County Durham and Darlington 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
• Environmental sustainability – sustainable development

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We found evidence of closed cultures and ways of working which have inhibited openness and transparency amongst staff at all levels. There was a culture of resistance to change in some areas. The current trust strategy expired in March 2026 with limited delivery of its goals and no effective plans to develop an updated one; leaders acknowledged the need for an interim position/plan for 2026/27 whilst one was developed. Whilst there was a vision, this was not owned or delivered; the new senior leaders were able to articulate their vision for the organisation.

There was an overarching trust strategy in place called ‘Our Patients Matter’. This had been used as the principal corporate strategy since 2018 and had been refreshed in 2023 and 2024 but was due to end in March 2026. There was no underpinning clinical or financial strategy that was up to date or fit for purpose. There was however a Procurement Strategy (2025-2028), which focused on estates, facilities and procurement support, a soon-to-expire Quality Matters Strategy (2022-2026) which focused on patient safety, experience and clinical outcomes, and a soon-to-expire People Matter Strategy (2023-2026) which was based around workforce sustainability, equity and inclusion and health and wellbeing.

The new Chair and Chief Executive Officer (CEO) both recognised the need for a re-set, starting with a revised trust strategy and clinical strategy. The CEO told us that the first step was to “reclarify our purpose”. They acknowledged the need for an interim strategy/plan for 2026/2027 that could be clearly articulated to the organisation and to stakeholders. The new CEO told us that the Trust’s identity was as a strong, district general hospital (DGH) with integrated community care.

The expiring strategy, ‘Our Patients Matter’ outlined the actions the Trust needed to take to achieve its ambition as a high performing trust that provided, safe, high quality care for patients. The strategy detailed four strategic goals:

• Enhancing patient safety: We are committed to reducing and preventing patient falls, minimising harm from sepsis and acute kidney injury (AKI), and improving the safety culture across all our services.
• Expanding access to care: By optimising our resources, we aim to ensure that care is accessible, efficient, and responsive to patient needs.
• Supporting our workforce: We strive to be the employer of choice, fostering a culture of engagement and continuous improvement among our colleagues.
• Financial responsibility: Ensuring that every pound counts, we are focused on managing our resources effectively to sustain and enhance service provision.

The Trust told us there was a robust system in place for monitoring progress of the strategic goals with monthly meetings to assess the status of key delivery plans, manage dependencies, and mitigate risks. They also stated the Board Assurance Framework (BAF) provided ongoing oversight of strategic objectives.

Whilst the Trust had a vision and a set of six values, not all staff had a clear understanding of them, the vision or strategy, or of their role in delivering these. The vision was “to deliver care which is right first time, every time”. The values were:

• Working together for patients
• Respect and dignity
• Commitment to quality of Care
• Improving lives
• Compassion
• Everyone counts

The Trust had a new chief pharmacist who was working on a draft medicines optimisation strategy, further work was planned to engage with the wider team and trust to develop, finalise and sign off the strategy. Pharmacy and medicines related policies and procedures were in place and there were processes to ensure that these were monitored and shared with staff when updates were made.

During our assessment, culture was described by many senior leaders as a significant challenge facing the Trust. We found evidence of closed cultures and ways of working which had inhibited openness and transparency amongst staff at all levels. A longstanding culture of resistance to change had developed under the previous executive leadership.

Feedback received during our assessment indicated that not all staff felt positive or proud to work for the Trust. The 2025 staff survey results showed that morale, staff engagement and ‘we work flexibly’ scores were lower than the national average. Some staff reported feeling that leaders were disconnected from frontline teams, and that there was a divide between the priorities of non-clinical management and patient-facing staff. This perception was consistent throughout the assessment. We found leaders were aware of the lack of cohesion and knew there was considerable progress needed to address the underlying causes.

The Trust had a response rate of 40% for the 2025 staff survey. This was lower than the 42% response rate for the 2024 NHS staff survey and was lower than the Trust’s benchmarking group average of 47%.

Board reports and the Board Assurance Framework referred to strategic objectives such as ‘Health and Wellbeing Matters’, ‘Inclusion Matters’, ‘People Matter’, ‘Workforce Sustainability Matters’ and other actions that promote a safe, supportive and compassionate culture, but it wasn’t clear how these plans were progressing and whether staff had experienced any positive changes. The Trust acknowledged that the score for ‘we are recognised and rewarded’ had decreased from 2023 to 2024.

Many leadership interviews were dominated by financial concerns. Some leaders shared concerns that the organisation had become too financially focused, with insufficient prioritisation on quality and safety. We held focus groups with a range of staff and consistently heard that they felt disconnected from the Trust’s leadership and believed there was a culture of excessive focus on financial matters. Staff told us they believed the Trust prioritised financial issues at the expense of patient safety. Staff voiced frustration at having to raise the same patient safety concerns repeatedly, rarely feeling listened to. For example, the lack of a call bell system in theatres at the University Hospital of North Durham was identified as a risk and added to the risk register in June 2023. Funding for a call bell system to be installed was agreed in December 2024 following a serious patient safety incident. However, the system was still not installed almost a year later. Staff felt that a lack of funding prevented effective mitigation measures.

During and after our onsite assessment, we received anonymous communications that described the Trust culture as a blame culture, lacking in accountability with a reluctance to challenge. The Trust was described as a place where people did not always feel psychologically safe.

Whilst the Trust had processes in place to identify and address behaviours that were inconsistent with its values, they were not always effective. There was a Disciplinary Procedure (ratified in March 2024) which detailed how issues of misconduct or poor performance would be handled fairly, consistently and transparently.

We reviewed six grievance cases from a sample of care groups across the Trust as part of our assessment; not all had been completed in line with the Trust's process. We identified patterns of poor documentation, governance, staff support, and organisational learning. Across the cases reviewed, timelines were found to be incomplete, inconsistent, or missing key information. Records were not maintained chronologically, important dates and case conference details were absent, and there were unexplained gaps in case progression. In several instances, delays between allegations, suspension, and subsequent interviews were poorly evidenced, with no documented risk assessments to justify decision making. The review of grievance cases found that employee support was inconsistently offered and/or inadequately documented; this included during periods of suspension. The handling of cases showed gaps in governance and adherence to the Trust policy. Overall, the findings indicated recurring systemic problems that impacted the transparency, defensibility, and fairness of the Trust’s grievance handling.

We had significant concerns about the Trust’s understanding of the statutory Duty of Candour and its capacity to meet the requirements of the regulation. Whilst there was a duty of candour policy and a process was in place, the trust’s approach to openness and transparency did not consistently meet the expectations of Regulation 20, which requires providers to inform patients and families as soon as reasonably practicable when a notifiable safety incident has occurred, to offer an honest explanation of what is known, provide appropriate support, and issue a clear apology. Our review found that processes for incident escalation and communication were not always robust, and in some cases concerns were not raised or acted upon in a timely manner. As a result, patients and families were not always notified following incidents that may have caused moderate or severe harm, indicating that the Trust’s culture and governance systems did not fully support the principles of candour expected of an NHS organisation.

Staff told us there had been a culture within the Trust in which the Duty of Candour was perceived as an admission of fault, which discouraged individuals from complying with the process.

The Trust maintained a spreadsheet tracking incidents and whether they met Duty of Candour criteria. We reviewed this dataset, covering the period 1 October 2024 to 30 September 2025. While each incident number was recorded, the accompanying narrative information was limited, requiring staff to refer back to the reporting system for full details. During this period, the trust recorded 73 incidents classified as either ‘Death (caused by the incident)’ or ‘Severe (permanent or long-term harm)’. On review, five patient deaths had been incorrectly recorded as ‘Severe (permanent or long-term harm)’, indicating further issues with the accuracy of reported data and the Trust’s assurance processes relating to Duty of Candour.

We were made aware of numerous missed opportunities for the Trust to be open and honest with patients and their families following harm or the risk of harm. We had previously requested data relating to these Duty of Candour cases; however, the Trust was unable to provide reliable, validated information, which highlighted deficiencies in its systems for identifying, recording and monitoring Duty of Candour compliance.

The Trust required all staff (7,651 at the time of our assessment) to complete basic Duty of Candour training and had 99.7% compliance. The training only needed to be completed once during a person’s employment. There was no requirement for refresher training. Despite compliance with training requirements, implementation was not effective.

We heard a theme from staff and leaders that some poor behaviours went unchallenged. Some leaders described a culture of non-compliance and a lack of accountability where not all staff and managers were held to account. Leaders recognised there was a need to strengthen accountability and reinforce professional standards to support cultural change.

The new leadership team aspired to embed a just culture across the Trust; however, they acknowledged that this was not consistently realised in practice. Staff described certain unacceptable behaviours becoming normalised and a lack of consistent accountability, which undermined psychological safety and confidence in the organisation. However, there was ambition to embed a fair and learning-focused culture, but it had not yet translated into consistent behaviours or experiences for staff across the Trust.

The Council of Governors shared that they do not always feel well informed about what has been happening across the organisation, and that the lack of structure in their meetings with trust leaders creates uncertainty about priorities and expectations. They also expressed frustration about their role and responsibilities, highlighting an unclear sense of purpose and direction.

As part of our assessment, we sought the views of external stakeholders for this quality statement. They reported that the Board appeared to have overlooked deeper cultural issues in the past. They described an insular culture with task driven pressures taking precedence over patient centred care, and staff feeling ignored or undervalued when raising concerns, contributing to low morale and a fear of speaking up. Stakeholders also noted inconsistent interpretation of policies across wards, poor communication around change, and instances where being open to change was perceived as being punished through role or ward moves intended to avoid conflict. Leadership was described as less visible with avoidance of difficult conversations and limited escalation routes experienced at ward level. However, partners felt recent leadership changes and new improvement efforts offered an opportunity for positive change.

At the time of our assessment, there had been very recent, significant changes within the executive leadership team, many of which were interim roles, and the Board was at the start of a required transformational period. Some leaders had the breadth of experience, capacity and capability to lead, but others were limited by a lack of broader experience. We found that the ineffective senior leadership previously in place at the trust contributed to the failures identified during our assessment of surgical services.

The Board consisted of a new interim Chair, supported by six non-executive directors (NEDs) and one Associate NED (non-voting). A newly appointed CEO was supported by six directors. NEDs told us they had a high level of confidence in both the incoming interim Chair and the new CEO. There were seven executive level posts:

• Chief Executive Officer
• Executive Medical Director (Acting)
• Executive Director of Operations
• Executive Director of Nursing, Midwifery and Allied Health Professionals
• Executive Director of Finance
• Director of Workforce and Organisational Development (non-voting)
• Managing Director Synchronicity Care Ltd (Estates & Facilities) (non-voting).

In the three months leading up to our well-led assessment of the Trust, there were several changes within the senior leadership team. The previous CEO retired and a new CEO was appointed. An acting Executive Medical Director was appointed in the absence of the substantive Executive Medical Director. An interim Chair was brought in following the departure of the previous Chair. The day before our well-led assessment commenced, the Deputy Director of Nursing was asked to act-up into the role of executive director of nursing, midwifery and allied health professionals with immediate effect because the incumbent was seconded out of the organisation.

Since our well-led assessment of the Trust, two further changes have occurred; an interim Executive Director of Nursing, Midwifery and Allied Health Professionals was appointed, and an Interim Chief Finance Officer was appointed after the Executive Director of Finance left his post.

