Northern Health and Social Care Trust Annual Quality Report 2024/25

Chief Executive Message

As Chief Executive of the Northern Health and Social Care Trust, I am pleased to share with you our Annual Quality Report, which covers the period 1 April 2024 to 31 March 2025.

Improving outcomes and experiences for our patients and service users is at the heart of what we do, and is a key priority within our organisation’s Vision and Corporate Plan.

As part of our ongoing commitment to quality improvement, we launched our first Quality Strategy in March 2025. This sets out an ambitious three-year plan that identifies key strategic priorities to deliver high quality care, and was co-produced by the Trust with input from more than 600 service users and members of staff.

The rollout of the new digital healthcare record system, encompass, in our Trust in November 2024, marked a huge milestone for Health and Social Care. We are already starting to see the benefits of going paperless, both for our patients and service users, and for our staff. Encompass is transforming patient care across the region, and enabling us to deliver more efficient, joined-up services for our community.

Embracing new technology is key to continuous quality improvement across our services and this year we became the first HSC Trust in the region to pilot the use of a new Artificial Intelligence (AI) programme which supports clinicians to read X-rays, helping to improve accuracy in identifying bone fractures in patients from the age of two.

We know that reform and transformation is critical if we are to continue to provide high quality care. I am pleased that we are making progress within our own Trust around service transformation with our Reform North programme, including a proposed new model for the future delivery of our general surgery service.

As part of that service transformation, we have made significant investment in same day emergency care at Causeway Hospital to help alleviate some of the pressures on our acute services. This is transforming service delivery and, as outlined in our Causeway Vision, it is helping to better meet the needs of our local population and its changing demographic by providing the right care, at the right time, in the right place.

A new MRI unit is due to open at the Causeway Hospital site later this year, giving local people access to state-of-the-art diagnostics on their doorstep. And at Antrim Area Hospital, construction work is now underway on an Alongside Midwifery-Led Unit which will give women living in the Northern Trust greater choice around their maternity care pathways, creating equity across the entire region.

Our Health and Social Care system finds itself at an important crossroads as it continues to grapple with financial challenges and the impact that has on our services, our patients, staff and wider community.

While we are not naïve about the challenges facing Health and Social Care, we remain steadfast in our commitment to delivering on our Trust’s vision, to provide compassionate care with our community, in our community.

Jennifer Welsh

Foreword

In 2011, the Department of Health, Social Services and Public Safety (now renamed to Department of Health (DoH)) launched Quality 2020: A 10 Year Strategy to ‘Protect and Improve Quality in Health and Social Care in Northern Ireland’.

The Strategy defines quality under three main headings:

• Safety – avoiding and preventing harm to patients and clients from the care, treatment and support that is intended to help them
• Effectiveness – the degree to which each patient and client received the right care, at the right time, in the right place, with the best outcome
• Patient and Client Focus – all patients and clients are entitled to be treated with dignity and respect, and should be fully involved in decisions affecting their treatment, care and support

The Northern Health and Social Care Trust Annual Quality Report is set out in line with the five strategic themes within the Quality 2020 Strategy. These are:

1. Transforming the culture
2. Strengthening the workforce
3. Measuring the improvement
4. Raising the standards
5. Integrating the care

This report aims to increase public accountability and drive quality improvement within the Trust. It reviews past annual performance against corporate priorities and the goals that were set, and identifies areas for further improvement over the coming year.

The Northern Health and Social Care Trust clearly identifies continual quality improvement as a key priority in the delivery and modernisation of health and social care.

About the Northern Health and Social Care Trust

Due to the implementation of encompass in November 2024, and ongoing validation of data, it has not been possible to acknowledge the full extent of activity for the 2024/25 year, therefore most of the data below is up to 7 November 2024 only.

• 48,083* inpatients, inclusive of elective inpatients
• 315,137* acute outpatients across all specialties
• 153,958** attendances at Emergency Department and Minor Injury Units
• 23,099* day case patients across all specialties
• 2,006* births
• 879 children looked after by Trust
• 555 children on child protection register
• 4,860 domiciliary care packages for older people provided in the community (as at 7 November 2024)

*Data reflects activity for the period 1 April 2024 – 7 November 2024

**Attendances at Emergency Departments and Minor Injury Units is based on data from 1 April 2024 – 31 March 2025, however the data from November 2024 to March 2025 continues to be validated, due to the implementation of the new encompass system

Theme 1: Transforming the culture

Open Just and Learning Culture

2024/25 was a transformative year for Team North with the launch of encompass in the Trust on 7 November 2024. Although the Team North Year looked different given the entire Team North effort to enable a successful encompass Go Live, we continued to embed our Open, Just and Learning Culture:

• Our focus in 2024/25 was to ensure that our people, as well as our systems, were prepared for the change of encompass, through the lens of being open and compassionate with ourselves and each other. The fundamental principles of open, just and learning culture were woven through the Trust’s encompass people readiness
• Our Senior Leader Forum event in April 2024 focussed on supporting our leaders to lead themselves and their teams well through change
• This was also the underpinning theme for the Trust’s annual Leadership Conference in June 2024. Speakers touched on the importance of compassion, listening to each other and learning together whilst navigating such a momentous change
• A number of staff information and engagement sessions were held in February 2025 for staff to support participation in the ‘Being Open’ Framework public consultation
• Over 850 staff attended the monthly Team North Welcome in 2024/25 and took part in our bespoke NURTURE programme, which introduces those new to our Trust to our Open, Just and Learning Culture and what it means here in Team North.

Personal and Public Involvement (PPI), including patient & service user experience

Involving service users, carers and communities

The Northern Health and Social Care Trust believes that service users and carers have unique expertise, which should be used to influence and redesign services. Our aim is to ensure that the voice of patients, carers, families, and communities are embedded at every level of the organisation, shaping how we design, deliver, and improve services.

Throughout the year, we have worked in partnership with service users, carers and our community to promote inclusive engagement, build trust, and ensure that lived experience informs decision making. This has been especially important as we respond to ongoing system pressures, rising demands, and a renewed focus on reducing health inequalities.

Our approach is guided by key strategic frameworks including Making Life Better which reflect the Trust’s commitment to our HSC Values. The Trust’s Involvement Plan sets out its vision, commitment and integrated approach to Patient & Client Experience (PCE), PPI and Co-production activities. Throughout this incoming year we will engage with our key stakeholders to co-design our new 3-year strategy, as we continue to build a culture of shared ownership and continuous improvement.

Understanding what matters most to local communities is really important, particularly given the diverse rural and urban differences in the Trust area. Partnership working with the voluntary and community, helps provide vital insight into groups across our communities, so that our services are accessible and responsive to all.

