The Care Quality Commission
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  • NHS hospital

Doncaster Royal Infirmary

Overall: Requires improvement read more about inspection ratings

Armthorpe Road, Doncaster, South Yorkshire, DN2 5LT (01302) 366666

Provided and run by:
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

All Inspections

22-24 August and 26-28 September 2023

During a routine inspection

Doncaster and Bassetlaw Teaching NHS Foundation Trust provides acute services for 420,000 across South Yorkshire, North Nottinghamshire, and the surrounding areas. The trust employs over 6000 staff.

Doncaster Royal Infirmary (DRI) is one of the acute hospitals forming part of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust. There are more than 500 beds. It provides a full range of acute clinical services to the local population including:

  • Urgent and emergency care
  • Medical care (including older people’s care)
  • Surgery
  • Maternity and gynaecology
  • Outpatients and diagnostic imaging
  • Critical care
  • End of life care
  • Children and young people’s services

27 to 29 November 2018

During an inspection looking at part of the service

We carried out a focussed unannounced inspection of the urgent and emergency care services at Doncaster Royal Infirmary on 27-29 November 2018. This inspection was to follow up concerns identified at our previous inspection in December 2017. In December 2017, we had concerns around the initial assessment process, paediatric nurse staffing levels, paediatric advanced warning scores (PAWS) were not always completed, compliance with mandatory training, including adult and paediatric life support was low, and there was a significant backlog of incidents that needed reviewing.

We inspected all five domains - safe, effective, caring, responsive and well led. At our previous inspection, safe, effective, responsive and well led had been rated as requires improvement. Caring was rated as good. This inspection was to see whether the required improvements had been made.

Following the inspection, we told the trust it must provide assurance that risks to patients were being addressed. The trust provided an initial action plan detailing actions to be taken to address the risks to patients. Further assurance was provided to us through regular updates and the trust established a working group to address the concerns we raised.

Our rating of this service stayed the same. We rated it as Requires improvement overall. Safe was rated as inadequate. Effective, responsive and well led were rated as requires improvement. Caring was rated as good.

  • Concerns identified at the previous inspection had not been fully addressed. We still had concerns about the risks posed to patients and the potential to cause harm.

  • When patients attended the emergency department (ED), adults and children stood in a queue waiting for triage/initial assessment. At the last inspection, we found there was no clinical oversight of this queue and we told the trust it must review this. Although the trust had now introduced ‘floor walkers’ to monitor the queue, they were unqualified staff (i.e. a band 2 receptionist, who had received little or no training). This presented an ongoing risk, as unwell or deteriorating patients would not always be identified.

  • The initial assessment was taking place in an environment not conducive to privacy and confidentiality. This also meant that full assessments, including observations and a full visual assessment were not taking place.

  • Paediatric advanced warning scores (PAWS) were not calculated consistently. We were concerned that this did not allow for early identification and prompt treatment for children who were deteriorating.

  • At our last inspection in December 2017, paediatric nurse staffing had been identified as an issue. Although service leads told us they had improved paediatric nurse staffing, since our previous visit there had not been recognition that there were insufficient paediatric nurses to provide safe and high-quality care. In addition, the paediatric training for adult trained nurses did not appear to have been addressed.

  • Paediatric nurse staffing and medical staffing did not meet national guidance. Not all staff had the correct skills and competencies to support paediatric patients, including paediatric life support.

  • Safeguarding adults and children training compliance for medical staff was low. Additionally, the safeguarding level three training did not comply with national guidance, as it was completed online.

  • The room used for patients with mental health needs was not in line with national standards. Although staff had completed a risk assessment and there were plans for changes to the room, this had not been identified on the risk register as a risk. It only appeared on the risk register as a risk due to its proximity to the paediatric waiting area.

  • Other risks identified at the inspection had not been identified on the risk register, or where they had been identified they had not been flagged as a significant risk.

  • Not all medicines were stored securely and fridge temperatures were not monitored in line with trust guidance.

  • The trust was failing to meet most of the standards in the Royal College of Emergency Medicine (RCEM) audits.

