Rotherham Doncaster and South Humber NHS Foundation Trust

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 remained requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us they felt safe on the wards. They said staff managed incidences of restraint in a safe way that had not resulted in them being harmed.

Staff described a culture of learning where they felt able to raise concerns and gave examples of how they had been treated and supported in a proactive way. Staff told us that learning from safety incidents was shared and they implemented this learning into their work practices.

Patients were allocated a named nurse from whom they could seek advice, support and information to help them with their health, wellbeing and manage their own risks.

Staff were able to demonstrate their understanding of the types of incidents that needed to be reported. Staff felt able to raise concerns about care and treatment freely and told us managers dealt with these well.

We reviewed a sample of incidents and saw that managers investigated these thoroughly, provided feedback to staff, and identified learning. There were trust wide patient safety meetings twice a week where ward managers and leaders met to discuss incidents and identify themes.

Managers held ‘after action reviews’ to review incidents and identify learning. These were then discussed at governance meetings

Staff told us they received lessons learned from investigating incidents, complaints and safeguarding concerns via emails, during team meetings and supervision. The psychology team held de-briefs after incidents and weekly reflective practice sessions took place on each ward.

There was a freedom to speak up guardian within the organisation who supported staff to speak up if they felt uncomfortable doing so alone.

Staff we spoke with knew what their responsibilities were under the duty of candour. They could provide examples of when they had provided apologies to patients when things had gone wrong.

Complaints from family members and people who used the service were investigated and resolved with actions put in place where required.

The service’s referral and admission processes aimed to ensure that all essential information about people was received to determine if their needs could safely be met. Staff within the trust completed gatekeeping assessments and liaised with managers to determine whether an admission was appropriate. Some admissions were unplanned and there were staff available 24 hours a day to support admissions at nighttime or weekends.

Patients we spoke with told us that services communicated well with each other to ensure they had continuity of care.

Staff told us there were effective working relationships with other relevant teams, both within and outside the organisation. Staff said that people’s risks were shared between teams during handovers.

Staff could explain the pathway in and out of the service. Patients were admitted from a variety of settings including accident and emergency, crisis and home treatment teams, 136 suites, and from other mental health wards.

The hospital had a safe and effective system to ensure the needs of patients being referred for admission could be safely met. Staff ensured they had information about risk, the section the patient was being detained under, what their current situation and presentation was, their usual accommodation, their physical and sensory needs, and the predominant reason for the referral.

We saw evidence in care records that staff supported patients in accessing care and treatment from other healthcare professionals such as GPs, dentists, dieticians and speech and language therapists.

Staff actively involved patients and their carers in care plans and multidisciplinary reviews. Staff documented people’s views in their care plans and reviews using their own words.

Patients felt supported by staff and that they could share any worries or concerns with them. Patients felt safe on the wards and had not experienced any abuse.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff kept up to date with their safeguarding training. At the time of inspection safeguarding training compliance was 100% for most wards for both safeguarding children and safeguarding adults modules.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff followed clear procedures to keep children visiting the service safe. These visits were pre-arranged and took place in a room away from the wards.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. They were able to identify different forms of abuse, and the signs associated with these. Staff attended regular meetings where important information and lessons learned were shared.

We saw evidence of multiagency working to manage concerns. There was a weekly escalation meeting in place with attendance from the police, local authority and the acute trust where the attendees collectively discussed concerns and identified actions.

Staff and managers discussed individual patient’s safeguarding concerns during multidisciplinary team meetings and developed safeguarding plans where appropriate. Safeguarding was an agenda item at care group governance meetings and staff discussed safeguarding concerns during patient safety huddles.

During our tour of wards, we saw posters on patient noticeboards relating to safeguarding, including reporting abuse.

There were safeguarding leads within the trust who provided advice and guidance to staff about potential safeguarding concerns.

The provider had safeguarding policies that staff could easily access. Care records showed that staff understood mental capacity and best interest decisions. Patients were appropriately supported to know their rights and make decisions that were safe and in the best interests of the person.

All wards were mixed gender, and staff followed the trust’s policy on mixed gender accommodation. This included completing zonal observations on each of the male and female corridors to keep patients safe.