Remaining executives at the Trust understood the impact of the leadership changes to staff. These leaders brought continuity and institutional knowledge during a period of significant organisational change.

The newly recruited executives (including interim posts) had started to address the Trust’s known concerns and outlined emerging plans for improvement. However, they had not been in post long enough for these actions to have resulted in any significant, demonstrable changes at the time of our assessment. There was a sense from most staff that things were changing, becoming more open and inclusive and the organisation was developing a new identity with quality, culture and finance as the three main drivers. But there was no sustained evidence of this at the time of the inspection.

The newly appointed CEO and interim Chair had recruited interim NEDs to broaden the breadth of experience and skill mix of the non-executive director group. We observed the new NEDs in a board meeting and noted they brought professional curiosity and a confidence to challenge. The Trust was recruiting to four NED posts, and the Chair told us they wanted representation in the group across clinical, financial and culture transformation backgrounds.

At the time of our assessment, we saw that the executive team had not been working cohesively; we heard frequently they had worked in vertical silos. The new CEO and Chair were aware of this and were developing plans to create an effective unitary board that functioned well in providing strategic leadership, governance, accountability and public assurance.

The Board was using an external organisation to facilitate the Board Development Programme, and had very recently appointed several, experienced external senior clinicians to support the board restructure.

At the time of our assessment, there was no formal leadership strategy. This was acknowledged by the new CEO and Chair and was another area for development. Senior leaders highlighted the considerable challenge of steering an organisation that must raise basic quality and safety standards while contending with significant financial pressures.

During our assessment, staff told us not all leaders were visible. However, many felt that this was improving as a result of the changes in senior leadership.

As part of our assessment of the Trust, we reviewed executive and non-executive director files to ensure they met the requirements of the Fit and Proper Persons Regulation (FPPR). FPPR is the regulation which requires NHS trusts to check that all executive and non-executive directors are suitable and fit to do their role. The Trust had a Fit and Proper Persons Test policy which was ratified December 2023. The policy stated the checks required and evidence to be obtained for all recruitment of board members (including internal recruitment).

We reviewed six files and found that none of the files had identity checks completed. None of the six files reviewed had followed the requirements of the Trust’s policy. Two files reviewed were for newer appointees; these files contained information including a CV, reference checks and additional checks required for employment. The other four files reviewed were for people who had been in post for several years and we saw limited checks undertaken prior to these appointments. There was a note in these four files which told us “The Aubrey Report November 25 made findings regarding leadership/governance and oversight, including that of the board. CDDFT are now considering the steps it should take in relation to ‘fit and proper persons test’”.

Following our review of the six files, the publication of the Aubrey Report and information shared with us during our well-led assessment of the Trust, we had significant concerns that recruitment procedures had not been operated effectively for some current and previous board members. The new leadership was aware of this and starting to effect change.

Staff told us of instances where medical staff had been recruited as ‘consultants’ but had not been on the GMC specialist register. We were informed that all incorrect appointments were being reviewed and progressed towards resolution. At the time of our assessment, many, though not all, had been resolved. This work was overseen by the Board’s People & Culture Committee.

Processes to ensure staff remained fit and proper for their roles were in place and there were checks with external bodies such as the disclosure and barring service.

The Trust had both a poor response rate of 40% for the 2025 national NHS staff survey and a poor outcome. The response rate had deteriorated from 42% in 2024 and was lower than the Trust’s benchmarking group average of 47%. For the People Promise elements, morale, staff engagement and ‘we are recognised and rewarded’ scores were lower than the national average. The Trust sat below the national average in all areas except ‘We are always learning’ and ‘We work flexibly’.

Since 2021, the greatest improvement at the Trust came in the ‘We are always learning’ element, which increased from 5.0 in 2021 to 5.7 in 2024, and the related sub-score for ‘Appraisals’, which increased from 3.9 in 2021 to 4.9 in 2024.

The newly appointed CEO had initiated open staff sessions to engage directly with colleagues. Operational briefings were cascaded through a structured communication process. Despite this, we heard from many staff that they did not always feel valued by trust leaders. Executive leaders acknowledged the need to improve visibility and engagement with staff.

Within the Surgery Care Group, Matrons had implemented a staff recognition scheme called ‘Cheers for our Peers’. This encouraged staff on some wards and teams to celebrate and acknowledge good practice. Comments were collated and shared at ward level.

The leaders we spoke with remained committed to the organisation despite the scale of the challenge facing the Trust. However, we observed signs of fatigue and pressure, which may impact their ability to lead effectively during a period of significant organisational change. Leaders we spoke with, particularly within IT, patient safety functions and the estates subsidiary, demonstrated integrity and compassion.

Staff told us that there was a disconnect between the front-line pharmacy staff, lower managers and senior pharmacy leaders with regards to their perceptions of stress, workflow and actions when issues were raised. Communication was highlighted as an area of concern in focus groups, pharmacy staff felt that changes were often made but not effectively communicated so that everyone was aware. Senior leaders in pharmacy described how the Trust’s large geography presented challenges with communication. We were not clear what steps were being taken to mitigate this challenge.

The Council of Governors shared a feeling of confidence in the newly appointed CEO and Chair, but they acknowledged there was a significant amount of work still required to develop an effective senior leadership structure.

Partners identified longstanding challenges affecting leadership, governance, and accountability across the organisation. They observed a disconnect between frontline teams and the Board, combined with siloed working and unclear lines of accountability, which contributed to inconsistent oversight and weakened organisational assurance.

Stakeholders commented that recent leadership changes signalled an important period of transition with the potential to reshape Board dynamics. External reviews, including those conducted by the Royal College of Surgeons and the Aubrey Report, further highlighted that outdated practices were allowed to persist unchallenged. The Aubrey Report concluded that individual Board members in post at the time and the Board collectively had not fully discharged their responsibilities, particularly regarding oversight of the breast service and the management of emerging risks.

Staff told us there was a culture where senior leaders were perceived as lacking authenticity in their approach to freedom to speak up (FTSU), with a Board and senior leaders’ culture that did not value the FTSU function. Staff had been, at times, discouraged from speaking up and concerns were not consistently listened to or acted upon. The Board acknowledged that this required further improvement and that staff experience had fallen short of the standards the Trust was aiming to achieve.

We were told of occasions where some managers and senior leaders were sceptical about concerns raised, and focused on the person raising issues, rather than the actual issues. The freedom to speak up guardian (FTSUG) received criticism for ‘only hearing one side of the story’. There were also delays to responses or case updates.

There had been a recent increase in concerns raised by staff at the Trust which the FTSUG felt indicated a better understanding and trust in the FTSU function. However, it was suggested that the increase could have been due to staff feeling frustrated when trying to resolve issues locally and having less confidence that their concerns would be heard.

The Trust had a FTSU policy which was updated in January 2024 to reflect changes in guidance from the National Guardian’s Office. The policy had an expiry date of January 2027. It provided details for the FTSUG with a link to the role of the FTSUG. It also outlined alternative options such as trade union representatives, the patient safety team and HR contacts.

The FTSU policy outlined the Senior Associate Director of Assurance and Compliance was responsible for supporting the effectiveness of the FTSU policy and a named NED was responsible for oversight of the FTSU function at the Trust. However, during our assessment we were told the newly appointed CEO had taken on a supportive role to the FTSUG and it was unclear who the named NED was. The policy provided details for the staff networks, guardian of safe working hours, practice placement facilitators and other useful points of contact.

The Trust had an experienced and well regarded FTSUG who worked 22.5 hours per week, although in practice additional hours were completed to meet the needs of the role. Insufficient hours and limited capacity within the role were identified as key factors constraining the overall effectiveness of the FTSU function. The Chief Executive Officer (CEO) acknowledged the FTSUG’s strong practice and confirmed they regularly discussed emerging themes and areas of concern.

The FTSUG submitted a bi-annual (six-monthly) freedom to speak up progress report for the Board which was provided in line with National Guardian’s Office recommendations. Trust Board papers regularly included a FTSU summary as part of its strategic updates. The annual FTSU report published in July 2025 was presented to the Board by the Trust’s FTSUG, providing an overview of themes, trends, issues and areas requiring attention. There was a focus on local resolution processes, improving responsiveness to concerns, raising awareness and promoting a supportive culture.

The FTSUG met monthly with senior leaders to discuss trends and to share information for insight. However, these meetings were not minuted, and it was unclear whether the information shared was used to inform the board. The Trust did not assure us that any developing cultural issues were identified and acted upon promptly.

The FTSUG described the range of initiatives they had taken to develop and embed an improved culture of speaking up. The FTSUG was supported by 16 FTSU Champions across the Trust. Champions supported local conversations and improved lines of communication between staff groups. We were told the champions did not have protected time for the role. This level of resource was low for the size of the organisation and its workforce. One of the champions was a resident doctor, and the FTSUG reported increased confidence that medical staff and medical students were more likely to speak up.

All staff were required to undertake freedom to speak up awareness training. This was broken down into three categories: all workers, managers, and senior managers. For each of the three modules there was no required renewal or refresher training date, this meant that staff only had to complete the training once during their employment at the Trust regardless of how long they had been in post.

The ‘all workers’ training was reported as 99% compliant. Training for managers was mandatory for 1,744 and had a compliance rate of 94%. FTSU training for senior managers was reported as 94% compliant and showed that 33 out of 35 senior managers had completed the training.

FTSU data from the Trust showed that 62 cases were raised between April 2025 and September 2025. This sat in the middle of reporting numbers for similarly sized trusts in the North East and Yorkshire region. The percentage of cases reported anonymously to the FTSUG was 3.2% between April 2025 and September 2025, which equated to two cases. The largest drivers of this rise were worker safety, which increased by 33% between Q1 and Q2 of 2025/2026. The number of cases with an element of bullying or harassment more than doubled, followed by patient safety and quality concerns which also increased throughout the reporting period. Bullying and harassment showed a quarter-on-quarter rise which indicated cultural issues that required sustained leadership focus. This data corresponded to feedback we received from staff who told us they had raised concerns regarding patient safety and risk management but did not feel listened to. Inappropriate behaviour/attitude reporting showed some improvements throughout the reporting period but remained a material theme. Detriment was recorded at a low level with three reported cases in the reporting period.

The 2025 NHS Staff Survey showed that 58.9% of staff agreed with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was in line with the national average but was slightly worse than the previous year’s score of 59.2%. The survey showed that 43% of staff agreed with the statement ‘If I spoke up about something that concerned me I am confident my organisation would address my concern’. This was below the national average and showed a year-on-year decline from the previous two years scores. Despite the efforts of the FTSUG, staff survey results indicated that the Trust continued to perform below the national average in key areas related to speaking up.

The Breast Surgery Review included in the July 2025 Board Report documented that staff had encountered difficulties in raising concerns. It found that staff were at times discouraged from speaking up and that concerns were not consistently listened to or acted upon. The Trust Board acknowledged that this required further improvement and that staff experience had fallen short of the standards the Trust was aiming to achieve.

During and after our onsite assessment, we received anonymous communications from staff who shared information with us that described a blame culture, where staff were reluctant to speak up and did not feel psychologically safe. However, we also heard some examples of how leaders had recently responded positively to concerns raised.

