Northern Lincolnshire and Goole NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Feedback was actively used to drive service improvement. As a result of feedback from people, carers and staff, the service had an end-of-life forum for staff, developed a ‘When a Person is Dying’ information leaflet and completed a Comfort Observations Audit to support learning and improve the quality of care provided.

There was a positive culture of learning from incidents, complaints and concerns. Incidents were routinely reviewed through Palliative end of life (PEOL) Quality Governance meetings, where trends, themes and learning were discussed. Governance reports for the previous 3 months identified incidents relating to syringe drivers, wound care and pain management.

Meeting minutes demonstrated incidents were reviewed, lessons learned were identified and shared with staff.

Managers investigated incidents and ensured learning was shared across the whole service and wider organisation. Clear and transparent processes were in place for reporting, reviewing and learning from incidents. Staff received feedback through Governance meetings and electronic governance boards and described a culture where they felt encouraged and supported to report concerns, near misses and safety events. Staff understood their responsibilities for reporting incidents and could identify the types of events that should be reported.

Staff demonstrated a good understanding of the complaints process and how concerns should be managed. They told us they would aim to resolve the concern promptly and ensure people were aware of their right to make a formal complaint. Systems were in place to investigate complaints, identify learning and support service improvement. People were informed of their right to make a formal written complaint if they wished.

Staff understood the principles of Duty of Candour. When things went wrong, people and their families received an apology, an explanation of what had happened and information about actions taken in response. People and staff were encouraged and supported to raise concerns and felt confident they would be listened to and treated with compassion and understanding.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

An electronic palliative care referral form had been developed with partner organisations, including Lindsey Lodge Hospice, to support a coordinated and consistent referral process. Referrals received were reviewed centrally, triaged by a clinician and allocated to the most appropriate service. Referrals were discussed at twice-daily multidisciplinary ‘huddles’ involving acute and community Specialist Palliative Care Nurses, District Nurses, the MacMillan Health Care Team Co-ordinator and Lindsey Lodge Hospice. These meetings enabled staff to share information, review referrals, identify emerging risks and coordinate care.

The service had introduced a daily Macmillan duty nurse role to review referrals and respond to calls from people and carers. Staff told us this improved responsiveness, and feedback indicated people valued being able to speak directly with a member of staff rather than leaving a message and waiting for a return call.

Referral and admission processes ensured staff received the information required to assess, plan and deliver care safely. Staff told us they could access the information they needed to support people’s care, including electronic patient records and, where appropriate, GP records. Key information about people’s wishes and preferences was available to relevant health professionals, helping to support coordinated care.

Staff understood how to escalate concerns when a person’s condition deteriorated and worked closely with other services to maintain continuity of care. This included collaboration with GPs, community nursing teams, social care services, Community Matron, hospice services and specialist clinical team such as tissue viability services.

We reviewed 6 care records and found assessments were accurate, up to date and coordinated between healthcare professionals. Care plans reflected people’s needs and preference, including anticipatory medicines and end-of-life wishes. During our assessment, we observed a multidisciplinary team huddle where staff shared updates about people’s needs, reviewed medicines administered overnight, discussed planned interventions and coordinated follow-up actions to ensure continuity of care.

The multidisciplinary team provided holistic care that addressed people’s physical, psychological, emotional and social needs. However, records did not consistently demonstrate sufficient consideration of people’s psychological and spiritual needs, or their end-of-life wishes. In addition, the service did not routinely use the Integrated Palliative Care Outcome Scale (IPOS) to assess and monitor people’s symptoms and concerns. Staff told us the use of IPOS was currently under review.

Overall, systems were in place to manage referrals effectively, support information sharing and maintain continuity of care. People and their families were central to care planning and delivery, and staff worked collaboratively with partner organisations to help ensure people received timely and coordinated care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood safeguarding responsibilities and knew how to identify safeguarding concerns. They told us they could access advice and support from the Trust safeguarding team, including designated safeguarding lead, when required.

Safeguarding policies were in place and were understood by staff. Training records showed compliance in Safeguarding Adults Level 3 and Safeguarding Children and Young People Level 2 was 100% in January 2026.

Staff considered safeguarding risks when assessing and planning people’s care. Individual needs were assessed prior to home visits and staff liaised with other health and social care professionals, where required, to inform risk assessments and support the delivery of safe care.