The Trust’s Engagement Advisory Board continues to ensure that the Trust is approaching engagement in a way that meets the needs and interests of all communities, with a focus on targeting the most hard to reach groups. We have recently recruited four new members, selected following an expression of interest exercise, to represent the communities we serve. This year members have helped us shape the Trust Corporate Plan, Quality Strategy and engagement regarding the Vision for Causeway. They have also provided pre-engagement advice on the General Surgery Consultation and the Piloting the use of Body-worn Camera Devices within the Emergency Department Consultation.

The Trust’s Involvement Network is made up of over 300 service users, carers and representative organisations who work in partnership with the Trust to develop health and social care services. The Network is a key resource to help shape and design services, and contribute to the development of service information. Members have received 63 involvement opportunities and 375 members have taken part in more than 35 engagement events.

Over the last year, service users and carers have helped to shape and develop number of service improvements – 101 projects have led to service improvements. The Trust’s Involvement Annual Report includes many examples of how service users and carers have worked with the Trust to drive change and improvement.

Care Opinion is a two-way feedback mechanism that provides the opportunity for open, honest conversations with service users and is the foundation to build and develop trusting relationships. Across the Trust, Care Opinion has become more widely recognised as supporting evidence for quality improvements initiatives and ward or department story reports inform Leadership Safety Huddles. Over the last year, the Trust has received 1102 stories, which is an increase of 33% from the previous year.

Shared Decision-Making is a collaborative process where healthcare professionals and patients work together to make decisions about treatment options. It involves discussing the available choices, considering the patient’s preferences, values, and circumstances, and reaching a decision that aligns with the patient’s needs and desires. Shared Decision Making empowers patients to be active participants in their healthcare, promoting better outcomes and satisfaction.

The Involvement Team is supporting the implementation of five pilot projects to conduct 10,000 More Voices Surveys within the Trust. Our first pilot went live in February. Patients attending Causeway Hospital’s pre-operative assessment clinic are being invited to take part in a survey, giving them the opportunity to describe their healthcare experience and how involved they have felt in decisions about their care and treatment options. The patient-centred approach, also referred to as Shared Decision Making, aims to give patients more autonomy over their care, encouraging a discussion between them and their clinicians when it comes to their personal healthcare journey.

Understanding what our service users want and expect, allows health and social care to design services that are efficient, effective, sustainable and responsive to needs. Bringing people on the journey, ensures that the best models of care are provided and we believe that service users and carers have unique expertise which should be used to influence and redesign services.

Quality Improvement

Quality Strategy

The Trust launched its first Quality Strategy which sets out our ambition and strategic priorities to deliver high quality care over the next three years. The strategy was designed with the involvement of over 600 services users and staff. It was formally launched in March 2025 with service users and staff reflecting on the process of engagement which led to the agreement of these five strategic priorities.

Skills to Improve

Over 100 staff completed a range of Quality Improvement training over the past year including:

• 39 staff completed the Safety Quality North programme cohort 7
• 4 completed the regional Social Work, Nursing and Midwifery programme
• 57 completed the Quality Coach programme
• 4 completed the Scottish Improvement Leaders programme
• 9,258 staff have completed Level 1 Quality Improvement Training in total.

Quality Management and Improvement Projects

An organisational approach to Quality Management was developed on how the Trust can continuously improve Quality and Safety.

Staff led 58 improvement projects over the past year to improve Quality and Safety.

Culture and Learning

• 583 staff trained in Understanding Human Factors and Quality Improvement as part of the NUTURE programme
• 4 poster presentations showcased at the International Forum for Quality and Safety which brings together the best of global learning in Healthcare.

Innovation

The My Journey project supports services to develop and deliver digital resources (videos, podcasts or webinars) for service users. During 2024/25, the project has had 4,825 downloads and 4,870 video views. A total of 6 new projects have been launched over the past year.

Example of My Journey projects include, the SLT Dysphagia Food and Drink Preparation videos and The Continence Challenge Podcast.

Two Trust projects were identified as examples of best practice in Northern Ireland. The ‘Enhanced Patient Care and Observation project’ (EPCO) and Mental Health Length of Stay “Right Care, Right Time, Right Place” were part of the yearlong HSCQI Delivering Value programme. Both projects were selected for regional scale and spread by demonstrating significant improvements in patient care, staff experience, financial sustainability and operational efficiency.

Celebration and Recognition

Over 150 staff were recognised for their contributions to improving Quality and Safety across the Trust.

Staff from Mental Health and Learning Disability celebrating their achievements at a Quality Improvement Celebration and Recognition event with Jennifer Welsh, Chief Executive.

During 2024/25, a total of 413 staff have been nominated for a Greatix award from another member of staff recognising excellence across the Northern Trust.

Complaints and Compliments

The Trust values all feedback received from patients and service users, including complaints, compliments and suggestions. The Trust is committed to listening to and learning from all of its patients and service users, so that the Trust can continually improve the quality of services, particularly when the care provided may not have been of the standard that would be expected.

Facts/Figures

• 979 formal complaints received (an increase from 854 in 2023/24)
• 100% of complaints acknowledged within 2 days
• 54% of complaints were responded to within 20 working days
• 7,067 compliments were received through the Chief Executive’s office (compared to
  5,827 in 2023/24)
• The two main categories of compliments that were received relate to professional behaviour/attitudes of staff and quality of treatment and care

The top five categories of complaints related to:

• Quality of Treatment & Care
• Staff Attitude/Behaviour
• Communication/Information
• Waiting list, Delay/Cancellation for Outpatient appointments
• Quantity of Treatment & Care

Learning from complaints

The Trust continues to review complaints in an open and transparent way and considers complaints to be an important source of learning. Discussing and sharing the outcome of complaint investigations is one of the ways it improves the experience for people using Trust services and ensures that staff take the learning on board.

Learning is shared and discussed in various forums including quarterly Safety and Care Quality meetings, which forms part of the Trust’s Integrated Governance and Assurance Framework. Learning is also discussed at monthly Divisional Governance meetings.

To ensure staff are aware of their responsibilities in respect of complaints, the Complaints Team provides training via e-learning and offers face-to-face training when required. Within 2024/25, a total of 4,425 staff completed Level 1 Complaints & Service User Experience Training. Level 2 Complaint Reviewer Training is offered to specific service groups of 10 or more via Microsoft Teams. Within 2024/25, a total of 219 staff completed Level 2 Reviewer Training.

NI Public Services Ombudsman (NIPSO) Cases

In instances where people are not satisfied with the outcome of an investigation into their complaint, there is an opportunity for them to approach the NIPSO Office directly.

