Quality Account 2024-25

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) was formed in 2019 when the mental health and learning disability services in North Cumbria were transferred to Northumberland, Tyne and Wear NHS Foundation Trust.   

We are one of the largest mental health, learning disability, autism, neurological, disability and specialist services organisations in the country and have an annual turnover of more than £611 million. 

We provide a wide range of mental health, learning disability and neuro-rehabilitation services to a population of over 1.7 million people in North Cumbria and the North East of England. We employ over 9,000 staff, operate from over 70 sites and provide a range of comprehensive services including some regional and national services. 

We support people in the communities of Cumbria, Northumberland, Newcastle, North Tyneside, Gateshead, South Tyneside and Sunderland working with a range of partners to deliver care and support to people in their own homes and from community and hospital-based premises. Our main hospital sites are:  

• Northgate Hospital, Morpeth 
• St George's Park, Morpeth 
• St Nicholas Hospital, Newcastle Upon Tyne 
• Walkergate Park, Newcastle Upon Tyne 
• Ferndene, Prudhoe
• Monkwearmouth Hospital, Sunderland 
• Hopewood Park, Sunderland 
• Carleton Clinic, Carlisle 

To focus on local populations and their needs we structure our services geographically into the following "Locality Care Groups"

• North - Northumberland and North Tyneside 
• Central - Newcastle and Gateshead 
• South - Sunderland and South Tyneside 
• North Cumbria 

What is the Quality Account?

All NHS healthcare providers are required to produce an annual Quality Account, to provide information on the quality of services they deliver.

We welcome the opportunity to outline how we have performed over the course of 2024-25, considering the views of service users, carers, staff and the public, and comparing ourselves with other Mental Health and Disability Trusts. This Quality Account outlines the good work that has been undertaken, the progress made in improving the quality of our services and identifies areas for improvement. To help with the reading of this document we have provided explanation boxes alongside the text, and some examples of service user and carer experience.

Statement of Quality from the Chair and Chief Executive 

Welcome to our quality report.  We are delighted to confirm that we have continued to make progress against our five strategic ambitions set in our Trust Strategy ‘With YOU in mind’.  While 2024/25 has been another very challenging, but successful year for Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW), our teams work together to deliver the highest levels of care.  

We have continued to focus on improving service access, quality and productivity, while also making significant progress to transform how we deliver our care and support to those who need it and creating stronger foundations for the future. We want to build on all the good work we collectively delivered last year, and the progress made in improving the safety and quality of our services. Taking our strategy to the next step, our community transformation work will be critical to this, and we continue to develop and implement our model of care and support alongside our partners in primary care, the voluntary and charitable sectors and Local Authorities. This year we became a national pilot for the development of new models of community care and support, and we are rapidly developing the model in Whitehaven and Copeland in West Cumbria.  This is our opportunity to go further faster. 

We are absolutely committed to providing the highest standard of care and to achieve this we listen to the views of our service users and carers, our staff, our partners and other stakeholders.   

Our aim is to make it easier for people to access care when they need it, to ensure the right organisations and people are involved at the right time, and that we have a joined-up approach to understanding and meeting people’s needs. The principles of our model of care and support apply across everything we do – they are grounded in humanity, respect for rights, partnership, continuity and fostering effective long-term relationships.  By working with our partners to understand and meet the long-term needs of the people and communities that we serve, we think that we, in CNTW, will be better able to focus our efforts in delivering skilled therapeutic interventions, and ensuring that we have the people, knowledge and skills to deliver them well. We will test and develop this model wherever we can, in all that we do. We also want to make sure that we provide consistent, therapeutic and trauma informed care across our inpatient environments. If people need inpatient care, they need to feel safe and supported and that their rights are protected. We will relentlessly pursue our goal of reducing all forms of restrictive practice and 
eliminating the use of coercive forms of restraint. We want to be an organisation that co-creates – that really values the views of the people and communities that we serve. We want to take the next steps in service user and carer involvement, so that it is deeply embedded in everything we do and in every decision that we make. 

Our quality priorities are set by the Board and shaped by the views of everyone we work with and for. This report outlines those priorities for 2025/26 which you feel will best help us continue our journey to achieving our strategic ambitions. We want to thank everyone who has been, and continues to be, involved in the work reflected in this report, as we continue to work to improve our provision of safe and effective care for all who need us.

Statement from Executive Medical Director, Executive Director of Nursing, Therapies and Quality Assurance and Chief Operating Officer 

In 2024-25 we have seen our staff, service users, carers and partners continue to work together to provide the best possible high-quality care underpinned by our trust strategy ‘With YOU in Mind’. We have continued to listen to our service users and their families, striving to achieve the best possible outcomes for people accessing our services and the Quality Account outlines our ongoing commitment to the delivery of compassionate person-centred care.   

Our 5 Quality Priorities this year have been: 
Implementation of the Patient Safety Incident Framework (PSIRF)  
Delivering on key learning form key safety improvement themes;

• Reduce levels of restrictive practice
• Reduce levels of violence and aggression towards staff and patients 
• Reduce levels of self-harm 
• Improve the management of physical health care 

Triangle of Care 
Embedding learning through research ands informing improvements in care delivery 
Embed a culture of Trauma Informed Care and its approaches across the 
organisation. 

Our staff have worked collaboratively with service users, carers, families and partners to make progress on these priorities, which is set out in detail in Part 2b of this Quality Account.  

Learning from the improvements we have made with the Quality Priorities in 2024-25 

we have refined the Trust’s Quality Aims and the underpinning goals, and we are delighted to present our new Quality Priorities for 2025-26 which are set out in Part 2a and will continue our commitment to work collaboratively to achieve outstanding outcomes. 

Statement from the Lead Governor on the Quality Account 

The Quality Account Report 2024/25 demonstrates the continued significant achievements the Trust has made over the last year, despite the challenges faced. In setting out the priorities for 2024/25, emphasis was placed on outlining the framework for the delivery of high-quality care and to include public accountability together with promoting quality improvements across the Trust. The Trust is committed to continuous improvement in all areas, and this is demonstrated by encompassing new technology, systems and procedures.   

Quality data shared with Governors on a regular basis has demonstrated the drive for continuous improvement across the Trust. The comprehensive Quality Account Report which details the progress and delivery of quality priorities is welcomed by the Council of Governors.  Public, Partner and Staff Governors continue to be active in all areas of the Trust, acting in an advisory capacity and by doing so, contributing to the strategic direction of the Trust. In addition, Governors act as ambassadors and as a link between the Trust and the communities we serve, by being represented on Committees and groups including:

• Resource, Assurance and Business Committee 
• Quality and Performance Committee
• People Committee
• Audit Committee
• Charitable Funds Committee
• Mental Health Legislation Committee
• Governors Nomination and Renumeration Committee
• Service User Reference Group 
• Bespoke groups driving forward service change 

The Council of Governors receives regular updates on the progress being made throughout the Trust and continues to monitor the ongoing work of all concerned throughout the organisation. Frequent service visits are undertaken, seeing how services are run and hearing directly from patients and staff about their experiences provides assurance to the Council of Governors that patient needs are consistently being met. One example is the visit to the recently opened state-of-the-art secure facility ‘Sycamore’ which looks after men with a mental illness, learning disability or personality disorder who have entered the criminal justice system.

