They shared lessons learned and made changes in response to recommendations from incidents
  • Patients’ physical and mental health risk assessments were comprehensive and appropriate management plans were in place.
  • Staff recognised safeguarding concerns and dealt with them according to procedures.
  • Staffing levels were sufficient to ensure the safe care and treatment of patients.

  • The trust had taken appropriate action to assess and monitor patients against the risk of venous thromboembolism. The service monitored and reviewed safety performance using the safety thermometer and performance showed a good track record.
  • Environmental risk assessments had been carried out and areas were visibly clean and well maintained. Staff followed national guidance in relation to hand hygiene and infection prevention and control. There were no cases of Clostridium difficile, MRSA, or methicillin sensitive Staphylococcus aureus in the community health services during the previous 12 months prior to the inspection.



Updated 28 June 2018

Our rating of effective stayed the same. We rated it as good because:

  • In mental health services staff undertook a full assessment of patients and monitored physical health as required in accordance with best practice guidance. Staff ran well-being clinics where they monitored patients’ physical health and offered healthier lifestyle advice and information.
  • Staff encouraged and supported patients to live healthier lives through promotion of heathy eating, exercise and reducing consumption of caffeine and smoking.
  • Patients had up to date and comprehensive care plans, which reflected national guidance and best practice and met the individual needs of the patient.
  • Staff were competent and had the skills they needed to carry out their roles effectively. They felt supported in their roles and there was good access to specialist training


  • Medical staff did not always complete Mental Capacity Act documentation completely or with sufficient detail and teams were inconsistent about recording assessments of capacity in patient notes. Some staff were not aware of the specific independent advocacy arrangements for patients.
  • Not all of the care records we reviewed contained a full comprehensive assessment on admission.
  • Patients in some areas had limited access to psychological therapies and occupational therapy.
  • Clinical supervision rates for non-medical staff were below the trust target in two core services on this inspection.
  • Not all staff had received an up-to-date appraisal of their performance



Updated 28 June 2018

  • We rated one adult social care location as outstanding, and three adult social care locations and all fourteen core services as good for the caring domain. This takes into account the ratings of core services which were not inspected this time.
  • Patients in some services actively participated in the recruitment and selection process of staff.
  • Patient involvement was evidenced in care plans and risk assessments. Staff supported patients to understand and manage their conditions, care and treatment and to access other appropriate services

  • Staff involved carers and relatives appropriately, and had strong links with carer support services and referred carers to the carers support team when required.
  • The patient led assessments of the care environments achieved scores above the trust and England averages for mental health and learning disability services.
  • Staff treated patients with dignity and respect and were compassionate and respectful when interacting with and carers.
  • Patients and carers had opportunities to give feedback about the care and treatment the wards provided. Feedback from patients and carers was mostly positive.
  • Staff were passionate about their roles and dedicated to making sure patients received the best person-centred care possible.
  • Appropriate communication methods were used to ensure all patients and carers could understand their care and treatment and did not feel isolated in the service.


  • It was not always clear whether patients or their carers had received a copy of the care plan in the wards for older people with mental health problems



Updated 28 June 2018

Our rating of responsive stayed the same. We rated it as good because:

  • Staff supported and encouraged patient engagement in the community.
  • Patients had access to recovery colleges and social prescribing designed to improve confidence and job skills and promote mental health recovery and well-being.
  • Information about how to make a formal complaint was widely available, patients and carers knew how to raise concerns or make a complaint and were comfortable doing so.
  • Wards and services had the necessary equipment to meet the needs of the relevant patient groups.
  • Services were planned and delivered to meet the needs of people and staff worked collaboratively with partner organisations, and other agencies.
  • The needs of people in vulnerable circumstances were met and reasonable adjustments were made to ensure people with a disability had equality of access to services.
  • People had access to the right care at the right time and managers had taken appropriate action to reduce the number of delayed discharges.
  • The trust had implemented the Accessible Information Standard and there was a wide range of information and leaflets available for patient, families, and carers.