The Advice, Support Service and Initial Screening Team (ASSIST) is the public’s first point of contact with the office.

Where the ASSIST team conclude that they cannot resolve the complaint, the case is forwarded to the Ombudsman’s Investigations Team. In 2024/25, there were 27 requests for information from the NIPSO Office:

• 4 cases were not accepted for investigation
• 3 cases went to alternative resolution
• 20 are on-going
• 21 further cases are ongoing from previous and current years

Incidents

An incident is described as ‘any event or circumstance(s) that could have, or did lead to, harm, loss or damage to people, property, environment or reputation, or a breach of security or confidentiality’.

The aim of the incident reporting system is to encourage an open reporting and learning culture within departments, divisions and Trust-wide, acknowledging that lessons learned need to be shared to improve safety, and apply best practice in managing risks.

The Trust uses DATIXWeb, an electronic risk management system. This web-based system facilitates the reporting of incidents in a timely manner; information regarding incidents is more accessible via dashboard reporting; and incident details are held in one single place. This supports timelier reporting, more efficient analysis and learning for the organisation, and facilitates the ownership and management of risk. Data and information on incidents also contribute to the identification and establishment of quality improvement projects within the Trust.

In terms of the wider Risk Management agenda, a number of other modules are available within the DATIXWeb system in the Trust; these are Risk Registers, Safety Alerts, Complaints, Serious Adverse Incidents (within the Incident module), Coroner’s and Claims. This holistic risk management system for the Trust supports more timely learning and identification of themes and supports decision-making.

A total of 28,137 incidents were reported in 2024/25, which is an increase of nearly 7% from the previous year. This increase is reflective of the ongoing training and awareness that has taken place around incident reporting and the continued use of Trigger Lists for incident reporting. Trigger Lists outline the types of incidents the Trust would expect to be reported should they occur.

Total number of incidents and top five reported incident types

Financial year 2024/25

• Total Incidents: 28,137
• Slip / Trip / Fall: 7274
• Violence / Aggression: 5126
• Medication: 1784
• Pressure Ulcer: 1170
• Self-Harm: 1107

Serious Adverse Incidents

A Serious Adverse Incident (SAI) is ‘an event which may have caused unexpected serious harm or death’. During the period 2024/25, a total of 89 SAIs were identified and notified to the Strategic Planning and Performance Group (SPPG). In the previous financial year, 88 SAIs were notified.

The table below outlines the number of SAIs involving death for the period 2024/25 at the time of reporting:

Division	Total SAIs notified to the SPPG involving death
Mental Health and Learning Disability Services	23
Children and Young People	1
Paediatrics, Women’s and Corporate Support Services	1
Community Care	1
Medical and Governance	1
Total	27

One of the criteria for determining if an incident is a SAI, is ‘Suspected suicide of a service user who has a mental illness or disorder and is known to/referred to mental health or learning disability services in the 12 months prior to the incident’. Sadly, the significant number of suicide related deaths means the number of SAI notifications from Mental Health and Learning Disability, involving a death, are higher than other Divisions.

Learning from Serious Adverse Incidents

Each SAI report is presented at a Safety Panel, chaired by an Executive Director, which considers the quality and robustness of the review and examines the recommendations to ensure the learning from the SAI is reflected in the outcomes and disseminated internally to staff and/or shared regionally. The Learning for Improvement Group (which is a sub-group, reporting to the Safety and Care Quality Steering Group, within the Trust’s overarching Assurance Framework) provides oversight of those recommendations and ensures that learning has been shared appropriately and trends identified.

Learning can be indicated for sharing regionally, which can be achieved through the issuing of an immediate alert, a learning letter, a reminder of best practice letter or through the regional newsletter ‘Learning Matters’ which can be accessed via Learning Matters Newsletters | HSC Public Health Agency

Leadership Safety Huddles

There are numerous informal and formal opportunities for senior leaders to engage with frontline staff and services to demonstrate that their contribution to safe service delivery is valued, and to strengthen collaboration between leaders and frontline staff. Leadership Safety Huddles is one of the formal opportunities for senior leaders to talk to and listen to frontline staff about issues and concerns relating to service user safety, and encourage participation in quality and safety improvement at all levels of the Trust.

Between April and August 2024, a total of 16 Leadership Safety Huddles were held across Trust services. Leadership Safety Huddles were then paused between September 2024 and March 2025 to enable the Trust to prepare for the implementation and embedding of the new encompass system. Leadership Safety Huddles will recommence from May 2025.

Theme 2: Strengthening the workforce

People and Culture Plan 2023-26

The People and Culture Plan 2023-26 was launched in May 2023. The Plan is informed by engagement with our people, insight and learning from Investors in People, regional staff surveys and engagement data, as well as benchmarking, and is aligned to our current and future challenges and ambitions.

The three-year Plan sets out our priorities and commitments to our people. Our people agenda in 2024/25 focussed on our commitments to ensure people readiness for encompass, to support a successful Go Live.

encompass people readiness

Enabling our talent – Digital Literacy

Encompass in numbers

• 15,518 email accounts recorded on HRPTS
• 11,008 professional registrations recorded on HRPTS
• 2,611 Active Directory Email account requests
• 4 helpdesk inboxes
• 555 ICT ‘Fundamentals’ training attendances
• 2,196 Super Users
• 500 PIFPIB staff ‘Thank you’
• 100% Super Users training compliance
• 2,506 Affiliated Users identified for ATAT
• 200 ‘Getting ready for change’ workshop attendances
• 14,000 staff attendances – Nursing and Midwifery User Labs
• 3,000 attendances AHP user labs
• 30 Pre Go-live clinics
• 670 staff/affiliate attendances
• 6 Soft Go-live clinics
• 39 JIT clinics at Help Hubs
• 177 Complete JIT – Staff 59 %, Affiliates 41%
• 90% Staff Affiliate – 1 Cert at Go-live
• 99% Permanent/temporary staff – 1 Cert at Go-live
• 99% Staff/Affiliate – Enrolled/Certified at 22 November 2024

Leadership, Management and Professional Development

A total of 167 delegates attended the annual Team North Leadership Conference in June 2024. The theme for the conference was Navigating a New North, focussing on in change leadership in the digital age. This was designed to coincide with the Trust’s encompass Go Live Road map.

For the first time the conference was held across a full day. The event was structured to include input from local, national and international experts in change and digital transformation, as well as engaging in conversation with colleagues and leaders supporting the encompass project, while ensuring service users remained at the heart of the conference as a reminder of why we do what we do.

The Organisation Development and QI teams collaborated to host a shared recognition event in June 2024 to mark the learning and achievements of our Team North Leadership Pathways Class to 2024 and SQN Graduates.

