Northern Lincolnshire and Goole NHS Foundation Trust

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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Staff treated people as individuals and involved them, and where appropriate their families, in decisions about their care and treatment. Staff ensured care and treatment was effective by assessing and reviewing people’s health, care, wellbeing and communication needs with them.

Clinical staff used structured templates when conducting care reviews, supporting the review of people’s wider health and wellbeing. The service had effective systems to identify people who were approaching end of life.

Staff were able to refer people with social needs, including those experiencing social isolation or housing difficulties, to a social prescriber. A social prescriber helps people find community support and local resources that promote better health and wellbeing, complementing traditional medical treatment.

CQC’s inspection team included a Specialist Nurse Advisor who reviewed the care records of 6 people receiving palliative and end-of-life care. Records demonstrated comprehensive care plans were in place to meet people’s needs and reflected their individual circumstances. Documentation was clear, with evidence of effective communication recorded within progress notes. All local professionals such as GPs were able to view and document in notes.

The service used the Electronic Palliative Care Coordination System (EPaCCS) to document and share information from discussions about people’s care and treatment. Basic information was maintained and reviewed during GP practice Gold Standards Framework (GSF) meetings. However, the system was not routinely utilised within the hospital setting. Further work was required to improve integration of EPaCCS across services to ensure people’s end-of-life wishes were consistently recorded, readily accessible and shared across care settings.

We reviewed 6 ReSPECT forms, including two electronic records and four original forms during home visits. All original forms were signed and dated by the appropriate people. Most forms had been completed appropriately; however, one incomplete form was identified by a district nurse during a home visit and was removed for amendment. Records demonstrated clear discussions had taken place with people and, where appropriate, their families, including clear documentation of the rationale for resuscitation decisions.

Staff used an electronic ‘Care in the Last Days of Life’ document, introduced in 2024, to support the assessment, planning and delivery of individualised care for people identified as being in their last days or hours of life.

People’s initial assessment included a section relating to religion and spiritual beliefs; however, this was often incomplete or left blank. Staff told us a revised version of the ‘Care in the Last Days of Life’document was being developed and was expected to strengthen the assessment and recording of people’s spiritual care needs.

Care plans did not consistently reflect people’s psychological and spiritual needs, despite these being important aspects of person-centred end-of-life care. While the ‘Care in the Last Days of Life’document contained sections relating to psychological and spiritual support, this was primarily focused on people who were imminently dying. Psychological and spiritual needs should be identified, assessed and supported earlier in a person’s care journey.

The service had effective processes to assess, plan and review people’s care and treatment needs. Assessments were person-centred and supported by structured review processes, comprehensive care plans and systems to coordinate care between professionals. Staff considered people’s wider health, wellbeing and social circumstances and involved them, and where appropriate their families, in decisions about their care and treatment. However, further work was required to strengthen the consistent assessment, recording and review of psychological and spiritual needs and to improve the integration of EPaCCS across care settings to ensure people’s end-of-life wishes were readily accessible and consistently shared.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff delivered care and treatment in line with current guidance, legislation and recognised best practice. Clinical records demonstrated care was planned, delivered and reviewed using up-to-date policies and evidence-based guidance.

Staff were competent and knowledgeable in their roles and were supported to develop new and transferable skills while sharing best practice across the service. Staff completed competency assessments before undertaking tasks independently, and additional training was tailored to meet individual learning and development needs. Staff attended multidisciplinary team meetings where people’s care, treatment options and emerging risks were discussed and reviewed. These meetings supported consistent, evidence-based decision-making and enabled staff from different professional backgrounds to share knowledge and expertise relating to end-of-life care.

We observed staff taking a holistic approach to care and involving people in the assessment, planning and delivering of their treatment. Staff completed comprehensive assessments using recognised tools where appropriate. These included assessments of pain, frailty, mental health, nutrition, skin integrity, mobility, falls risk, bladder and bowel function, sleep, pressure care, symptom management and medicines optimisation.

Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were completed in line with national guidance. Advanced care plans were developed in partnership with people and those important to them. These plans recorded preferences for future care and support and helped ensure care at the end of life reflected what mattered most to them.

Staff understood their responsibilities under the Mental Health Act and Mental Capacity Act 2005 and protected people’s rights by following the relevant legislation and associated codes of practice.

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 had access to the information they needed to assess, plan and deliver people’s care, treatment and support in their own home. The service worked collaboratively to ensure people's healthcare needs were met through a multidisciplinary approach. The team included medical and nursing staff, healthcare assistants, occupational therapists, physiotherapists, social workers, complimentary therapists, administrative staff, and other support staff.