  • The rehabilitation services did not have clear models of delivery, there was no clear rehabilitation pathway at Emerald Lodge between patients staying in the ward and the bungalows to ensure that patients received care that met their needs and promoted their recovery and it was not clear how Coral Lodge met national guidelines on rehabilitation services.
  • Some relatives of people receiving care from the Domiciliary care service expressed concerns about the number of care hours allocated to their family member, as they felt activities were restricted.
  • In some of the acute wards for adults of working age there was no evidence that planned activities were taking place during the weekend.
  • Some patients in the Doncaster social inclusion service had waited a long time to receive a service; some patients had waited between 7 and 11 months to be allocated to a care co-ordinator.
  • Discharge planning wasn’t always evident in patient care records.



Updated 28 June 2018

This was our first review of well led under our next phase methodology. We rated it as good because:

Checks on specific services

Substance misuse services


Updated 12 January 2017

We have rated substance misuse services as good overall because:

  • All locations were clean and well maintained, clinic rooms were clean and equipment was regularly serviced with stickers visible detailing when the next service was due. The risk assessments we saw reflected the needs of the clients and were in date.

  • Controlled drugs were stored appropriately and contracts were in place for the collection of clinical waste.

  • Assessments were seen to be detailed and contained both a physical health assessment and an assessment of substance use. Recovery plans were seen to be strength based and recovery focused.

  • The service employed a range of staff disciplines through the trust and partner agencies which meant clients had access to a range of medical and psychosocial interventions recommended by national guidance.

  • Staff assessed clients’ physical health care needs. Staff communicated with GPs concerning physical health and prescribed medications and the systems used linked up so that notes could be shared.


  • We were unable to find risk assessment for three clients in the records we inspected; one of whom had been using services for a number of years.

  • Mandatory training compliance was at 78% which was below the trusts benchmark of 90%. Only 58% of staff had attended the resuscitation level one training.

  • The care plan template in use did not reflect the four domains recommended by the Department of Health, drug misuse and dependence guidelines. This created inconsistency in the quality of the recovery plans and meant some recovery plans were more holistic than others.

  • 58% of the records we looked at did not contain signed consent for information to be shared with the National Drug Treatment Monitoring System.

Wards for older people with mental health problems


Updated 28 June 2018

Our rating of this service stayed the same. We rated it as good because:

  • The wards had systems and processes in place to keep patients and staff safe. Staff recognised safeguarding concerns and escalated these appropriately. They identified patient risks and put plans in place to manage these. Staff followed effective medicines management practices to ensure the proper and safe use of medicines.
  • Staff provided compassionate care and treatment to patients. They took the time to interact with the patients and feedback was positive across all wards. They supported patients with dignity and respect and involved them in their care.
  • Carers were involved and encouraged to be partners in the care of the patient. Staff involved them in decision-making and supported their needs in addition to the patients.
  • Staff carried out a comprehensive assessment to identify a patient’s needs. Care plans reflected the needs and incorporated the patient’s history and preferences. Staff reviewed the plans regularly and involved other specialists when needed.
  • Wards included, or had access to a full range of specialists required to meet the need of the patients. Staff were suitably skilled and had the knowledge and experience to deliver effective care, support and treatment.
  • All the wards had welcoming premises and the facilities to meet the needs of patients. Bedrooms were all ensuite and patients had a secure place to store their belongings. There were quiet areas on the wards where patients could meet visitors or make phone calls in private.
  • Staff mostly enjoyed their roles and felt supported and valued within their immediate teams. Ward managers had the skills, knowledge and experience to support their role and promote high quality care. They had a good oversight of their ward’s performance.


  • Staff on Windermere, Glade and Fern wards did not regularly review or consider the restrictions on a patient’s ability to freely access the ward’s garden or lounge areas.
  • Staff were not fully compliant in all mandatory training units.
  • Staff did not always complete Mental Capacity Act documentation fully or with sufficient detail.
  • Wards did not display a notice to tell informal patients that they could leave the ward freely.
  • Staff on the wards felt disconnected from the wider trust and from the older people’s wards in the different localities. They had limited knowledge of the trust’s vision and values.

