Doncaster and Bassetlaw NHS Foundation Trust provided health services across three acute hospitals (Bassetlaw Hospital in Worksop, Doncaster Royal Infirmary and Montagu Hospital, Mexborough), as well as community locations including Retford Hospital.
A range of outpatient services and a diagnostic imaging service was provided at Retford Hospital. There were no inpatient beds at Retford hospital.
We inspected the Retford Hospital as part of the comprehensive inspection of Doncaster and Bassetlaw NHS Foundation Trust. We inspected the Retford Hospital on 16 and 29 April 2015.
Overall, we rated Retford Hospital as ‘requires improvement’. We rated it ‘good’ for being caring and responsive, but it requires improvement in providing safe and well-led care. We inspected but did not rate effectiveness; we are currently not confident that we are collecting sufficient evidence to rate effectiveness for Outpatients & Diagnostic Imaging.
Our key findings were as follows:
- The departments were visibly clean. Monthly hand hygiene and cleanliness audits were undertaken.
- Staffing levels were appropriate.
- Patients spoke positively about the services provided.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- ensure that the public are protected from unnecessary radiation exposure.
- ensure that staff receive mandatory training.
- ensure that staff receive an effective appraisal
- audit the Radiation Exposure/ Diagnostic Radiation Levels.
- ensure accurate records are maintained and safety and risk assessments are recorded.
In addition the trust should:
- review systems so medicines are appropriately stored and managed within the outpatients department
- identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents.
- review the audit programme to monitor the effectiveness of services
- continue improvements to meet the 6 week target referral to treatment target for medical imaging.
- review the processes for identifying and managing patients requiring a review or follow-up appointment.
- further develop the outpatient’s services strategy to include effective service delivery.
- identify and monitor key performance indicators for outpatients.
- implement plans to ensure radiology discrepancy and peer review meetings are consistent with the Royal College of Radiology (RCR) Standards.
- consider reviewing provision of call bells within the diagnostic imaging departments.
Professor Sir Mike Richards
Chief Inspector of Hospitals