Corporate Induction

The Trust’s new Team North Welcome launched in January 2024, replacing the online corporate induction. The new format gives new colleagues the opportunity to network with one another in person, hear from our Chief Executive or Deputy Chief Executive, as well as learn more about what it means to be part of Team North.

A key part of Team North Welcome is the Trust’s NURTURE programme, which introduces those new to the Trust to our Open, Just and Learning Culture and what it means here in Team North. Over 850 staff attended Team North Welcome in 2024/25 and took part in our bespoke NURTURE programme.

Professional Development

Overall, 11 Healthcare Assistants from 4 Directorates successfully completed their Open College Network (OCN) Level 3 Certificate in Healthcare Support, and their achievements were recognised along with fellow Regulated Qualifications Framework (RQF) Learners at recognition events held in February and March 2025.

Staff Communications

During 2024/25 the Trust refreshed the branding of Staffnet, the Trust intranet, to create a modern, contemporary logo.

The ‘Celebrating Team North’ Section was introduced which focuses on recognising and celebrating the achievements of staff across our Trust – both individuals and teams – and highlighting the positive impact on patients, service users and the wider community.

Our ‘Health, Wellbeing and Inclusion’ section on Staffnet continues to support the delivery of the Health, Wellbeing and Inclusion (HWBI) Strategy within our People and Culture Plan. This has been further developed by the introduction of a monthly staff newsletter focussing on HWBI resources that are available to staff. The ‘Well at Work’ newsletter replaced ‘People Pulse’.

We worked closely with our Trade Union colleagues around industrial action by their members, and communicated with staff and service users around the impact to services.

Team North Manager and Supervisor Recognition Events

The Trust held a series of Team North Manager and Supervisor Recognition Events in February and March 2025. The four events were specifically tailored for our Team North Managers & Supervisors at Bands 3–7.

The purpose of these events was to recognise and celebrate the vital role that managers and supervisors have. A total of 400 managers / supervisors / learners attended and feedback was overwhelmingly positive, with people leaving feeling inspired, motivated and uplifted.

The events also included a presentation of certificates to honour the achievements of Team North colleagues who had completed a vocational qualification through the Trust’s Northern Assessment Centre in 2024/25.

Quality 2020 Attributes Framework

Overall, 76% of Trust staff have now successfully undertaken level 1 of the Quality 2020 training attributes framework. The Level 1 training programme provides staff with an introduction to Quality Improvement and the critical role that it plays in the provision of care for patients, clients and service users.

Promoting Openness

As at 31 March 2025, a total of 1,039 (79%) of Trust managers have now successfully completed Openness training.

The Regional HSC Raising Concerns in the Public Interest (Whistleblowing) Framework was launched in April 2024 & adopted as a Trust policy in June 2024.

Supporting Equality, Diversity and Inclusion (EDI)

In June 2024 we published our annual Equality Newsletter and on 10 June 2024 our EDI Chair formally launched new artwork pieces in both Antrim and Causeway Hospitals themed ‘valuing the diversity of our NHSCT staff’. We also contributed to a number of Conferences in June 2024 and February 2025 outlining our commitment to inclusion and showcasing our work to support neuro-diverse staff. We also continued to show our support for PRIDE events in Belfast, Mid Ulster and Portrush.

In March 2024, the Trust launched its new Workplace Support Strategy for Domestic and Sexual Abuse following approval at Trust Board. The Strategy includes our new policy, a support pack for staff and managers, a comprehensive training programme and the development of a network of experienced advisors across the Trust. At Christmas we ran an awareness campaign #16daysofaction challenging misconceptions and highlighting key supports, and were highly commended at the NI Hummingbird awards in March 2025.

We once again celebrated National Race Equality Week in February 2025 and participated in various events with Northern Ireland Practice and Education Council (NIPEC) and the HSC Leadership Centre with a focus on access to education, learning and development.

Support was also provided to our staff forced to leave their homes as a result of civil unrest in the Summer of 2024.

Health, Wellbeing and Inclusion

In June 2024, a celebration event was held for our Staff Health, Wellbeing and Inclusion Champions. As well as providing an opportunity to mark their hard work and achievements, the event was also a platform to share ideas and inspiration across teams.  The Trust’s new Staff Health, Wellbeing and Inclusion Strategy launched in August 2024. It sets out a series of actions that aim to improve the overall health and wellbeing of our staff, with a strong emphasis on the need to embrace a culture of equality, diversity and inclusion.

Revalidation of Medical and Nursing Staff

Revalidation is a mechanism for doctors, nurses and midwives practicing in the United Kingdom to prove their skills are up to date and they remain fit to practise. The Trust continues to ensure that all relevant staff are revalidated.

Staff Flu Vaccination Rate

The Staff Autumn Vaccination Programme commenced in October 2024 and staff were able to avail of flu and/or COVID vaccines at pop up clinics across Trust locations from October through to March 2025. The final uptake figures for staff were:

• Flu vaccine: 2,229 (18.97%)
• COVID booster: 788 (9.05%)

Fit testing

Fit testing is a vital element of staff health protection. Work has been ongoing to increase the compliance rate for those staff who have been identified as requiring fit testing for their job role. The compliance rate for those staff that have been identified as requiring fit testing for their job role and have a valid fit test was 63% as of the 31^st March 2025. The internal Occupational Health and Wellbeing Staff Health Protection Team continue to work directly with departments to work towards increasing compliance.

Appraisal

As at 31 March 2025, a total 53% of Trust staff have taken part in an in-year annual Appraisal Conversation and agreed Personal Development Plan and a Wellbeing Appraisal. The HR Helpdesk and the Organisation Development Support Team continued to provide support to line managers to by recording appraisals on their behalf.

Recruitment/Resourcing

The Resourcing team saw an increase in requisitions in 2024/25. The activity data is shown below:

	Total Requisitions received	Lead Requisitions created	Requisitions Created for Manager	Medical, Dental & Senior Exec Requisitions	Total
2022/23	2945	193	35		3173
2023/24	2435	147	35	110	2727*
2024/25	2422	176	55	104	2757*

*Student social work streamlining sat outside of process above, with the team supporting the recruitment of 48 students in 2023/24 and 49 in 2024/25 into the Trust.

The team also administered bespoke recruitment for trainers and students to support our go-live with encompass; undertaking over 100 pre-employment checks.

New support has been put in place for staff via our Recruitment and Selection Clinics – 13 clinics were facilitated during 2024/25, with 275 staff attending.

The Trust Time to Fill is within target; reducing from 59.9 working days in July 2024 to 45.9 working days in March 2025. Time to Fill shows the average time to recruit a post, from the point it reaches the Recruitment Shared Services Centre to the date the candidate receives their final offer of employment.