In interviews with executive leaders, they shared a commitment to improving organisational culture and strengthening the FTSU function. Leaders understood the scale of the challenge and told us that people had not been psychologically safe; they identified FTSU as a key priority. However, while some progress had been made, there remained a significant journey ahead to build trust, psychological safety, and a culture where staff felt empowered to raise concerns without fear.

Partners told us staff were aware of the FTSU routes available to them, but many described an ineffective speaking up culture characterised by fear of negative responses and a lack of follow up action that led some to stop raising concerns. As a result, the Trust was reviewing its FTSU arrangements.

There were some shortfalls in the Trust’s delivery of an inclusive and fair culture. Staff networks were in the early stages of development. Whilst we were assured the Trust reported on the legislative requirements of WRES, WDES and the gender pay gap, it was not clear how the EDI reporting tools were used to drive improvement and reduce disparity other than the WRES disparity ratio at senior positions.

The Trust recognised it was at the start of its Equality, Diversity and Inclusion (EDI) journey. It had a dedicated EDI Lead who was supported by two members of staff working within Organisation Development. One of the supporting staff members was also the staff chair of the Disability and Long-term Conditions network.

There was no standalone EDI strategy in place. However, the Trust had a soon-to-expire People Matter Strategy (2023-2026) which was based around workforce sustainability, equity and inclusion and health and wellbeing.

EDI featured within the People Matter strategic objective of the expiring trust strategy. The Trust had set five objectives for 2025/2026 relating to EDI. The first was to ensure EDI training was at 90% or above across the Trust. At the time of our assessment, compliance was reported at 99%. Staff told us that limited resources were affecting their ability to further strengthen EDI activity and fully achieve the Trust’s wider EDI objectives.

The second objective was to ensure all EDI policies remained current and were reviewed in line with the policy schedule. We saw that the Equality, Diversity and Human Rights Policy was ratified in September 2024, with revisions intended to modernise the language used. However, on review, the policy contained outdated terminology that was no longer supported within the NHS, which indicated further work was required to ensure policies fully reflected national standards.

The third EDI objective was to reduce unwanted behaviours associated with harassment and bullying across all metrics. At the end of quarter two, compliance with sexual misconduct training was 85%. Staff told us this had increased to 93% at the time of our assessment toward the end of quarter three. We also saw that the Trust had established a sexual safety working group to strengthen oversight, improve staff awareness, and support ongoing work to address harmful workplace behaviours.

The fourth EDI objective set for 2025/2026 was to increase membership across staff network groups. We saw a range of actions in place to support this aim. The workforce team had actively promoted the networks, linking communications to wider organisational campaigns and events, including South Asian Heritage Month and the launch of the reciprocal mentoring recruitment programme. High numbers of Rainbow Badge requests in June suggested growing engagement with the LGBTQ+ Network. An internal EDI leads programme was launched in quarter two, and network visibility was strengthened through updated content for new starter welcome events. Additional initiatives included the release of podcasts supporting staff with disabilities, long-term conditions and caring responsibilities.

The final EDI objective set by the Trust for 2025/2026 was to improve participation in the annual staff survey to above 55%. At the time of our assessment, the Trust reported a participation rate of 40%, indicating further work was required to meet the target.

The findings of a recent employment tribunal against the trust found indirect discrimination and harassment. It stated that the Trust had not provided suitable alternative facilities and had not taken staff concerns seriously, resulting in an environment that violated the dignity of the affected staff. The judgement identified failures in the Trust’s processes, including the absence of appropriate risk assessments, inadequate management of staff concerns, and shortcomings in the implementation of inclusive policies.

During our assessment, we met EDI representatives who were passionate and experienced members of staff who understood the purpose and importance of EDI within an NHS trust.

The EDI representatives told us there was a private Facebook page to support staff engagement with EDI. They had approximately 5,000 staff members on the page and used the platform to raise EDI awareness and understanding: for example, sharing educational content and videos. They told us feedback on the page was positive.

When asked about the wider benefits of the organisation’s equality, diversity and inclusion work, they were less able to articulate its strategic impact. Examples provided were focused on low-level or historic activities rather than recent or outcome focused achievements. Staff told us they would benefit from clearer executive level direction to help them understand and communicate the strategic impact of EDI projects and processes.

Equality Impact Assessments were completed by another team, and EDI representatives told us they were not involved in this process. As a result, opportunities for EDI input and oversight in this area were limited.

Four staff networks were in place to promote EDI; all were accountable to the EDI Strategic Group. These were the Unity and Ethnic Diversity Staff Network Group, Disability and Long-term Conditions Staff Network Group, LGBTQ+ Staff Network Group and the Faith Staff Network Group which was also accountable to the Chaplaincy Service. Each network was chaired by a member of staff. Trust leaders told us that Network Chairs received protected time to undertake their roles; however, this was not consistently experienced by those in post.

Staff network groups were still in the early stages of development and continued to establish themselves. Staff told us they would value a clearer structure and more regular, scheduled meetings to support consistency, visibility, and sustained engagement. The networks also shared they would like to be included in development of the new trust strategy.

Although there was an Associate NED whose focus was EDI and Health Inequalities, staff network groups told us there was currently no executive sponsor in place. They felt this limited their ability to influence decision making and have representation at Board level. The Associate NED’s focus was with the health inequalities team, so there was a feeling of missed opportunity for triangulation by not working with the networks. Network chairs highlighted that financial constraints were limiting the reach and overall impact of the EDI group’s work and more work was needed to strengthen organisational culture and ensure inclusion was embedded consistently across the Trust.

However, the groups had already made some positive changes within the Trust. For example, the Disability and Long-term Conditions Staff Network Group had introduced staff health passports. Staff health passports provided a clear and consistent record of an individual’s health needs and agreed adjustments, helping staff feel supported and reducing the need to repeatedly disclose their condition.

The Unity and Ethnic Diversity Staff Network Group recognised the challenges new colleagues from overseas, such as international nurses, faced when joining the Trust and adjusting to a new life in the region and wanted to make this transition as smooth as possible for them by providing support and advice.

The Trust monitored equality, diversity and inclusion in line with the NHS Workforce Race Equality Standard (WRES). WRES was introduced in 2015 to help NHS organisations identify improvements to manage and monitor inequalities. It aims to support a more inclusive NHS workforce and improving care quality, patient satisfaction and workforce experience.

The most recent 2024 WRES report showed ethnic diversity in staff groups (15%) was lower than the national average (27%); however, this figure was higher than the ethnic diversity percentage of the local population. Diversity in the Trust Board was 7% which was higher than national average. Since the WRES data was published there had been considerable changes made at board level. The newly appointed CEO and Chair acknowledged the limited diversity at board level.

White staff represented 94% of staff in non-clinical management grades at band 8c or above, higher than the national average of 85%. For clinical management roles (excluding medical and dental) at band 8c or above, white staff held 100% of the roles compared to the national average of 86%.

Representation differed amongst medical staff which showed white staff held 19% of trainee roles, 32% of non-consultant roles and 49% of roles at consultant level.

Metrics showed white staff were two times more likely to enter the formal disciplinary process compared to staff from ethnic groups. Ethnic minority employees continued to report poorer experiences than white staff, particularly regarding career progression, bullying, harassment and inclusion.

The Trust monitored equality, diversity and inclusion in line with the Workforce Disability Equality Standard (WDES). WDES allows NHS trusts to compare the experiences of staff with a disability, a long-term condition (LTC) and/or other types of illnesses, with those of non-disabled staff. Data from the most recent 2025 NHS staff survey showed more negative experiences for staff with a LTC or illness in six out of seven metrics, compared to staff without a LTC or illness working at the Trust.

The most recent 2024 WDES report showed disability declarations in all staff groups was (5.2%) which was lower than the national average (7.0%). We reviewed WDES data across different staff groups and saw variation in the levels of disability declarations across the Trust.

The proportion of staff with a LTC who experienced harassment, bullying or abuse from managers had improved overall from 2020 (22.3%) to 2024 (13.4%). The proportion of staff with a LTC who experienced harassment, bullying or abuse from other colleagues had marginally improved from 2020 (28.7%) to 2024 (26.8%).

WDES data showed that 77% of disabled staff at the Trust felt their employer provided reasonable adjustments that enabled them to meet the requirements of their job role. This was higher than the national average score for NHS trusts which was 73%.

In response to the WDES data, the Trust recognised that substantial work was needed to ensure equitable treatment and to address the gaps highlighted across these measures. Several areas for focus and improvement were identified which included: strengthening support for underrepresented groups by linking anti‑harassment and anti‑bullying campaigns with staff network groups and exploring additional tailored support; using staff stories and feedback to raise awareness of the lived experience of disability; engaging with staff networks and finding new ways to reach underrepresented colleagues. Staff told us the organisation also planned to promote career development opportunities, including a reciprocal mentoring scheme between underrepresented staff and senior leaders and the Disability Confident Leader programme which will be embedded across the workplace. Further focus will be placed on helping managers and staff provide effective reasonable adjustments through additional guidance and shared experiences. The Trust also planned to strengthen links between staff networks and the Trust’s health and wellbeing services to ensure the needs of underrepresented groups are fully recognised and met.

At the time of our assessment, trust wide average sickness rates were 5.9% which was worse than the NHS national average of 5.3%.

The Trust monitored gender pay gaps and reported to the board annually. The gender pay gap shows the differences in the average pay between men and women. The data reported for 2024 showed the Trust’s gender pay gap was still prevalent and women continued to earn less than men. Compared to NHS trusts nationally, CDDFT’s gender pay gap was higher which placed it in a worse performing category. Further analysis indicated the greatest difference was observed in senior leadership, medical and advanced clinical roles where there was a higher number of males employed. However, the Trust’s gender pay gap reported in 2024 had reduced from the previous 2023 report.

To support required improvement in this area, the Trust had implemented a gender pay gap action plan.

In addition to a notable gender pay gap, the Trust was also managing a different pay scale for staff working in the estates subsidiary, Synchronicity Care Limited (SCL). This meant that staff employed in the estates and facilities function did not receive the same benefits as other members of staff employed by the Trust. This created tension between staff groups and could be a barrier to recruitment.

SCL had approximately 600 employees. The organisation conducted its own staff survey and initiated staff recognition schemes separate to the Trust. SCL had a more engaged workforce and staff felt they were led by an experienced, engaged, and caring Managing Director.

Partners told us the Trust had a diverse and inclusive workforce, but operational pressures, such as unsafe staffing levels, inconsistent skill mix, and varying application of policies, affected staff wellbeing and equity. These issues contributed to stress, low morale, and reduced capacity for safe, high quality‑ care. There was a need for the Trust to strengthen consistency, support, and workforce sustainability to ensure an inclusive and fair culture.

There were significant failings in the trust’s governance and risk management processes which meant they were not operating effectively to ensure the safe and effective delivery of care. Senior leaders had only recently recognised that there were significant failures of governance and risk management across the Trust. What reporting was in place to board regarding governance and risk was complex and lengthy.

The new Chair and CEO had recognised the significant failings within the governance and risk management processes. They told us they were restructuring the Board and its assurance structures with a focus on quality, people, culture and finance. These four areas would form the focus of the Trust’s strategy going forward, underpinned by a single improvement plan and a more developed leadership and decision-making approach. In November 2025 the Trust had appointed two Board advisors, one to support executive leaders and the Trust with strengthening floor to Board assurance and governance, and one to support with clinical strategy. The CEO planned to commission a bespoke three-level development programme for the Trust which would be focused on Board, executive and senior leadership.