We are assured that there is a clear, continued focus on the quality improvement plan across Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust as we develop collaboration further with North East and North Cumbria ICB colleagues and Integrated Care System partners.

The Trust Strategy ‘With YOU in mind’ sets out five ambitions, underpinned by Trust commitments to service users, carers, staff and partners, co-produced by our stakeholders, that will help our teams to plan and take decisions, always ensuring that the focus remains on improving services for our community. We are excited about the future and about the improvements that closer working with others will bring to services for the benefit of all our community.

The Council of Governors want to take this opportunity to thank the Board of Directors and the dedication, commitments and compassion of our workforce, working within the Trust and the community in continuing to help and support those who need us in these challenging times.
 

Care Quality Commission (CQC) Findings 

In 2018, the Care Quality Commission (CQC) conducted an inspection of our services and once again rated us as “Outstanding”. We are one of only eight Mental Health and Disability Trusts in the country to be rated as such, as of 1 April 2025.

During July and September 2024, the CQC assessed all wards for people with a learning disability or autism. At the time of writing this report the Trust had received the draft assessment report and was in the process of checking this report for factual accuracy.

In February 2025, the CQC conduced a focused inspection of community mental health and early intervention in psychosis teams. At the time of writing this report the Trust had not received the draft inspection report.

CQC Rating

The Trust was last rated 4th August 2022. Below are the headline ratings overall and ratings for the 5 domains. Read the full report here: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust - Overview - Care Quality Commission (cqc.org.uk) 

Overall rating - Outstanding 

Are services 

• Safe? Good
• Effective? Outstanding
• Caring? Outstanding
• Responsive? Outstanding
• Well-led? Outstanding 

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust always aims to work in accordance with our values:

We are caring and compassionate... because that is how we'd want others to treat those we love. 

We are respectful... because everyone is of equal value, is born with equal rights and is entitled to be treated with dignity. We want to protect the rights of future generations and the planet that sustains us all. 

We are honest and transparent... because we want to be fair and open, and to help people make informed decisions. 

Our Values 

Our values are what bind us. We have considered these in the light of what people have asked of us. We believe that these are the values that we share together, and that we need to uphold if we are to meet our commitments.

Our strategy 'With YOU in mind' from 2023 

We have developed long-term commitments in response to asks that developed during engagement, which will guide everything we do. We know that we are not currently achieving all these commitments – but we want them to be our guide. We want these commitments to be our inspiration for how we work and how we change over the years ahead.

Our aim is to deliver on these commitments every day, in every contact. In this document we set out how we will meet these commitments, through our vision, our values, and the ambitions that we are setting ourselves.

Commitment to our service users:

• Understand me, my story, my strengths, needs and risks. Work with me and others, so I can keep healthy and safe;
• Protect my rights, choices and freedom;
• Respect me and earn my trust by being honest, helpful and explaining things clearly;
• Support me, my family and carers in an effective, joined-up way that considers all my needs, and
• Respond quickly if I am unwell or in crisis, arranging support from people with the right expertise. Make sure I don’t have to keep repeating my story.

Commitment to our families and carers (also known as our 'Carers Promise')

• Recognise value and involve me.
• Listen to me, share information with me and be honest with me when there is information CNTW cannot share.
• Talk with me about where I can go for further help and information and let me know what I can expect from CNTW.
• Work with me to ensure we are all aware of my needs as a carer.

Commitment to our staff 

• Respect me for who I am, trust me, value me and treat me fairly.
• Allow me freedom to act, to use my judgement and innovate in line with our shared values.
• Protect my time by making systems and processes as simple as possible so I can deliver the work I aspire to, learn, progress & get a balance between work & home.
• Offer me safe, meaningful work and give me a voice, working as part of a team that includes other professions and services, and
• Support me with compassionate managers who communicate clearly and understand what it’s like to do my job.

Commitment to our partners and communities 

• Explain what to expect from CNTW.
• Help us to fight illness, unfairness and stigma.
• Make sure that organisations talk to each other and put the needs of people before their own. Share responsibility for getting things right.
• Get to know local communities. Respect their wisdom and history.
• Be responsible with public funds.
• Share our buildings, grounds and land.
• Protect the planet.

Our Vision 

To work together, with compassion and care, to keep you well over the whole of your life.

Our Values 

Our values are what bind us. We have considered these in the light of what people have asked of us. We believe that these are the values that we share together, and that we need to uphold if we are to meet our commitments:

We are caring and compassionate... because that is how we'd want others to treat those we love. 

We are respectful... because everyone is of equal value, is born with equal rights and is entitled to be treated with dignity. We want to protect the rights of future generations and the planet that sustains us all. 

We are honest and transparent... because we want to be fair and open, and to help people make informed decisions. 

Trust overview of service users

Table 1 below shows the number of current service users as at 31 March 2025 by locality, and table 2 shows the total number of referrals in the year. Both tables have a comparison of the last 4 years.

Table 1: Service Users by locality 2021-22 to 2024-25 (data source: CNTW)

 

ICB Place Area	2021-22	2022-23	2023-24	2024-25
NHS COUNTY DURHAM (TOTAL)	1,288	1,373	1,454	1,584
DURHAM DALES, EASINGTON AND SEDGEFIELD	573	606	641	698
NORTH DURHAM	708	765	809	878
NHS NEWCASTLE GATESHEAD (TOTAL)	16,731	18,584	21,454	25,091
GATESHEAD*	5,640	6,516	7,820	9,642
NEWCASTLE*	11,080	12,052	13,623	15,355
NHS NORTH CUMBRIA	9,982	10,969	11,419	11,440
NHS NORTH TYNESIDE	4,935	5,764	6,694	7,123
NHS NORTHUMBERLAND	10,751	12,408	14,467	16,258
NHS SOUTH TYNESIDE	5,114	5,652	6,154	6,301
NHS SUNDERLAND	12,084	13,052	14,546	15,968
NHS TEES VALLEY (TOTAL)	751	815	892	987
DARLINGTON	153	166	169	189
HARTLEPOOL AND STOCKTON-ON- TEES	278	313	362	409
SOUTH TEES	315	334	360	388
Other	785	920	932	924
Total	62,421	69,537	78,010	85,676