Registration of professional staff

The Trust continues to ensure that all professional staff (e.g. social workers, social care staff, pharmacy staff, allied health professionals, etc.) are appropriately registered. Registration demonstrates that their skills are up to date and they remain fit to practise.

Staff Absenteeism

The Trust cumulative sickness absence percentage for 2024/25 was 7.65% against the Trust target of 7.5%.

The chart below compares the cumulative absence position over the past 2 years.

The following chart details the top 10 reasons for absence during 2024/25:

The Trust’s Supporting Attendance Management (SAM) group continues to oversee attendance management in the Trust. Throughout 2024/25 a series of HR and Occupational Health (OH) clinics have been provided to Managers to support complex case management and HR have also introduced scheduled Absence Hearings each month to enable more effective progression of complex cases. The group continues to review trends and hotspots and there are strong links with parallel work supporting Health Wellbeing and Inclusion.

Investors in People – 24 Month Review

Having achieved Investors in People (IIP) Silver status in January 2023, the Trust had its 24-month Interim Review meeting in March 2025. This meeting provided an opportunity for the Trust to check in with the IIP Team to provide an update on:

• our people progress over the past year
• outline plans, priorities, challenges and context ahead of re-accreditation in 2025

Staff Achievements

During 2024/25, the Trust received a number of awards, both regionally and nationally for achievements in driving improvement and engendering a culture of excellence across health and social care. Listed below are only a few examples of the external awards received by our staff:

The Rapid Response Team based in Antrim Area Hospital received the Healthcare Cleaning Team of the Year Award in August 2024. The Award is supported by the British Institute of Cleaning Training and Services and the judges paid tribute to the team’s honesty, humanity, team work and all done with a smile on the face!!

Cahal Bradley, Ward Manager in Antrim Area Hospital was recognised as the Royal College of Nursing (RCN) Northern Ireland Nurse of the Year in 2024. Cahal’s success at the RCN awards reflects his leadership skills, encouraging his team to improve patient safety and care standards by reducing inpatient falls whilst creating an environment of clinical excellence.

The Macmillan Hospital Specialist Palliative Care Team were joint winners of the ‘Palliative Care Nursing’ Award 2024 at RCN Awards. The judges recognised a team that is in a unique position to provide specialist palliative care advice and support to patients and their loved ones by guiding them through their palliative and end of life care journey and relieving some of their anxiety and distress during an extremely difficult and uncertain time in their lives. As well as patients and their families, the team provides specialist support, advice and expertise to other health care professionals within hospital and community settings, including GPs and district nurses. The judging panel noted the strong evidence of person-centred care throughout all that they do.

Connect North is the Northern Trust area wide integrated social prescribing service which was co-designed with stakeholders including service users and carers. The Team were Runners-Up in two categories in the Patient Experience Network National Awards (PENNA) 2024. The Awards recognise best practice in patient experience across all aspects of health and social care in the UK.

In March 2025, The Trust was awarded Highly Commended in the NI Hummingbird Awards for its Domestic and Sexual Abuse marketing campaign ‘not everyone’s Christmas will be merry and bright’. The Awards recognise excellence in advancing Equality, Diversity and Inclusion.

The Northern Trust’s collaborative working was recognised at the prestigious NI Local Government Awards 2025 in March 2025.

Three projects led by the Trust’s Health and Wellbeing team were shortlisted altogether, with the Autism Friendly Initiative developed alongside Mid and East Antrim Borough Council winning the overall award in the Equality, Diversity and Inclusion category.

The Causeway Healthy Kids project with Causeway Coast and Glens Borough Council was runner up in both the Service Innovation & Improvement and Collaborative Partnership Awards, while the Family Support & Social Supermarket Programme was runner up in the Engaging Communities category, with Antrim and Newtownabbey Borough Council.

Trust Medical Awards

The Trust annual Medical Awards ceremony took place in July 2024 to celebrate the projects completed by junior medical staff. Dr Catherine Whiteside & Dr Dan Soutar (Dept of Palliative Medicine, AAH) won the Best Oral Presentation category for: Do you think they are dying doctor? The role of palliative medicine-based simulation sessions in preparing newly qualified doctors for foundation training.

Macmillan Excellence Awards

The Palliative Care Service Improvement Team and the Community Specialist Palliative Care Team were highly commended in 2024 national Macmillan Excellence Awards in the Integration Category. The judges recognised the Team’s steadfast commitment to building compassionate communities. They commented on how the team have formed an astonishing number of creative and committed partnerships that raise awareness of sensitive topics like grief and loss, and their work is transforming people’s perceptions of palliative care.

British Society for Rheumatology – Droitwich Medal

In April 2024, Hilary McKee, Consultant Pharmacist for Older People, became the first pharmacist to receive the prestigious Droitwich Medal and delivered the associated Droitwich Lecture, titled “Is there a Pharmacist in the Rheum?” at the British Society for Rheumatology (BSR) annual conference. This landmark achievement reflects the increasing recognition of the vital role pharmacists play in rheumatology and exemplifies the leadership and expertise of pharmacy professionals within multidisciplinary care.

Since then, Hilary has contributed significantly to the advancement of pharmacy within rheumatology on both national and international platforms. She has delivered presentations at key events including the PERM (Pharmacist Evolution in Rheumatology) meeting in June 2024, the BSR Allied Health Professionals (AHP) course in July, and the BSR Core Skills and ERM (Evolution in Rheumatology) meetings in November. In October 2024, she presented four workshops at the European Society of Clinical Pharmacy (ESCP) conference in Krakow, focusing on polypharmacy, frailty, and deprescribing in rheumatology. She also contributed as the pharmacist representative to the publication of the BSR/BAD (British Association of Dermatology) guidelines on the management of Behçet’s disease. In September 2024, she was invited to join a EULAR (European Alliance of Associations for Rheumatology) task force developing recommendations on osteoporosis management in patients with rheumatic and musculoskeletal diseases (RMDs). She continues to represent the pharmacy profession as the sole pharmacist member on the EULAR Health Professionals in Rheumatology (HPR) committee. Most recently, in March 2025, Hilary was interviewed by Medical Update Online, further showcasing the breadth and impact of her work.

Maternity and Public Health Nursing retain Joint Baby Friendly Gold Award

Maternity and Public Health Nursing were delighted to have been reaccredited as Baby Friendly Gold Services. The Trust was the first in the region to have achieved Gold status and have now held this accreditation for 7 years.

The UNICEF’s UK Baby Friendly Initiative (BFI), which is internationally recognised, is based on a set of interlinking evidence-based standards for maternity, health visiting, neonatal and children’s centres services. These are designed to provide parents with the best possible care to build close and loving relationships with their baby and to feed their baby which will support optimum health and development.

