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 in the outpatients department (OPD). These audits meant that shortfalls could be identified and addressed. Surveys were also carried out to obtain patients views about the service they received.

Patients who attended for an outpatient appointment on the day of inspection told us they were happy with the service and their views were listened to. Comments included, “The consultant always takes our views into account”, “I can’t fault them: They are efficient and effective as well as friendly’ and “This hospital is like hospitals used to be; all hospitals should be like this.”

We found the trust had a complaints policy and procedure and complaints were recorded, investigated and reported on. Comments from patients spoken with during their attendance at the OPD, “They would be open to listening to us” and “My opinion would be listened to and I hope it would be acted upon.”

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