 

*Note when Gateshead and Newcastle are separated a small number cannot be allocated too either

Table 2: Total referrals by locality 2021-22 to 2024-25 (data source: CNTW)

 

ICB Place Area	2021-22	2022-23	2023-24	2024-25
NHS COUNTY DURHAM (TOTAL)	2,666	2,843	2,910	3,040
NHS NEWCASTLE GATESHEAD (TOTAL)	49,508	51,904	54,160	53,897
GATESHEAD	18,303	19,818	20,839	20,838
NEWCASTLE	30,344	32,035	33,258	32,854
NHS NORTH CUMBRIA	43,961	44,817	46,964	42,640
NHS NORTH TYNESIDE	19,280	18,710	19,019	17,761
NHS NORTHUMBERLAND	35,519	37,729	37,805	35,094
NHS SOUTH TYNESIDE	16,971	17,568	18,065	17,049
NHS SUNDERLAND	46,612	43,584	44,272	41,574
NHS TEES VALLEY (TOTAL)	764	754	858	919
Other	2,356	2,471	2,810	2,555
Total	217,637	220,380	226,863	214,529

 

Breakdown of service users by age, gender, ethnicity 

Graphs 1a-r: Gender, age and ethnicity breakdown of service users for our local ICB Place areas

 

This section of the report outlines the annual Quality Priorities identified by the Trust to improve the quality of our services in 2025-26.

Each year we set annual Quality Priorities to help us to achieve our long-term Quality Goals. The Trust identifies priorities in partnership with service users, carers, staff and partners from their feedback, as well as considering information gained from incidents and complaints, and by learning from Care Quality Commission findings.

CNTW will maintain commitment to progressing work across the previous 5 Quality Priorities including the Safety Themes and look forward to incorporating 2 more into our new Quality Aims:

• Continue to develop and embed a positive and safe culture.
• Improve physical health care.
• Reduce levels of restrictive practice and violence and aggression
• Reduce levels of self-harm
• Improve the care of people with a severe and enduring mental illness and/or physical disability.

To achieve these aims, the following priority areas have been identified:

• Strengthen communication with families and carers, ensuring they are actively involved in care decisions and when a patient deteriorates.
• Promote care planning that is person-centred, co-produced, and informed by the multidisciplinary team.
• Develop a consistent and evidence-based approach to risk assessment and safety planning across all services.
• Ensure safe and coordinated transitions between services.
• Improve the early recognition and response to deteriorating patients.
• Continue to improve sexual safety by reducing incidents and strengthening prevention and response.
• Improve handovers of care across inpatient services.
• Improve therapeutic engagement and observation across inpatient services.
• Manage and reduce the risk of cardiorespiratory arrest caused by sedative medication.
• Manage and reduce the risk of severe clozapine-induced constipation.
• Support staff wellbeing through increased access to resources, compassionate leadership, and healthy workplace culture.

Work in these areas will be reported on during 2025/2026, to provide a strong governance, assurance and oversight of delivery.

​​​​​​​

In this section we will review our progress against our 2024-25 Quality Priorities and consider the impact they may have made on each overarching Quality Goals.

How we did 

Quality Priority 1 

Quality Priority 1: Implementation of PSIRF (Patient Safety Incident Response Framework)	Leads: Claire Thomas, Peter Astbury
Summary of Progress
Continued alignment with the four PSIRF aims. Panels (PSLIP) were operational with Group representation added to strengthen learning integration. System-based learning approaches like Early Learning Reviews (ELRs) and After Action Reviews (AARs) remain active and under continuous review. PSIRF maturity audit planned with "Audit One" and development of a Patient Safety Partners plan in Q4.
Evidence of Impact
Tangible improvements through structured learning panels. Reflective exercises on incident review effectiveness suggest an iterative improvement cycle.
Key Strengths
Systematic engagement with PSIRF principles. Strong focus on data-driven and compassionate learning. Organisational responsiveness through template and membership reviews.
Identified Areas for Development (Carried forward)
Need to finalise qualitative and quantitative impact assessments. Clarify how risk assessments are driving change in clinical practice.

 

Quality Priority 2

Quality Priority 2: Safety 5 Improvement Themes	Leads: Claire Thomas (with individual leads per theme)
Summary of Progress
Themes include Violence Reduction, Physical/Public Healthcare, Self- Harm/Suicide Reduction, and Reducing Restrictive Practice. Violence Reduction has made strides in response to new NHS England guidance and targeted ward-level strategies. Physical Health group re-established; audits conducted and new strategies in development with an emphasis on improving health equity and outcomes in smoking cessation, obesity and metabolic syndromes. Reduction of Restrictive Practices work has led to significant reduction in use of Prone, Mechanical Restrain Equipment (MRE) and Seclusion in most services. Agreement to roll our ‘Sleep Well’ initiative across Inpatient, Specialist and Secure settings.
Evidence of Impact
LifeVac devices and dysphagia training show proactive risk mitigation. Continued reduction in the use of Long-Term Segregation Many ward teams wish to progress with the decommissioning of seclusion suites, indicating positive shifts in clinical aspiration and change in ward culture.
Key Strengths
Comprehensive and multi-faceted focus areas. Responsive to external guidance (e.g. NHS England). HOPEs training and improved observation strategies are progressing (detailed narrative below) Positive inter-departmental collaboration. Voice of people with lived experience now included in Reducing Restrictive Practice Steering Group
Identified Areas for Development (Carried forward)
Seclusion and MRE data anomalies highlight need for better data accuracy and governance. Continued review of Clinical Model and Pathway across Specialist Inpatient CYPs Services to reduce the use of Restrictive Practice. Further integration of lived experience and stakeholder feedback would enhance initiatives.

 

Quality Priority 2: Reducing Restrictive Practice

We can again report some encouraging reductions in 2024-2025 for the use of prone restraint. An ambitious target to eliminate the use of prone across the Trust has been agreed by the Trust Board. Alternative use of techniques to prone has resulted in increases within the restraint category.

The Positive and Safe team continues to be involved in a broad range of work across the trust. An overview of this year’s work follows:

The positive and safe team undertook a wholesale revision of the Trusts previous reducing restrictive intervention policy. The revised Reducing Restrictive Interventions and Violence Reduction Policy has now been ratified.

All inpatient teams will receive training relating to the policy throughout the year to ensure it is embedded within practice and further supports the Trusts ambition to reduce/eliminate both violence and restrictive practices.

A revision of the Trust wide Restraint Reduction meeting and governance has been implemented, with an increased focus on delivering ongoing reductions to restrictive practices, ensuring that care groups senior leaders’ expertise and experience is effectively utilised to support a strategic approach to reducing restraint.