The UNICEF Baby Friendly Gold award is the highest level of accreditation and celebrates excellent and sustained practice in the support of infant feeding and parent-infant relationships.

Antrim Area Hospital’s Neonatal Unit retains prestigious Baby Friendly award from United Nations International Children’s Emergency Fund (UNICEF)

The re-accreditation in 2024 follows on from its initial success in 2023. It remains the only Neonatal Unit in Northern Ireland to hold the recognition, acknowledging the exceptional standard of care provided to sick and vulnerable babies and their families. UNICEF’s Baby Friendly Initiative is a global programme which aims to transform healthcare for babies, their mothers and families as part of a wider global partnership between UNICEF and the World Health Organization (WHO).

Nurture Clinic

The Nurture Clinic in Antrim won a prestigious award from the Royal College of Midwives (RCM) for its collaborative approach to helping new mothers who are experiencing drug and alcohol misuse.

The award is for a midwifery or maternity team that is able to demonstrate attributes of dynamism, commitment and enthusiasm, and high levels of excellent inter-professional partnership with others. The Nurture Clinic also won the Management of Substance Use Award at the recent NI Healthcare Awards.

Within the Antrim region, it is estimated that around 40,000 children live with parents who have substance misuse issues. Approximately 40% of these children are on the Child Protection Register as a direct result of parental substance misuse.

The team at the Nurture Clinic realised that addressing some of these issues required a multi-disciplinary approach. Recognising and screening for drugs and alcohol during early pregnancy required a higher level of expertise than that held within the midwifery team so they collaborated with the Trust addictions team who also provided inpatient care for women experiencing detox and withdrawal during pregnancy and the postnatal period.

An addictions pathway was established by involving obstetrics, midwifery, the addictions team, inpatient addiction services, paediatrics, various safeguarding practitioners, pharmacy and anaesthetics. This initial pathway was successful but multiple appointments caused women to disengage so the specialist midwife and advanced addiction nurse practitioner established a joint clinic to provide continuity of care as well as liaison with all key health professionals.

The clinic now offers three sessions per week, enabling those who attend to not only benefit from physical and psychological support but also from monitoring for up to six weeks after having given birth.

“The tag line ‘everyone wants to hold the baby, but who wants to hold the mum?’ succinctly captures the team’s underpinning motivation for extending the service so successfully.”

RCN Directors Award Winner

The maternity service in the Trust identified a need to centralise inpatients and births from Causeway Hospital to the main Antrim Hospital site. Clinicians had advised that the provision of inpatient maternity services in Causeway was unsustainable due to falling birth rates, workforce challenges and the absence of a neonatal unit.

As Assistant Director of Women’s Service and Head of Midwifery, Caroline engaged inclusively and constructively with staff to collectively determine how to provide acute maternity services in the future. Caroline held a number of meetings, briefings and workshops with staff within the maternity service and she worked collaboratively with other services which interface with maternity such as Emergency Department, anaesthetics and support services. Within the ‘Considering the Options’ document, Caroline identified future population health needs within the Causeway locality which signified that the population served by Causeway Hospital is changing; Northern Ireland Statistics and Research Agency (NISRA) envisage that over the next 20 years the number of births in the area is projected to fall by 11% and the population of older people (over 75 years) is expected to grow by 65%.

The clinically deliverable options were collectively identified through staff listening events, attended by over 70 staff. Additionally, during the public consultation period 2 separate in-person listening events occurred, attended by a wide range of stakeholders and by a further 32 staff members including Trade Unions.

Driven by paediatric regional surge plans during the COVID-19 pandemic, Caroline had previously led on the centralisation of maternity inpatients and births on the Antrim site for a duration of 4 months. This experience assisted Caroline to positively influence on the feasibility of the options and to provide assurance that the change in service model was safe and deliverable.

Caroline coordinated a major change initiative ensuring that all 40 staff whose jobs were impacted and service users were engaged in the change programme. All staff received their first choice of new post and service users’ experience of safe care was enhanced.  Caroline acknowledged that there was sadness and a sense of loss within the Causeway maternity team but staff understood the challenges and championed the change. As a result of the well managed change process the usual negative attitudes associated with transformational change were avoided.

Perhaps the best assessment of the effectiveness from a local BBC journalist, Marie Louise Connolly: “In less than a year, the Northern Trust has managed to deliver a major permanent change to how one of its core services will be delivered with little fuss or opposition. In Northern Ireland that is remarkable”.

Autism NI Impact Award

Autism is a lifelong developmental condition that influences how individuals communicate and interact with their surroundings. Many autistic individuals face challenges in processing everyday sensory information, such as sights, smells, touches, tastes, and sounds. As a result, attending healthcare appointments and interacting with healthcare professionals can become a stressful experience.

The prevalence of autism is increasing annually in Northern Ireland. The Autism NI Impact Award aims to assist organisations in creating an inclusive and welcoming environment for autistic service users and employees. Achieving this award signifies that a service is recognised as an autism-accessible and friendly environment.

Maternity staff participated in a number of online training courses facilitated by Autism NI, completing five hours of training that covered core characteristics of autism, including:

• Social and communication differences
• Restrictive, repetitive patterns of behaviour and interests
• Sensory differences
• Daily challenges faced by autistic individuals
• Practical strategies for staff to implement

A total of 56 maternity staff members completed this training across six courses, allowing them to collaborate on potential changes within their service. These ideas were then advanced by autism champions in their respective areas to develop action plans. In maternity services, 11 champions worked together on four action plans that address Causeway Community Hub, Maternity birth suites and ward in Antrim Area hospital alongside Outpatients 4 and maternity education. As part of becoming autism champions those staff had to complete an examination and this was submitted to the Assessment and Qualifications Alliance (AQA) for accreditation. These champions continue to meet with others across the trust to learn and share good practice as part of the Autism Champion Network within the trust on an ongoing basis.

Theme 3: Measuring the improvements

What does measuring the improvement mean for the Northern Health and Social Care Trust? It is about exploring more reliable and accurate means to measure, value and report on quality improvement and outcomes. During 2024/25, each Trust was required to measure a number of quality improvement indicators, and listed below are some examples of measuring the improvement.

Healthcare Associated Infections

Controlling the spread of healthcare associated infections (HCAI) remains a concern in healthcare facilities, necessitating ongoing surveillance, vigilance and preventative measures to reduce their incidence and transmission. Performance on the reduction of Clostridioides difficile (C. difficile) and Methicillin-resistant Staphylococcus aureus (MRSA) infections remain a primary focus with previous reduction targets set for each Trust based on the number of actual cases each year. This way of measuring performance of HCAI for C. difficile and MRSA has now changed.