Systems were in place to support effective information sharing between organisations. Care records, handover documentation and staff feedback demonstrated the service worked with partner organisations, including Lindsey Lodge Hospice, community services, GPs and social care teams. This supported effective care coordination and helped maintain people’s safety. Safeguarding concerns, actions and outcomes were reviewed daily through staff handovers and multidisciplinary huddles.

Records showed relevant information was shared appropriately when people moved between services. Established transfer and handover processes were used when people were admitted to or discharged from the service, including transfer from acute hospital settings, to support continuity and safety of care.

Safeguarding systems, processes and practices supported staff to uphold people's rights and protect them from abuse, discrimination and avoidable harm. Staff understood their responsibilities under the Mental Capacity Act 2005 and Equality Act 2010 and supported people to understand their rights wherever possible.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People were advised about risks associated with their condition and what actions to take if their condition deteriorated.

We reviewed a sample of care records and observed staff providing care in people’s homes. Staff had completed risk assessments, and identified risks were appropriately managed or mitigated. Risk assessments were completed on admission and reviewed regularly, including following incidents.

Records and observations showed staff used recognised tools to assess and monitor risk. For example, ReSPECT forms were original documents and were signed and dated by the appropriate people. A ReSPECT form is a personalised plan for emergency care and treatment, created when a person cannot make or express decisions.

ReSPECT forms were completed appropriately, although one form was incomplete. The district nurse identified this during a visit and took prompt action to rectify it. Records showed clear discussions with people and their families, including the rationale for resuscitation decisions. Completed ReSPECT and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms helped staff understand and respect people’s wishes if they were no longer able to communicate them.

Staff used nationally recognised tools, including the National Early Warning Score 2 (NEWS2), to identify and escalate deterioration appropriately. This supported staff to record physical observations and share concerns with doctors when required. Staff shared key information during handovers and daily multidisciplinary huddles to support continuity of care and ensure changes in people’s needs or risks were communicated promptly. Staff demonstrated an understanding of specific risks, including pressure damage and malnutrition and took appropriate action to manage these.

Staff communicated with people in ways that helped them understand their care and treatment, including adapting communication to meet individual needs.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were 2 premises on site, both of which have security measures in place and were secure. Staff and visitors signed in on entry to help ensure only authorised people accessed the buildings. A reception area was in place, although this was not routinely staffed. After 18:00 hours, the doors were locked and visitors were required to ring a bell for staff to grant access.

Equipment was available to support the delivery of care. The service was replacing syringe drivers as some older devices remained in circulation and had been identified as contributing to medication-related incidents. This risk was recorded on the Trust risk register, and a replacement programme was in place.

Health and safety risk assessments were completed in line with Health and Safety Executive (HSE) guidance. These included assessments relating to fire safety, water safety, security and other environmental risks Records show mitigating actions had been identified and implemented where required.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The service had recruitment processes in place to ensure staff were suitable to work with vulnerable people. We reviewed 8 recruitment files and found the necessary pre-employment checks had been completed including proof of identity, references, interviews, Disclosure and Barring Service (DBS) checks, qualification verification and Nursing and Midwifery Council registration checks, where applicable.

The service had a range of clinical, non-clinical staff and managers within the service and ensured suitable cover was available. Managers told us rotas could be adjusted to ensure suitable cover was in place.

New staff completed a comprehensive induction programme, which included mandatory training, an introduction to their role and responsibilities and a period of supervised practice. Staff worked alongside experienced colleagues until they had been assessed as competent to work independently.

Staff discussed their learning needs with line managers and were supported to develop their skills and knowledge.

Nursing staff received regular clinical supervision, with additional support for newly qualified nurses. Annual appraisals included discussions about career development and learning needs. We saw evidence within team meeting minutes that Personal Appraisal and Development Review (PADR) completion was reported as 86%, which was above the Trust target of 85%. However, at the time of our assessment staff clinical supervision rates were 71.4%.

Staff completed mandatory training through a combination of face to face and e-learning sessions. Managers monitored compliance through a training matrix. Training data showed an overall compliance rate of 91.4%.

Staff described a culture of continuous learning, and they were provided with a lot of different opportunities to develop their knowledge and skills. For example, the service was a member of the Queens Institute of Community Nursing (QICN) which provided access to a range of healthcare services. This scheme offers a huge range of benefits to organisations and their nursing and Allied Health Professional staff. The benefits include career development, leadership programmes, innovation and quality improvement webinars.

