County Durham and Darlington NHS Foundation Trust

We inspected County Durham and Darlington NHS Foundation Trust from 3–6 February 2015 and 27 February and undertook an unannounced inspection on 25 February 2015. We carried out this comprehensive inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

The trust had an evolving executive team. The Chief Executive was previously the Finance Director and Chief Operating Officer, and was appointed in 2012. The Chief Nurse was leaving the trust in April 2015. The Chair had been in post since 2007 and was stepping down in February 2015 with a newly appointed Chair taking up post shortly after. There was a Chief Operating Officer starting in post in February 2015 and this role was a new development.

We inspected the following core services:

• The University Hospital of North Durham – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, end of life care, outpatient services and diagnostic imaging.
• Darlington Memorial Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, outpatient services and diagnostic imaging.
• Community health services, including:
  • Community health inpatient services
  • Community adult and long-term conditions
  • Community end of life care
  • Community health services for children, young people and families
  • Urgent care centres
  • Dental Services.

Overall, the trust was rated as ‘Requires Improvement’. Safety, effectiveness and well-led were rated as required improvement; caring and responsive were rated as good.

Our key findings were as follows:

• Across both the acute hospitals and in the community, arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that most areas we visited were clean. Rates of Methicillin-resistant staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) were within an acceptable range for the size of the trust.
• Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, on the whole, they were content with the quality and quantity of food.
• There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs, both in hospitals and across community services.
• There was effective communication and collaboration between multidisciplinary teams.
• There were staff shortages, particularly on some medical wards and in maternity and gynaecology , mainly due to vacancies for nursing and medical staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank, agency and locum staff were being used to make up for any deficits in staff numbers and staff were working flexibly, including undertaking overtime.
• The emergency department at Durham did not have a paediatric trained nurse on all shifts
• Mortality rates were within acceptable limits for a trust of this size, and processes for reviewing morbidity and mortality had been established and were evolving to include the core service teams. There was a weekly review of morbidity and mortality by a senior group of Clinicians and this informed the Mortality Committee.
• Equipment was well maintained, both in the hospitals and in community services.
• Incidents were reported and lessons were learnt and disseminated.
• A small proportion of community staff reported that there was no clear vision or strategy for community services, although there was a clinical strategy that was still being developed at the time of inspection.
• Care and treatment was delivered with compassion, and patients reported that they felt they were treated with dignity and respect.
• Staff did not always feel engaged with the development of their services. The contract for a number of community services was due to be re-tendered, but staff reported not being engaged with this process.
• There was evidence to demonstrate that there were differences between the acute hospital sites with regard to clinical practice and leadership; these differences were seen in areas including the provision of non-invasive ventilation services and maternity services.
• There were inconsistencies in the provision of pharmacy support in hospitals and community services.
• There was inconsistent access to therapy services in the community.
• Governance processes were not fully embedded across all parts of the organisation.

We saw several areas of good practice including:

• An exceptionally caring critical care service in Darlington, where inspectors observed individualised care and attention to detail given to patients and relatives. This was shown by the trust's work with the end of life team, its visitor’s charter, care of patients with learning disabilities, and implementation and consideration of the deprivation of liberty safeguards (DoLs). In addition, memory bands were used for patients and their relatives.
• Safety huddles had been implemented on the wards at the University Hospital of North Durham.
• There was consistently positive feedback from patients and relatives about community nursing teams, with care being described as 'excellent'.
• The dietetics team was committed to improving nutrition, with the work it had undertaken being published and shared nationally.
• The County Durham Rapid Early Specialist Team (CREST) service provided early senior and multidisciplinary assessment for frail older people, which facilitated safe, early, supported discharge, and managed patients with an anticipated short length of stay.
• There was a family nurse partnership established to provide intensive support for teenage mothers.
• Staff in the CT department had received ‘Making a difference’ award in February 2014.
• Staff on ward 52 had recently been awarded the ‘Quality mark for elder-friendly hospital wards’.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly the trust must:

• Review current governance processes to ensure they are embedded to ensure consistency across acute and community services.
• Review and ensure that all members of the board are fully aware of their lead responsibilities within the Board Assurance Framework.
• Review the achievements and actions taken to address national targets within the accident and emergency departments (A&E).
• Review consultant levels against CEM guidance.
• Ensure the A&E departments meet cleanliness, infection control and hygiene standards, particularly relating to high and low level dust, blood stains, equipment and floors. Chairs and equipment that have deteriorated must be removed and replaced.
• Ensure all toys are cleaned properly to reduce the risk of infection within the A&E department.
• Ensure sharps bins are managed appropriately to reduce the risk of needle stick injury within the A&E department.
• Ensure that all resuscitation drugs and equipment within the A&E department are regularly checked, cleaned and in date. This should include all grab bags and anaphylaxis kits.
• Ensure that all relevant staff know where the Difficult Airway Kit is kept.
• Ensure there are robust risk assessments in place for the paediatric environment within the A&E department. These must be readily accessible and available to all staff in the department. Risk mitigation must be outlined and an action plan to improve the area must be written.
• Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance and taking into account patients’ dependency levels on medical wards, particularly where patients are receiving non-invasive ventilation (NIV) and require level 2 intervention.
• Undertake a review of current documentation relating to the care and management of patients receiving NIV to ensure that it is consistent across both the University Hospital of North Durham and Darlington Memorial Hospital.
• Have arrangements in place for patients receiving NIV that comply with the British Thoracic Society guidelines (2008) for the use of NIV for acute exacerbation of chronic obstructive pulmonary disease.
• Undertake a regular audit of the provision of services to patients requiring NIV to ensure that the service is safe and of appropriate quality.
• Ensure that patients are placed on the most appropriate ward to meet their needs, including a review of the care of patients requiring NIV to ensure that they are admitted to a suitable ward with appropriately skilled and experienced staff in line with best practice guidance.
• Ensure that patient records, including those for patients awaiting discharge, are kept up to date, are patient-centred and contain relevant information about their treatment and care, in order to eliminate unnecessary delays.
• Ensure that the trust undertakes a review of the skills, knowledge and capabilities of nurses to complete accurate and timely care plans that meet the needs of the patients.
• Establish a consistent approach to critical care outreach services across the organisation.
• Ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced medical staff within maternity and gynaecology services.
• Ensure that there are processes in place by which to identify, acknowledge and address risks through robust management processes within maternity and gynaecology services.
• Ensure the paediatric high dependency unit room has specific standard operating procedures or protocols available to guide suitably trained staff.
• Ensure advanced paediatric nurse practitioners have a set of standard operating procedures available to guide their practice and care.
• Review paediatric nurse cover in the A&E department at Durham to ensure all shifts are covered with a paediatric nurse either through service level agreement with the paediatric department or through the appointment of paediatric nurses to the department, to ensure a consistent approach across the organisation.
• Ensure that staff know the syringe driver policy and carry out/record syringe driver checks in line with this policy.
• Add audits of syringe driver administration safety checks to the annual end of life audit programme.
• Ensure medical staff record mental capacity assessments for patients who are unable to participate in decisions about ‘do not attempt cardiopulmonary resuscitation’ (DNACPR).
• Ensure audits of mental capacity assessments are incorporated into audits of DNACPR forms.
• Ensure robust implementation of structural changes to the specialist palliative care team to support the development of the end of life care services.
• Ensure data are available to identify and demonstrate the effectiveness of the end of life service.
• Ensure that all resuscitation equipment is checked daily and stored securely, and introduce a monitoring system to ensure that checks take place within the outpatient departments.
• Address the lack of consultant medical staff cover in end of life community services.
• Develop access to out-of-hours advice for healthcare professionals caring for palliative and end of life patients within community.
• Ensure there is effective leadership and management in place to maintain and develop the community end of life service.

In addition the trust should:

• Continue to review College of Emergency Medicine (CEM) audit data to ensure patient outcomes are met.
• Review the complaint process in terms of board oversight, CEO involvement and clinical direction.
• Direct medical staff to check resuscitation equipment and drugs before the start of their shift even when nursing staff have completed the checks.
• Encourage all relevant staff within the A&E department to attend violence and aggression training.
• Ensure patients have their medicines reconciled in accordance with trust targets.
• Review access to patient information in languages other than English.
• Review dedicated management time allocated to ward managers.
• Review the patient flow of higher dependency patients throughout the hospital to ensure care is given in the most appropriate setting.
• Have an up-to-date standard operating procedure (SOP) for both acute hospitals which clearly sets out the management of admitted patients who require NIV.
• Ensure that this guidance/SOP includes clarity on the setting/specific ward in which patients can be managed.
• Ensure that this guidance/SOP includes staffing-to-patient ratios that are in line with current guidance.
• Ensure that there is a training plan in place, which is delivered to all staff involved in the care of patients receiving NIV, and that it is competency based and in sufficient detail to demonstrate competence in all aspects of NIV.
• Ensure that any guidance/SOP includes an escalation plan that includes action to be taken when a bed is unavailable in an appropriate setting and when patient numbers do not match agreed staffing ratios.
• Ensure that the intensive care unit has an outreach team to identify and monitor deteriorating patients.
• Ensure that there is clinical pharmacist input in the intensive care units on both sites in line with ‘Core standards for intensive care’ guidelines.
• Consider ways of improving engagement between staff and managers within the care closer to home directorate with a view to achieving a joined up approach within maternity and gynaecology services. Also, consider ways of improving responsiveness and efficiency in respect to service-level decisions within this service.
• Consider ways in which it can identify the required standards within the maternity service dashboard.
• Consider, within the maternity and gynaecology services clinical and quality strategy for 2014–16, timelines for review and achievement.
• Consider ways of developing a coherent plan for joint working on improvements in maternity and gynaecology services.
• Consider ways for improving timely and responsive human resource management processes, including personnel issues that impact on service delivery in maternity and gynaecology services.
• Formally nominate an executive or non-executive director to represent children at board level, separate from the safeguarding children executive lead role.
• Ensure actions in response to the National Care of the Dying Audit (NCDAH), and other identified actions to develop the service, are carried out in a planned and timely way with continued evaluation.
• Ensure systems support ways of identifying when incidents and complaints relate to end of life care so that specialist input can be provided and recorded in terms of investigation and learning.
• Ensure that any out of date medication is removed from stock cupboards once it has expired, in line with the trust medication management policy, and have a process for monitoring this within the outpatient departments.
• Ensure that all fridge temperatures are checked daily and that there is a system in place to monitor checks taking place within the outpatient departments. The trust should ensure that the cold chain is robust.
• Ensure that all clinicians within children and young people’s community services have the appropriate level of children's safeguarding training.
• Improve audit activity to monitor quality and patient outcomes within the urgent care centres.
• Review staffing at night within the urgent care centres.
• Review the need for paediatric-trained nurses in the urgent care centres.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.