Patients told us they felt safe, and that staff supported them to manage risks. We reviewed 16 risk assessments during this assessment. Staff completed these for each patient on or soon after admission using a tool built into the trust’s care records system. Care records showed that risk assessments were detailed, personalised, and that staff reviewed these regularly, including after any incident.

Staff knew about the risks associated with each patient and acted to prevent or reduce them. Staff could easily access risk information about patients in patient records. Managers also recorded important risk information about patients on visual display boards in the nursing office.

Staff discussed incidents regularly at a variety of meetings. These included handovers, team meetings, ward rounds, multidisciplinary team meetings, and clinical governance meetings. Staff escalated concerns to managers when needed.

Staff were aware of guidance around restrictive practice and could provide examples of how they used the least restrictive option, for example regarding access to section 17 leave.

The service recorded and monitored incidents and discussed these during regular meetings. Incidents were scored in terms of level of severity and reviewed by managers, with actions put in place where necessary.

Blanket restrictions were only used when needed. Staff recorded any restrictions on a blanket restrictions log. Banned and restricted items on the wards were appropriate for the risks associated with the patient group. These included access to alcohol, drugs, sharp items and lighters.
 

Patients generally told us that they felt safe on the ward and could speak with staff if they had any concerns. Staff were observed completing observations in communal areas and corridors depending on the location and observation level of each person.

Managers completed regular walk rounds of the wards to check the environment and escalated any concerns to the estates team. Ward areas were generally clean, well maintained, well-furnished and fit for purpose.

All staff carried panic alarms and could respond promptly to alerts. M managers told us that occasionally staff provided cross ward cover to ensure baseline staffing numbers were met.

We reviewed the environmental risk assessments and found that managers completed and regularly updated these. The assessments clearly highlighted areas of risk and appropriate mitigations that were in place to help reduce the risk level. Following an internal quality review at Swallownest Court, managers had identified concerns with the fencing on Sandpiper ward and Osprey ward. They had arranged for maintenance work to be completed, which was in progress, and temporary arrangements were in place to staff observed patients in the garden until this was complete. This was recorded on the blanket restrictions log.
 

There were mirrors in corridors and communal areas to mitigate risk from blind spots. We saw staff undertaking observation checks regularly and completing documentation accordingly. All doors were anti-ligature and anti-barricade.

There were policies, procedures and risk assessments in place for health and safety and business continuity.

Most patients told us there were plenty of staff to support them whereas others fed back that there were not enough staff to meet their needs.

Staff told us that staffing levels were sufficient to keep people safe. However, some staff felt they were often stretched or did not have time for therapeutic engagement with patients. Staff survey results also showed that only 40% of staff felt there were enough staff within the organisation for them to do their job properly.

Managers monitored staffing via a staffing meeting which took place 3 times per week. The meetings aimed to ensure that there enough staff numbers for each shift and that the wards had the right skill mix to safely meet patients' needs.

We asked several managers how they were assured that there were always enough staff to safely meet the needs of patients on the wards. They told us service managers, matrons and ward managers had oversight of staff rotas to ensure sufficient staff levels. They also said they were able to use staff from the older adults’ service within the trust if needed.

There was an electronic staffing document which was live across the whole trust which managers reviewed daily. If additional staff were needed, ward managers completed a form which was reviewed by a senior manager for approval. Some staff fed back that this process could be time consuming and that they sometimes had to wait for staffing requests to be approved. Managers planned staffing at least 3 days in advance which usually gave them time to make any necessary staffing adjustments if these were needed.

Throughout our assessment, there were enough staff members on the wards to deliver safe care and treatment. Our discussions with staff clearly evidenced they had the skills and experience to meet the patients' needs.

We looked at staff rotas on the wards and found the planned numbers of staff for a particular shift matched the actual numbers on the day.

There were some vacancies at the time of inspection, but managers used NHS professionals’ bank staff to meet baseline numbers. Data provided by the service showed that all wards used NHS professionals bank staff regularly. Skelbrooke ward had the lowest use of bank staff at 11% for the previous month, with Cusworth ward having the highest at 34%.