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 28 June 2018

Our rating of this service went down. We rated it as requires improvement because:

  • The trust did not have a clear model of service delivery. All of the wards had blanket restrictions, which were not in accordance with legislation of guidance. At Coral Lodge, it was not clear how the service met national guidance on rehabilitation services. In addition to blanket restrictions, Coral Lodge was a locked rehabilitation ward, we received conflicting information about whether or not the ward only accepted detained patients or whether it would accept informal patients. The patients’ fridge and freezer at Coral Lodge was locked at all times. The trust had not ensured there was a clear pathway at Emerald Lodge or risk assessment process to ensure patients moving from the ward to bungalows on site would be safe. The care plans for patients at Emerald Lodge lacked information about where they were staying and their support needs.
  • Teams did not all have the required disciplines to meet the psychosocial and rehabilitation needs of patients. There was limited access to psychology at Emerald Lodge and Goldcrest. Emerald Lodge did not have an occupational therapist.
  • Ineffective risk management oversight had not identified lapses in risk assessment of group activities and therapies.
  • Four care plans had not recently been reviewed. A further four care plans had not been updated with the date to reflect they had been reviewed by staff.
  • Appraisal rates were low for staff working at Emerald Lodge and Coral Lodge.


  • Staff were positive and enthusiastic about the work they delivered and the trust leaders were visible within the services. Staff and leaders felt supported at all levels and they had an established social media presence to promote their work and key messages. Staff and patients had opportunities to participate in research and quality improvement work streams.
  • Patients provided positive feedback on the service and observations showed that staff treated patients well. Patients were involved in their care and treatment. They had access to a range of groups and activities to promote their mental health recovery. Patients knew how to raise concerns.
  • Physical health monitoring was embedded well into patients’ care and treatment. Staff promoted positive healthy lifestyles.
  • With the exception of the issues identified at Emerald Lodge, the service had improved individual patient risk assessments. These were comprehensive and contained risk management plans. Staff understood their responsibilities in reporting incidents and under the Mental Health Act and Mental Capacity Act.

Community-based mental health services for adults of working age

Requires improvement

Updated 28 June 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Staff did not always record important information about patients’ allergies on their medication records.
  • Not all teams were up-to-date with their mandatory training and not all staff were clear about the correct procedures for reporting safeguarding concerns through the incident system.
  • Managers had not carried out an appraisal with all their staff.
  • Not all staff were aware of the independent advocacy arrangements for patients and teams were inconsistent about documenting assessments of patient capacity.
  • Not all staff were aware of the trust’s Freedom to Speak Up Guardian.
  • The trust did not have effective systems in place to monitor staff compliance with line management supervision. They did not ensure all teams had access to effective medicines management audits.


  • Staff carried out risk assessments of the care environment and with patients in treatment. They updated these when they needed to.
  • Patients told us staff were caring, compassionate and listened to them. They felt involved in their treatment.
  • Staff ran well-being clinics to help patients manage their condition. They worked with other services so patients had access to programmes aimed at promoting recovery.
  • Staff felt supported by their line managers and had access to regular team meetings. They knew how to report incidents and made changes in response to incident reviews.
  • Patients had access to complaints procedures and systems to provide feedback.

Community health inpatient services


Updated 28 June 2018

Our rating of this service stayed the same. We rated it as good because:

  • The leadership, governance, and culture promoted the delivery of high quality person-centred care. Staff had the skills they needed to carry out their role effectively and in line with best practice. Managers were visible and there was a strength and resilience across ward teams to deliver high quality care to patients.
  • Since the previous CQC inspection, managers had taken appropriate action to mitigate and manage the risk to patients by assessing and monitoring venous thromboembolism (VTE).
  • Staff told us they were proud to work for the trust and promoted a patient-centred culture.
  • Patients, families, and carers felt staff communicated with them effectively and made them feel safe. Staff involved and informed them about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
  • Services were organised to meet the needs of people. Managers and healthcare professionals worked collaboratively with partner organisations and other agencies to ensure services provided flexibility, and continuity of care.
  • Staff were competent and had the skills they needed to carry out their roles effectively. The majority of staff had completed mandatory and statutory training and managers had good oversight of the process.


  • Although medicines were securely stored and handled safely, we found evidence of prescribing and transcribing errors in the medicines administration charts we looked at. For example, we found incorrect spelling of medicines and use of non-approved abbreviations. Medicines also accounted for 23% of all incidents reported between 1 October 2016 and 30 September 2016. Errors included incorrect dosage and incorrect prescription.
  • Compliance level for safeguarding adults level two and level three was variable across the three wards and below the trust target.

