Northern Lincolnshire and Goole NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The vision and values were set at organisational level and were understood by staff working within the service. Staff we spoke with were able to describe the service’s vision and values and demonstrate how these were applied in their day-to-day work.

We observed staff treating people with dignity and respect, showing compassion in their interactions and taking time to listen to what mattered most to people. Staff worked collaboratively within multidisciplinary teams to support people’s care, treatment and end-of-life wishes.

Staff treated colleagues and professionals from other organisations with kindness and respect.

Managers had a good understanding of the services they managed and were able to clearly explain how their teams worked to deliver high-quality care. Staff understood their role in delivering effective care within the resources available and could explain how they balanced service delivery with budgetary requirements.

Senior managers told us the increasing demand from people requiring urgent and specialised care occasionally placed pressure on staffing and resources. Despite these challenges, leaders demonstrated awareness of the risks and continued to focus on delivering safe and effective care that met people’s needs.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. During the assessment, leaders demonstrated the skills, knowledge and experience required to lead the service. Staff described leaders as supportive, approachable, visible and responsive to concerns. They understood people’s needs, risks and the day‑to‑day pressures experienced by staff and used this knowledge to support the delivery of safe and effective care.

Leaders maintained oversight of risk through the organisational risk register and were able to clearly describe current risk priorities and the actions being taken to mitigate them. For example, leaders identified risks associated with the continued use of older syringe drivers and had implemented a replacement programme to phase these out and introduce newer devices.

Leaders demonstrated a good understanding of the services they managed and clearly explained how their teams delivered care. They maintained visibility within the service and remained accessible and approachable for staff.

Leaders promoted staff wellbeing through supportive supervision, access to wellbeing support services and a compassionate approach when following challenging events or incidents.

The service supported several student nurse placements, including students undertaking learning disability nursing programmes. Students were typically on placement for 12 weeks and were supported throughout by designated practice assessors within the multidisciplinary team. This ensured appropriate supervision, assessment, and opportunities to develop their skills and experience.

The service had adopted the Safe Learning Environment Charter, which promotes a positive safety culture and encourages continuous learning across all NHS learning environments. The Charter is underpinned by the principles of equality, diversity, and inclusion, helping to ensure students are treated fairly, feel valued, and are supported to achieve their learning outcomes in a safe and inclusive environment.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak Up arrangements, and staff were aware of how to raise concerns.

The service promoted an open and transparent culture where staff were encouraged to raise concerns, share ideas and report safety issues without fear of blame or reprisal. Staff understood the processes for escalating concerns, knew where to seek support and were confident concerns would be listened to and acted upon.

Staff described a positive speaking-up culture and told us they felt safe and supported to raise concerns and did not fear negative consequences for doing so.

Leaders encouraged open discussion and challenge within teams and demonstrated a commitment to learning and improvement. Staff reported that concerns raised were taken seriously and feedback was provided where appropriate.

These arrangements helped to promote a culture of openness, transparency and continuous improvement.

Staff described a positive speaking‑up culture and told us they felt safe and supported to raise concerns. They were confident their views would be listened to and acted upon where appropriate.

The service fostered a positive culture where people felt they could speak up and were confident their voice would be heard. When something went wrong, people received a timely apology and are told about any actions being taken to prevent the same happening again.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

A staff survey from 2025 demonstrated positive staff engagement, with results exceeding the organisational target across all key workforce themes.

The findings provided evidence of a positive workplace culture and informed ongoing organisational workforce planning, recruitment, wellbeing, and continuous improvement initiatives.

Staff were able to apply for flexible working arrangements to accommodate personal circumstances, including caring responsibilities and health needs.

Leaders put reasonable adjustments in place to support staff in carrying out their role. For example, staff returning to work following sickness absence were supported through flexible phased returns.

The service monitored equality data of its workforce to ensure it remained diverse. Policies supporting equality, diversity and inclusion were in place.

Staff reported they were treated fairly and respectfully, and managers considered individual circumstances when providing support or making reasonable adjustments.

Staff had access to continuing professional development, support, and mentorship opportunities, as well as occupational health services.

The service had established career development pathways which supported staff to develop and progress within their roles.

Staff told us they felt empowered and were confident their concerns and ideas contribute to positive change, helping to shape services and promote a more equitable and inclusive organisation.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. Governance processes operated effectively at team level and performance and risks were well managed. There were clear structures, processes, and systems of accountability in place to monitor service performance and support effective oversight.

A framework was in place to ensure essential information was reviewed, shared and discussed at both team and service level.

Learning from incidents and complaints was used to improve services and outcome for people.

The service had regular Patient Safety Incident Response (PSIR) reviews, which were discussed at the Palliative End Of Life (PEOL) Quality Governance monthly meetings. Managers held monthly Clinical Governance Meetings, which were open to all staff. We reviewed meeting minutes from April 2026, which included discussion of performance, incidents, complaints, risks and PSIR reviews.

Several committees operated at service level, including clinical governance, health and safety, infection prevention and control, safeguarding and medicines optimisation committees. These committees reviewed incidents and other quality and safety information, with senior leaders contributing to provider-level discussions.

