3 December 2019
County Durham and Darlington NHS Foundation Trust (CDDFT) is a member of a collaboration of Cumbria and North East NHS bodies working towards Integrated Care System status, and, at sub-regional level, a key member of the Integrated Care Partnerships for the Centre (Sunderland, South Tyneside, North Durham) and the South (rest of Durham, Darlington, Tees Valley, Hambleton and Richmondshire) of the trust’s geography.
Trust services are organised into, and operations managed through five care groups: Integrated Medical Specialties (medical, emergency and urgent care including elderly care and stroke); County Durham Community Health Services (community services); Surgery (including critical care and anaesthetics); Family Health (acute obstetrics, gynaecology and paediatrics and community paediatrics); clinical specialist services (including pathology, radiology and other diagnostics, pharmacy and therapies).
The trust provides acute services at Darlington Memorial Hospital (DMH) and University Hospital North Durham (UHND), and elective inpatient and day case surgery at Bishop Auckland Hospital (BAH).
There are some smaller contracts with Public Health England for bowel screening, diabetic retinopathy, ante-natal and new-born (ANNB) and cervical screening and dental care; with specialist commissioners (mainly for drugs, intensive care and neonatal care) and Youth Justice.
(Source: Routine Provider Information Request (RPIR) – Sites tab / Acute context tab)
3 December 2019
Our rating of the trust improved. We rated it as good because:
- We rated safe as requires improvement and effective, caring, responsive and well led as good.
- We rated both University Hospital of North Durham and Darlington Memorial hospital as good.
- We rated well led at trust level as good. This was not an aggregation of the core service ratings for well led.
- In rating the trust, we took in to account the current ratings of the services that we did not inspect during this inspection but that we had rated in our previous inspection.
- Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website.
3 December 2019
3 December 2019
29 September 2015
Overall, we rated community health services for adults as good. We found there was a robust reporting system in place and staff felt able to report incidents and raise concerns in a ‘no blame’ culture. Equipment was well maintained and fit for purpose. Staff adhered to good infection control practices and we saw that medicines were stored and administered safely.
Electronic records were complete but we found patient-held paper records to be incomplete. We saw that staff used care planning and care pathways to effectively manage patients’ health needs. There was positive multidisciplinary working across and between services and different professionals, which provided good, effective outcomes for patients.
We did not identify any long standing staff vacancies and we were confident that staff were trained in safeguarding, the Mental Capacity Act and deprivation of liberty safeguards.
We saw numerous examples of compassionate care and patients’ dignity and privacy being respected. All the patients and carers we spoke to told us they valued the service and found the staff excellent. Patients and their carers received emotional support from staff during visits.
Patients were treated in their own homes or clinics and services were provided to prevent hospital admissions. We saw that patients were supported when they were moving between services and we observed positive inter-professional relationships. We found that complaints were addressed at the lowest possible level, but, when identified, lessons were learnt and disseminated effectively throughout the service.
All staff were aware of the vision and strategy for the trust and their service and could relate their roles in achieving this. Governance and quality measures were embedded in the service. Audits were widely used to monitor quality and receive patient feedback. Leadership within the service was strong and visible and staff demonstrated a clear respect for local leaders. The culture within the service was positive and all the staff we spoke with spoke highly of their teams and line managers.
29 September 2015
There were systems in place for reporting and investigating incidents involving children and families. Systems were in place, through the integrated governance reporting system, to identify themes and to learn and share the learning from incidents. Incident reporting was increasing and support was available for practitioners who reported incidents. There was a good understanding of infection control procedures and we saw that staff used hand hygiene gels during two immunisation sessions we attended. Similarly, there was good knowledge of how to keep medicines safe in schools and children centres. Health visitor caseloads were within an acceptable range and met Lord Laming (2009) recommendations. There was one risk identified in relation to raising the level of safeguarding training required to Level two for clinicians. There was an action plan that set out the timescale for this change and a targeted approach.