Board papers were long, often exceeding 600 pages. We were told by several board attendees that this made them difficult to navigate and made it challenging to locate key information quickly. This lack of clarity can hinder effective decision making and oversight.

At the time of our assessment, the Trust’s committee structure for assurance was principally through the: Integrated Quality and Assurance Committee (IQAC), Operational Performance Assurance Committee (OPAC) and Audit committee; all chaired by NEDs.

The IQAC met monthly. In addition, there was a Quality Committee which operated as an executive committee, providing direction and oversight, and also met monthly. Staff told us there was a perceived lack of effective action in response to indicators of concern at the Quality Committee and, subsequently, at IQAC.

The OPAC met monthly and had recently been replaced by two new Board assurance committees: a People and Culture Committee and a Finance and Performance Committee. Alongside these, the Strategic Change and Investment Board (SCIB) met monthly as an executive committee responsible for direction and oversight.

The Trust had until recently operated a Gold ‘command and control’ structure, under which all issues were escalated to the executive team for review. This meeting took place once per week and had originated during the COVID‑19 response. It was accompanied by a senior leadership team meeting each week. The new CEO discontinued this approach and instead introduced a more proportionate operational model, including regular minuted Collective Leadership Team (CLT) meetings.

The board assurance framework (BAF) was complicated and had 18 objectives identified. A BAF is a strategic tool used by NHS trusts and other healthcare organisations to help boards identify, assess, and manage risks that could impact the achievement of their key objectives. In addition, there was a separate risk register related to the BAF and a “Risks over tolerance” report for operational risks that were reviewed by Board.

The 18 objectives were to be delivered through the eight key plans within the expiring ‘Our Patients Matter’ strategy and the Trust’s Green Plan. Each objective within the BAF had an assigned executive lead and was aligned to a corresponding Board Assurance Committee for oversight and monitoring.

The BAF identified some of the strategic risks faced by the trust to the delivery of its strategic objectives and improvement plan. The top three risks all related to quality – safety culture and harm reduction, patient experience and compassionate care, and sustainable achievement of high-quality clinical services. Recorded risks were mainly aligned with what leaders told us they were concerned about. Mitigating actions for risks were updated where there were changes to report.

However, we found that the financial, clinical, and people risks were not adequately reflected within the BAF. For example, the significant deterioration in the Trust’s financial position had only recently been incorporated into the framework.

The risk score for finance remained at 12 (considered a medium-high level risk) until midway through the 2025/2026 financial year, when it increased to 20 (considered a very high/extreme risk). Given the financial position at the time of our assessment and the anticipated year‑end forecast, this suggested that the BAF had not been functioning effectively in relation to financial risk. A similar conclusion could also be drawn for other key risk areas, particularly in light of the significant external clinical reviews.

The BAF was supported by the Strategic Risk Register (SRR) which was difficult to navigate, with no organisation-wide trigger or tolerance level to determine which risks should be added to it. The SRR contained two additional organisational risks that were not documented within the BAF.

The first related to the Trust’s Breast service which had been subject to a number of external reviews. These reviews, together with the findings from more recent incident investigations, indicated the potential for patients to have been over‑treated and, in some cases, to have experienced missed or delayed diagnoses. There was also acknowledgement that similar issues may have existed within other services across the Trust. This was assigned a score of 16.

The second related to the Trust’s Summary Hospital-level Mortality Indicator (SHMI) rate. This reports on mortality at trust level across the NHS in England using a standard and transparent methodology. The Trust was noted as a persistent outlier with respect to its SHMI rate. The SRR outlined that further investigation was needed to understand whether there were any underlying quality issues contributing to the higher-than-average rate. This was assigned a score of 12.

The Risk Matters (Group Risk Management Strategy) conflated the purpose of the BAF and the management of operational risk. The duration of the Risk strategy was unclear: the expiration date on the front sheet was the 28 February 2026. However, the introduction stated it was a 2-year strategy expiring in March 2025 and that it lasted 3 years. No review of it has been recorded since February 2023.

The Council of Governors felt unable to perform their scrutiny role effectively at times due to limited communication and unclear expectations from the Trust. They reported a lack of responses to their questions, which diminished effective challenge. In addition, there was a perceived absence of training or development opportunities for governors which is felt as undermining their overall governance capability.

Partners told us that recent reviews had highlighted significant weaknesses in governance effectiveness and oversight at the Trust. Slow and inconsistent governance processes were delaying action, with key issues frequently stalling at middle management level without appropriate escalation. Important quality concerns were not presented to the Quality Committee for an extended period despite repeated prompts, raising questions about transparency.

The trust did not have effective systems in place to assess and mitigate operational risks. For example, the risk registers provided fail to document all significant risks or explain how those risks were identified. They also do not show that risks, such as inadequate governance processes and lack of oversight, were being appropriately mitigated. Risk management processes were complex and appeared fragmented, resulting in inconsistent documentation and escalation of risks across care groups. The overall process for managing and escalating risks was unclear, and not all departments or care groups were adhering to the current policy. The approach to adding to risk registers lacked a systematic method, leading to variation between care groups and a reliance on individual judgement and personal risk tolerance.

Most operational staff did not have access to and were not trained to report and record risks onto the system. We asked the trust about risk management training and were told it was provided to Trust Board and the Senior Leadership Team once every three years. However, the risk strategy says biannually. Risk management training was not mandated across the trust. We were informed that only specific staff (matrons, general managers, and clinical leaders) received training and had the ability to add risks to care group risk registers. When asked for compliance data, the trust provided attendance records for sessions held in December 2022, February 2023, and August 2023. These records identified attendees but did not demonstrate overall training compliance across the organisation. Across the three sessions, there were 102 recorded attendances, including some duplication where staff attended more than once. The trust employs over 7,500 staff, indicating that training coverage was very limited.

There were individual risk registers for the care groups. However, staff below care group management level were unable to articulate and directly add risks to the risk registers, which meant there was a disconnect between what the care groups perceived and understood to be significant risks, and the views and focus of the executive team and board. While some risks were escalated, others were held at care group level with no organisational oversight, and not all known risks were mitigated and actioned in a timely way. Staff told us they escalated risks to their managers, who then decided whether these should be added to the register. Staff were often unaware of whether the risks they raised were recorded. Some staff also reported feeling unable to raise concerns due to fear of detriment. The trust could not demonstrate it had suitable and sufficient oversight of all relevant risks across the organisation. This was unsafe because there was potential for patients to be exposed to repeated risks and patient safety was compromised.

The CEO planned to establish a formal risk review board to strengthen oversight and improve consistency in how risks were assessed across the Trust. He highlighted the need for a more standardised approach to risk scoring and for a review of the organisation’s risk tolerances.

The trust had recently introduced a tool and pathway to implement Martha’s Rule. Staff asked patients each day if they were concerned and this was recorded on handheld devices at the bedside. The tool was rolled out trust-wide in all adult in-patient areas in August 2025. The trust reported on the effectiveness of the system through formal reports, 4 times a year, which included numbers of calls for concern received and example case studies.

The new senior leaders were starting to identify the main challenges facing the Trust and were open and transparent about areas where performance had fallen short and improvement was required. The Trust was in the very early stages of its improvement journey, and leaders were realistic about the required pace and trajectory of change. They acknowledged that the Trust had historically taken a reactive rather than proactive approach, and there was a willingness to change this. Leaders wanted to improve the quality and safety of care across the trust. However, persistent quality care failures had led to enforcement action by CQC in relation to surgical services at the Trust following our assessment in October 2025. These concerns were identified at care group level but reflected wider, systemic issues across the organisation.

Some leaders expressed confusion about lines of accountability within the Trust’s operating model. During interviews, leaders provided varying interpretations of reporting structures, indicating that the model was not fully embedded or clearly communicated. This inconsistency created uncertainty around roles and responsibilities, particularly in relation to care group decision making and oversight.

We repeatedly heard from staff that the trust was overly focused on financial matters. Observations of committee meetings and a review of board agendas indicated that there was improved focus on quality, safety, and patient outcomes. However, we saw several examples of financially focused decisions made which had impacted on patient safety.

Compared to other trusts nationally, County Durham and Darlington NHS Foundation Trust had ‘similar to average’ performance for sickness absence at the beginning of 2025. However, the trust reported a sickness absence rate of 5.9%, which was higher than the Trust’s own target of 5%.

The Trust acknowledged the negative impact that sickness absence could have on patient safety and staff wellbeing and had implemented several initiatives aimed at addressing the causes of sickness and reducing overall absence rates. Anxiety, stress, depression and other psychiatric illnesses had been the leading reasons for sickness absence across the organisation.

Pharmacy staff sickness was above the trust target for sickness levels. In focus groups staff spoke of the impact that sickness had on workflow and morale. Further work was needed to review the impact of sickness on workflow and morale.

Risks relating to workforce were not managed effectively. Gaps in the nursing workforce were a concern. At Month 6 of 2025/2026, 7% of all qualified nursing posts were filled by temporary staffing, comprising 5.3% bank staff (the majority of whom are substantively employed by the Trust) and 1.8% other temporary staff. At the same time point, approximately 30% of unqualified nursing posts were covered by temporary staff.” This level of reliance presented risks across all three of the Trust’s key priority areas: quality and safety, people, and finance. Workforce concerns were not limited to nursing roles. Staff reported an over‑reliance on locum medical staff to fill rota gaps, and this issue was also reflected on the Strategic Risk Register.

The Workforce Sustainability Matters objectives for 2025/2026 included focused reduction in the Trust’s reliance on temporary staffing. The Trust had aimed to reduce agency staff usage by 30%, although this had not been achieved by the end of Quarter 1. In contrast, the objective to reduce bank staff usage by 10% had been achieved by the end of Quarter 1.

During this assessment and our assessment of surgical services a recurring theme emerged from staff who felt they did not always have sufficient staffing levels to provide safe and effective care for patients. However, the Trust’s strategic objectives showed that it was developing a number of controls to record and collate data relating to staff retention, improved recruitment and strategic workforce planning. This information was to be provided to managers for action and to the Board for assurance.

The trust had systems to monitor compliance with supervision and appraisal. Appraisal rates for staff were in line with Trust’s target, but staff told us there was a lack of regular, robust supervision. As part of our assessment, we asked the Trust for evidence of previous and planned appraisal dates for the executive and non-executive directors. This information was provided for 2025 with proposed appraisal dates for 2026.

The Trust had a Guardian of Safe Working (GOSW), who was allocated 2 PAs (8 hours) per week to carry out the role. Safe working hours reports were presented to the Board quarterly. However, working practices were not always safe.

In Quarter 1 of 2025/2026, the GOSW issued three fines for breaches of working time rules, including two violations of the 13‑hour maximum shift length and one failure to provide the required 11 hours’ rest within a 24‑hour period. In Quarter 2 of 2025/2026, two further fines were issued: one for exceeding the 72‑hour limit within a 168‑hour period, and another for a repeat breach of the 13‑hour maximum shift length where required rest was not achieved.

