County Durham and Darlington NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the trust had arrangements in place to support people to receive safe care and treatment.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they felt there was an open, supportive culture across the teams. They knew where to escalate incidents and concerns both within the teams and through Freedom to Speak Up Guardians.

Staff felt that management supported them to report issues and listened when they spoke up and took action where appropriate. For example, staff told us that staffing levels had improved in the last year following concerns raised. However, some staff told us that workloads still fluctuated and at times were difficult to manage.

Some staff told us about issues relating to the connectivity with their lone worker devices. Some of the areas covered by the team were remote and staff told us they struggled to get devices to work. However, we did observe these devices being used on home visits. Staff told us that the lone worker app had been updated and managers told us that they were exploring options with IT to resolve remaining connectivity issues. The trust had a lone worker policy in place and a recent review of this found that 81% of staff were compliant.

Staff told us about issues relating to the information contained in risk assessments not being reflective of the situation when they arrived at home visits. This was a particular issue where patients had recently been discharged from hospital and information had not been communicated. However, staff told us that they were supported by line managers not to enter situations where they felt unsafe and actions were taken to support the safety of the staff. For example, the trust had recently written to patients requesting that resident dogs were not present or safely contained during visits. However, staff also expressed concerns about not all staff being consistent in enforcing this.

Following incidents, rapid reviews took place with staff to understand why things have happened and identify learning. Learning was fed back through meetings and other forms of communications. For example, a number of incidents had taken place in relation to the administration of insulin. As a result, the trust had completed a thematic review and identified contributory factors such as checking information with the patient prior to administering the medicine. From this they had then identified actions designed to strengthen the process and were monitoring the efficacy of it for improvements. We observed staff completing appropriate levels of checks with patients during home visits. Staff told us teams worked hard to ensure incidents didn’t occur again.

The trust had ‘Tuesday Topic’ in place where they circulated one page information to staff about certain topics to assist staff with learning. For example, we viewed a ‘Tuesday Topic’ covering violence and aggression that informed staff about where this information was location on the electronic patient record and how to use it.

Patients had care plans in place to help staff deliver care safely and staff involved all necessary healthcare professionals in the development of these.

Staff completed risk assessments that supported the safety of patients. Some patients had mobility problems and risk assessments outlined their ability to complete tasks, identified risks, and ensured these were managed or mitigated appropriately. Patients were given information on how to access the service for re-assessment.

Staff worked collaboratively with other agencies, to ensure continuity. For example, care plans and risk assessments had been shared with domiciliary care agencies, informal carers and family members. Social workers were integrated into the teams to ensure robust planning and joint working to keep people safe.

Staff told us their teams often received referrals from acute hospital settings that did not contain sufficient information. They were working with these hospitals to improve the quality and safety of transfers of care to community settings.

The trust had a safeguarding policy in place to support staff. Staff told us they received training in safeguarding and felt this was beneficial to help them keep people safe.

Staff told us that when a potential safeguarding incident was identified, they would escalate this to their manager to discuss appropriate actions and, if deemed to meet the threshold, they would raise an incident report on their internal reporting systems as well as reporting externally to the local authority safeguarding team. Staff told us where a situation needed immediate response, they would escalate this immediately to appropriate partner agencies, for example, the police or local authority safeguarding teams.

During a visit we observed a staff member identify a safeguarding concern which they escalated appropriately both internally and externally. We also observed the staff member raise their concerns with the manager of the care home the patient was residing in.

The trust had an internal safeguarding team who supported them with decision making around safeguarding but also with information sharing from multi agency forums such as, Multi Agency Risk Assessment Conference, Multi-Agency Public Protection Arrangements and Child Protection Meetings. They also supported with the communication of information between the acute areas of the trust and community.

There was evidence that staff had worked collaboratively with patients, their families and carers to create risk management plans. Staff ensured these were reviewed on a regular basis. Patients told us they knew what their care plans was, that they had a copy in their home, and that staff explained different elements of the care plan to them so they understood them fully.

Staff enabled patients to make advance decisions when appropriate. Staff ensured that patients could access advocacy where needed.

We observed regular meetings and huddles where staff shared key information to keep patients safe when handing over their care to others. We were assured that shift changes and handovers included a good level of information necessary to keep patients, and staff safe.

We reviewed evidence of acceptable behavioural agreements where there were risks to staff from patients, or their family members. This included agreements regarding threatening or abusive behaviour, derogatory terminology and certain family members not being present during visits.