To align with the new UK National Action Plan (NAP) 2024-29, to tackle antimicrobial resistance, a new methodology was introduced in 2024/25 for C. difficile and MRSA target setting which will now set targets for these metrics as a rate per 100,000 bed days instead of the previous count of episodes or cases. This change allows for standardised comparison of C. difficile and MRSA infections over time and across Trusts, considering variations in hospital capacity and patient exposure to infection risks within each Trust.

Clostridioides difficile

Clostridioides difficile (C. difficile), is a bacterium that some people may carry in their bowel and is normally kept under control by good normal gut bacteria. Certain antibiotics can disrupt the natural balance of bacteria in the bowel, enabling C. difficile to multiply and produce toxins that may cause mild to severe illness, including symptoms of diarrhoea. Older adults, patients with weakened immune systems and patients receiving antibiotic therapy are particularly vulnerable.

1. difficile is mainly acquired in healthcare settings where antibiotic use is common and can spread via environmental surfaces, contaminated equipment or the hands of healthcare workers. This emphasizes the importance of a high standard of hygiene practices and infection control measures in preventing its transmission.

The Trust performance on C. difficile infections at the end of March 2025 was a cumulative rate of 11.98 against a C. difficile target rate of 15.3; at year-end the Trust performance was notably below the C. difficile target rate set by the Public Health Agency (PHA).

MRSA

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia is a type of bacterial blood stream infection that is resistant to a number of widely used antibiotics. As a result, it can be more difficult to treat than other bacterial infections. MRSA bacteraemia infections are typically linked to invasive procedures like surgery or use of medical devices, including intravenous lines and urinary catheters. Elderly patients and those with weakened immune systems are particularly at risk.

The Trust performance on MRSA bloodstream infections at the end of March 2025 was a cumulative MRSA rate of 3.37 cases against an MRSA target rate of 4.41; at year-end the Trust performance was also notably below the MRSA target rate set by PHA.

Safer Surgery / World Health Organisation Checklist

The World Health Organisation (WHO) Surgical Safety Checklist is a tool used by clinical teams to improve the safety of surgery and reduce deaths and complications. The checklist was designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and checking essential care interventions. During 2024/25 the Trust achieved 96% compliance with the WHO Surgical Checklist.

A Band 6 Clinical Sister/Clinical Charge Nurse in each area completes WHO audits monthly to ensure compliance of completion. With the introduction of encompass these audits have had to be adapted to the new digital way of working. A regional group has been established to review the WHO checklists. There are also three-monthly observational audits carried out where the Clinical Sister/Clinical Charge Nurse will observe all practices within the theatre environment. Each department manager also conducts an audit in another theatre department to assess compliance. Compliance with these three-monthly observational audits for 2024/25 was 99%.

Maternity services

Time well Spent, Maternity Discharge

The Maternity Sister in Antrim reviewed the time spent doing tasks that took midwives away from direct contact with mothers and babies. One area considered was the handover postnatal discharges to Community midwifery teams. The Trust has one of the largest geographical catchment areas, therefore community teams need to plan their daily visits effectively. The model involved community teams phoning into the ward and taking a verbal handover, however this was time consuming and vital information could have been transcribed incorrectly. Therefore, a shared mailbox that all community midwives could access was set up, the discharges were at emailed at 2pm and late discharges at 9am. This simple but effective improvement resulted in fewer missed discharges, reduced communication errors and increased direct patient contact. This has also resulted in the ward phone line being kept free.

Emergency Obstetric Unit

The Emergency Obstetric Unit (EOU) at the Antrim site provides unscheduled care for women throughout the pregnancy continuum, managing approximately 520 episodes annually. Feedback from both women and staff indicated opportunities to enhance the woman’s journey and streamline care pathways, with an emphasis on safety, satisfaction, and efficiency.

A thorough process mapping exercise was undertaken to better understand the EOU clinical pathways. Several Plan-Do-Study-Act (PDSA) cycles have since been implemented to address the collection of baseline data, to identify waiting times and potential bottlenecks within the departments. From this baseline analysis, a range of targeted quality improvement projects have been identified, each aimed at reducing waiting times and ensuring seamless progression through clinical pathways. These projects are due to commence in 2025/26.

By sustaining this improvement approach and continuing to apply PDSA cycles, the EOU aims to achieve measurable reductions in delays and deliver a more coordinated, woman-focused service.

Paediatric services

QI Project – The Introduction of Documentation to Record Risk Based Decision Making with Regards to Community Children’s Nurse (CCN) Delegation

The Paediatric Lead Nurse undertook a QI initiative in relation to nurse delegation through the Regional Quality Improvement Programme for Social Work, Nursing and Midwifery. The aim of the project was to improve the recording of risk-based decision making by registrants in the delegation of nursing care to non-registrants within CCN support packages. Through the use of questionnaires, PDSA cycles, development of a bespoke child specific decision matrix as well as focused workshops, she was able to demonstrate a 79% increase in the recording of decision making.

Supporting Staff – Team North Paediatric Newly Qualified Nurse Induction Programme

This bespoke paediatric nurse induction is aimed at newly qualified nurses who are moving into posts within acute wards, Neonatal Unit and the Community Children’s Nursing services. As the transition from student to registrant can be daunting, the Paediatric Practice Education Facilitation team through this programme provides support and guidance as new staff members navigate this process.

The six-day induction programme involves a combination of classroom learning on specific paediatric topics delivered by the Paediatric Practice Educators and information sessions facilitated by specialist guest speakers. These cover a wide range of topics, including paediatric bereavement, infection prevention and control, paediatric diabetes, paediatric asthma and allergy, introduction to library services, discharge planning and transition, and new-born screening, to name but a few. The Practice Education Facilitation team also provides important information and guidance on the commencement of the Newly Qualified Nurse (NQN) preceptorship process.

Of particular note this year were two newly qualified nurses, Denise Simpson and Nicola Hollis, who graduated via The Open University programme. Both previously worked as Senior Nursing Assistants within the Community Children’s Nursing service and are part of the first cohort to qualify as children’s nurses in Northern Ireland which is a fantastic achievement.

encompass

In November 2024 the Trust went Live with encompass. Encompass is a HSCNI-wide initiative which supports the delivery of long term, sustainable digital transformation of our health and social care services across Northern Ireland. By creating an integrated digital care record for citizens receiving health and social care services in NI, encompass enables everyone involved with a person’s care to work from a single health and care record.