The GOSW and the medical education rota quality and compliance team continued to support resident doctors and their supervisors by offering guidance, increasing awareness, and ensuring the Trust remained compliant with the doctors in training contract. The Trust was also working towards implementing NHS England’s new 10‑point plan aimed at improving the wellbeing of resident doctors.

During our assessment, we noted many leadership interviews were dominated by financial matters. Some leaders shared concerns that the organisation had become too financially focused, with insufficient prioritisation on quality and safety.

External reviews had identified breaches of the Trust’s Standing Financial Instructions (SFIs). In response, senior leadership revised the SFIs and began implementing plans to refresh training and strengthen awareness to ensure compliance going forwards.

There was evidence that the finance team had attempted to centrally manage the deteriorating financial position, relying heavily on nonrecurrent measures, using balance sheet flexibility and reserves. This approach did not sufficiently encourage ownership of financial pressures across the organisation.

The Trust’s IQEW (savings) target for 2025/2026 had been set at £57 million, a level it had never previously achieved. The prior year’s target had been £40 million, with a significant proportion delivered on a non‑recurrent basis. Leaders told us they considered the 2025/2026 financial plan to be unrealistic. At the time of our assessment, the Trust was approximately £2 million behind planned delivery of the IQEW Plan, and although many schemes were weighted towards the second half of the year, they appeared unlikely to deliver the required level of savings.

The Trust had processes in place to complete Equality Impact Assessments (EIAs) and Quality Impact Assessments (QIAs) for all Cost Improvement Programmes (CIPs). However, although these assessments were completed, there was no evidence that they were routinely reviewed to determine whether the cost improvement measures had adversely affected patient outcomes or service quality. Additionally, EIAs did not routinely involve the Equality, Diversity and Inclusion (EDI) team, limiting the assurance that potential equality impacts had been fully considered.

The Trust’s likely forecast position had deteriorated to an estimated £23 million deficit, compared with the £2 million surplus assumed in the original plan. In response to these concerns, the Trust had commissioned external financial reviews and had appointed an experienced former Director of Finance as a Financial Improvement Director.

The Internal Audit team reported that executive engagement with the internal audit plan had historically been positive, and until 2025/2026 only a small number of adverse opinions had been issued. However, during the year more significant issues had emerged, including concerns related to conflicts of interest within the use of third-party providers, salary overpayments, and gaps in learning from never events.

Leadership arrangements for Estates, including private finance initiative (PFI) management, remained unclear, with responsibilities split between SCL and the Finance Directorate.

Financial reporting to the public Board was too brief, providing little indication of the underlying financial position, income and expenditure run rates, forecast or the balance sheet. Coverage of the Trust’s efficiency (IQEW) and quality improvement plans and achievements was lacking. Leaders recognised that the current financial reporting provided to the Board and committee was insufficient.

There were multiple examples of significant concerns in identified in the leadership, governance, management and oversight of the Trust’s services. The most significant being the Breast Surgery service, which had been identified through external reports. The Trust commissioned an independent external review of governance within the service which highlighted serious harm to patients, including missed cancers, delays in diagnosis, and unnecessary procedures, with the new Chair and CEO issuing a public apology acknowledging failures in care and governance across the service.

The Royal College of Surgeons’ Invited Service Review confirmed that the Breast Surgery service had not met required national standards, and identified concerns with surgical decision making, documentation, multidisciplinary working, and overall care delivery. The report also raised issues relating to professional practice, duty of candour, and the freedom to speak up culture within the service.

The lack of executive level scrutiny and oversight contributed to the persistence of unsafe practices. Governance processes were bypassed at multiple levels, including failures to follow patient safety governance procedures and to involve patient safety leads following receipt of National Clinical Audit findings. This resulted in delays in issuing apologies and in fulfilling statutory duty of candour requirements.

The impact of these service failures extended beyond the Trust itself, affecting neighbouring organisations required to support patients through additional clinical review and follow up. The Trust’s Executive Director of Operations has been an effective and proactive participant in system level discussions to manage and mitigate these impacts.

Overall, the findings demonstrated systemic failures in leadership, governance, escalation, and oversight within the Breast Surgery service. The Trust has accepted these findings in full and acknowledged the need for significant organisational change to restore safety, rebuild trust, and ensure compliance with regulatory expectations.

The Trust was outsourcing clinical work to several third-party providers; there were substantial failures in the management and governance of these subcontracted services, such as Limited Liability Partnerships (LLPs), private providers, and WLI (Waiting List Initiative) work. These included inadequate quality assurance, weaknesses in managing conflicts of interest, and insufficient processes to ensure value for money. Senior leaders acknowledged the need for a significant overhaul of contract management and were developing plans to strengthen oversight, governance, and compliance.

These concerns were consistent with the commissioned independent governance review of breast services and were also reflected in the Royal College of Surgeons’ Invited Service Review. Both identified longstanding weaknesses in the oversight of external contractual arrangements, alongside significant issues in surgical decision making, documentation, multidisciplinary working, and overall care delivery.

Staff referred to a central contracts database, but not all contracts were included within it. Some contracts with private providers were more than 10 years old and predated the establishment of the Trust’s subsidiary company (SCL). Staff also reported that some LLP related arrangements were not formal contracts, making them insufficiently robust.

There was insufficient governance of the organisation contracted to deliver the Trust’s maternity home birth service. The lack of oversight meant the Trust was unaware the provider had subcontracted work without the necessary assurances. The newly appointed Director of Midwifery had acted quickly to review the situation and terminated the contract.

Regulatory action was taken following an Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) inspection in June 2025. An action plan request was issued to the Trust in relation to justification for use, referrer identification, non-medical referrer entitlement, referral guidelines and governance processes. The breach of governance processes referred to oversight of incident reporting, investigation and analyses of incidents and not notifying relevant enforcing authority when required.

Communication to stakeholders about identified serious issues had been poor. Registered providers have a responsibility to inform CQC of any notifiable incidents. However, on several occasions, CQC became aware of serious incidents through the media or parliamentary contacts rather than being notified directly by the Trust.

The IR(ME)R inspection in June 2025 also noted this in the documented governance breach: “Where the Employer knows or has reason to believe that an accidental or unintended exposure has occurred, they must notify the relevant enforcing authority.”

The pharmacy department had a set of Key Performance Indicators which were monitored as part of governance processes. Data provided showed that the trust had a target of 70% for medicines reconciliation in 24 hours on pharmacy managed wards. However, in July 2025 data showed 18% of patients received a medicines reconciliation in 24 hours and in September 2025 that increased to 21%. The trust’s target for all wards was 50% completed in 24 hours however figures provided showed this was 16% in July 2025 and 18% in September 2025. This had not been captured on the risk registers provided to us. Undertaking medicines reconciliation within 24 hours of admission to an acute setting (or sooner if clinically necessary) enables early action to be taken when discrepancies between lists of medicines are identified.

The Trust’s medication safety officer (MSO) role was at the time of inspection covered by the deputy chief pharmacist. There was a clear remit to the MSO role which included identifying medicines incident themes, reviewing and escalating incidents where necessary and actioning and delivering learning from incidents. It was clear to see from meeting minutes and speaking with staff that there was a positive culture for incident reporting and sharing of learning.

The trust had a draft antimicrobial strategy. In addition, there was an antimicrobial management meeting with agreed terms of reference (TOR). The TOR clearly set out what was required for the meeting to be quorate. However, it was not clear from the meeting minutes if quoracy was complied with as job titles were not recorded. Meeting minutes also showed that these meetings were not well supported by the wider trust and care groups. Although antimicrobial audits were completed by the pharmacy team there was a lack of care group ownership and actions with some areas showing decreasing compliance with antimicrobial stewardship from the audit data provided.

Although medicines related risks had been identified and documented, it was not clear from the information provided how these risks were being monitored or escalated. For example, some risks stated that actions had been deferred to the next meeting, yet there was no indication of when that meeting was scheduled to take place. Other actions depended on vacant posts being filled, but there was no information on the anticipated timelines for recruitment.

Recent Healthcare Quality Improvement Partnership (HQIP) national audit results and September 2025 board papers show variable performance against local and national standards across the Trust and its services. Darlington Memorial Hospital and University Hospital of North Durham performed below national expectations in several areas, including discharge care and oxygen prescribing. Darlington exceeded standards in case ascertainment and preoperative risk documentation and both Darlington and Durham achieved strong pressure ulcer prevention.

The NHS Oversight Framework allocates all NHS trusts to a segment based on their performance and the level of support required. At the time of our assessment, the Trust was placed in Segment 3, indicating notable performance concerns that required enhanced, targeted regional support and closer oversight from NHS England. The Trust was ranked 69 out of 134 of acute trusts with patient safety performing poorly but access to services was above average.

Trust wide activity included a 12-week infection prevention and control (IPC) ‘Secret Shopper’ programme, and maternity audits identified some risks of noncompliance, though perinatal surveillance aligned with British Association of Perinatal Medicine (BAPM) standards.

In November 2025, the Trust was notified by the National Lung Cancer Audit (NLCA) that it had been identified as a potential alarm outlier for the indicator ‘one year survival’. This indicated that the Trust’s performance was significantly lower than expected when compared with national results. During the reporting period, the national one year survival rate for England was 51%, whereas the Trust’s rate was 44%. This was being reviewed at the time of our assessment to understand the underlying factors contributing to this variation.

The trust was identified as an outlier for joint revision surgery. An investigation into higher-than-expected surgical site infections in hip replacement patients at Bishop Auckland Hospital in the period July to September 2024, identified consistent aspects of care that were not aligned to the World Health Organisation (WHO) surgical site infection prevention guidelines. We reviewed this during our assessment of surgical services and saw there was a correlation between specific surgeons and infections rates. The Trust told us it continued to review its processes and surveillance in surgery. In addition, they planned a one-year period of surveillance for elective total hip replacements at Bishop Auckland Hospital.

The Trust shared details of its planned clinical audit programme for 2025/2026. Participation was inconsistent across the care groups, with the Surgery and Family Health teams showing significantly higher engagement than other areas. Key audits were not always scheduled, and those that were scheduled were not always completed as planned. Staff reported that this variation was partly due to differences in how care group leaders viewed the importance of audits.

Data collection lacked consistency and there was limited oversight of audit processes. Resulting action plans were often incomplete or poorly implemented, which reduced the effectiveness of audits and limited assurance that improvements were made. Some completed audits, which identified areas for improvement, did not have associated action plans, and actions that were identified through audit were not embedded. This meant audit processes were ineffective, there was lack of oversight and monitoring of clinical practice, there were limited quality improvements following audit and no assurance that staff always worked in accordance with policy and best practice guidance, including NICE.

Senior leaders also told us they found it challenging to determine whether audits had been completed or if resulting actions had been embedded into practice.

Infection Prevention and Control (IPC) data was reported to the Board monthly through IQAC. It was also documented in the Director of Infection Prevention and Control (DIPC) Annual Report. For the period from July 2024 to June 2025, the trust was in the highest (least favourable) national quartile for MRSA infections, ranking 114th out of 134 trusts. The Trust’s rates of C. difficile and E. coli infections were higher than the national average; however, it was not in the highest (least favourable) quartile for either indicator. The September 2025 open trust board report highlighted a risk relating to an increase in trust-attributed C. difficile infections. Data showed low compliance with IPC practices. The report also noted that the Trust does not have sufficient side-room capacity across its sites to accommodate all infectious patients.