Acute wards for adults of working age and psychiatric intensive care units

Requires improvement

Updated 28 June 2018

Our rating of this service went down. We rated it as requires improvement because:

  • The service did not always reflect safe practice in their processes and adhere to the trust policies in relation to medicines management. The recording and documentation of information for fridge and clinic room temperatures was inconsistent.
  • The equipment on wards didn’t always ensure the safety of patients. Nurse call alarm systems were not in place in all patient bedrooms and seclusion rooms were not fully equipped with necessary items, as identified in the Mental Health Act 1983 code of practice.
  • Comprehensive assessments of patients weren’t always fully completed or carried out on every patient. Not all patients had physical health care checks completed upon admission. Patient care plans were not holistic across six wards.
  • Mandatory training in prevention and management of violence and aggression sat at only 15% compliance on one of the wards.
  • There was a lack of evidence of activities being available to patients, especially on weekends. The ward facilities did not always promote patient’s privacy and dignity.
  • Not all ward managers had full oversight of their wards performance measures. Staff had little knowledge of the trust’s vision and values. Staff were also unaware of the role of the freedom to speak up guardian within the trust although they did know how to raise concerns.


  • Staff were kind, caring and respectful towards patients and knew the patients well. Staff also promoted a healthy lifestyle for patients and actively supported them in achieving this.
  • There were development opportunities for staff, access to specialist training and staff felt supported by their teams and managers.

Wards for people with a learning disability or autism


Updated 11 May 2017

We rated wards for people with learning disabilities at Bungalow 2 as good because

The ward was clean and tidy. Durable material covered walls and surfaces making them safer for the patient.

Staff were skilled and trained in safeguarding.

Care records were up to date, there were comprehensive care plans in place.

Due to the specific needs of the patient, there had been three independent assessments of the patient. This was to look at their treatment pathway and suggest interventions.

The ward had significant staffing issues following the unavailability of some staff following a safeguarding incident in February of this year. This however had been temporarily resolved and some senior staff had been brought in to ensure support, consistency and oversight of the service.

Government policy and the department of health’s document ‘positive and proactive care’ endorsed positive behaviour support. Key staff had attended training to facilitate this approach and further ‘train the trainer’ training was planned for September 2015.


  • Incidents of restraint in this area were the highest in the trust between 01 November 2014 and 30 April 2015 272 incidents were recorded. The provider and ward staff were aware of this and were working hard to reduce this amount.

  • Whilst staff supervision figures showed a steady rise, they were below the trusts expected target.

Specialist community mental health services for children and young people


Updated 12 January 2017

We rated specialist community mental health services for children and young people as Good because:

  • Staffing levels had been effectively calculated as part of the restructure and managers had been able to recruit above the previous staffing levels to ensure each care pathway had adequate staff to deliver care.

  • Care was provided in line with National Institute for Health and Care Excellence guidelines including offering patients access to a range of psychological therapies.


  • Care records, including risk assessments and care plans on the electronic system were found to be incomplete or missing.

  • The system did not enable risk assessment updates to retain relevant information from previous assessments which meant that risk information was not readily available on the system. The electronic records system used by the trust contained limited evidence of patients consent to treatment.

  • Lone working procedures were inconsistent across the service and there was no formal process in place at St Nicholas house to mitigate the lack of call point in interview rooms.

Community mental health services with learning disabilities or autism


Updated 12 January 2017

We rated community mental health services for adults with a learning disability or autism as good overall, because:

  • There had been improvements since our last inspection. The trust had upgraded the safety and security of the buildings occupied by community teams for learning disability. Staff had carried out and recorded service user risk assessments. Staff caseloads were reduced at the Ironstone Centre because staffing levels had been increased. This meant safer care was being delivered.

  • Decision specific capacity assessments were recorded in service user care records where appropriate. Managers told us new Mental Health Act training had been introduced and most of their staff had attended.

  • Staff reported that morale was better although reorganisation at Doncaster was causing staff some concerns.

  • Following our inspection in September 2015, we rated the services as 'good' for Caring, and Responsive. Since that inspection, we have received no information that would cause us to re-inspect those key questions or change the ratings.

