County Durham and Darlington NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Care plans included a comprehensive assessment of the patient and staff completed these in a timely manner. Staff assessed patients’ physical health needs on a regular basis. Staff developed care plans that met each person/ patient’s needs identified during assessment. Care plans were personalised, holistic and recovery oriented. Staff updated care plans when necessary.

We observed triage processes across community services including the bladder and bowel service, and physiotherapy. This was completed using an integrated screening tool. We observed triage nurses dealing with high levels of complexity but taking time to listen to the patient. They used effective communication strategies to ensure the correct level of information was obtained and the patient understood everything discussed. We also observed staff considering capacity as part of the call. The patient was also signposted to a number of other resources as part of the assessment.

Staff were competent and knowledgeable. Managers proactively supported staff to acquire new skills, use their transferable skills, and to share best practice. Managers ensured all new staff undertook a full induction tailored to their role before they started work. Staff were required to complete competency assessments before undertaking tasks independently and additional training was tailored to meet the individual needs of staff. Staff told us they were dedicated to providing high quality care based on up-to-date information and guidance.

Staff’s skills, competence and knowledge was recognised as being integral to ensuring high quality care. Staff and leaders had up to date knowledge in relation to good practice and standards, relevant to their service. Staff followed up-to-date policies to plan and deliver high quality care in line with national guidance.

We observed morning meetings and huddles throughout the day where staff routinely referred to the physical, psychological and emotional needs of patients, their relatives and carers. During home visits, we observed staff monitoring levels of pain and discussions about pain management taking place. The service used the malnutrition universal screening tool used to assess nutritional risk in adults (MUST), and staff were appropriately trained to support people with nutrition and hydration needs.

The trust monitored the frequency and quality of staff supervision and appraisals. Managers made sure staff attended team meetings or had access to meeting minutes when they could not attend. Staff told us they were supported to gain further qualifications relevant to their role.

Teams had positive relationships with external health and social care stakeholders. Staff worked effectively with NHS trusts, social care and primary care clinicians to deliver high quality services.

Staff worked collaboratively to ensure patients received high levels of care. However, staff told us that referrals from the acute areas of the trust did not always include accurate referral information including risks. We raised this with managers during the inspection and they told us work was ongoing to improve communication and the level of information they received. Information was shared between teams and services to ensure continuity of care.

District nursing teams had regular meetings to discuss patients and these were attended by managers including community matrons. District nurses described effective multidisciplinary and integrated team working between tissue viability, diabetic services and leg ulcer teams. The bladder and bowel team utilised a rota system which ensured each member of staff had the opportunity to attend daily huddles and meetings. Staff told us this helped them feel part of a team and gave them the chance to see other team members, with some staff telling us the community nurse role could sometimes be isolating. There were also regular meetings which focused on particular areas such as infection control and palliative care.

District nursing staff arranged calls with GPs to discuss their individual patients where appropriate. The electronic record system enabled staff to share and receive information from GP practices.

People and their families gave us examples of positive multidisciplinary working. One family member told us that following a review with the District Nursing Team, their family member was referred to another team for further follow up. Another told us, “If they [the nurses] find anything different, they inform the doctor - everything links through the surgery.”

Staff comprehensively assessed each patient’s health and provided support for any individual needs to live a healthier lifestyle and we observed evidence of this during home visits. Patients and their families also confirmed that they received advice regularly from staff on how to stay healthy.

Teams had relevant information promoting healthy lifestyles and support in their area. They also provided interventions groups to support people who were newly diagnosed. For example, we observed a group session for people who had recently received a diagnosis of Parkinson’s disease. The group lasted 8 weeks and was jointly led by staff from the occupational therapy physiotherapy teams covering a mixture of exercise, educational information and relaxation. At the end of the 8 weeks, members were also supported to access other resources and groups in the community. We spoke to members of the group who spoke highly about the support they received through it.

Managers and staff carried out a comprehensive programme of regular audits to check compliance and improvement to support the delivery of care. Managers told us they monitored team performance through supervision and oversight of audit findings.

Outcomes for patients were positive, consistent and met expectations such as national standards, and managers and staff used the results to improve patients' outcomes.

We observed staff supporting patients to make their own decisions and to access advocacy where necessary. The provider had a link Mental Capacity Act nurse in place to support staff teams.

We requested the training compliance for mental capacity act and deprivation of liberty safeguards training from the Trust. They told us that they had recently reviewed the training requirements for registered professionals who were patient facing. Prior to this review, there were only a small number of staff that were allocated mental capacity act training, mainly medical staff. The outcome of the review meant that there were now an additional 936 members of staff in the community health services for adults who were eligible to undertake this training. Therefore, the compliance levels for this training at the time of our assessment were at 41%. There was a plan in place for these new staff to have completed the training by the end of July 2026.

We observed staff gain consent from patients for their care and treatment in line with legislation and guidance. We also saw evidence of staff assessing capacity during appointments on a decision-specific basis. Staff made sure patients consented to treatment based on all the information available.

When patients lacked capacity, or could not give consent, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history but did not always document this robustly. We also found evidence that where family or friends held delegated decision-making powers, staff had not always seen, or held documents to confirm this was in place. Senior leaders within the team were already aware of this following feedback from the coroner in relation to a patient death. Whilst the constraints of the electronic patient record did create difficulties, they were in the process of designing a new template to support staff with documenting consent and capacity more robustly.

We requested the most recent audits of the community health services for adults use of the mental capacity act. The Trust told us that these had only been introduced towards the end of 2025 when a new template was added to the patient records system for staff to record the use of the mental capacity act. As such, there had only been one audit of the use of the Mental Capacity Act within these teams that we could review. Prior to the new template introduction MCA recording within the patients' electronic record was not coded and therefore not available to report or audit.