NHS England flu vaccination data was reviewed as part of our assessment. The most current figures available, covering the period from 1 September 2025 to 30 November 2025, showed that 48% of healthcare workers with direct patient care had been vaccinated against seasonal influenza. This was higher than the national average for NHS trusts over the same period (42%). This also represented an increase compared with the same reporting period in 2024 (1 September 2024 to 30 November 2024), when 44% of healthcare workers with direct patient care had been vaccinated.

In April 2017, County Durham and Darlington NHS Foundation Trust set up a wholly owned subsidiary, Synchronicity Care Limited (SCL). SCL provided estates, facilities, procurement, materials, supply chain management, equipment maintenance and transport services to the Trust. During our assessment we found appropriate oversight and management of SCL. Staff told us that SCL was well run with good governance arrangements. However, the arrangements for security management had been unclear for staff, with SCL responsible at the University Hospital of North Durham site while the Trust’s Head of Assurance and Compliance held responsibility at the Darlington Memorial Hospital site, as part of his responsibility for the Trust’s Health, Safety and Security function.

There were concerns regarding the trust’s current level of preparedness for cyber-security incidents. The trust had identified Cyber Security as a risk, and it was recorded on the BAF reflecting the increasing complexity and frequency of cyber-attacks across the health sector. The trust recognised the need to ensure cyber security training was refreshed in line with latest threats and continue oversight to mitigate future risks.

Information governance and data security training was required of 7,651 members of staff and was recorded as 94% compliance. In addition, the Trust required enhanced data security training to be completed annually by 511 members of staff; this had 92% compliance at the time of our assessment. There were no reportable breaches to the Information Commissioner’s Office (ICO) during the reporting period 2024-2025.

There was an increased risk associated with the Trust’s electronic patient records (EPR) system. The system required further optimisation across a number of areas, and there were risks linked to ongoing functionality issues. The Health Informatics team had limited staffing with the technical expertise needed to support the application. A clinically led risk assessment was needed to identify the priority changes required within the system and to determine the residual risks. This would enable the Trust to make an informed decision about the level of resourcing required going forward.

There was limited evidence of partnership working at a strategic level. Communication with stakeholders of identified serious issues has been poor, including CQC being made aware of serious patient safety events via the media instead of directly from the Trust. There were significant failings in the trust’s oversight of feedback and complaints, and the engagement with people related to this. The Trust had not developed a clear strategy for patient engagement. However, we saw some examples of partnership working at an operational level, especially in community services. Leaders acknowledged that further work was needed to embed meaningful patient and public involvement across the organisation.

There were significant failings in the trust’s oversight of complaints and the engagement with people related to this. Complaints were not reviewed and acted upon in a timely manner. The potential for learning lessons from complaints and lack of action planning meant opportunities were missed to prevent patients being exposed to the risk of harm. Whilst there was a process in place for managing and responding to complaints and concerns it was not managed effectively.

Reporting of complaints data was inconsistent. Between 1 June 2025 and 31 October 2025, the Trust had received 497 complaints. Of these only 28% were completed within the appropriate time frame. An average of 49% of complaints received were upheld or partially upheld. Medicine, UEC and surgery care groups received the most complaints.

At the time of our assessment, the Trust had 18 open Parliamentary and Health Services Ombudsman (PHSO) cases. The highest proportion (5) of these sat within the Medicine directorate, followed by 4 cases related to the Surgery directorate.

There were notable inconsistencies in the reporting periods used across datasets. This resulted in misaligned information being presented to the Board and reduced the clarity and reliability of the data. For example, within a single report, data was drawn from the following periods: 1 June 2025 to 31 October 2025; 1 July 2025 to 31 October 2025; and 1 October 2024 to 31 October 2025. Additionally, further data was provided for the period 1 October 2024 to 30 September 2025. The use of multiple, non‑aligned reporting periods within the same report created confusion and undermined the interpretability and credibility of the information presented.

Staff told us the complaints and patient experience functions were under significant pressure due to rising demand. They highlighted the need for more meaningful engagement with families and noted that the team had visited another regional trust to learn from their complaint handling practices. The current complaints policy and response templates were described as poor, lacking compassion and at times appearing defensive.

The 2025 staff survey results showed a score that was lower than the national average for the statement ‘My organisation acts on concerns raised by patients/ service users.’ This result was also lower than the 2024 result.

Leaders acknowledged the importance of strengthening the fundamentals of complaint handling. The new CEO had expressed dissatisfaction with the standard of complaint responses and requested oversight of these prior to issue. The pharmacy department supported the trust with medicines related complaints and incident reviews. Staff valued the patient safety partner’s role in contributing the patients’ perspective to responses.

Concerns were raised about gaps in training for complaint investigating officers, with previous requests for training reportedly declined. Leaders had identified a need to improve thematic analysis of complaints and to use this insight more proactively to address recurring issues and drive improvement. An internal review of complaints at the Trust had identified several cases that met the criteria for patient safety incidents but had not been classified or reported as such at the time. In response, the Trust had implemented measures to strengthen the interface between complaints and patient safety processes. All new complaints were reviewed on receipt to determine whether they constituted a patient safety incident, and a retrospective review of open complaints was underway to ensure correct classification.

As part of our assessment, we reviewed six complaints (both formal and informal) received by the trust in the period 01/10/2024 – 30/09/2025. The review identified substantial variation in the time taken to complete and close investigations, with timescales ranging from three months to more than eleven months. This was not in line with the trust’s Complaints and Concerns Policy. In the majority of cases, complainants received an apology and were offered a meeting with the complaint investigator. However, we found a lack of consistency with regard to the quality of the investigation and quality of the response to complaints received.

Hospital passports for patients with learning disabilities, autism, dementia and other long-term health conditions were not consistently used throughout the Trust. During our assessment of surgical services at the Trust, we reviewed documentation for three patients living with advanced dementia and none had hospital passports in place. However, the learning disability and autism team with the Trust’s digital team had developed an initial assessment template within the electronic patient record system which was for use with all patients admitted with a learning disability and/or autism. They also introduced a specific ‘Social Worker Contact Details’ section within the record which encouraged information sharing and enabled more coordinated, joined up care.

The Trust’s 2025/2026 annual planning report identified the development of the patient safety partner role as one of its aims. At the time of our assessment, there were two patient safety partners, one in a lead role. The lead role had funding for two days per week. The lead patient safety partner reported feeling valued in their role and felt included and listened to in meetings. They were confident in constructively challenging decisions and advocating for the patient perspective.

There was work underway reviewing information available to patients across services to become a health literate organisation and ensure information for patients, families and carers was written in an accessible and understandable manner. The patient safety partner was keen to include British Sign Language usage in communications.

As a foundation trust, the organisation had a Council of Governors which comprised of 37 elected and appointed members from partner organisations. The Council met publicly four times a year. From speaking with governors, there was an overarching feeling among the group of disempowerment and under‑utilisation. The governors reported that there had been no investment in training for the Council of Governors; however, the Trust provided information to us that detailed numerous training sessions offered to governors over the past three years. The governors felt that their role, meeting structure, and agendas lacked clear definition and structure. However, there was also cautious optimism, with early signs of improved engagement from the new leadership team.

We reviewed the Council’s meeting agendas for the February, May and September 2025 meetings. Agendas provided the governors with access to performance information. We were told that NED attendance at the Council of Governors had been historically perceived as poor. However, the Trust provided information to us which indicated the majority of NEDs attended each of the 10 meetings prior to our assessment.

Governors demonstrated an understanding of strategic concerns, for example concerns related to the breast service. While meeting minutes showed the governors had previously asked questions and raised concerns, some reported that assurance was not always provided. There were instances where issues were perceived to have been prematurely closed or dealt with without governor consultation. This highlighted a need to enhance assurance pathways and ensure that concerns were tracked and resolved effectively.

The trust had engagement meetings with Staff Side representatives and met with them regularly, but it was noted there was a long-standing absence of CEO attendance or engagement with them. Staff Side reported that they did not feel leaders always communicated effectively and often became aware of organisational issues only after formal reports were published, leading to a sense of learning about concerns retrospectively.

They described historic frustrations from staff regarding openness and honesty within the Trust which impacted on wellbeing and morale. It was felt there were missed opportunities to involve Staff Side more meaningfully in the Trust’s improvement journey. The Staff Side team was well informed and proportionate in its approach, with a good understanding of wider health inequalities. They shared they had an effective working relationship with the HR team.

Safeguarding partnership working needed strengthening. Concerns were raised prior to our assessment about the trust’s safeguarding arrangements, particularly in relation to patients presenting with mental health needs or a learning disability and their quality of care. Staff told us there were inconsistencies in identifying and accurately reporting key safeguarding issues within operational services. During our assessment we saw a lack of clarity regarding the Trust’s responsibilities when caring for patients with mental health needs or learning disabilities. This disconnect fed into associated incident investigations where we saw an over-reliance on the associated mental health trust to lead these reviews.

Completion and documentation of capacity assessments was poor, and staff told us more training and oversight of compliance was needed in this area. We saw inconsistent recording of restraint, particularly in relation to physical and chemical restraint. Although some progress had been made in this area, further work was needed.

The trust was part of the County Durham Care Partnership, a multi-agency collaboration which brought together NHS providers, primary care, social care, voluntary organisations and patient advocacy bodies to deliver integrated, community focused care.

The safeguarding team were part of an alliance board with a local mental health trust, the ICB and local authority. They told us the group had not met for some time, but it was something they needed to address to ensure services work seamlessly and safely across organisational boundaries.

The Trust’s soon-to-expire strategy identified health inequalities as a priority, and the health inequalities team expressed a clear ambition for this to become a stronger, integrated ‘golden thread’ within the forthcoming trust strategy rather than a standalone workstream. The team described the use of national frameworks, including Core20PLUS5 and the NHS Provider Toolkit, to guide their approach. Core20PLUS5 is a national NHS England framework that targets the populations and clinical areas most affected by health inequalities, enabling organisations to focus improvement efforts where access, outcomes and experience are poorest. The NHS Provider Toolkit for Health Inequalities gives trusts structured guidance, tools, and evidence-based actions to embed health inequalities work into everyday practice.

The team told us there were clear health inequalities reporting routes from care groups to the Board. Risk stratification was routinely used to identify priority areas, and the aligned Associate NED was recognised as an active advocate who provided constructive challenge, particularly in relation to data. At the time of our assessment, the team was focused on addressing deprivation related disparities through a range of projects. The team acknowledged that they were not yet able to demonstrate the financial impact from their work, nor outcomes for people and communities. However, the team shared an evidence pack which outlined outcomes from a number of projects which included: the roll out and embedding of making every contact county (MECC), securing grant funding for a project to reduce Was Not Brought cases among children in the Trust’s Core 20 population, and further targeted work in maternity and cancer services. The Trust recognised that more work is needed in this area to secure trust-wide impacts.

The new leadership at the Trust was aware of the need to assess local population needs to ensure the Trust delivers tangible outcomes that matter to communities. They acknowledged that ‘one size does not fit all’ and committed to tailoring the Trust’s offer so that local communities benefit from more targeted improvements.