Human rights awareness training has been delivered to all inpatient wards:

• Talk 1st is the trusts bespoke reducing restrictive interventions initiative and is entering its 8th year. We promote the use of Safewards and across all our inpatient wards.
• Each ward receives clinic visits from the Talk 1st team to support with action planning, scaffolding for teams, sharing good practice across the trust and any part of embedding Talk 1st initiatives.
• We encourage and support the use of data on both a ward and individual level to support in understanding distress, client view is also available for people to view their own data, with support, to promote better understanding of their own needs.
• Each ward attends quarterly Talk 1st cohort meetings these form the basis of the Trust ongoing quality cycle.
• Trauma informed care (TIC) the team have developed a training package which has been delivered during each team’s cohort meeting along with revised prompts within the team’s self-assessment tool to ensure TIC forms part of the ward’s quality initiatives.
• Annual Joint Conference with Tees Esk and Wear Valley Trust the sixth successful conference with over 200 delegates in attendance was held in 2024 with both national and trust staff providing some excellent and inspiring sessions during the day.
• Annual Report this year’s report is currently being completed and will be available in June.
• Quarterly insight reports the team continue to provide groups with interpretation of the relevant quarters trends as related to the application of restrictive interventions. Including cohort attendance from teams. The reports in future will be jointly produced between group and the positive and safe team.
• Post Graduate Certificate in reducing restrictive practice the course continues to develop and grow, a record number of staff applied this year with both internal and external candidates now taking part in this year's course.
• Long Term Segregation Panel the panel has supported and enhanced the HOPE(S) initiative, monitoring and providing advice/input to teams caring for patients within long term segregation and prolonged seclusion. A full day workshop was undertaken this year to refine and improve the work of the panel, the results from the day will inform future improvements to the work of the panel.
• The Talk 1st team continues to deliver bespoke training across the trust including:
  • sensory training and scaffolding offered to teams as well as support revamping chill out rooms
  • Pause training is a scenario-based training package.
  • Safety huddle offers a quick and simple process asking, ‘Is the ward positive and safe?’ and ‘What can we do to make it better?’.
  • Sleep Well is an initiate to improve sleep on inpatient wards, improving ward environments to be more conducive to a good night's sleep, offering psychoeducation sessions to improve sleep and a protected sleep period overnight where people are left undisturbed for people who are risk assessed as this being appropriate, sleepwell is currently being rolled out to all inpatient teams across the trust following board approval.
  • Talk 1st awareness sessions.

Spotlight on HOPE(S)

HOPE(S) is a clinical model used to help individuals who are cared for in Long Term Segregation (LTS). The model is person centred, relentlessly positive and human rights based and looks to support teams to enhance the individuals’ quality of life whilst working towards ending the segregation. LTS is harmful to individuals causing emotional and physiological harm. Certain groups are particularly vulnerable to segregation use; autistic people and people with a learning disability representing around 95% of all individuals in segregation in England.

There is a national HOPE(S) team commissioned by NHS England and CNTW have established an internal lead role to support its ambition to significantly reduce and work towards ending segregation use.

National HOPE(S)

Independent research from Manchester Metropolitan University will be published in May 2025.
36 episodes of segregation ended in the North East and Yorkshire region through HOPE(S) intervention. 7 individuals in CNTW and their teams have received national HOPE(S) intervention. There is a regional community of practice and a national family network supporting families of individuals in segregation.

Average seclusion lengths in Trust 

	2018-19	2019-20	2020-21	2021-22	2022-23	2023-24
Time in hours	37.00	74.51	89.91	79.85	64.53	54.63

 

*Whilst there is no way of directly attributing this to the work specifically around segregation such as HOPE(S), we do know that HOPE(S) directly communicates the critical period for harm to happen (48hours) and gives teams information on the need to reduce the length of seclusion.

CNTW HOPE(S)

The HOPE(S) role has continued to support the embedding of the model within CNTW.
The graph below shows the reduction in segregation and prolonged seclusion use since introducing the role, the segregation panel and the national team.

• Supervision/ reflective practice support to teams on an ongoing basis.
• Practice sharing group/peer support for HOPE(S) trainers in place.
• Database of LTS cases and support provided including intervention targets.
• Review of prolonged seclusions or frequent seclusion users monthly. HOPE(S) lead will review case and offer support to teams proactively to prevent LTS use.
• Individualised in situ support.
• Seclusion policy revision to include HOPE(S) and bring trauma informed care and Human Rights to the forefront of the policy.
• Continued capturing of experiences and learning to share with others in training, Learning Improvement Group (LIG) etc.

Training and engagement 

• 10 cohorts of staff trained in 2 day training to use the model. At least one session monthly for the next 3 months.
• Rolling HOPE(S) awareness sessions offered trust wide (1 session monthly)
• Engagement with key stakeholders; service user and carer reference group, boards, governor’s, advocacy, self-advocacy, estates.
• Peer supporter reflective practice monthly session.
• Lancaster University and Cumbria University have taken up the offer of HOPE(S) training and sessions have been delivered.
• HOPE(S) have supported 35 cases preventatively of LTS and none of these individuals went on to be in LTS.

 

Training Type	CNTW March 25
Train the trainer programme – 5-day	24
Barriers to Change Checklist - 2-day training	347
Awareness training (3 hours)	670

 

This represents a significant proportion of the national numbers in relation to HOPE(S) training.

LTS panel 

All individuals in LTS in CNTW have had a Barriers to Change Checklist as part of HOPE(S) support to address Human Rights and work towards ending LTS and we are working to embed the process for reviews. All individual’s checklists should be reviewed at least 6 weekly. HOPE(S) practice informs LTS panel in trust – Human Rights focused.

How has the Improving the inpatient experience Quality Priority helped support the Safety Quality Goal of Keeping You Safe? 

We aim to demonstrate success against this quality goal by reducing the severity of incidents and the number of serious incidents across the Trust’s services.

Table 3. Patient Safety incidents impact 2022-23 to 2024-25

Patient Safety Incidents by Actual Impact	2022-23		2023-24		2024-25
No Physical Harm	16186	62.68%	17364	61.91%	25962	65.33%
Low Physical Harm	7584	29.37%	8083	28.82%	13042	32.82%
Moderate Physical Harm	1813	7.02%	2299	8.20%	448	1.13%
Severe Physical Harm	91	0.35%	116	0.41%	138	0.35%
Fatal	148	0.57%	184	0.66%	148	0.37%
Total Patient Safety Incidents	25822	100%	28046	100%	39738	100%

 

The Trust continues to report its activity of patient safety incidents into the Learn From Patient Safety Events Service (LFPSE)

From April 2024, the grading of incidents was changed to reflect the national language of harm, and this is now used for all incidents within the Trust for both patient and staff activity. This grading is now used as standard and has been included for all incident data above.