The service implemented the PSIR approach, and staff acted on learning from incidents, deaths and safety reviews. Managers maintained oversight of risks, issues and performance and reviewed these regularly. Staff had access to the risk register and were able to escalate concerns when needed. Concerns raised by staff during discussions reflected those recorded on the risk register.

The service had contingency arrangements in place to manage emergencies and service disruption, including business continuity plans for adverse events.

Team managers had access to information to support their roles, including data relating to performance, staffing and quality of care. Staff completed local clinical audits to provide assurance and acted in response to audit findings.

Staff understood how to work effectively with other teams, both within and outside the organisation, to meet people’s needs. Information governance arrangements were in place, and staff understood their responsibilities in relation to confidentiality and the secure management of care records.

Managers provided regular support and oversight to all staff. Staff we spoke with were clear about their individual roles and responsibilities. Managers met regularly with staff to complete appraisals and performance reviews. There was a process for staff to complete Calderdale competencies, which were reviewed and signed off by managers on completion.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and leaders engaged with people, communities and partners to share learning and identify opportunities to improve services and outcomes for people.

Staff collaborated with other agencies to support seamless care and effective communication across services. For example, they worked with hospital teams to support safe discharge arrangements and liaised with GPs to enable people to receive care and treatment at home where appropriate.

Records from multidisciplinary team (MDT) meetings demonstrated effective collaboration between family members, key stakeholders and healthcare professionals throughout people’s journey.

The service worked closely with local authorities, healthcare providers and voluntary sector organisations to ensure services met people’s needs. Staff were actively involved in community initiatives, including the national Dying Matters campaign, to raise awareness of end-of-life care within the local population.

The service contributed to education and workforce development within the wider community. Staff delivered teaching sessions to 45 students enrolled on a location health and social care programme.

Staff demonstrated a commitment to sharing learning and developing knowledge across the wider health and care system. In October 2025, the service delivered a 2-day ‘Care Camp’ programme for allied health professionals across the Trust. The event was attended by 50 people and covered topics including palliative care, assessments, advice and support transition, end-of-life care, symptom management and syringe driver training. The training was well evaluated, and plans were in place to deliver further events during 2026.

The service had established a network of End of Life (EOL) Champions, comprising Health Professionals from various disciplines who met regularly to share learning and promote good practice. In November 2025, the service facilitated and EOL Champions Day attended by 45 staff. Topics included palliative rehabilitation, communication, identifying end-of-life needs and staff wellbeing. Evaluation feedback indicated the training met its objectives, with key learning points focusing on individualised care, recognising and supporting spiritual needs and ensuring care reflected what mattered most to people.

The service was involved in Professional Nurse Advocate networks, which provided restorative supervision, support following clinical incidents, career development opportunities and quality improvement activities. Staff told us these networks helped promote wellbeing and support service improvement.

The Bluebell project demonstrated how the service worked in partnership to improve care for people approaching the end of their lives. The initiative provided tailored packages of care to support people and their families, focusing on recognising deterioration, developing personalised care plans and maintaining compassionate communication throughout care.

Staff extended their support beyond the provision of direct care. Following a person’s death, families received a letter offering bereavement support. Staff worked with local bereavement services and community groups to develop a bereavement booklet for relatives and carers, helping to improve access to information and support within the local community.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Leaders promoted a culture of continuous learning, innovation and improvement across the community end-of-life service. They demonstrated a commitment to improving people's experiences, outcomes and quality of life by developing equitable and innovative approaches to care. The service actively contributed to the development of safe and effective practice through education, partnership working and the sharing of learning.

Medical staff attended a regional specialist consultant learning group, which met quarterly. This enabled clinicians to share best practice, review emerging evidence, benchmark performance and access peer support helping to continually improve the quality of care provided.

The service had delivered a key objective within its 5-year strategy through the appointment of General Practitioners with a Special Interest (GPwSI). This strengthened clinical leadership and supported closer integration of end-of-life care across primary care and community services, improving continuity of care for people.

The medical team delivered education and training through a range of professional forums. This included advance care planning and ReSPECT training for GPs during protected learning time, helping to improve clinicians' knowledge, confidence and consistency in end-of-life decision-making.

Leaders had strengthened partnership working with the local hospice to improve access for people with complex palliative care needs. As a result, arrangements were in place to support appropriate hospice admissions 7 days a week, enabling timely access to specialist care when needed.

Staff worked collaboratively with community organisations, charities and faith communities to implement the Bluebell Initiative. This demonstrated a commitment to reducing inequalities and strengthening community support for people approaching the end-of-life and those important to them.

The service had also worked in partnership with the local bereavement service to develop a community bereavement booklet, providing practical information and signposting for relatives and carers following the death of a loved one.

In addition, the service was working with a local supplier to improve access to mouth care products, supporting people’s comfort, dignity and quality of care at the end-of-life.

These initiatives demonstrated a commitment to innovation, partnership working and continuous improvement, with a focus on improving care experiences and outcomes for people receiving end-of-life care.