Montagu Hospital, Mexborough

Updated 28 March 2024

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.

Montagu is a small non-acute hospital with over 50 inpatient beds for people who need further rehabilitation before they can be discharged. There is a nurse-led Urgent Treatment Centre, open 9am-9pm (final check-in is 7:45pm), each and every day excluding Christmas. It also has a day surgery unit, renal dialysis, a chronic pain management unit and a wide range of outpatient clinics.

Updated 28 March 2024

Updated 28 March 2024

Updated 19 February 2020

We previously inspected outpatients jointly with diagnostic, so we cannot compare our new ratings directly with previous ratings.

We rated this service as good because:

• The service provided mandatory training to all staff. Equipment and the premises were visibly clean. Staff managed clinical waste well. There were enough staff to keep patients safe and provide the right care and treatment.
• Staff kept records of patients’ care and treatment. Records were up to date and easily available to staff providing care. The service administered, recorded and stored medicines safely. Medical staff prescribed and administered pain relief for minor procedures.
• Staff recognised incidents and reported them appropriately. Managers shared lessons learned locally with the team.
• Staff worked together as a team to benefit patients and provide good care and were competent for their roles. All staff had completed their appraisal. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
• The service provided outpatient clinics between 9am and 5pm, Monday to Friday. People could access food and drink. The service had relevant information promoting healthy lifestyles and support.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported patients, families and carers to understand their condition.
• The service planned and provided care to meet the needs of local people. The service was inclusive and took account of patients’ individual needs and preferences.
• People could access the service when they needed it. Although some specialties struggled to meet demand, most waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards. Staff treated concerns seriously, investigated them and managers shared lessons learned with staff.
• Local managers were visible and approachable for patients and staff. They supported staff across the department. Staff felt respected, supported and valued, and focused on the needs of patients. The service provided opportunities for career development.
• Although the ‘did not attend’ rate was higher than the England average at all of the trust’s sites, a new text reminder and respond system had been implemented. Managers and booking centre staff told us the trust had been able to reduce the rate significantly over two full months prior to our inspection.
• Leaders operated effective governance processes. Managers worked with partner organisations. Staff at all levels were clear about their roles.
• Environmental risks were identified and recorded.
• The service collected information to understand performance, make decisions and improvements. The information systems were integrated and secure.
• Leaders and staff engaged with patients, staff, and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

However:

• There was not always an indication on equipment that it had been cleaned and cleaning checklists were not always completed.
• Not all equipment had undergone annual external service and maintenance checks in line with trust policy.
• Records were not always clear, and staff did not always adhere to professional record keeping standards.
• Learning from never events was not shared widely across different outpatients departments at the trust.
• The trust did not display information for patients on how to make a complaint.
• There was a waiting list for review patients in ophthalmology and an incident had occurred where a patient had not received the right care promptly. Patient review appointments were managed centrally by the trust bookings team and managers said their processes were robust and would not allow a backlog of review appointments. However, the incident investigation had identified over 700 patients in ophthalmology had no review appointments. Following the inspection, staff told us the trust, with the CCG, had commissioned an external review of all waiting lists. They told us all ophthalmology patients on the review list had their appointments brought forward.
• Information provided by the trust prior to our inspection showed no clinics were cancelled. However, they later provided information to show 20% of all outpatient clinics were cancelled.
• Some staff were unaware who executive leaders were.
• Although staff were aware of departmental plans relevant to their own area, not all staff were aware of how they linked in with the overarching trust strategy.
• Risk registers did not include all risks and reviews of actions taken were not always documented.
• Senior leadership operated at directorate level and outpatients departments and specialties worked separately from each other. It was not clear if leaders had an overview of the outpatients department as a whole.

Updated 28 March 2024

Updated 28 March 2024