The Healthy Child Programme was delivered to children and young people and initiatives such as UNICEF baby friendly were in operation. Children and young people’s needs were assessed and treatment was delivered in line with current legislation, standards and recognised evidence-based guidance. For example, the trust had a Family Nurse Partnership team. Staff worked to deliver assessment and treatment in accordance with standards and evidence-based guidance. There was some monitoring of outcomes for patients and plans were in hand to redesign and restructure the services to make better use of resources and improve effectiveness. Multidisciplinary team working was effective. Staff were competent and working well as an integrated team in the interests of patients. Staff development, supervision and performance appraisal were in place and compliance was good.
Overall we rated children’s and young people’s services good for the quality of care. In all the services we visited we staff were providing compassionate and sensitive care. Children and families were encouraged to be involved in their care. Patients we spoke with, and their families, felt that they were treated with dignity and respect.
We found that the services were planned and delivered to meet the needs of children and their families. Structures had been redesigned in response to the people’s changing needs and the need to manage resources between ‘universal’ and ‘targeted’ services. We found that there was good access to translation services and an understanding of the need to respond to cultural differences in the area. There was an open and transparent approach to complaints and they were treated as an opportunity for shared learning and service improvement.
There was a clear vision and strategy where the priorities of the trust were understood locally. Staff working in community children’s services were committed to their work and understood the priorities of the service and their individual teams. The integration of community services into the trust was ongoing. There was strong support for the local leadership and staff appreciated the high levels of honest communication and new drive for quality.
29 September 2015
Overall, we rated community dental services as good. We found dental services provided safe and effective care. Patients were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.
Dental services were effective and focused on the needs of patients and their oral healthcare. We observed good examples of effective, collaborative working practices within the service. It can be difficult for the service to recruit dentists essentially because of the rural nature of County Durham and the current financial climate of the NHS. However, the service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.
The patients we spoke with, and their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were through what they did.
At each of the clinics we visited the staff responded to patient needs. We found the service had begun actively seeking the views of patients using a variety of means. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs at the right time. Through effective management of resources, delays to treatment were kept within reasonable limits.
The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said that they generally felt well supported and that they could raise any concerns.
29 September 2015
Overall, community in patient services were good. Medical cover was provided in different ways at each location. Advanced nurse practitioners held responsibility for inpatient services at night, but in some locations the most senior member of staff on duty was a band 5 staff nurse. Services did not use a nursing dependency tool to calculate numbers of nursing staff required. On most wards there were two qualified nurses on duty for all shifts. When the ward was full this meant that there was a qualified nurse ratio of 1:11 or 1:12 (1 qualified nurse for 11 or 12 patients). This falls outside the recommended Royal College of Nursing (RCN) ratio of 1:8.However, managers supported staff to access additional nursing and healthcare assistant staff when clinical needs or new complex admissions required extra staff. Staff told us that their managers were supportive and trusted them to make clinical decisions regarding staffing.
Most patient records were appropriately completed, care plans were individualised and we found evidence of goal setting and discharge planning. However, medical nursing documentation received from the acute site with patient transfers was not always complete and all pages were not always sent to the community ward. We found that nursing assessments and risk assessments were in place and where risks were identified relevant to scores and patient status, appropriate action plans were in place and regularly reviewed during inpatient stays.
Incidents were reported, managed and investigated. There was evidence that learning and subsequent changes had taken place as a result of incidents. Staff understood their personal and professional responsibilities and applied the principles of the Duty of Candour legislation as part of their working roles.
Staff followed infection control principles and were seen to wash their hands and use hand sanitising gel appropriately. All staff were ‘bare below the elbow’. Staff felt involved and were encouraged to give feedback on patient care both informally and at ward handovers.
Peer review was carried out across the care closer to home directorate using an observational site visit tool. This gave a rating against each quality assurance target and recommendations for actions where appropriate. Staff told us that this activity was valued by all senior staff as an opportunity to share good practice. There was little evidence that community hospitals benchmarked their outcomes or quality of care against national guidelines or standards.
