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 found patients were asked to provide their consent verbally (and in writing for surgical interventions) prior to care and treatment being carried out. Staff did not always record verbal consent had been given. Patients told us they were treated with dignity and respect and staff listened to their views. Comments included, “I was consulted every step of the way” and “They are very polite and they ask permission for everything.”

We found patients who had fractured their hip had their needs assessed. Care and treatment was delivered in line with their care plan and also in line with clinical guidelines. Comments included, “They have treated us really well”, “Everyone was nice, helpful and compassionate”, “The care has been brilliant” and “They are very professional, always treat you with dignity and as a human being and always make sure your privacy is maintained.”

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.

We carried out an unannounced inspection of maternity services at Bassetlaw Hospital. We visited the antenatal clinic, labour ward and postnatal ward. We spoke with patients, managers, midwives and doctors.

Women we spoke with told us they were given sufficient information to help them make decisions. One woman said: "I have been kept fully informed of all decisions made and been involved in the decision making." Another woman told us: "You are not pressured into making choices and everything is explained clearly."

Care and treatment was planned and delivered in a way that ensured people's safety and welfare. Women spoke positively about the care and support they received. Two women told us they had received an excellent service.

We observed there were enough qualified, skilled and experienced staff to meet people's needs on the labour ward and in the antenatal clinic. None of the women we spoke with expressed concerns about the numbers of staff available.

We found women were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Women told us staff were well trained and competent at carrying out nursing and medical interventions.

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 were implemented

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.

We carried out a focussed unannounced inspection of the urgent and emergency care services at Bassetlaw District General Hospital 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, effective and well led were rated as requires improvement. Caring and responsive were 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.

• 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 was not meeting national guidance. Not all staff had the correct skills and competencies to support paediatric patients, including paediatric life support.

• There were no substantive full time consultants in post at Bassetlaw District General Hospital, cover was provided by locum consultants and six substantive consultants who worked across both sites. Around 85% of the middle grade rota was covered by locum staff.

• Adults and children safeguarding training compliance for medical and nursing 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.

• 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.

  However:

• There had been some improvements since our last inspection.

• The initial assessment had been changed at Bassetlaw District General Hospital, which had reduced the risk to patients waiting in the queue and had improved the assessment process.

• 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.

• 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.

• Staff spoke positively about their leaders and morale was generally good.

• 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 three requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)