The trust received 531 responses to the 2024 adult inpatient survey and scored ‘about the same’ compared to other trusts in the majority of the survey sections. Survey results indicated that the Trust did not perform ‘worse’ than other trusts that took part in any of the questions asked. However, the Trust performed ‘somewhat better than expected’ compared with most other trusts that took part in the survey in several areas, including meeting patients’ basic needs, such as ensuring they had enough to drink, and involving them in decisions when leaving hospital. The Trust also performed better in providing adequate notice of discharge and ensuring that care was available to patients after they left hospital.

Feedback from local Healthwatch organisations reported that while there had been some engagement from the Trust, it had not been sufficient. Information shared by the Trust was described as overly data driven, with limited insight into lived experience. They noted that opportunities for open, honest information sharing required greater attention and development.

Stakeholders told us the Trust demonstrated some regional engagement by participating in partnership committees and aligning with the wider shared vision. The Integrated Care Board (ICB) was invited to participate in the Trust’s internal meetings including the Executive Quality Committee from its inception in 2023 and was subsequently welcomed into governance forums relating to serious concerns within the Trust’s Breast service, suggesting collaborative working and transparency. However, historically staff and leaders were not always open and transparent and did not always fully collaborate with all relevant external stakeholders and agencies. Engagement had appeared superficial at times, as diary constraints led to absences from certain system events. They also noted that information provided was sometimes too data heavy, limiting opportunities for open, experience-based learning exchanges.

The trust had over 150 volunteers who supported a range of roles, including welcoming and greeting people, spending time with patients and their relatives and helping with patient survey completion. Some volunteers assisted with mealtimes, took on driving roles and helped within the hospital radio service. There was a formal recruitment process to become a volunteer which included a DBS check.

The trust had significant shortfalls in its approach to continuous learning and improvement across the organisation. There was an inconsistent emphasis on learning, innovation, and improvement in several areas. While some individuals and teams demonstrated good practice, leaders acknowledged that substantial work was required to address these gaps and to embed a more consistent and systemic culture of improvement.

Feedback from staff and external partners described the trust as being reactive rather than proactive in recognising where improvements were needed and in implementing sustained change. This was reflected in several areas of the trust’s performance, particularly the dissemination of learning from incidents.

The 2025 staff survey element ‘We are always learning’ showed a decrease from the 2024 result. The score for the statement ‘When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again.’ also decreased from 2024 to 2025. Both years the score was lower than the national average. This data is consistent with staff feedback during our assessment. Staff told us they felt learning was not shared well which resulted in people not wanting to speak up and/or report incidents.

Training completion rates were variable across the trust with an average mandatory training compliance reported as 93%. At the time of our assessment, appraisal compliance rates were recorded as 91% across all staff. Mandatory training compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was recorded as 89%, but this figure was misleading. Only 928 staff members were identified as requiring the training despite the trust employing more than 7,500 people. Given that MCA training is required for all patient facing roles, the number of staff expected to complete this training should have been much higher, indicating that the training cohort had been significantly under identified. Since our assessment of surgical services in October 2025, where we found poor understanding and application of the MCA and insufficient documentation of consent, the trust had approved and commenced the rollout of MCA training to ensure more comprehensive coverage across relevant staff groups.

Following a coroner’s case, the trust developed a pocket guide and an MCA/DoLS poster for staff. While the pocket guides were made available on the intranet and the poster was shared with ward managers, matrons and MCA Link Nurses, funding to print and display the posters trust wide was not approved due to financial constraints. The team also requested updates to the EPR system to provide clearer guidance for completing Mental Capacity Assessments and Best Interest decisions; however, progress was delayed pending an EPR upgrade.

As referenced earlier in the report, we reviewed 6 grievance cases from a sample of care groups across the Trust as part of our assessment. The Disciplinary Procedure was reviewed and updated in October 2020 to add emphasis on the Just and Learning Culture approach. The aim was to ensure conduct issues were dealt with in line with procedure, legislation and the Just and Learning Culture, and placed equal emphasis on accountability and learning. The procedure stated that “Any learning/recommendations from the case are considered, disseminated and implemented as appropriate within sphere of responsibility.”

However, we found a lack of effective organisational learning in this area. We reviewed a grievance case linked to a patient with dementia. There was no reference to staff training needs in dementia awareness, other dementia related guidance, Mental Capacity Act training or consent processes. A different case we reviewed related to IT governance. There was no identified learning or reference to training needs for either staff or the Trust. Another grievance case we reviewed showed patterns of repeated misconduct, this was not referenced or used to identify learning needs for the individual or the Trust. These examples represented missed opportunities to strengthen processes, apply learning and reduce risk.

The trust demonstrated significant gaps and no consistent approach to learning, improvement and innovation, across the organisation or within the wider local system. Although examples of good practice existed, leaders recognised that substantial action was needed to address these gaps and embed a more robust improvement culture across the trust.

The Trust did not have an organisational Quality Improvement (QI) methodology that was consistently understood or applied across all areas. Although some improvement programmes were in place, there was limited evidence of a strategic or coordinated approach to quality improvement or innovation at trust level. This resulted in variation in how QI was undertaken across services. However, the trust had a designated QI Lead whose approach was aligned with recognised improvement methodologies and national frameworks. The QI Lead was knowledgeable and demonstrated a clear commitment to ensuring that QI activity translated into measurable improvements in patient care and outcomes across the trust. This approach was not yet embedded throughout the organisation, and staff reported inconsistent awareness and uptake of QI principles.

At the time of review, the trust told us it had 12 active QI projects and had trained over 1,000 staff to novice level, over 70 staff to practitioner level and 20 staff to ambassador level. A Quality Hub existed, bringing together clinical audit, research, organisational development, and QI functions. These elements were situated within different directorates, and there was no director level sponsor providing strategic oversight or integration. There was no routine or structured patient involvement in QI activity. Opportunities to involve patient advocates more effectively in co‑design were not being maximised, limiting the potential impact on patient experience.

The QI Lead provided updates to the Board twice a year; however, current reporting arrangements did not provide strong visibility or assurance regarding progress, outcomes, or learning from QI work.

The organisational culture was described as challenging, with some resistance to curiosity, exploration, and improvement focused behaviours. This limited the extent to which a culture of continuous improvement could be embedded across the trust.

The Trust was noted as a persistent outlier with respect to its Summary Hospital-level Mortality Indicator (SHMI) rate. SHMI is the ratio between the actual number of patients who died following hospitalisation at the trust and the number that would be expected to die, based on average figures across England. The most recent published SHMI data for November 2024 to October 2025, recorded a SHMI of 1.29, categorised as ‘higher than expected’. At site level, UHND had a SHMI of 1.37, also above expected levels. For comparison, the trust’s SHMI for November 2023 to October 2024 was 1.20, and 1.21 for November 2022 to October 2023, showing no improvement over time and maintaining its position as an outlier.

The trust’s outlier status was included on the Strategic Risk Register, which stated that further investigation was required to understand whether any underlying quality related issues were contributing to the higher than average mortality rate. This risk was assigned a score of 12.

The trust had a medical examiner service that provided independent scrutiny of deaths, ensuring the cause of death is accurate, appropriate referrals to the coroner are made, and bereaved families have a clear, compassionate point of contact to ask questions and raise concerns, with a view to supporting better governance and learning across the Trust. The medical examiner service provided an additional layer of oversight and contributed to the trust’s governance of mortality.

Structured Judgement Reviews (SJRs) are a nationally recognised method used in the NHS to review the care provided to patients who have died. They are part of the Learning from Deaths framework and aim to identify areas of good practice, opportunities for learning, and potential improvements in care. As part of our assessment, we reviewed six SJRs. We found the quality of care provided by the Trust varied, with some cases rated as poor and others as excellent, particularly in ongoing care and end-of-life situations. Organisational improvements in clinical care, application, and ITU referral were identified as key learning points and sharing of learning with care groups, service lines and wards. The Trust told us mortality reviews are also carried out on a random sample of non-priority deaths to identify area so learning and good practice.

While the trust had mechanisms in place to review deaths and identify learning, the low completion rate of SJR’s limited the effectiveness of this process. Although learning was identified, there was insufficient assurance that learning from deaths was being consistently captured, analysed, and used to inform improvement. This represented a missed opportunity to strengthen clinical governance and improve patient safety.

We reviewed incidents from both the Strategic Executive Information System (STEIS) and the Learning from Patient Safety Events (LFPSE). Both systems are used by NHS organisations in England to report serious incidents and events. STEIS data was reviewed for the period 31 October 2024 to 31 October 2025. LFPSE data was reviewed for the period 1 November 2024 to 28 October 2025.

Analysis of patient safety incidents logged in STEIS and LFPSE reports revealed multiple recurring themes. These were: loss of patients to follow up/ missed test results; quality of in-patient documentation, discharge information, handover and communication; Health Care Associated Infections; VTE assessment and prophylaxis; identification and response to the deteriorating patient; maternity services; mental health crisis; flow of patients from ED/ Impact of Full Capacity Protocol; falls; tissue viability; Mental Capacity Act and Safeguarding (including the safe use of chemical restraint).

Between November 2024 and October 2025, the trust reported 43 STEIS incidents, including 6 never events and 24 unexpected or potentially avoidable deaths. Fewer than half were reported within two weeks, and over a quarter were submitted after 90 days, indicating significant delays in serious incident reporting. A sample review also found insufficient detail in free text fields, highlighting concerns about reporting quality.

LFPSE data showed 24,600 notifications, but only 17 ‘Good Care’ and 2 ‘Risks’, with almost all entries recorded as incidents. This pattern suggests underreporting of risks. The Trust told us that although staff do not always use LFPSE to report good care, it routinely captures excellence reports to support proactive learning. The variation in reporting practice indicates some inconsistency in application of the process. Although most incidents (93%) were reported within two weeks, analysis showed notable peaks in April and May 2025, with some cases reported over a year post incident, and fatal or severe harm incidents were disproportionately affected by delays (15% after 90 days; 7% after a year), indicating inconsistent timeliness for the most serious events.

Reporting timeliness varied widely between specialties. Medical Oncology had the highest proportion of reports submitted after 90 days (49%), while General Surgery had the greatest number of reports made more than a year late (65), representing around a quarter of the trust wide total. Although none of these delayed reports involved severe harm or fatal outcomes, the variation indicates an uneven reporting culture across specialties.

A review of 38 fatal LFPSE incidents confirmed that the trust did have learning and escalation processes, including AARs, PSIIs, and Senior Clinical Leader reviews. However, the review also reinforced that delayed reporting of serious and severe incidents remained a recurring issue, signalling a need for strengthened governance, oversight, and responsiveness.

Between 1 November 2024 and 31 October 2025, the trust reported six never events. Never events are serious, largely preventable patient safety incidents that should not occur if national guidance and preventative measures are properly implemented. We saw examples of recurring never events, that included wrong site surgery and retained objects which indicated processes were not being followed to keep patients safe. The trust patient safety and experience report from November 2025 showed a recent internal audit provided only limited assurance with respect to learning from never events.

We reviewed seven Prevention of Future Death (PFD) reports issued since 1 January 2024. These reports highlighted recurring concerns that aligned with wider issues across the trust. The trust had responded to all PFDs within the coroner’s required timeframes, demonstrating that it had acknowledged the issues and outlined actions taken or planned to support learning, improve practice, and reduce the risk of future deaths. A consistent theme was inconsistently completed medical documentation, frequently lacking essential clinical information, which posed risks to continuity of care and clinical decision making.