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.

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.

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.

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.

Overall, we rated this service as good, although safety was rated as requires improvement. Although staff told us that there were usually sufficient staff to meet the need of the patients, there were high levels of staff sickness at the urgent care centre at Peterlee Community Hospital. Long-term sickness was being managed and agency staff were occasionally used to cover at Peterlee, with cover at other sites being provided by staff working longer hours or staff from other centres covering vacant shifts. Several staff from Bishop Auckland urgent care centre had recently left the service due to the uncertain future of the service. Staff teams usually consisted of GPs, urgent care practitioners and healthcare assistants. Staffing levels in centres were much higher during the day than at night and often, at Shotley Bridge urgent care centre, a single member of staff could be left to work in the department if a GP was called away. In one centre, the urgent care practitioner also held the second crash pager for the whole community hospital, to support the Advanced Nurse Practitioner within the hospital. Incidents of violence and aggression towards staff had been reported by staff and a security alert had been raised at Peterlee urgent care centre when a member of staff had felt threatened at night. A risk assessment had subsequently been carried out.

Staff were confident in reporting incidents and safeguarding concerns and we saw from staff meeting minutes that incidents and learning from incidents were discussed regularly. There was a child protection lead practitioner in the team. Documentation was correctly and consistently completed. Staff knew the procedure to follow if a patient’s condition deteriorated and transfer to the emergency department or admission to the acute site was required.

We saw some evidence of assessment tools in use. There was audit undertaken to monitor quality and people’s outcomes Multidisciplinary team meetings were held quarterly in each centre and included a range of staff (e.g. GP/Reception/Practitioner/HCA). Cross Centre Clinical Governance meetings were held monthly. Across all centres there were good relationships with local GP practices. Information was available via the electronic records system and discharge information was available electronically to other users of the system, such as local GPs.

Staff were competent in their roles and attended regular quarterly team meetings. They discussed best practice and changes in guidelines. Staff competency documents and supervision notes were unavailable during our visit. There were a number of care pathways in use, which demonstrated good patient outcomes. Staff told us that trust guidelines and National Institute for Health and Care Excellence (NICE) guidance were followed across all centres. They also explained that they frequently used their own clinical judgement and relied on professional integrity and responsibility.

Patients and their relatives or carers were treated in all interactions with dignity, respect and care was provided in a compassionate way. They were provided with relevant verbal information, emotional support and explanations about their care and staff checked patients’ understanding of the care planned and provided.

Radiology was available during the day at Shotley Bridge, Bishop Auckland and Peterlee centres. Patients attending Seaham urgent care centre would need to be transferred to Peterlee urgent care centre for radiology services. Premises were accessible for patients with limited mobility and peoples’ individual needs were well met by the delivery of patient-centred care. All services worked well together and coordinated within and across sites to ensure the best possible care was given. There was good access for staff to refer to the mental health team, who would attend the unit if called. There were clear criteria for ensuring all babies and pregnant women were seen by a GP, as well as patients returning to the centre on two or more occasions.

Governance structures were clear to both staff and managers. Learning from incidents was shared via the urgent care clinical governance group, which also discussed peer support and reviews. The management and leadership of urgent care had changed and a relatively new postholder was managing services across the stand-alone urgent care centres (Bishop Auckland, Shotley Bridge, Peterlee and Seaham). The culture within the service was mostly positive and confident and was actively looking at ways to improve. All the staff we spoke with were positive about the contribution they made to patient care and were very positive about the teams they worked in. Staff felt supported by managers, despite experiencing a prolonged period of transition and change, and reported effective team working. The changes were aimed at improving the services for local communities and ensuring sustainability.