Darlington Memorial Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We assessed 6 quality statements. The service did not always plan and deliver patient’s care and treatment with them, so they were fully informed. They did not routinely monitor patient’s care and treatment to continuously improve it. Staff did not always follow current evidence-based good practice and standards. The service did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of patients themselves.

However, staff worked well together in teams and supported people to lead healthier lives.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement

Requires Improvement: This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Elective surgery patients were pre-assessed prior to admission. Patients completed a comprehensive questionnaire which staff used to inform their pre-assessment.

Staff assessed and met patient’s needs for food and drink and for specialist nutrition and hydration. Wards observed protected mealtimes. Staff used colour coded trays and water jugs to identify patients who needed help with eating and drinking. Individual patient dietary needs were discussed at handovers. Pre-operative fasting times were in accordance with national guidance to ensure people did not go too long without food and oral fluids prior to surgery.

Care plan templates we saw on the EPR system, for example, falls, nutrition, skin and pressure area risk assessments, were individualised according to patient needs. Assessment completion within 4 hours compliance was monitored monthly and ranged from 93% to 99% across the care group.

Staff we spoke with told us they used visual pain charts to support patients with communication needs. However, we saw none of these used during our assessment.

The trust had a policy for care of patients who experience mental ill health during admission. Staff completed a triage tool in the EPR, for assessment of patients with mental health needs, who were at risk of self-harm. However, we did not see any examples of individualised care plans. The trust clarified a working group was in the process of being set up to look at personalised care planning, which was in response to collaborative work with a nearby mental health trust.

We scored the service as 1. The evidence showed significant shortfalls. The service did not follow legislation and current evidence-based good practice and standards. They did not plan and deliver people’s care and treatment, in accordance with national best practice guidance.

Policies and procedures were not all up to date and staff did not follow best practice guidance. The care group policy log showed 7 of 24 (29%) policies were overdue review. This meant policies referred to by clinical staff may not always be in accordance with current national best practice guidance.

Staff we spoke with told us they were not always familiar with key national safety guidance. For example, of 15 staff we spoke with in theatre, all said they were unaware of NHS England’s 2023 revised National Safety Standards for Invasive Procedures (NatSSIPs 2) guidance. This guidance was designed to improve patient safety, enhance team-working, and reduce the risk of ‘Never Events’ (serious, preventable incidents) during procedures that involve entering the body, such as surgeries, biopsies, and endoscopy, by standardising safety checks. It was unclear how the trust was assured that staff were kept up to date with best practice guidance.

There were concerns about outdated breast surgical practice, which was not in accordance with current National Institute for Health and Care Excellence (NICE) best practice guidance, and resulted in poor outcomes. The trust had been flagged as an outlier locally and nationally, and this was confirmed by both internal and external audits. The subsequent investigation and review were ongoing at the time of our assessment.

Clinical teams had access to specialists including occupational therapists, social workers, pharmacists, speech and language therapists and dieticians, required to meet the needs of patients in the service.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff shared information about patients shift to shift at handover meetings. Staff recorded information on their own handwritten handover sheets and referred to patient information on the portable computers, which they used to access patient records at the bedside.

We observed effective multidisciplinary team (MDT) meetings and saw that teams had effective working relationships, including good handovers, with other relevant colleagues within the organisation (for example, care co-ordinators, discharge teams, and specialist teams) and links with other trusts.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Pre-operative patients were screened for smoking and alcohol consumption, and those identified as high-risk were referred to the treating tobacco dependency service or alcohol care team. The specialist teams provided in-hospital support, including education, advice, pharmacological interventions, and referrals to community services to sustain positive changes post-discharge.

There was a cancer support service for people going through cancer treatment including surgery. This offered support with physical quality of life, lifestyle changes, emotional wellbeing, spiritual and religious links, as well as practical and financial guidance.

Specialist nurses and allied health professionals provided tailored interventions to surgical patients, supporting behaviour change and post-operative recovery. For example, physiotherapists worked with patients following surgery to help mobilisation and support discharge to meet the needs of the patient, promoting independence and physical activity.

Staff could refer patients to a community partnership program which supported positive lifestyle and mental health changes.

Recent health promotion initiatives included flu and COVID-19 vaccination campaigns, mental health support, service navigation and health inequality reduction.

Information was displayed on health promotion display boards and information leaflets such as alcohol and smoking cessation advice, patient experience information and IPC guidance was available in patient areas. Most leaflets were up to date, however, the good hand hygiene information for patients and visitors was overdue review.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There was an annual schedule of care group clinical audits with trackers, which listed progress of priority and non-priority audits.

The trust told us it used audit for assurance that National Institute for Health and Care Excellence (NICE) guidance was followed. However, of 5 NICE audits on the tracker, 3 were complete and 2 were behind schedule.

The tracker for 2024/25, showed 16 of 31 (52%) of priority audits were behind schedule. Ten of these (32%) were audits for completion of local safety standards for invasive procedures (LocSSIPs) (surgery specific audits). In addition, the tracker for priority audits 2025/26 showed 18 of 19 (95%) priority audits were behind schedule. This meant there was a risk of delays to learning and implementation of improvements following audit activities.

Patient Reported Outcome Measures (PROMs) priority audits to assess the quality of care delivered to NHS patients from the patient perspective, (hip replacements and knee replacements), remained behind schedule on the trackers for 2024/25 and 2025/26. However, the non-priority audit tracker showed that in the last 12 months, 89 non-priority audits had been completed and of 38 that were ongoing 12 (32%) were behind schedule.

None of the front-line staff we spoke with at all sites were able to describe recent significant audit findings and completion of audits in the clinical areas appeared to be inconsistent, due to the lack of oversight by senior managers.