The community outpatient parenteral antimicrobial therapy (OPAT) team who delivered care and treatment to people with IV medications in the community had developed a policy procedure for self - administration of Intravenous (IV) therapy. This offered an opportunity for patients to self-administer their intravenous medicine. This had been introduced in response to the large geographical areas covered, and weather challenges and meant patients could administer their own medicine in circumstances where professionals were unable to attend the home. There policy contained inclusion and exclusion criteria, and we received positive feedback from this from staff and patients.

The design of the environment followed national guidance. Staff carried out daily safety checks of specialist equipment. The service had suitable facilities to meet the needs of patients’ families. The service had enough suitable equipment to help them to safely care for patients. Staff disposed of clinical waste safely. One patient told us they found the hospital environment very calm when they attended for appointments.

Environmental risk assessments had been completed for patients’ homes that included information regarding parking, lighting, condition of the home and additional risks such as patient’s alcohol use, risk of passive smoke inhalation and any risks posed by animals. Patients had been included in reducing or mitigating those risks by being asked not to smoke for one hour before visits, or to ensure dogs were housed safely in a separate room.

Staff told us they worked on the principle of dynamic risk assessments which could change between appointments. The team lead confirmed the risk assessments and care plans were updated quickly where appropriate.

In line with the national picture, demands on community services were high, due to increasing complexity of needs, rising population pressures, and limited resources, compounded by recruitment issues. At the time of our inspection, some of the teams were experiencing increased levels of sickness, and late shifts were difficult to staff. We conducted an out of hours inspection to ensure care delivered during evenings was safe and effective. We found that staff were working hard to maintain quality despite high caseloads and workforce challenges. This included staff picking up bank shifts within their own teams to ensure consistency for patients and ensuring that additional bank staff had appropriate levels of knowledge and skills.

There were a range of induction courses available to new starters and a preceptorship programme to support them through their initial employment. These covered trust values, accountability, resilience, communication, inclusivity, and clinical skills through themed sessions and simulations. Key topics include chronic disease management, infection control, clinical governance, caring for complex needs, and career development, with ongoing support for health and wellbeing throughout the program.

The trust’s approach to preceptorship was structured around a 12-month programme designed to support new staff. A standardised preceptorship framework is used to guide meetings, reflections, and record learning and development, alongside role-specific competency packages.

Staff told us they were supported to complete their mandatory training however, sometimes needed to do this in their own time. They told us there was support available for newly qualified nurses, and opportunities for staff to develop if they wanted to complete nurse training, master’s or degree top ups.

Staff told us they received clinical supervision and the opportunity to receive supervision as and when needed. Staff also received an annual appraisal. Staff told us support was available from Band 6 or 7 registered nurses where needed.

Some members of the team were accredited to The Queen’s Institute of Community Nursing. This accreditation is available to registered nurses who have demonstrated a high level of commitment to patient care and nursing practice.

Hospital and clinic environments were clean and tidy. During home visits, we observed staff taking measures to maintain good levels of hygiene, cleanliness and infection control. We observed staff utilising personal protective equipment during the visits. Where waste was created, we observed staff disposing of this in an appropriate manner. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

Managers completed audits to ensure that staff maintained appropriate standards of cleanliness and infection control. Cleaning records were up to date and demonstrated that the environment was regularly cleaned.

Staff followed systems and processes to prescribe and administer medicines safely. Staff were suitably trained and competent to administer medicines. Staff had access to support from the pharmacy department if needed. Staff told us they worked within their areas of competence when prescribing and had access to appropriate peer support when considering how to manage complex medicine and prescribing decisions.

Care records showed that staff reviewed each patient’s medicines regularly and patients were involved in decisions about their care and treatment. Staff discussed treatment options with patients, including and the risks and benefits of these. We saw clinicians adapting their approach to ensure that people with communication difficulties could also express their preferences. Patients and their families gave us positive feedback about medicines management across the service.

Staff supported people to receive their medicines in a way which met their individual needs. Copies of all the relevant care records were kept in the person’s home and were reviewed and updated regularly. Concerns about deteriorating conditions or lack of response to current treatment were escalated and discussed in huddles.

Staff completed medicines records accurately and kept them up to date. Staff stored and managed all medicines and prescribing documents safely.

Staff learned from safety alerts and incidents to improve practice. Where known issues had arisen, leaders completed thematic reviews to understand why these had happened and identified actions to reduce the risk of reoccurrence.

The trust had a controlled drugs policy(CD) in place to ensure they were compliant with the legal requirements of the Misuse of Drugs Regulations (1971), all other relevant CD Legislation and NHS Guidance.