The Care Quality Commission
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  • NHS hospital

Montagu Hospital, Mexborough

Overall: Requires improvement read more about inspection ratings

Adwick Road, Mexborough, South Yorkshire, S64 0AZ (01709) 585171

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.

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.

14 – 17 April 2015

During a routine inspection

Montagu Hospital, Mexborough was one of the 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.

Montagu Hospital, Mexborough provided medical services on two wards in the Rehabilitation Centre, day surgery, outpatients and diagnostic imaging services. In addition, there was a minor injuries unit open seven days a week. It had approximately 58 inpatient beds in addition to the day surgery unit.

We inspected Montagu Hospital, Mexborough as part of the comprehensive inspection of Doncaster and Bassetlaw NHS Foundation Trust. We inspected the hospital on 14 April 2015.

Overall, we rated Montagu Hospital, Mexborough as good. We rated it good for caring, responsive effective and well-led. We rated it as requires improvement for safe.

Our key findings were as follows:

  • The inpatient areas were clean and well-maintained. However, areas of the minor injuries unit required improvement in this area.
  • There were sufficient numbers of staff to meet the needs of the patients.
  • Patients received adequate hydration and nutrition.
  • Patients were overall positive about the care they received at Montagu Hospital, Mexborough.

We saw several areas of outstanding practice including:

  • The Operational Manager was working with Sheffield University in developing specialty specific training for rehabilitation nurses from Band 2 to 7.

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

Importantly, the trust must:

  • The trust must ensure the minor injuries unit is clean and well-maintained.
  • The trust must ensure that staff receive mandatory training including adult and child safeguarding training.
  • The trust must ensure that staff receive an effective appraisal.
  • The trust must ensure that medicines are safely managed within outpatients and diagnostics.

In addition the trust should:

  • The trust should review systems in place to monitor the quality and outcomes of care on the Minor Injuries Unit.
  • The trust should review practices for completing safeguarding records within the Minor Injuries Unit.
  • The trust should review staff understanding of major incidents and their role.
  • The trust should review the impact of introducing seven day therapy services on the therapy staffing levels and take appropriate action if required.
  • The trust should review availability of information about making a complaint so it is easily accessible for all patients and their families/carers on the wards.
  • The trust should review maintenance and deep cleaning schedules on the day surgical unit.
  • The trust should review access to single sex toilets on Rockingham ward.
  • The trust should review systems so patients are protected from unnecessary radiation exposure.
  • The trust should identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents within outpatients and diagnostics.
  • The trust should review processes for checking emergency equipment within outpatients and diagnostics.
  • The trust should review the audit programme to monitor the effectiveness of services within outpatients and diagnostics and the minor injuries unit.
  • 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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

2 October 2013

During a routine inspection

Patients on the rehabilitation wards told us they were happy with the care and treatment they received. Comments included, 'Care has been good', 'I feel quite safe here', 'Everybody is approachable', 'You are always treated with dignity and in private' and 'They have a nice way of going about things.' One patient who had only been on the ward for a day told us they were made to feel welcome and they said, "I am treated very much as an individual.' Other patients spoke about staff being professional and caring. One patient said, 'Everybody is really good, the doctors, nurses, physios and even the cleaners.' Whilst another patient said, 'I have come on leaps and bounds since I came here.'

Some patients commented on the noise from the building work being carried out on the new rehabilitation unit and others commented that staff were very busy.

We found that patient's needs were assessed on admission, risks identified and plans of care completed. Therapy staff completed treatment plans and set goals with patients to be achieved during rehabilitation.

We found patients who attended the minor injuries unit were seen quickly by emergency nurse practitioners. Patients described the service they received as, "Brilliant" and "Very good."

We found staff had access to essential training, additional training relevant to their role and annual performance development assessments. 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.