  • The trust’s unplanned re-attendance rate to ED within seven days was worse than the national standard.

  • The service did not meet the trust target for completion of appraisals.

  • Staff morale in the department was low and we received mixed feedback about the leadership of the department. Some staff told us they felt that there was lack of support from senior staff.

However:

  • More staff had been recruited to investigate incidents to help reduce the backlog that had been identified at our last inspection.

  • Staff’s understanding of the mental capacity act had improved since our last inspection.

  • There was evidence of effective multidisciplinary working.

  • Staff were caring and compassionate. We received positive feedback from patients.

  • Managers worked closely with the clinical commissioning group and other stakeholders to try to provide appropriate services for patients.

  • There was a new minor injuries unit, which meant there was an alternative pathway for those patients attending the department with minor injuries. This had also created extra space in the main department and staff had ideas for how to utilise the space more effectively.

  • From November 2017 to October 2018, the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was better than the England average.

  • From November 2017 to October 2018, the trust’s monthly median total time in A&E for all patients was similar to the England average.

  • There were governance structures and processes in place.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with five requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)


12 to 14 December 2017 and 16 to 18 January 2018

During a routine inspection

Our rating of the hospital stayed the same. We rated the hospital as requires improvement because overall the domains of safe, effective and well led required improvement whilst caring and responsive we rated as good.

14 – 17 and 29 April 2015

During a routine inspection

Doncaster Royal Infirmary was one of the acute hospitals forming part of Doncaster and Bassetlaw NHS Foundation Trust. The trust served a population of around 420,000 people in the areas covered by Doncaster Metropolitan Borough Council and Bassetlaw District Council, as well as parts of North Derbyshire, Barnsley, Rotherham, and north-west Lincolnshire.

Doncaster Royal Infirmary provided a range of services including medical, surgical, maternity and gynaecology, services for children and young people, end of life and critical care. It had approximately 800 beds. The hospital also provided emergency and urgent care and outpatients and diagnostic imaging.

We inspected Doncaster Royal Infirmary as part of the comprehensive inspection of Doncaster and Bassetlaw NHS Foundation Trust. We inspected the hospital on 14 – 17 and 29 April 2015.

Overall, we rated Doncaster Royal Infirmary as requires improvement. We rated it good for being caring and well-led and requires improvement for responsive, effective and safe.

Our key findings were as follows:

  • We found that most areas at the hospital were visibly clean. However, the theatre sterile supply unit was found to have some areas that required cleaning.
  • Clostridium difficile (C. difficile) rates for the trust (44 cases) were within trajectory (45 cases) for the Trust for 2014/15.
  • Staffing levels were reviewed and monitored. There were some areas of the trust particularly in children’s services and medicine that were not adequately staffed. We found this had an impact on patient care.
  • Patients were assessed for their nutritional and hydration needs and referred to a dietician if required.
  • The Summary Hospital-level Mortality Indicator (SHMI) (01-Jul-13 to 30-Jun-14) showed no evidence of risk. The Hospital Standardised Mortality Ratio indicator (01-Jul-13 to 30-Jun-14) showed an elevated risk.
  • Records indicated compliance with mandatory training and appraisal rates were generally low across the services. It was unclear in some areas if this was a recording issue; in any event, the trust were not assured that staff had received necessary training.
  • Within diagnostic imaging, there were some doors with no signage that had unrestricted entry to x-ray controlled areas.

We saw areas of outstanding practice including:

  • The Integrated Discharge Team was a beacon of good practice, as recognised by the 2015 National Award for Collaborative Leadership and was very active in providing a discharge planning service to all adult in-patients. The Frailty Assessment Unit was another example of effective collaborative working; the service enabled rapid assessment of elderly patients and person-centred care planning.
  • Selected Serious Incidents were rerun in the Clinical Skills department with the team originally involved in the incident to identify learning points.
  • The staff support and training packages provided by the clinical educators in all areas where children and young people were seen in the trust.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must review arrangements for the initial assessment of patients, including the use of streaming and triage, and add streaming / triage to the risk register
  • The trust must ensure appropriate numbers of medical, nursing and support staff of the required skill mix are available in the emergency department
  • The trust must ensure patient waiting times are reduced to ensure the 95% target for patients seen within four hours is met and maintained
  • The trust must ensure patients’ pain symptoms are assessed, and pain relief administered promptly for all groups of patients.
  • The trust must review nurse staffing of the children’s inpatient wards to ensure there are adequate numbers of registered children’s nurses and medical staff available at all times to meet the needs of children, young people and parents.
  • The trust must ensure that the public are protected from unnecessary radiation exposure.
  • The trust must ensure that staff receive mandatory training.
  • The trust must ensure that staff receive an effective appraisal.
  • The trust must ensure that a clean and appropriate environment is maintained throughout the theatre sterile supply unit, emergency department and critical care unit that facilitates the prevention and control of infection.

In addition the trust should:

  • The hospital should review how the privacy and dignity of patients is maintained, particularly in the central (overflow) area of the emergency department
  • The hospital should review equipment in the emergency department to check appropriate and adequately serviced, working equipment is available.
  • The hospital should take steps to support and develop working arrangements between the emergency department and other specialities within the trust
  • The hospital should review arrangements for sharing with staff lessons learned from root cause analysis and investigation of incidents
  • The hospital should consider reviewing its audit programme for evidenced based guidance to include the review of adherence to clinical guidance
  • The hospital should record and monitor daily temperatures of fridges used for storage of medicines
  • The hospital should review and complete actions identified in CQC’s review of health services for children looked after and safeguarding, September 2014
  • The trust should review the need for diabetes management to be included in the mandatory training programme for trained nurses.
  • Medical services management should seek assurance that deprivation of liberty is being appropriately assessed and an order sought where required.
  • The trust should review access to an emergency buzzer system on M1, M2 and G5.
  • The trust should review the midwife to birth ratio.
  • The trust should review the rates of induction of labour and non-elective caesareans.
  • The trust should consider employing a specialist diabetes midwife.
  • The trust should review the management of medicines on the maternity unit, particularly the area the home birth trolley/ drugs are kept.
  • The trust should consider having a designated bereavement area in maternity.
  • The trust should review the domestic abuse policy to ensure it is consistent with NICE guidelines
  • The trust should continue to manage patient flow to reduce the number of outliers in surgery and gynaecology.
  • The trust should review the need for a standardised way of ensuring cleaning has taken place (environment and equipment).
  • The trust should ensure that it has effective assessments and plans in place for any evacuation of the critical care unit.
  • The trust should take action to improve the provision of storage facilities across the critical care unit.
  • The trust should improve the standards of infection prevention practice on the critical care unit.
  • The trust should as part of its overall patient pathway management ensure that patients on the critical care unit are discharged in a timely fashion to a more suitable environment.
  • The trust should consider in its overall development strategy a more suitable location for its critical care unit.
  • The trust should review segregation of children from adults in the recovery areas of the theatres.
  • The trust should review the individual risk assessment tools with in the children’s service. For example, the service should ensure the initial nursing assessment includes nutritional status and nutritional risk assessments.
  • The trust should identify a board level director who can promote children's rights and views. This role should be separate from the executive safeguarding lead for children.
  • The trust should review the system for recording mental capacity assessments for patient’s unable to be involved in discussions about DNACPR decision
  • The trust should support staff involved in receiving bodies into the mortuary with adequate training to carry out the role
  • The trust should identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents.
  • The trust should review the audit programme to monitor the effectiveness of services within outpatients and diagnostic imaging.
  • The trust should review actions to improve safety and privacy within the medical imaging department particularly for inpatients who attend the department on beds.
  • The trust should continue improvements to meet the 6 week target referral to treatment target for medical imaging.
  • The trust should review the processes for identifying and managing patients requiring a review or follow-up appointment.
  • The trust should further develop the outpatient’s services strategy to include effective service delivery.
  • The trust should identify and monitor key performance indicators for outpatients.
  • The trust should implement plans to ensure radiology discrepancy and peer review meetings are consistent with the Royal College of Radiology (RCR) Standards.
  • The trust should consider auditing the call bells within the diagnostic imaging departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

30 September and 4 October 2013

During a routine inspection

The inspection team consisted of one compliance manager, six compliance inspectors, two specialist professional advisors (one in A&E and one in orthopaedics) and an expert by experience who obtained patient views. The focus of the inspection was how older people with a fractured hip experienced care and treatment from the moment they attended A&E, to inpatient care and through to discharge to their home.