Community health services for children, young people and families


Updated 19 January 2016

The trust had appropriate risk reporting structures in place. The trust investigated and reported incidents in line with an appropriate policy. We saw evidence of the service sharing learning incidents with staff. There were safeguarding systems in place to ensure children and young people were protected from harm. Staff were knowledgeable and experienced in the safeguarding of children and young people, and in responding to patient risk. Staffing levels and caseloads were broadly appropriate for the service being delivered and were in line with commissioned levels. Where shortages in staff were identified this was raised with the local commissioning service to request additional resources.

Staff received mandatory training, although it was not clear whether all staff were up-to-date with their mandatory training. This was due to a discrepancy between data provided by the trust and local data shown to us by managers. There was a broad awareness of the principles of duty of candour and an appropriate policy was in place. Only management level staff had received full training on this at the time of our inspection.

Staff practiced evidenced based care and treatment. The service used technology and telemedicine to keep in touch with potential service users, including those in hard to reach groups. There was good evidence of multi-disciplinary working within the trust and with local networks. Staff were aware of the principles of consent, and we observed them practicing it during their work. There were also clear and easily accessible referral routes into services. We heard good examples of transition planning for children moving between the health visiting and school nursing service.

The trust was not meeting some targets set by NHS England for this year and its Commissioning for Quality and Innovation (CQUIN) target for breastfeeding. However, the service had identified these issues and mitigating action was being taken to address them. There were variable levels of staff appraisal rates throughout the service. It was not clear whether all staff were up-to-date with their appraisals. This was due to a discrepancy between data provided by the trust and local data shown to us by managers.

We spoke with children, young people and families, and observed care taking place. We found evidence that staff practiced compassionate care and provided emotional support to children, families and other professionals. People who used the services told us they felt involved and understood the care and advice offered to them.

The trust planned and delivered services that met people’s needs and were responsive to the changing needs of the local population. It also used innovation in care to meet the needs of local population and hard to reach groups. This included ensuring additional resource was available when the service noted low breastfeeding uptake. This took into account equality and diversity needs and the needs of people in vulnerable circumstances. There was full access to translation and interpretation services, and links with new migrants to the area and the local lesbian, gay, bisexual and transgender (LGBT) community.

Services were easily accessible and children and young people could access services in a variety of ways, in a manner and at a time to suit them. We saw examples of learning from complaints. This included the use of action plans to inform improvements.

There was a clear vision within the service that focused on innovation and placed the patient at the heart of services. Leadership was not a top down process and staff of all levels showed leadership within services. There was a system in place for the local and corporate management and leadership of the children, families and young people’s service. There were systems in place for linking governance, risk management and quality measurement at service level and at board level. We saw examples of how this information was also cascaded to staff.

There was a positive and responsive leadership supported by an open culture. Leaders supported and empowered staff to drive improvements and to develop. There was extensive evidence of engagement with both the public and staff, and we saw clear examples of staff and public feedback and interaction used to drive and improve services. There were many examples of innovation aimed at increasing access to services and educating children, young people, and their families. There were systems in place to ensure improvement and sustainability. We saw good examples of evaluations of projects taking place to ensure that the service understood and could learn from its successes and failures.

Forensic inpatient or secure wards


Updated 19 January 2016

We rated the forensic inpatient/secure wards as good because:

  • Staff at all levels of the service we spoke with talked about how they worked with people, listening to and responding to the views and wishes of patients. We witnessed staff using enabling language and positive interactions with patients. Staff spoke about patients in a respectful manner and demonstrated a good understanding of their individual needs.

  • Staff carried out comprehensive assessments of patients’ needs. Patients were involved in all aspects of their care planning. Staff had a good understanding of positive behaviour support in the forensic service. There were effective strategies in place to protect patients, including those with more complex needs and to enable patients to be safely involved in the local community.

  • There was evidence that the provider and commissioners had good working practices. Discharge was the focus of intervention and care across the service. There were good links with community teams and work was ongoing to reduce the difficulties with moving patients into least restrictive environments in community-based settings. The balance between providing sufficient security to keep those on the wards safe, the least restrictive environment and proactive discharge planning was appropriate for the needs of the patients.

  • There was good access to healthcare. All patients had a health action plan in place specific to their individual needs. Patients were encouraged and supported to manage their own health needs.