Staff generally completed and kept up to date with their mandatory and required training with most of the training modules being over the trust’s target of 90% compliance. Some of the outliers included clinical record keeping which was 70% on Brodsworth ward and 50% on Skelbrooke ward, and Mental Health Act in Practice, which was 58% on Kingfisher ward.

The training modules were appropriate to meet the needs of the patient group and included safeguarding, reducing restrictive practice, infection prevention and control, and resuscitation training. All staff completed Oliver McGowan training, which isa specialised training programme focused on learning disability and autism.

Managers ensured all staff had up to date DBS checks in place prior to starting work and monitored this with support from the human resources team. Managers also monitored when registered nurses were due to complete their revalidation and ensured this was completed.

Staff received regular managerial and clinical supervision. The compliance rates at the time of our assessment were 96% for managerial supervision and 96% for clinical supervision. Staff told us discussions in supervision sessions were used by managers to identify their training and developmental needs.

Staff had the opportunity to undertake specialist training for their role. Examples of training offered and undertaken included bloods and electrocardiograms.

The service monitored sickness levels on each ward. Data showed that sickness levels had reduced during the previous 3 months. Kingfisher ward had the lowest at 3% and Sandpiper ward had the highest at 12% 2025.

The service had recruited 4 volunteers in the last month who were volunteering in non-clinical roles. These including supporting at the gym, delivering activities and working on reception.

During our tour of Osprey and Sandpiper wards at Swallownest Court, we observed that the therapy kitchen used by the wards was dirty. This included a dirty cooker, mould in the fridge, and dirty microwaves. We raised this with staff who arranged for the kitchen to be cleaned. Staff said that it was unclear whether ward staff or therapy staff had responsibility for cleaning the kitchen. They also told us there were no cleaning records in place for the kitchen. We were concerned this did not follow adhere to infection prevention standards. However, managers conducted regular checks of the ward environments. Nearly all ward areas were clean, tidy, and free from clutter. Outside areas were also tidy, clean and the spaces provided were quiet, calm and therapeutic. There were no concerns raised by patients or their family members about cleanliness on the wards. Staff had access to personal protective equipment and hand washing facilities. There were clear roles, responsibilities and procedures around infection prevention and control. The trust had an infection prevention and control policy which was up to date. Staff could access support or guidance from the infection prevention and control team within the trust. The wards had cleaning schedules which staff had completed and were up to date. Domestic staff worked regular hours over 7 days a week across the hospitals to ensure the wards were clean and adhered to infection control measures. However, we found gaps in clinic room cleaning records on Brodsworth ward and Cusworth ward with housekeeping staff not always signing the records to confirm that cleaning had taken place. At Brodsworth ward, staff did not always use the appropriate 'I'm clean' stickers to confirm when clinic equipment had been cleaned. There were monthly health and safety meetings attended by the catering, domestic, estates teams and ward staff to discuss any issues relating to environment or infection prevention and control concerns. Staff followed waste management processes. We saw that all bins were marked, and the trust used a waste removal company for the disposal of clinical and non-clinical waste.

Pharmacists and pharmacy technicians were available to help with medication queries, and they reviewed patient medication cards to oversee that medicines were being prescribed and administered safely. A member of the pharmacy team attended multidisciplinary team meetings where appropriate.

Staff responsibilities for medicines management were set out in the trust's safe and secure handling of medicines manual. There were standard operating procedures in place relating to relevant areas of medicines management. However, we found that the medicines fridge on Brodsworth ward had a sticker confirming that an annual service was due in February 2025 and there was no written record that this had taken place. On Brodsworth Ward we found that open liquid medicines including lactulose and E45 cream did not have date stickers confirming when these were opened or the date, they needed discarding. On Cusworth ward we also found e45 cream, ibuprofen gel, and suncream that did not have the appropriate stickers. In addition, the digital Sphygmomanometer had a sticker showing that it was last calibrated in 2023. This should have been done annually.  

Patients were aware of their medicines and said staff discussed these with them. Pharmacists completed regular medicines audits on all wards. These identified any issues that may need to be addressed, and any medicines related themes were reported via incident forms. These were actioned appropriately, and staff knew the correct processes to follow if needed. Relevant legal documents needed to comply with the Mental Health Act were in place and up to date to ensure patients were receiving their medicines in line with legislation.