The Trust continues to see an increase in the numbers of incidents reported into the national system since go live. This continues to be seen as a positive in our incident reporting culture, with still most incidents being reported as no physical and low physical harm incidents. As we move into 2025 / 26 there will be major development work to join the learning from the Patient Safety Incident Response Framework (PSIRF) investigations, linking them to the incidents that have been reported into the LFPSE, to join up national from local learning. There are also potential developments over the next year that will see organisations having a greater focus on staff related activity with the potential to report violence against staff information into national systems.

Degree of harm in incident reports 

The following categories are used across the NHS for patient safety incident reports:

No Physical Harm - a situation where no physical harm occurred: either a prevented patient safety incident or a no physical harm incident. 

Low Physical Harm - Minimal harm occurred - patient required extra observation or minor treatment. Did not or is unlikely to need further healthcare beyond a single GP or A&E visit. Did not or is unlikely to need further treatment beyond dressing changes or short courses on oral medication. 

Moderate Physical Harm - Has needed a likely to need healthcare beyond a single GP or A&E visit and beyond dressing changes or short courses of medication, but less than two weeks additional inpatient care and/ or less than 6 months of further treatment and did not need immediate life-saving intervention. 

Severe Physical Harm - Permanent harm/ permanent alteration of the physiology needed immediate life-saving clinical intervention, likely to have reduced the patient's life expectancy. 

Fatal, Death - any unexpected or unintended event that caused the death of one or more patients. 

Table 4: Total incidents 2024-25 by local authority, includes patient safety and non- patient safety incidents

 

Place	No Physical Harm	Low Physical Harm	Moderate Physical Harm	Severe Physical Harm	Fatal Harm	Total
Cumbria	5822	2186	99	20	279	8406
Gateshead	5117	1704	97	12	86	7016
Newcastle North and East	4592	2168	134	18	156	7068
Newcastle West	4029	1360	151	13	133	5686
North Tyneside	5904	2239	127	22	159	8451
Northumberland	10980	4026	247	141	335	15729
South Tyneside	5321	2886	143	10	157	8517
Sunderland	6796	2908	148	25	307	10184
TOTAL	48561	19477	1146	261	1612	71057

Data source: CNTW 

Openness and Honesty when things go wrong: the Professional Duty of Candour 

All healthcare professionals have a duty of candour which is a professional responsibility to be honest with service users and their advocates, carers and families when things go wrong. The key features of this responsibility are that healthcare professionals must:

• Tell the service user (or, where appropriate, the service user's advocate, carer or family) when something has gone wrong.
• Apologise to the service user. Offer an appropriate remedy or support to put matters right (if possible).
• Explain fully to the service user the short and long term effects of what has happened.

A key requirement is for individuals and organisations to learn from events and implement change to improve the safety and quality of care. As part of the Trust implementation of the Patient Safety Incident Response Framework (PSIRF), we have reviewed and updated our Incident policy and our Duty of Candour practice guidance note, using the new NHSE guidance engaging and involving patients, families and staff following a patient safety incident. Training is being developed to further raise awareness of the duty at all levels of the organisation.

Healthcare professionals must also be open and honest and take part in Patient Safety Incident reviews and investigations when requested. All staff are aware that they should report incidents or raise concerns promptly, that they must support and encourage each other to be open and honest and not stop anyone from raising concerns.

At CNTW we try to provide the best service we can. Unfortunately, sometimes things go wrong. It is important that we know about these so we can try to put things right and stop them from going wrong again. If you wish to make a complaint you can do so by post to: Complaints Department, St. Nicholas Hospital, Gosforth, Newcastle upon Tyne NE3 3XT
By email: complaints@CNTW.nhs.uk By phone: 0191 245 6672

Quality Priority 3

Quality Priority 3: Triangle of Care (ToC)	Leads: Sarah Rushbrooke, Alane Bould
Summary of Progress
Annual review of performance and co-production of ToC Annual Report 2024 completed successfully. Trust retained its Star 1 and 2 accreditations from the Carers Trust. Ongoing refinement of Carer Awareness Training and documentation.
Evidence of Impact
External endorsement from the Carers Trust, praising innovation and leadership. Co-review and co-design of carer information and resources. Development of a regional Carer Passport showcases leadership and collaboration
Key Strengths
High-quality carer engagement and co-production. Alignment with organisational changes shows flexibility and relevance. Strategic planning for future dashboard development and performance monitoring.
Identified Areas for Development (Carried forward)
Training consistency and record-keeping remain areas for improvement across groups. Subgroup restructuring to re-align with care group changes. Mandating Carer Awareness Training and standardising data capture should be prioritised.

 

Quality Priority 4

Quality Priority 4: Research and Learning	Leads: Simon Douglas
Summary of Progress
Learning and Improvement webinar established as a regular monthly session, supported by a cross-CNTW steering group. Staff Research Community created to engage staff and build service connections. Research conference (sold out) held on 2nd April 2025, with greater representation of all disciplines, people with lived experience and carers. Bespoke research learning webinars launched, covering topics such as data use, evaluation techniques, critical appraisal, and learning organisation principles
Evidence of Impact
Webinars are up and running with strong attendance and participation.
Key Strengths
Growing culture of research embedded across the Trust. Strong efforts toward workforce education and engagement.
Identified Areas for Development (Carried forward)
Research link roles in CBUs still pending full implementation. Clearer dissemination pathways for research opportunities needed.

 

Quality Priority 5

Quality Priority 5: Embed Culture of Trauma Informed Care (TIC)	Lead: Rebecca Courtney-Walker
Summary of Progress
A variety of tools were used to assess how well we are doing as a trauma informed organisation and to identify actions to support improvement in different areas of the Trust. A standard one day training package was developed as part of the inpatient Quality Standard Framework; over 200 staff have been trained in inpatient and secure services; this is also used to train staff in other settings in the Trust. A broader Trustwide training strategy and the development of a programmatic plan for trauma informed research has been commenced. All training and benchmarking was coproduced with people with lived experience. Several other large scale initiatives have been completed, including work on hate crime, sexual safety, development of an inpatient clothing bank. A variety of sessions have taken place with focused groups, including a Culturally Inclusive Trauma-Informed Care session held to embed inclusion into practice, a session with the Disability Network to further ‘empower’ our staff with disabilities, Trauma informed Practice sessions for Chaplaincy and for our Workforce departments. The Trust Board and our Trust Leadership Forum have also engaged in sessions to think about how we become a Trauma Informed Organisation We have worked with workforce to develop key workforce policies to support our staff in a trauma informed way
Evidence of Impact
Revised and trauma-informed policies (e.g., Health, Wellbeing, and Absence Policy). Benchmarking and lived experience feedback identifies areas for long-term improvement. Reduction in restrictive practice in inpatient settings where the benchmarking was completed, and actions were put in place. Staff reported increased confidence and skills in engaging with people with lived experience of trauma as a result of training
Key Strengths
Integration of trauma-informed principles into policies, procedures, practice and leadership. Strong co-production with staff and lived experience voices. Diversity and inclusion considered as part of trauma-informed workstreams.
Identified Areas for Development (To be carried forward 25/26)
Standardised 60-minute trauma and adversity online induction due to be launched in September 2025 Tiered training delivery plans need to be embedded across all specialties. Benchmarking shows that we have many opportunities for developing as a trauma- informed organisation—implementation will require long-term commitment

 

Assessment and Recommendations 

Overall Assessment and Recommendations

Strengths

All five quality priorities are underpinned by robust frameworks and collaborative efforts. Visible leadership and accountability with clear deliverables. Integration of feedback loops (e.g. Audits, panels, co-production) is commendable.