The trust had implemented the Patient Safety Incident Response Framework (PSIRF) in line with national requirements, supporting a more compassionate and systems-based approach to learning from patient safety incidents. However, at the time of our review, there had been a significant number of overdue PSIRF incidents and action plans, which raised concerns about the trust’s capacity to manage its incident response workload and ensure timely learning and improvement.

Although the framework was in place, the volume of overdue actions showed that PSIRF processes had not yet been fully embedded, and further assurance had been required to confirm that incidents were being reviewed within expected timeframes and that learning was being translated into timely and meaningful change.

As of November 2025, the trust had 2,236 open patient safety incidents that required review across the organisation, 705 of which had been open for more than 60 days. Of these, 357 were undergoing a PSII, MNSI, Specialty Led Review, Rapid Review or Thematic Review and 348 were open without a clear rationale. The trust’s patient safety incident response plan had outlined the expected learning and improvement pathway for each type of incident.

Of the 25 commissioned PSIIs, 10 sat within the medicine care group, 7 within surgery, 5 in urgent and emergency care, 2 in family health, and 1 in clinical specialist services. These cases had been progressed under PSIRF, with collaborative meetings arranged where multiple organisations were involved.

Oversight of Patient Safety Incident Investigations (PSIIs) was led by the Patient Safety Leads, who were described as committed staff working in a challenging role. They were focused on embedding PSIRF, improving the quality and timeliness of complaint responses, and strengthening patient safety and patient experience across the trust.

Staff told us there had previously been insufficient resource to complete PSIIs within expected timescales, including one investigation that had taken eleven months, completed to meet coronial deadlines. The team understood that high quality PSIIs were essential for identifying learning and ensuring that actions to improve safety were effectively embedded.

As part of our assessment, we reviewed six serious incidents and their associated PSIIs. One PSII, relating to an incident in December 2024, identified several early safety actions, including the need for an emergency call bell in theatre and the requirement for staff training in the use of emergency portable mechanical CPR equipment. The trust informed us that training was subsequently delivered to theatre staff in September 2025. They also told us that installation of a theatre call bell had been postponed due to financial constraints. The risk associated with the lack of call bell in theatre had been added to the risk register in June 2023 but not actioned.

We reviewed a further PSII concerning an incident in May 2025 which referenced the use of the emergency mechanical CPR device, despite the training identified in the earlier incident not having yet been completed at the time, as well as the continued absence of a call bell in theatre. This incident occurred five months after the previous event and demonstrated the critical importance of timely learning, effective dissemination, and the robust embedding of safety actions in order to prevent repeat risks and avoid unnecessary harm to patients.

In one investigation, the PSII relied solely on the local mental health trust’s review, with no additional input or learning contributed by County Durham and Darlington NHS Foundation Trust. This raised concerns about the robustness of cross organisational learning and the Trust’s internal oversight.

Across the PSIIs we reviewed, recurring themes included poor timeliness of completion, slow or inconsistent embedding of safety actions, limited evidence of learning being shared more widely, insufficient challenge when contradictory timelines were identified, and a lack of documented follow up when cultural concerns were raised. Staff also described frustration at repeatedly raising patient safety concerns without seeing sufficient action in response.

These findings indicated that the Trust had not yet established consistently effective systems to ensure timely investigation, reliable learning, and sustained improvement following patient safety incidents.

Staff told us that there were confusing governance structures, with unclear responsibility and accountability, which had hindered the consistency and effectiveness of safety oversight. However, new leadership at the Trust had acknowledged the need for rapid improvement in this area.

In November 2025, the trust published the findings of an independent external review into its breast surgery services. The review identified long‑standing governance failings, including delayed diagnoses, unnecessary procedures, and persistent outdated practices arising from what was described as a ‘culture of complacency’. These issues had been raised repeatedly over many years but were not acted upon, limiting opportunities for organisational learning and resulting in avoidable harm. The review highlighted weak clinical governance processes, poor escalation of concerns, fragmented accountability, and low psychological safety among staff. These factors collectively hindered the trust’s ability to identify concerns at an early stage and respond effectively. Key learning requirements included strengthening governance systems, improving the use of audit and national guidance, clarifying leadership responsibilities, and fostering a culture that supports speaking up and continuous organisational learning. The review emphasised that these lessons must be embedded across the wider organisation.

In early 2025, the Royal College of Surgeons’ invited review identified significant concerns within the trust’s breast surgery service, including unusual surgical practice, high re-excision rates, and issues with diagnostic quality, particularly inadequate biopsy sampling. These factors contributed to delayed or missed diagnoses and unnecessary procedures. This review found weaknesses in clinical governance, inconsistent MDT functioning, and insufficient oversight of outsourced and out of hours clinics. These gaps limited the trust’s ability to detect risks early and respond effectively. Gaps included strengthening governance and accountability, standardising practice in line with national guidance, improving diagnostic pathways, and embedding systematic learning from harm reviews. The findings emphasised the need for the trust to establish safer, more consistent care and ensure that lessons are applied across the wider organisation.

Together, the findings demonstrated the need for organisation wide learning, strengthened accountability, and a culture change to support safe and effective care.

Staff and external partners reported that the trust tended to respond to issues only once they had arisen or when they were identified by stakeholders, rather than proactively identifying where improvements were needed or taking early action. This reactive approach was evident in several aspects of performance, including the sharing of learning from incidents, learning from deaths, and safeguarding concerns. Partners told us there had been a history of slow resolution of issues, and that limited challenge to outdated practices had reduced opportunities for organisational learning within the trust. In response to the recent external reviews, the trust had developed improvement plans, committed to a comprehensive governance review, and appointed two independent Board advisors to support this work. Immediate safety reviews had taken place across services, drawing on national guidance, with some early learning evident. Senior leaders had also taken steps to increase transparency. However, ongoing communication failures about changes continued to create perceptions of blame and resistance, limiting the trust’s ability to embed learning effectively and sustain improvement.

The trust participated in several recognised external accreditation programmes, including the Macmillan Quality Environment Mark, the Human Tissue Authority, and the UNICEF Baby Friendly Initiative (BFI). These accreditations reflected areas of strength where services met defined quality, safety, and performance standards. However, further work was required to ensure a consistent approach to accreditation and quality assurance across all sites and services. BFI accreditation was in place only for the neonatal service. The maternity service was working towards achieving accreditation in the future.

The trust was also progressing work to gain accreditation in three additional schemes: Joint Advisory Group (JAG) accreditation for Gastrointestinal Endoscopy, Elective Surgical Hub accreditation for the surgery care group, and British Society of Echocardiography accreditation for the medicine care group.

Of the ten accreditation schemes currently in place across the Trust, all were clinically focused. However, the finance function has achieved the Future Focused Finance Accreditation Award, and the Group holds several non-clinical quality certifications for functions delivered through SCL, including sterile services, clinical engineering, soft services and procurement.

The trust had implemented nationally recognised training in learning disability and autism, with a target of achieving 95% compliance across 7,642 eligible staff members. As of December 2025, compliance stood at 90%, demonstrating positive progress towards the target.

The trust had a Head of Research who reported that research activity was focused on addressing unmet patient needs and supporting the development of evidence-based practice. The trust worked in partnership with a local university to strengthen research capability and promote collaborative learning. There were very few concerns identified in relation to research governance. The research team demonstrated awareness of the need to maintain good record‑keeping and ensure ongoing compliance with regulatory standards, including those set by the Medicines and Healthcare products Regulatory Agency MHRA and CQC. At the time of our assessment, the research team was overseeing approximately 70 active studies across the trust, with strategic oversight provided by the Medical Director.

The trust has participated in an NHS pilot focused on developing the use of artificial intelligence (AI) to improve spirometry. Spirometry is a key diagnostic test used to identify lung conditions such as COPD and asthma. The initiative aims to improve test quality, reduce long waiting lists, and support staff in interpreting complex results.

The pharmacy leadership team supported staff to present and submit good practice posters and learning to conferences. In the last year eight posters had been submitted and presented at UK and European conferences where an award was won.

There were some shortfalls in the trust’s approach to environmental sustainability and sustainable development. Strategic board level leadership was unclear. Staff we spoke with felt that the Green Plan was underdeveloped. We were told people were not following waste streams on site, which impacted on achievement of the waste reduction targets. Staff commented that there had been financial challenges implementing some of the sustainability changes which meant they probably would not meet the carbon reduction target.

The Trust was responsible for a large estate which varied in age and condition, with many buildings and infrastructure elements presenting challenges for environmental sustainability.

The Trust had two named sustainability leads who led on both internal and external engagement on environmental sustainability. The Trust did not share information of any Green Champions throughout the Trust.

The Trust had a Green Plan 2024-2027 which was launched in October 2024 and replaced the previous three-year Green Plan 2021-2024. The new Green Plan introduced several new priorities, expanded targets and updated sustainability ambitions. The overall aim of the new Green Plan was to:

• Reduce the Trust’s environmental impact
• Improve patient care using more sustainable models, including delivering more care digitally and increasing communication via the NHS App.
• Align with national Greener NHS commitments
• Provide a detailed roadmap toward Net Zero by 2045

During our assessment, we asked staff about board level representation, awareness and understanding of sustainability and the Green Plan. We were told that there had been a challenge to educate the board on the objectives and progress that had been made and there was a need to gain support at board level, and below it. It was felt that the recent changes at executive level improve delivery of the plan.

People we spoke with did not know who the board level lead for environmental sustainability was. The Trust told us that the previous board-level lead with responsibility for the Green Plan had retired. We received conflicting information when we asked who the lead would be moving forwards. We were told the Managing Director of the estates subsidiary, Synchronicity Care Limited (SCL), was in the process of taking over the role; however, we were also told that the role would sit with the Executive Director of Operations and the Green Plan would be updated to reflect this change.

The Trust was involved in a North East Combined Authority project to improve transport and bus links to and from the main hospital sites. This externally funded initiative was to support patients, staff and visitors travelling to Darlington Memorial Hospital, University Hospital of North Durham, Bishop Auckland Hospital and community hospitals. The project helped with a reduction of missed appointments, improved staff commutes and provided staff, patients and visitors with a greener transportation option by reducing the number of cars being used. Travel timetables and bus information was displayed on digital display screens in public areas. People could also access the information via the website or app.

The Trust had planned to introduce the use of heat pumps which would improve its energy efficiency. The Trust advised it was conditionally awarded external funding for heat pumps but was unable to meet the required timescales for associated works due to internal funding constraints. As a result, the funding was lost. Heat pumps use electricity to transfer heat instead of producing it by burning fuel. Because they don’t burn fuel, they don’t produce carbon emissions.

The Trust shared some of their successes in environmental sustainability initiatives. Examples included: changing from disposable theatre caps to reusable theatre caps, which led to a decrease of 100,000 units each year. They stopped using couch roll which has seen a reduction of 40-50 tonnes of product each year. Another initiative was a move away from single-use plastic; this change led to a reduction of 25 tonnes of single-use plastic each year across services. The Trust also implemented an initiative to reduce anaesthetic-related greenhouse gas emissions; this led to a reduction of approximately 700 tonnes each year.

The estates subsidiary had changed the majority of its vehicle fleet to electric vehicles. In addition, they were installing LED lighting across the Trust which was reducing costs and increasing efficiency.