We asked the trust to provide audits of patient records including nursing pathways, medical documentation and risk assessments. However, no comprehensive audit data was provided. This meant the trust was unable to demonstrate records were always kept in accordance with trust policy. The trust acknowledged a unified documentation standard was required, to provide structure, encourage safety and improve documentation standards across the trust.

We scored the service as 1. The evidence showed significant shortfalls. The service did not tell people about their rights around consent or respect these when delivering care and treatment.

The trust had not ensured that all appropriate staff were fully trained regarding consent, best interest decision making, Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), in accordance with trust policy and national guidance.

The trust training matrix stipulated MCA and DoLS training was mandatory for all clinical staff with patient contact, as identified by the policy lead. Training was through e-learning, face to face and occasional external training sessions.

However, the trust’s training policy did not stipulate specific staff groups, frequency or how much of the training staff were required to do. Care group MCA and DoLS training compliance data was not broken down into clearly defined staff groups and showed only 328 staff across all sites were required to complete the training. The trust told us this was because only certain (unspecified) substantive staff received this training where there was a specific need or risk of reduction in capacity such as end of life. The trust did not ensure that bank, and locum staff had relevant training around consent, best interest decision making, MCA and DoLs.

MCA training compliance for DMH and BAH combined (staff who worked across both sites) showed 61% compliance against the 85% trust target.

The trust consent policy stated there was a mandatory online consent training package, which required a pass mark of 60%. All medical staff were required to complete this, however, it was not included in the mandatory training matrix, and the trust did not provide any training data to show substantive medical staff compliance. The trust could not demonstrate that all appropriate substantive medical staff received training in accordance with the trust’s policy regarding informed consent and national guidance.

In 10 surgical patient records we looked at, across all sites, we found consent was obtained on the same day of elective surgery in all 10 documents we reviewed and was not clearly documented as a 2-stage process, in accordance with the trust consent policy. Doctors we spoke with told us consent was obtained through verbal conversation ahead of the day of surgery. However, these conversations were not recorded in any of the records we checked. Risks and complications were not recorded as discussed, in advance of signing the consent form, on the day of elective surgery. The trust could not demonstrate that elective surgery patients were enabled to provide fully informed consent in accordance with trust policy.

We found mental capacity assessments were recorded inconsistently, and some were completed after consent was obtained, for some patients with cognitive impairment. This meant the risk of invalid consent to care and treatment was not suitably and sufficiently mitigated, for patients who lacked capacity, in accordance with the trust’s policy.

We asked the trust to provide all consent audit data and associated action plans for the last 12-month period, for all sites. The trust provided only 5 audits, 4 of which were for DMH. Sample sizes were small (22 to 25), and audits only related to breast, inguinal hernia, anterior resection (bowel surgery) and laparoscopic cholecystectomy surgery. Although the results of the audits showed overall good compliance, the trust did not provide audits from other surgery care group specialisms, including, but not limited to trauma and orthopaedics, ENT, ophthalmology, dermatology and plastic surgery.

This meant there was no appropriate oversight of the effective completion of these documents throughout the whole care group, to ensure consent was obtained in accordance with trust policy and best practice.

We asked the trust to provide MCA audit data for the last 12-month period, for all sites. However, the trust provided no surgery MCA audits for any site, which meant the trust could not demonstrate appropriate oversight of the effective completion of MCA assessments and that records were made in accordance with trust policy and best practice.

Despite the trust having completed a thematic review in August 2024 which covered mental capacity assessment, do not attempt cardiopulmonary resuscitation (DNACPR) documentation and best interest decision making, the evidence and records we reviewed over year later showed staff still did not always follow the trust Mental Capacity Act 2005 policy and guidance.

We found decisions regarding escalation of care and hospital DNACPR were sometimes made without involving next of kin, advocates and family members. For example, a patient with cognitive impairment, was documented as ‘not fit for escalation of care.’ Although they had a community DNACPR in place, no hospital DNACPR was completed. In addition, there was no assessment of mental capacity made either in the patient record or the EPR system, although a foundation year 2 (FY2) doctor told us they understood this patient did not have mental capacity. There was no record of patient or family involvement in the decision about escalation or otherwise of care.

A patient with a diagnosis of dementia had no mental capacity assessment. However, they were noted in the record as DNACPR, but the paper record was incomplete, with no attempt to contact family documented. This meant there was no apparent attempt to involve them in decision making.

It was unclear how the trust was assured trust policy was always followed regarding involving families and carers in best interest decisions for patients who lacked capacity. In addition, there was a risk DNACPR could be applied inappropriately and not in accordance with the trust’s policy. This could lead to a patient receiving unwanted and potentially harmful resuscitation, or conversely, having potentially life-saving treatment withheld inappropriately.

We brought this to the attention of senior leaders at the time. The trust told us it would liaise with their digital health team to enable recording of mental capacity, mental health assessment and reasonable adjustments clearly as part of the admission process. In addition, it would provide simulation sessions for medical staff and raise MCA awareness trust wide.

We also saw consent forms were used incorrectly. For example, consent form 1 should be used for adult patients who have mental capacity to agree to a medical procedure or treatment. Consent form 4 should be used for adult patients who lack capacity to consent to a medical procedure or treatment. However, we saw examples of patients who had consented using form 1 instead of form 4, when they lacked capacity.

We saw an example where consent form 4 was used, but no capacity assessment was undertaken or documented, nor was it documented that the family was involved in this decision. It was unclear how the trust was assured that the risk of invalid consent to care and treatment was suitably and sufficiently mitigated, for patients who lack capacity, in accordance with the trust’s policy.