  • There was a range of staff specialities and the team were skilled and experienced in working with this patient group. Staff had a good understanding of the mental health act, mental capacity act, deprivation of liberty safeguards and the corresponding guiding principles.

  • Both wards were clean, homely and in reasonably good repair and décor. Regular environmental assessments were undertaken. The service acted on the findings from these in order to achieve a high standard of repair and cleanliness. Patients and carers told us the wards were always clean.


  • There were difficulties with the environment, such as a lack of child visiting areas, inadequate fencing for two courtyards, lack of activity areas and blind spots in all areas including the seclusion room, which affected observation of patients. These issues were recognised in the trust risk register and staff mitigated against these environmental risks with good relational security.

  • Attendance at mandatory training was low however; the trust had plans to address this low attendance.
  • Some blanket restrictions were evident with patients highlighting bed times, smoking times and restrictions on mobile phone use on Amber ward.

Community health services for adults


Updated 19 January 2016

Serious incidents were investigated and feedback was given to staff. Staff used safeguarding procedures appropriately and medicines were managed safely. Equipment for patients was supplied promptly. Infection control procedures were followed and community locations were visibly clean. Staff knew how to escalate concerns.

Community services used and contributed to NICE guidance. Pain relief and nutritional needs of patients were addressed. The tele health service had significantly reduced home visits and admissions to hospital. The service consistently achieved performance and outcome targets. Staff were supported to develop their skills. Multi-disciplinary working was well developed. Access to mental health services was straightforward. Staff appraisals were not up to date and the audit programme required development. Not all staff received consistent clinical supervision. Staff did not always assess capacity or fully document consent.

Patients and relatives were treated with respect, dignity and compassion. Confidentiality was maintained. Patients spoke very positively about quality of care they received. Staff offered clear explanations and checked the patient’s understanding. Patients were empowered to engage in self-care. Staff provided emotional support to patients and their relatives and carers.

Services were planned and delivered to meet the needs of patients particularly those with complex conditions. The service met the needs of hard-to-reach groups, the traveller community and bariatric patients. Patients were assessed promptly and referral to treatment times met the 18 week target. Mental health services were accessible. The needs of minority ethnic patients were reflected in service provision. There were few complaints but learning was shared with staff. The needs of patients with dementia were not always considered appropriately.

The leadership of the service was joined up with the executive leadership and staff knew the trust’s vision and values. A risk register was in place for the service. Regular governance meetings were held. Managers and staff felt supported by the trust and the service reflected an open and honest culture. Staff opinions were sought. We found examples of innovative and outstanding practice. We identified some concerns in the supervision of Band 5 nurses.

Compliance with mandatory training, including safeguarding training, was below the trust’s target of 90%. There were shortages in the permanent staffing of community nursing teams; this was on the corporate risk register. Caseloads for community nurses were higher than planned. Capacity and demand information was used daily to support the movement of staff in response to patient workload; this demonstrated a shortfall in nursing hours or units.

There were gaps in clinical risk assessments and insufficient planning for the review or evaluation of care needs. Risks linked with electronic record systems were being addressed.

End of life care


Updated 19 January 2016

We rated the end of life care services at Rotherham Doncaster and South Humber NHS Foundation Trust hospital as good for safe, effective, caring, responsive and well led.

There were sufficient staff for the number of patients at the hospice. Community nursing had challenging caseloads and often had to prioritise their work. Bank staff were used to backfill sickness and absence. Staff were aware of incident reporting and there was evidence that lessons had been learnt and improvements have been implemented to maintain safety. The hospice and the day care centre were visibly clean, tidy and staff worked bare below the elbow to reduce the spread of infection.

We found staff attendance of mandatory training was slightly less than the trust expected level of 90%. This has been identified by the management and action is being taken to improve it. There was sufficient equipment to deliver care in a safe manner. The hospice had a bariatric bed. Two bedrooms had been designed to support patients with dementia.

There was good evidence that staff were aware of the most up to date guidance, such as the five priorities of care. They explained that the guidance ensured that people and their families are at the centre of decisions about their treatment and care.