The service recognised the ongoing development of staff knowledge, skills, and competence, as important part of delivering high-quality end-of-life care. Staff were supported through regular training, supervision, competency assessments, and reflective practice and were encouraged to share learning through multidisciplinary team meetings, audits, significant events, compliments and feedback from people using the service and their families to develop their knowledge and skills.

Staff received training in areas including advance care planning, end-of-life communication, symptom recognition and management, and the safe use of anticipatory medicines and syringe drivers. The service supported End of Life (EOL) champions across the Trust and held an EOL champion event in November 2025 attended by 45 Allied Health Professionals from various disciplines, which received positive feedback.

Additional educational initiatives were available through programmes including Principles and Practices in Palliative and End of Life Care, for registered practitioners, access to national conferences, informal learning sessions and membership of the Queen’s Institute of Community Nursing. Staff worked with partner organisations to support end-of-life education across the wider health and social care system.

Clinical support was available 7 days a week from Clinical Nurse Specialists, Consultant in Palliative Medicine, and GPs with a special interest in Palliative Care.

Staff had access to urgent response services and hospice support when required, including out of hours.

Staff told us they felt supported and described a culture of continuous learning. Many staff had worked within the service for several years. One staff member said, ‘I love my job and it’s the biggest privilege I could have’. Records and staff feedback demonstrated that staff worked within the areas of their competence and were supported to develop the knowledge and skills required for their roles.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff effectively assessed and managed infection prevention and control (IPC) risks.

During home visits we observed staff demonstrating good IPC practices. Staff followed aseptic procedures, including effective hand hygiene, when providing care and treatment. Equipment used during home visits were visibly clean and well maintained.

Staff adhered to IPC principles, including maintaining ‘bare below the elbows’, following hand hygiene guidance and using personal protective equipment (PPE) correctly. Disposable aprons and gloves were readily available and were used when delivering care and treatment to reduce the risk of cross-infection.

The service had a designated IPC lead, and all staff had completed relevant IPC training. Risk assessments and audits were undertaken regularly, with actions identified and implemented to mitigate risks.

Meeting minutes demonstrated managers maintained oversight of IPC matters. IPC was a standing agenda item at team meetings, enabling concerns to be discussed and actions monitored.

The service did not always demonstrate effective oversight of safe storage of medicines and management of prescription stationery. Oversight processes were not consistently implemented, resulting in gaps in monitoring and assurance. However, they involved people in planning, including when changes happened. Staff provided people with compassionate care that promoted their dignity and comfort at their end-of-life.

Staff worked with GPs to ensure urgent prescriptions for regular medicines were completed promptly, enabling people to receive medicines when needed. Effective processes were in place to support timely access to anticipatory medicines used to keep people comfortable in the last days of life.

Prescription charts were completed appropriately and included clear indications and maximum dosing for medicines prescribed on an ‘as required’ basis. Syringe drivers (equipment used to deliver medicines over an extended period) were checked regularly and maintained appropriately.

The service had access to both medical and non-medical prescribers (NMPs). NMPs had achieved 100% compliance with annual revalidation requirements and had completed necessary documentation to be included on the Trust prescribing register. Robust governance arrangements were in place for NMPs, including regular reviews of prescribing activity and clear supervision and prescribing support arrangements.

Compliance with medicines management training was good across the service. Training covered areas including antimicrobial stewardship, syringe driver management, symptom management in end-of-life care, and the safe use of insulin.

Emergency medicines were available within the service; however, processes to support their safe storage and handling were not in place. We escalated this concern during the inspection. The pharmacy advised they would address this with their medication safety officer. Pharmacy staff were unable to confirm whether Trust audits relating to the safe and secure handling of medicines had been completed within the service.

During the inspection, staff told us people were not always able to access medicines from community pharmacies, particularly during the bank holidays. This had led to difficulties obtaining medicines in a timely manner, including medicines required for a syringe driver. The service maintained a list of pharmacies able to provide anticipatory medicines to support access.

The pharmacy team had recently introduced an out of hours support service. Staff told us they had used this service for advice regarding unlicensed medicine for people who needed their medicines crushed or split for administration. However, there were no systems in place to ensure staff received medication safety alerts, including information about medicine shortages. Staff reported receiving such information late and often from external sources, including primary care services.

The Trust operate in a Group structure with Hull University Teaching Hospitals which had impacted some medicines governance processes. The pharmacy department did not have oversight of all medicines-related processes within the service, although they had supported the management of NMP applications. Staff described some challenges in prescribing medicines in line with the new Trust formulary; however, these issues had been recognised and were being addressed by the pharmacy team.