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.

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.

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”

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)