Admission criteria and pathways were in place and patients were mostly admitted appropriately for nursing care and/or therapy input, although there were some inappropriate admissions to the community wards from the acute services, especially A&E. Access to therapy was inconsistent between services. Some had access to part-time therapy support on weekdays while others carried out assessments prior to admission but on-going maintenance therapy was not available. Discharge planning was integral to the care of patients and home visits were incorporated into the plans to help assess the patients’ moods, wellbeing, safety and mobility needs. This allowed sufficient time to identify any equipment required and to allow efficient ordering prior to a formal discharge. Delayed transfers of care throughout the trust were due to a range of causes, most of which scored equally or considerably less (better) than national averages.
Patients and visitors told us that the care they received from staff was excellent and that patients felt safe and cared for during their stay. We observed staff speaking to patients in a sensitive and compassionate manner. There was a good range of quality information leaflets for patients and families to read and keep. Staff ensured they were as involved as possible about making decisions about their care and feeling empowered to care for themselves as soon as they were able.
Staff understood the trust’s overall vision, but there was no clear vision or strategy for the future regarding community services. There had been recent changes within community inpatients and staff expected further change in future. Risk management meetings were held monthly, but staff awareness and the engagement of risk management was inconsistent. Staff we spoke to were very positive and proud of the service, the team and provision of care to patients. Ward staff encouraged patients to complete a questionnaire prior to discharge. Although low numbers of patients completed the questionnaires the results were good overall and all patients commented that the staff had been kind, considerate and caring. Staff felt they provided a good link between acute services and the community and had good connections with therapy teams who followed up patients’ progress at home.
29 September 2015
Overall community end of life services were good, although there were some aspects of well-led that required improvement. The community specialist palliative care service (CSPCS) provided a safe service. Staff were clear about their responsibilities for clinical safety, operated within clear national clinical guidelines and reported and analysed clinical safety issues and incidents. The service had arrangements in place for reporting and analysing incidents. Staff were aware of current infection prevention and control guidelines and we observed good infection prevention and control practice. Medical support for the CSPCS was provided by one full-time consultant in palliative care medicine. The consultant in post had been absent for several months. The post had been covered by a recently retired consultant who provided cover six sessions per week. A second consultant post was vacant.
CSPCS had been developed in line with national guidance. The service used the palliative and end of life guidelines developed by the North of England Cancer Network. These provided staff with guidance on palliative and end of life care planning, pain management, symptom management and emotional and psychological support. CSPCS staff were appropriately qualified and experienced to give specialist advice and we saw evidence of good multidisciplinary team working as part of the approach to supporting patients in the community. The service had arrangements in place for managing patient’s pain, managing symptoms and supporting their nutrition and hydration needs. The Liverpool Care Pathway had been replaced by guidance developed by the Northern England Strategic Clinical Networks, ‘Guidance for care of patients who are ill enough to die’, June 2014. There was no access to specialist palliative care advice out of hours. There was no specialist or general training programme in place for palliative and end of life care. Some community nursing staff who were coordinating people’s care had not received training in palliative and end of life care.
Patients were treated with dignity, respect and compassion.
The service worked well with other services and had developed services in partnership with the local clinical commissioning group to ensure patients needs were met. Specialist community palliative care staff reviewed the needs of newly referred patients and adjusted their priorities to ensure they provided a responsive service. Any complaints were reviewed and investigated, and any learning from complaints was cascaded to staff.
The service had been without senior leadership for some time. The consultant in palliative care medicine in post had been absent for several months. The post had been covered by a recently retired consultant who provided cover six sessions per week. A second consultant post was vacant. Team leaders had been identified for each of the localities. These were senior nurses who took on operational management responsibilities over and above their clinical caseloads. Staff understood the strategic aims of the organisation and felt involved in the clinical quality improvement framework.