We saw patients were regularly assessed and appropriate pain relief was administered in a timely manner by staff at the hospice and in the community. If a patient was not receiving adequate nutrition or hydration by mouth, even with support, the doctor considered other forms of clinically assisted nutrition or hydration, such as intravenous fluids, to meet the patient’s needs. The managers were working collaboratively with the service commissioners to improve the monitoring of the services to demonstrate progress.

Patients and family members told us that staff understood their needs, treated them with respect and maintained their dignity and privacy. We observed several examples where staff treated the whole family with care and compassion. This was especially the case when young parents with children required palliative and EoLC. Patient’s records showed that when patients experienced physical pain, discomfort or emotional distress staff had responded compassionately and appropriately.

At meetings, staff addressed each patient’s holistic wellbeing by discussing physical, psychological, social and spiritual needs. This meant that that they were able to understand the needs of the individuals and involve them and their family members in the plan of care. Patients and relatives were empowered and supported by staff to manage their own health, care and wellbeing to maximise their independence. The hospice worked closely with different religious groups and had twenty-four hour access to support groups for different religious needs.

There were arrangements in place to ensure patients and their families were able to access the appropriate care without delay. People who used the service knew how to make a complaint or raise concerns. Patients and relatives told us that staff encouraged them to make constructive comments and they felt that staff listened to them.

Patients were admitted to the hospice between 8.30am and 4pm between Monday to Friday. This meant some patients who were eligible for admission were delayed or were admitted to other NHS wards. However, there was on call out of hours cover for patients.

We visited the living well team and found them to be the hub for outreach engagement. They had a membership of multicultural staff and had links with diverse groups of people within the serving population. Independent interpreters were used to help patients and families to help staff meet patient’s needs. The facilities at the hospice were focused on Christian worship and staff acknowledged there was work to be done around providing multicultural facilities for people.

The community staff said their strategy was to lead the way with compassionate care, to be a workforce that reflects the community, and to ensure they provided good quality care. The ultimate vision was for staff to work in partnership with all services, take ownership and be proud of care delivered.

There was a good supportive culture within staff in EoLC and palliative care teams. We also witnessed management ensuring measures were in place to protect the safety of staff who worked alone and as part of dispersed teams working in the community.

Staff were encouraged to bring their ideas forward and action those where appropriate.

There were clear lines of accountability including clear responsibility for escalating and cascading information between senior management team and the clinicians and frontline staff. Staff made comments that feedback from surveys and investigatory outcomes was delayed in reaching them.

Community-based mental health services for older people


Updated 19 January 2016

We rated Rotherham Doncaster and South Humber NHS Foundation Trust as good because:

  • The skill mix within the service was sufficient to ensure good quality care and treatment. This led to flexibility across the teams allowing staff to cover essential visits and clinics in the event of unexpected illness or holiday leave.
  • Patient risk assessments were updated when new risks were identified and during patient reviews. Staff documented daily any increased risks if a patient’s mental health deteriorated. The care records we reviewed all had up-to-date risk management plans. This meant staff could make changes to the care they gave their patients keeping them safe.
  • Multidisciplinary teams managed the referral process, assessments, on-going treatment and care by discussing the best treatment and pathway options for each individual. This meant patients received care and treatment that suited their individual needs.
  • Patients gave positive feedback and felt personally involved in the development of their care plans. Staff delivered care to patients and their carers in a compassionate and respectful manner. Support groups for carers were available and staff arranged for respite care when appropriate. Carers consistently told us that staff actively supported them and valued this service.
  • Patients took part in national initiatives to raise awareness of the needs of people with young onset dementia. The day care facility attached to the young onset dementia service allowed patients to organise their own activities and therapies. It supported people to live active lives in their community and maintain their day-to-day skills, friendships, hobbies and interests. The memory services either had accreditation or were in the process of achieving accreditation with the Royal College of Psychiatrists’ memory service national accreditation programme. The young onset dementia service in Doncaster was carrying out research in partnership with Sheffield Hallam University. Rotherham memory service was researching a cognitive stimulation therapy project. Staff from North Lincolnshire set up a choir for service users and carers. They were finalists at the recent Alzheimer’s Society dementia friendly awards for best dementia friendly involvement initiative.