Staff worked in partnership with a range of external organisations, including domiciliary care agencies, GPs, the local hospice, and other community healthcare teams involved in supporting people at home. Staff described positive working relationships with health and social care partners. They told us they worked effectively with inpatient services, social care and primary care clinicians to coordinate care and improve outcomes for people using the services.

We observed a staff handover and daily huddle, where there was evidence of effective collaboration and communication between staff of all grades and professional backgrounds. Discussions demonstrated an inclusive approach to decision making, with all staff encouraged to contribute. Staff told us the twice daily huddles support shared decision-making and provided opportunities to discuss changes in people’s conditions, review concerns and coordinate care. Relevant information and actions were recorded in people’s care records.

Staff worked closely with local acute hospitals to support people’s transition of care between hospital and community settings, including transfer to the local hospice where required. This included agreeing clear discharge summaries and ensuring staff had timely access to all relevant clinical information before people were discharged into community care.

A Clinical board round took place once a week where all new referrals and ongoing complex people are discussed with a Palliative Medicine consultant and clinical nurse specialists.

Staff held regular multidisciplinary meetings to review people’s needs and support coordinated care. Weekly multi-agency meetings involved acute and community Palliative Care teams alongside representatives from the local hospice, to discuss people receiving end-of-life care. These arrangements helped ensure clinical oversight, timely decision-making and a coordinated approach to care delivery.

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, reduce their future needs for care and support. People were supported to achieve the best possible quality end-of-life care. They had access to information, advice, and specialist support to help manage symptoms including breathlessness, pain, fatigue, anxiety, nausea, and other distressing symptoms. Care was focused on promoting comfort, dignity, independence, and emotional wellbeing, enabling people to make informed decisions about their care and treatment.

Staff worked collaboratively with the multidisciplinary team to provide timely symptom management and ensure care was personalised to meet each person's needs, wishes, and preferences. People and those important to them were offered practical advice, emotional support, and information to help them understand what to expect and access additional support when needed.

Staff took a proactive approach to identifying and managing risks to people’s health, including people thought to be in the last 12 months of life, those at risk of developing long-term conditions and those with caring responsibilities. This supported the timely identification of needs and enabled appropriate care and support to be put in place.

We reviewed the records of 2 people who had a ‘Care in the Last Days of Life’ care plan in place. These care plans were individualised and reflected people’s assessed needs, preferences and priorities. They included guidance relating to the management of breathlessness, respiratory secretions, communication needs, delirium, nausea and vomiting, pain, personal hygiene, mouth care and spiritual support.

Records demonstrated care planning considered both the needs of the person and the support required by those important to them.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. The service had a structured approach to monitoring and improving the quality care and treatment provided.

Managers undertook audits and used the findings to drive improvements. Audit outcomes were shared with staff to promote learning, support good practice and ensure staff understood actions required to improve outcomes for people receiving care.

The service participated in the National Audit of Care at End of Life (NACEL). This national audit supports providers to improve end-of-life care by collecting and analysing data, identifying areas of good practice and highlighting opportunities for development. Participation in the audit enabled the service to benchmark performance and support the delivery of compassionate, evidence-based care.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied relevant legislation relating to consent and decision-making. Capacity assessments and consent were clearly documented within people’s care records. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and had been made in line with relevant legislation and national guidance.

Staff took time to explain people’s rights in relation to consent and ensured they understood the decisions they were making about their care and treatment. Staff respected people’s choices and promoted person-centered care by seeking consent before providing support and taking practical steps to help people make their own decisions where possible. The service had arrangements in place to support effective communication with people. This included access to telephone translation and interpreter services as well as communication cards to support people who were deaf or experienced communication difficulties.

Mental capacity assessments were routinely completed as part of assessment processes. Staff demonstrated a good understanding of the principles of the Mental Capacity Act 2005 and best interest decision-making. Where people lacked capacity to make specific decisions, staff involved family members and those close to the person, where appropriate, to support decision-making in their best interests.

Staff understood relevant consent and decision-making requirements, including the Mental Health Act, Mental Capacity Act 2005 and Children Acts 1989 and 2004, and knew where to seek additional advice.

Staff discussed treatment escalation plans with people and involved them in decisions about their future care and treatment preferences, including care in the event of deterioration and approaches to symptom management. People’s preferences were discussed and documented within care plans from admission. This included their preferred place of death and who information could be shared with, ensuring consent was obtained and respected throughout.

Staff completed mandatory training relating to the Mental Capacity Act and Deprivation of Liberty Safeguards. At the time of inspection, compliance with this training was 100%.