We spoke with 10 patients and seven relatives in A&E and 14 patients and two relatives on the orthopaedic wards. Patients spoken with told us they were asked for their consent prior to any examination or treatment. Records confirmed written consent to surgical procedures had been obtained although verbal consent to procedures and examinations in A&E was not always recorded. Comments included, 'They asked if I would have bloods taken and have an ECG done' and 'They have consulted with me all the time I have been here.'

We found there were some concerns with space, the numbers and flow of patients through A&E and staffing levels in A&E. However, the trust Board of Directors was aware of the issues and plans were underway to address them. The triage system in A&E did not make the best use of experienced staff.

Patients had their health care needs assessed and received appropriate treatment to meet them. Patients told us staff were kind and caring although we found the experience for some patients could be improved. Comments included, 'They have really cared for us and my mother' and 'I was terrified in the night and a nurse came and held my hand and told me everything would be alright ' I was so grateful.'

We found that staff worked with other agencies involved in patients care and treatment. This helped to ensure important care wasn't missed for patients during admissions to the hospital and discharges to their home environment.

We found staff had access to essential training, additional training relevant to their role and annual performance development assessments (PDAs). We found data regarding training and PDAs had not been recorded fully although some gaps in training had been identified and steps taken to address them. Staff told us managers were supportive and they felt able to raise concerns knowing they would be listened to. They also told us there had been a positive change in the culture of the organisation which was described as encouraging and open.

We found there was evidence the trust had a governance infrastructure which was adequately resourced and with the appropriate level of expertise. We saw that audits were carried out which meant that shortfalls could be identified and addressed. Surveys were also carried out to obtain patients views about the service they received. We found the trust recorded and investigated serious incidents and complaints as part of governance procedures.

13 December 2012

During a routine inspection

We carried out an unannounced inspection of maternity services at Doncaster Royal Infirmary. We visited the antenatal clinic, labour and postnatal wards. We spoke with patients, managers, midwifery and medical staff.

Most women we spoke with told us they had received sufficient information to help them make decisions. However, some women were not aware of the birth options available to them. One woman told us: "I didn't know about any choices especially the birthing pool, but I'm not complaining.' We found people's diversity, values and human rights were respected. We observed staff treated patients with dignity and respect. Women we spoke with confirmed staff respected their privacy and dignity.

Care and treatment was planned and delivered in a way which ensured patient safety and welfare. Women spoke positively about the care and support they had received.

We observed there were enough qualified, skilled and experienced staff to meet patient's needs on the labour and postnatal wards. The women we spoke with did not raise any concerns about the numbers of staff available. We found patients were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

There was an effective system to regularly assess and monitor the quality of service that patient's received. There was evidence that learning from incidents and investigations took place and appropriate changes implemented.

22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

21 April 2011

During a themed inspection looking at Dignity and Nutrition

Patients we spoke to told us that they felt they were treated with dignity and respect by staff at the hospital. They were complimentary about staff and said that they took time to discuss with them the reasons for their being in hospital and the care and treatment options available to them.

'I feel as though I have been well-treated by staff and they listen to you'

'Could not be better ' very helpful'

'Staff are very kind ' they are lovely'

Patients we spoke to on the day were mostly positive about their experience of food within the hospital. They told us that there was plenty of choice, and that they enjoyed the food. They told us that they got the support they needed to eat their meals

'I ask staff to cut it up for me ' they do'

'A good choice of food, I get enough'

'They always bring lots of nice hot tea'