  • The community mental health teams held caseloads that exceeded Department of Health guidelines.
  • Patients’ care plans were not always personalised or holistic and the quality varied across the teams. Some care plans did not consider all aspect of the patient’s wellbeing or support their recovery.

Mental health crisis services and health-based places of safety


Updated 19 January 2016

We rated mental health crisis services and health-based places of safety as outstanding because:

There was a skilled multi-disciplinary team. Some staff were trained as best interest assessors and some had undertaken training in cognitive stimulation therapy, wellness recovery action planning and motivational interviewing. The advanced nurse consultant was a Queen’s nurse. The title of Queen’s Nurse indicates a commitment to the values of community nursing, high standards of practice, excellent patient-centred care and a continuous process of learning and leadership. Staffing levels and the skill mix within the teams meant the staff on duty were able to meet patients’ needs.

We saw a number of excellent examples of proactive work to improve patients’ experiences. The teams actively promoted advance decision making so that other people could understand how patients would like to be cared for when they were not well.

In Doncaster, there was a carers’ support worker and a wellness action recovery worker. There was an innovative peri-natal mental health service that provided specialist interventions at home to reduce admissions to mother and baby mental health units.

In Rotherham, there was a dedicated service for deaf patients with mental health problems. They worked with children and young people aged 14-18 as well as adults. They supported patients by promoting their deaf identity, to help them live and work as valued members of the deaf and wider communities.

Rotherham and Doncaster operated a new model liaison and diversion service introduced by NHS England. The service supported patients with mental health conditions, substance misuse problems and learning disabilities who were suspected of committing an offence and came into contact with the police. There was also a street triage team working with the police. This team had significantly reduced detentions under section 136 Mental Health Act 1983 (MHA). This year, the street triage team had won the trust’s award for partnership working and the Doncaster district police diversity achievement of the year award.

At Great Oaks, the acute care service, including the mental health crisis service, had planned a “perfect week”. This was a groundbreaking exercise in mental health services. It focused on organisational development and better patient care, safety and experience.

There was a drive to increase participation in research, such as research into decision making around treatment for patients diagnosed with personality disorders and research into early discharge.

The service had significantly reduced waiting times for mental health assessments for patients with learning disabilities and autism, in line with National Institute for Health and Care Excellence (NICE) guidance.

The referral system enabled patients to access help and support directly when they needed it, 24 hours a day, seven days a week. The mental health crisis services focused on helping patients to be in control of their lives and build their resilience so they could stay in the community and avoid admission to hospital wherever possible. The teams had established positive working relationships with other service providers such as the acute admission wards, GPs and community services and groups. The teams worked with the acute wards and community teams to plan patients’ transitions between services in a holistic way. They ensured discharge arrangements were considered from the time patients were admitted, to ensure they stayed in hospital for the shortest possible time.

All but one patient we spoke with told us they had a copy of their care plan and that they had been involved in formulating it. They said staff sought feedback from them about care planning and their views had been included in the care plan. Carers told us that they had been able to ask questions and the staff responded knowledgeably and informatively. The care plans we reviewed and the care we observed showed that patients’ individual, cultural and religious beliefs were taken into account and respected. Patients were supported to maintain their social networks and independence in the community.

In all the teams, we saw the staff were kind, caring and compassionate and supportive of patients. When we spoke with patients, they were positive about the support they had been receiving and the kind and caring attitudes of the staff team.

All the teams were managed well. There was a good governance structure to oversee the operation of the mental health crisis teams. Staff received appraisal and a range of supervision, managers investigated complaints, incidents were reported and investigated, changes were made when they were needed, staff participated in audits and safeguarding and Mental Health Act 1983 procedures were followed.

The staff understood their responsibilities relating to the duty of candour. They knew what a notifiable safety incident was and explained what they were expected to do. They were clear that they would explain and apologise to patients and their families in any event.

The staff we spoke with told us that morale was good. Many staff told us they were proud of the job they did and said they felt well supported in their roles. They felt valued and were positive about their jobs. We saw excellent examples of staff suggestions being implemented.

There was excellent commitment to quality improvement across all the teams and they had developed various services to improve care. However, at the time of the inspection we did not see any formal process for the teams to meet with each other. This meant they may miss opportunities for learning and sharing. We found examples of good or excellent practice in all the teams that could have been shared across the service.