Key Risks and Gaps:

Inconsistent implementation across some themes Carer Awareness and data capture processes require further governance. Several impact assessments are still pending—limiting full evaluation of success.

Recommendations:

Ensure consistent reporting across all streams, especially where gaps are evident. Prioritise impact measurement to validate changes. Strengthen governance and training tracking mechanisms (e.g., dashboards, training logs). Expand lived experience integration into learning cycles and policy refinement. Prepare consolidated action plans in Q4 to guide 2025/26 priorities

 

Our feedback through the CQC Community Mental Health Survey 

The Trust values the feedback from people accessing our Community Mental Health services. This survey is a good way of comparing ourselves with other similar Foundation Trusts and is a survey we have been involved in for over 20 years.

The summary below shows that the Trust performed better than expected across 5 survey questions. One question also scored much better than expected, which is equal best with 3 other Trusts. The trust performed about the same as other Trusts for 24 questions and did not perform worse than other Trust in any question.

 

The table below shows the breakdown of how the Trust performed in each of the 13 sections, as well as the questions within those sections.

Table 5. CNTW performance for all questions and in comparison, to other Trusts

The question which scored much better than expected when compared to other Trusts was:
Question 22_3 ‘have any of the following been discussed with you about your medication? Side effects of medication?’

The 9 questions that offered us a score of better than expected related to:

• Service ​​​​​​​users having and being involved in the care planning process as well as being supported to make decisions about their care and treatment.
• Carers and close relative being involved in care planning.
• Services users being informed about their medication in areas such as the purpose, benefits and potential side effects.
• Service users feeling well supported in areas such as knowing who to contact outside of office hours if needed, being helped to access services and services helping to support people with physical health needs.

Performance against mandated core indicators 

Patient experience of community mental health services' indicator score regarding a patient's experience of contact with a health or social care worker during the reporting period. 

The Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust considers that this data is as described for the following reasons – this is an externally commissioned survey.

Table 6: Community Mental Health survey scores, 2019 to 2024

 

Health and social care workers	2019	2020	2021	2022	2023	2024
CNTW	7.7	7.6	7.3	7.1	7.1	7.2
National Average	7.2	7.2	6.9	6.9	6.5	6.7
Highest national	7.8	7.8	7.8	8.1	7.7	7.6
Lowest national	6.2	6.1	6	6	5.7	5.9
Score out of 10, higher are better. Scores based on same two questions used in 2019 Data source: CQC

 

The Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has taken the following actions to improve this score, and so the quality of its services by constantly engaging with service users and carers to ensure we are responsive to their needs and continually improve our services.

During 2022-23 the Trust has developed a ‘You Said – We Did’ poster resource for all wards and teams. This is built into the current Your Voice dashboard and supports each team to respond to the previous month’s feedback in a meaningful way, by discussing the major themes that have emerged during that month.

Importantly the ‘We Did’ section allows the team to say what will be done to respond to each theme as it develops.

During 2023-24 ‘You Said – We Did’ developed to become an important function for wards and teams. Continuing the good work that started in the previous year.

During April 2024 we moved from Points of You (PoY) to our new co-developed service user and carer experience survey Your Voice.

An update on our Service User and Carer Experience Survey - Your Voice 

In April 2024 we moved to our new co-developed service user and carer experience survey Your Voice.
Some highlights from the first year of Your Voice are:

• 6,239 ​​​​​​​surveys were completed by service users and carers, 4,247 of these were completed by a service user and a further 576 were completed for a service user when they could not do this unaided. 1,206 surveys were completed by a carer. 210 surveys were completed where no option was chosen.
• 185 teams and wards received feedback in the year.
• The Friends and Family Test (FFT) score for the year was 8.6 out of 10, this score is around average when compared with mental health providers nationally. National average in January 2024 was 8.9.
• From April 2024 there have been 15,546 themed comments, of which, 74.1% were positive.
• The main themes discussed by service users and carers were Communications, Patient Care and Values and Behaviours.
• 624 You Said – We Did posters have been routinely produced.

In the last year, 6,239 surveys were completed by service users and carers. 4,247 of these were completed by a service user, 576 were completed by someone supporting a service user to share their experience, 1,206 were completed by a carer, relative or friend of a service user and 210 were completed by someone who shared an experience of a service without letting us know if they were a service user or a carer.

With the introduction of Your Voice, we took the opportunity to review how we could reach more service users and carers in a cost effective and environmentally friendly way opposed to just by mail. We now send a link for completion online via email and text and sending by mail is the last option we now use.

Between April 2024 – March 2025 we have sent:

• 13,344 emails
• 33,083 texts
• 10,642 letters

Question 1 of the Your Voice experience survey is the Friends and Family Test (FFT) question. This question is set by NHS England and all Foundation Trusts are required to ask it.

The question is: ‘Overall, how was your experience of our service?’, with the person answering from a set list of options from ‘Very Good’ to Very Poor’. Each chosen answer gives a score that leads to an average position over time.

The FFT question offers the Trust the opportunity to compare the overall satisfaction locally and with similar Trusts.

Question 1: Overall, how was your experience of the service?

6,119 responses were received with 85.9% stating they had a good or very good experience.

Question 2: How was the care we provided?

Overall, 6,046 responses were received with 5165 (85.4%) stating their care was very good or good.

Question 3: How involved were you in your care?

Overall, 5,867 responses were received with 5294 (90.2%) stating they were very involved or somewhat involved.

Question 4: Did you feel safe with our service?

6,091 responses were received to this question with 87.5% stating yes, they did feel safe.

Question 5: Were you given information that was helpful?

6,052 responses were received to this question with 5,025 (87.5%) stating yes, they did receive helpful information.

Question 6 is a three part question giving service users and carers the opportunity response to medication, treatment and waiting times.

