County Durham and Darlington NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients were actively involved in decisions about their care, with staff providing clear information, monitoring changes in health, and arranging timely referrals or adjustments to treatment plans to ensure care remains responsive to individual needs.

We observed examples where staff worked closely with people to adapt care plans in response to changing health needs, such as arranging specialist referrals and providing clear guidance on self-care.

Staff also described how they regularly monitored individuals’ conditions and communicate any changes promptly to ensure decisions are made collaboratively, keeping the person’s preferences and wellbeing at the centre of their care.

Staff told us t how they used the electronic patient records system to monitor patients moving between acute areas of the trust and the community to promote better communication and continuity of care for the person receiving care. We saw evidence of a daily list which alerted community staff when someone had been admitted to hospital. This enabled staff to provide a handover to colleagues, and we observed this working efficiently during our on-site assessment.

A ‘reactive nurse’ was on shift every day who dealt with any additional cases or unplanned work that arose, for example, responding to 2-hour crisis responses. This supported members of the team to have protected time for staff huddles; to check on staff welfare, and the opportunity to discuss complex cases or seek advice from peers.

Patients and their families spoke positively about the responsiveness of the services to their needs. One patient told us he had been struggling to get a GP appointment, however, after calling the single point of access line, they were quickly supported and able to secure an appointment with a physiotherapist on the same day. Another patient told us when they needed an x-ray, they were able to use a walk in service at a time that was convenient for them. Patients told us that they had been seen in a timely manner after being referred by their GP, particularly to the physiotherapy service. They also told us that clinics tended to run on time and that these were rarely cancelled.

There were processes in place to contact patients who did not attend appointments, or who missed planned home visits. During home visits we observed staff supporting colleagues to manage their workload, particularly where a member of staff had been delayed at an appointment or was dealing with a crisis. The service had also brought in extra staff to help deal with extra demands on the staff from winter pressures.

The service displayed information leaflets in English at all sites. Where leaflets were required in other languages, staff told us these could be obtained.

Clinics had ‘welcome’ posters in various languages. Leaflets subjects included struggling to cope with the financial effects of cancer, dental care and carer support services. Team bases had information displayed about supports available to patients.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights, and how to complain. Staff made information leaflets available in languages spoken by patients. Interpreters were available for people who needed them.

Staff ensured carers and families were regularly updated about the patient’s progress. One family member told us, “Mum is getting good treatment. They are very helpful if I have any questions. I’m happy,”

The service complied with the Accessible Information Standard.

The service treated concerns and complaints seriously, investigated them and learned lessons. Between January and December 2025, they had received a total of 458 complaints. The most frequent reasons for complaints were communication of information and appointments.

The complaints had been thematically reviewed and actions taken were documented. These were shared with the whole team and the wider service.

Patients, relatives and carers knew how to complain or raise concerns. Information about complaints was displayed in public areas at each site.

Managers worked to keep the number of cancelled appointments to a minimum. Managers monitored waiting times and made sure patients could access services when needed and received treatment within agreed timeframes and national targets.

When patients had their appointments cancelled at the last minute, managers made sure they were rearranged as soon as possible and within national targets and guidance.

Managers and staff started planning each patient’s discharge from the community service as early as possible. Staff planned patients’ discharge carefully, particularly for those with complex mental health and social care needs. Staff supported patients when they were referred to other services or transferred between services.

The geographic area covered by the trust incorporates four prisons. Staff had completed a visit to a one of the prisons for an appointment to see an elderly patient based on the hospital wing. Staff explained how they had maintained the patient’s dignity throughout the appointment but ensured that a prison officer was present to ensure the safety of the community nurse.

People experienced a person-centred approach, which promoted equity of experience.

The trust listened to people who were most likely to experience inequity and aimed to develop services to address this. People working in services reflected the diversity of the communities they worked in.

Staff worked hard to empower patients to make choices around their care and treatment. Staff had a clear and detailed understanding of the individual needs of their patients. Staff gave us examples of times where they had respected peoples culture and faith, particularly during intimate examinations to preserve dignity.

Specialist teams delivered good quality care and worked collaboratively with district nursing teams to deliver joined up, holistic care.

The trust utilised different methods of collating information relating to equality, diversity and inclusion including a dashboard which outlined actions to be taken and monitored progress of this.

Care plans were holistic and included persons’ wishes. People’s preferred place of death was clear for those receiving end of life care.

We observed staff providing end of life care during our inspection. Staff were respectful sensitive during these times, taking time and going the extra mile to ensure patients and their families were well supported

Managers supported staff to complete advance care planning (ACP). ACP supports patients to plan for their future care and support, including medical treatment, whilst they have the capacity to do so. Staff support patients to make decisions about their care and treatment and their future – for example DNACPRs (stands for do not attempt cardiopulmonary resuscitation). A person can express a wish that if they suffer a cardiac arrest medical professionals should not perform CPR. We also reviewed examples of training provided to staff to improve understanding of DNACPR processes, legal considerations, and communication strategies. It sets the stage for a detailed discussion on ethical, clinical, and procedural aspects of DNACPR.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.