Question 6: How did we do with medication?

5,091 responses were received with 66.1% stating they had a positive experience regarding medication.

 

Question 6: How did we do with Treatment?

4,936 responses were received with 76.0% positive response.

Question 6: How did we do with Waiting Times?

4,936 responses were received with 76.0% positive responses.

All question in the Your Voice experience survey offer the opportunity for service users and carers to share their experiences through a text box function. These comments are themed by the Commissioning and Quality Assurance team and included in a dashboard that all staff can access.

The comments as well as being themed into positive, negative and neutral are also assigned a main and sub-theme.

The most common theme for compliments has remained ‘Values and Behaviours’ across all years, with staff being ‘Kind/Caring/Friendly’ being the most discussed sub-theme of this main theme.

Themes	Compliment		Negative		Neutral		Positive
Category	%	Count	%	Count	%	Count	%	Count
Access to treatment or drugs	4.2%	27	27.1%	176	6.9%	45	61.8%	402
Admissions and discharges			65.0%	13	10.0%	2	25.0%	5
Appointments			29.7%	110	14.3%	53	55.9%	207
Clinical treatment			19.9%	27	9.6%	13	70.6%	96
Communications	1.5%	74	15.5%	743	8.1%	388	74.9%	3591
Facilities	3.5%	27	21.7%	168	6.1%	47	68.7%	532
Other			14.7%	40	76.6%	209	8.8%	24
Patient Care	2.7%	146	15.3%	820	6.1%	327	75.8%	4052
Prescribing	0.3%	1	27.0%	84	26.4%	82	46.3%	144
Privacy, Dignity and Wellbeing	3.5%	28	15.2%	120	6.8%	54	74.4%	587
Staff Numbers			47.9%	23	16.7%	8	35.4%	17
Trust Admin/ Policies/ Procedures	4.8%	1	47.6%	10	4.8%	1	42.9%	9
Values and Behaviours	4.1%	135	5.7%	190	1.5%	49	88.7%	2936
Waiting Times			44.7%	335	12.1%	91	43.1%	323
Total	2.1%	331	15.7%	2439	8.1%	1253	74.1%	11523

Table 7. Main themes of comments 2024/25

Positive comments account for 11,523 of all comments or 74.1%. The main themes for these comments have been in relation to ‘Patient Care’, ‘Communications’ and Values and Behaviours’.

Neutral comments account for 1,253 of all comments or 8.1%. The main themes for these comments have been in relations to ‘Patient Care’ and ‘Communications’.

Negative comments totalled 2,439 or 15.7% of all comments themed. The most common theme related to Patient Care’, with 820 (15.3%) of all negative comments relating to this theme.

You Said - We Did 

You Said – We Did (YSWD) is a monthly opportunity for teams to respond to the themes that emerged in the previous month. This happens through choosing a comment from a service user or carer that is representative of a dominant theme and responding as a team.

YSWD has been used informally by many wards and teams in the Trust for many years. A centralised system is available to all wards and teams to support being responsive to experience feedback as a monthly process.

The system is attached to the Your Voice dashboard and was designed to be a simple 2 step process that any staff member can carry out, without the need for ratio access.

YSWD is ‘Listen’ and ‘Do’ part of the NHS England » Ask Listen Do – feedback, concerns and complaints process that Your Voice supports. Something that the CQC are actively looking for evidence of during their visits. See the infographic below that explains the process and how Your Voice and YSWD fit into this process.

Complaints 

Information gathered through our complaints process is used to inform service improvements and ensure we provide the best possible care to our service users, their families and carers.
Complaints have increased during 2024-25 with a total of 816 received. This is an overall increase of 37 complaints (5%) in comparison to 2023-24 and the highest number of complaints received per annum to date.

Table 8: Number of Complaints received 2022-23 to 2024-25

Financial Year	Total
2022-23	686
2023-24	779
2024-25	816

 

The Community Care Group accounted for 72% of the complaints received, followed by the Inpatient Care Group with 15% and the Specialist Care Group with 11%. The other 2% of complaints related to the non clinical directorates.
The three highest complaint categories: patient care, communication and values and behaviours:

• Patient ​​​​​​​care complaints increased by 10%
• Communications complaints increased by 4%
• Values and behaviours complaints decreased by 15%

Complaint categories which have significantly increased in comparison to 2023-24 are:

• Admissions and discharges complaints by 26%
• Appointments complaints by 28%
• Prescribing complaints by 42%

Complaint categories which have significantly decreased in comparison to 2023-24 are:

• Waiting times complaints by 19%

The Patient Advice and Liaison Service (PALS) gives service users and carers an alternative to making a formal complaint. The service provides advice and support to service users, their families, carers and staff, providing information, signposting to appropriate agencies, listening to concerns. We can also signpost complainants to local advocacy services who offer support and advice around making a complaint.

We now have access to the Interpreting Service and can request interpreters for complainants who are deaf or do not use English as a first language.

Table 9: Number of complaints received by category 2022-23 to 2024-25

 

Complaint Category	2022/23	2023-24	2024-25
Patient Care	180	193	214
Communications	104	111	116
Values and Behaviours	98	110	94
Admissions and Discharges	53	55	74
Clinical Treatment	43	47	42
Appointments	31	26	36
Prescribing	33	39	67
Trust Admin/ Policies/Procedures	21	31	32
Access to Treatment or Drugs	25	28	25
Other	11	9	13
Facilities	15	14	9
Waiting Times	62	108	87
Privacy, Dignity and Wellbeing	4	2	3
Restraint	2	3	0
Staff Numbers	2	1	2
Integrated Care	0	0	0
Commissioning	0	0	0
Consent	1	1	2
Transport	1	1	0
Total	686	779	816

Data source: CNTW 

Outcomes of complaints 

Within the Trust there is continuing reflection on the complaints we receive, not just about the complaint but also on the complaint outcome. In 2024-25 we responded to complaints in line with agreed timescales in 94% of cases which is a 12% increase in comparison to 2023-24 and reflects the ongoing improvements made since the team staffing levels have been at full capacity.

Table 10: Number (and percentage) of complaint outcomes 2022-23 to 2024-25

 

Complaint Outcome	2022-23		2023-24		2024-25
Closed - Not Upheld	168	24%	195	25%	236	29%
Closed - Partially Upheld	234	34%	196	25%	197	24%
Closed - Upheld	108	16%	102	13%	100	12%
Complaint Withdrawn	100	15%	115	15%	93	11%
Decision Not to Investigate	36	5%	66	9%	78	10%
Still Awaiting Completion	6	1%	56	7%	66	8%
Unable To Investigate	34	5%	49	6%	46	6%
Total	686	100%	779	100%	816	100%

Data source: CNTW 

Complaints referred to the Parliamentary and Health Service Ombudsman 

If a complainant is dissatisfied with the outcome of a complaint investigation, they are given the option to contact the Trust again to explore issues further. However, if they choose not to do so then Stage 1 of the NHS complaints procedure has concluded. If they remain dissatisfied, they have the option to refer their complaint to the Parliamentary and Health Service Ombudsman (PHSO). This is known as Stage 2 of the NHS complaints procedure.

The role of the PHSO is to consider further independent investigation of complaints where individuals feel they have been treated unfairly or have received poor service from government departments and other public organisations and the NHS in England.

Activity during 2024-25 was as follows:

Table 11: Outcome of complaints considered by the PHSO	Number
Upheld	1
Partially upheld	3
Not upheld	1
Decision not to investigate	7
Investigation ongoing	11
Total	23

Data source: CNTW 

NICE Guidance Baseline Assessments Completed 2024-25

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. During 2024-2025 the Trust undertook the following assessments against appropriate guidance to further improve quality of service provided. Assessments were conducted against all published NICE guidance deemed relevant to the Trust.

1.    NICE Baseline assessments undertaken in 2024-2025 compliant at baseline (6)
The following baseline assessments, undertaken in 2024-2025, were compliant at baseline and did not require action plan monitoring.

Ref.	Topic
NG 51	Suspected Sepsis: recognition, diagnosis and early management
NG 191	COVID-19 Rapid guideline: managing COVID-19
QS 11	Alcohol-use disorders: diagnosis and management
QS 207	Tobacco: treating dependence
NG 214	Integrated health and social care for people experiencing homelessness
NG 232	Head injury: assessment and early management

 

2.    NICE Guidance baseline assessments undertaken in 2024-2025 that require action plan monitoring (3)
The following baseline assessments are currently in action plan monitoring:

 

 

 

 

Ref.	Topic	Key Findings
		Evidencing in discharge letters where they are   Use of alerts on Rio regarding DNACPR, EHCP and ACP decisions.   The plan is to now think about how this can be operationalised within older people’s services. 4. An increase in education as detailed in response to statement 3 would also help to reinforce the processes and documents available to support access to specialist palliative care advice out of hours. There are actions underway due to other work being undertaken around this subject as a result of baseline assessment against NG142 End of life care for adults: service delivery and the participation in the recent National Audit of Care at End of Life   Although CNTW do not provide an out of hours palliative care services staff teams can access Specialist palliative care advice lines for support via local hospices.   A scoping exercise has also been carried out which identifies specialist palliative care teams across all CNTW localities subsequently a document has been produced containing contact details for these services both in and out of hours so that CNTW teams can access specialist palliative care support available Teams also have access to medical staff via agreements within their own services to support with clinical decisions for individuals.

 

3. NICE Guidance baseline assessment complete and action plan fully implemented in 2024-2025 (10)

 

 

NG 209	Tobacco: Preventing Uptake, Promoting Quitting and Treating Dependence (Update)
	Initial Compliance: Partial Compliance Submitted for action plan monitoring: 10.05.24 Deadline for fully implemented action plan: 01.10.24 The action plan was fully implemented on 01.10.24 and signed off at CEC on 11.10.24
QS 140	Transition from Children’s to Adult’s Services
	Initial Compliance: Partial Compliance Submitted for action plan monitoring: 01.05.24 Deadline for fully implemented action plan: 31.10.24 The action plan was fully implemented and signed off at CEC on 11.10.24

 

4.    NICE Guidance baseline assessments undertaken prior to 2024-2025 that are currently in action planning (2)
The following baseline assessments are currently in action plan monitoring:

Ref.	Topic
NG 197	Shared decision making
QS 139	Oral health in the community

 

5.    NICE Guidance baseline assessment in progress (7)
The following baseline assessments are currently underway within 2024-2025

Ref.	Topic Details / Objective	Date Published	Current Deadline
NG 23	Menopause: diagnosis and management	14.03.25	tbc
NG 116	Post-traumatic stress disorder	16.01.19	30.04.25
NG127	Suspected neurological conditions: recognition and referral	02.10.23	30.05.25
NG 216	Social work with adults experiencing complex needs	26.05.22	31.05.25
NG 222	Depression in adults: treatment and management	29.06.22	31.10.25
NG 236	Stroke rehabilitation in adults	18.10.23	30.04.25
NG 248	Gambling-related harms: identification, assessment and management	28.01.25	31.03.25

 

6.    Statistical Information

NICE Baseline Category	Total
Compliant at Baseline 24-25	6
Action Plan Monitoring Required 24-25	3
Action Plan Fully Implemented 24-25	10
Action Plan Monitoring Pre 2024-25	2
In Progress as at 01.04.25	7
Total	25

 

7.    Rapid Quality Improvement Projects (RQIP) Completed 2024/2025

 

 

 

 

 

95	RQIP-23-0135	Re-Audit of RQIP-23-0056 for Cardiovascular monitoring with the use of acetylcholinesterase inhibitors in the Older Person’s Community Mental Health Services.
96	RQIP-24-0034	Audit on the use of the risk assessment tool on RiO for patients referred to the CaPE clinic.
97	RQIP-23-0076	Limitations of Medical Information Provided on Admission – Development and Implementation of a Preadmission Medical Triage Tool
98	RQIP-24-0035	Psychotherapy waiting times to receive assessment and treatment
99	RQIP-24-0056	An assessment of expected physical health monitoring associated with high-risk medications during inpatient admission
100	RQIP-24-0057	Limitations of Medical Information Provided on Admission to Specialised Inpatient Neurorehabilitation – Closed-loop QIP Evaluation Following Implementation of a Preadmission Medical Triage Tool
101	RQIP-24-0090	Audit of the Multiple Sclerosis Rehabilitation Clinic for Patients with Multiple Sclerosis at Walkergate Park.
102	RQIP-24-0065	Audit of the number of patients who DNA appointments at the Forensic Community Service from Oct 2023 to Oct 2024.
103	RQIP-24-0079	An audit to assess the quality of the process of Category 3 referrals coming into Complex Neurodevelopmental Disorder Service (CNDS), measured against the standards of CNDS referral pathway protocol
104	RQIP-24-0117	Review of the referral triage process for psychodynamic psychotherapy in the Newcastle Centre for Specialist Psychological Therapies
105	RQIP-24-0121	Re-Audit of Preadmission process on Berwick Medium secure Rehabilitation ward against QNFMHS standards (Reaudit of RQIP-24-001)
106	RQIP-23-0102	Audit of blood testing in NTaR drug and alcohol service
107	RQIP-24-0135	Management of clozapine induced hypersalivation
108	RQIP-24-0102	Audit of prescribing databases at Plummer court and review of prescribing database standards.