This has provided the opportunity for the digitalisation of the Nursing Key Performance Indicators (KPIs); this will be transformational as it will move from small samples (10 records per KPI per area) to complete dataset availability, and from point in time monthly reports to real time reporting. This will enable a significant shift in practice by providing the service leads the opportunity to address issues at the time rather than use the reports retrospectively; however quarterly reports will still be produced to ensure trends and areas for improvement are identified. The Nursing & Midwifery Safety, Quality & Assurance team continue to work with the Cogito team from encompass, Nursing and Midwifery Quality Assurance Network (NMQAN) and professional leads across the region to build the revised KPIs into encompass; the work to date has focused on the acute nursing and district nursing KPIs. There has been significant learning from this process in terms of the digitalisation of the KPIs; one of the main challenges has been ensuring accurate adoption onto the system.

Prevention of Falls

‘Slips, Trips & Falls’ remain one of the most common incident types within the Trust during 2024/25.

The National Institute for Clinical Excellence (NICE) Clinical Guideline NG249 states a fall is ‘an unexpected event in which the participants come to rest on the ground, floor, or lower level’. Although falls can occur at any age, they become increasingly common as people get older. Around a third of people aged 65 and over, and around a half of people aged 80 and over, fall at least once a year. The impact of falls, especially in people aged 65 and over, includes distress, pain, injury including fractures, loss of confidence, loss of independence, and mortality.

The number of falls during 2024/25 has increased to 1,798. The following reasons continue to contribute to these rates:

• Increasing ageing population
• Increasing prevalence of multi-morbidity, polypharmacy and frailty
• Deconditioning of the elderly population and associated social isolation

The Trust continues to see the importance of falls prevention as a key component to healthy ageing. To facilitate this, the Trust has a Falls Steering Group focusing on a multi-disciplinary and agency approach to the prevention and management of falls.  The Falls Prevention Team continues to support a number of Quality Improvement initiatives within the Trust focusing on reducing falls and staff education. The Team has also worked within the acute setting to ensure safe post fall care. The Trust has recently developed an acute falls and frailty link nurse programme using the Department of Health (DoH) Link Nurse Framework with the first meeting held in February 2025.

A number of Regional Falls Awareness e-learning modules are available for all staff.  Modules available include a Universal awareness module and further area specific modules covering acute, community and care home specifics.

The Regional Falls pathway for care homes has been launched, which includes a guideline for the immediate management of a resident who has fallen. The Trust is continuing to support staff to embed this in practice and continue to offer a falls prevention screening and advisory service to Trust and Care Home staff via the telephone, offering further advice and guidance regarding falls and injury prevention.

The established Falls Screening Service continues to accept referrals via Northern Ireland Ambulance Service (NIAS), the Trust Emergency Departments (ED), Minor Injury Units, Fracture Liaison Service, GP’s and other multidisciplinary staff. The service also accepts self-referrals directly from service users. After completion of a multi-factorial falls screening, onward appropriate referrals are made to internal and external services, to help reduce the risk of falls and subsequent injuries.

Within the Trust’s inpatient settings, the FallSafe bundle is embedded into practice. The Trust also continued to complete post-fall investigations on all inpatient falls that resulted in a moderate to catastrophic injury. Areas identified for learning and improvement are discussed with ward managers, and shared with Senior Management. Action plans are taken forward within teams to address any gaps in practice. This learning is also shared with the Public Health Agency, and is used to form the basis of the yearly Learning from Falls Newsletter. The purpose of this newsletter is to share information and key learning from inpatient falls across all Health & Social Care Trusts.

With the introduction of encompass, staff now complete falls risk assessments on the digital system. The falls team are continuing to collaborate with regional colleagues in relation to this new way of working.

Falls rate per 1000 bed days

Due to the implementation of encompass in November 2024, the Falls Rate for 2024/25 is unavailable at this time.

The total number of falls across all adult inpatient areas in 2024/25 was 1,798 (compared to 1,698 in 2023/24), and there were 37 falls resulting in moderate to catastrophic harm (compared to 39 in 2023/24).

Next steps

• Ongoing Regional Falls collaboration to standardise assessments post-fall within the inpatient setting on encompass
• Development of a falls dashboard within the digital system to allow for overview and auditing purposes

Prevention of Pressure Ulcers

Pressure ulcers are defined as localised damage to the skin and/or underlying tissue, as a result of sustained pressure or pressure in combination with shear. Pressure ulcers usually occur over a bony prominence, but can be related to a medical device or other object (NPUAP/EPUAP/PPPIA, 2019). Many patients are at risk of pressure ulcers due to multiple co-morbidities and key contributory factors such as, immobility, poor nutrition, weight loss, skin moisture, sensory deficiency, and advancing age.

Pressure ulcers are a major patient safety concern and a quality indicator of care. The Trust therefore, in line with the rest of the region, has a focus on the prevention of pressure ulcers. Preventing pressure ulcers involves firstly, promptly identifying those patients at risk and secondly, reliably implementing prevention strategies for all patents identified as being at risk. In the Trust, this is currently supported by the use of the Pressure UlceR Primary or Secondary Evaluation Tool (PURPOSE T) risk assessment tool and the SSKIN bundle (see below).

S: Surface
S: Skin Assessment
K: Keep Moving
I: Increased moisture Management
N: Nutrition

Tissue Viability pressure ulcer documentation, including the SSKIN bundle and Pressure ulcer risk assessments (PURPOSE T for adults, and Glamorgan for paediatrics) are available as flowsheets on encompass in community and hospital settings.

Key facts

During 2024/25, the Trust has built upon the foundations laid in previous years aiming to reduce the number of avoidable pressure ulcers. During 2024/25 the Trust reported 567 hospital acquired pressure ulcers which were graded stage 2 and above (compared to 483 in 2023/24). Of these, 199 were stages 3 and 4 (compared to 152 in 2023/24). Of the total number of Stage 3 and 4 pressure ulcers, 78 were deemed avoidable (compared to 75 in 2023/24).

Due to the implementation of encompass in November 2024, the rate of hospital acquired pressure ulcers graded 3 and above for 2024/25 is unavailable at this time.

This increase may be reflective of an improved, more robust post-incident review process. The Wabalogic Medical Photography App has been replaced with imaging on encompass since November 2024. Staff continue to embrace the use of medical photography. These images support the Tissue Viability Nurse (TVN) to appropriately triage referrals and improve the timeliness of TVN patient advice.

Using the Department of Health (DoH) Link Nurse Framework, a total of 70 Tissue Viability Link Nurses have been recruited to support the TVN and the inpatient / outpatient departments in all acute and community hospitals to achieve safe, effective, person-centred wound care. The TVNs hosted a successful link nurse learning event in Causeway Hospital in May 2024. A total of 33 staff attended from the acute and community hospitals. Staff benefited from practical sessions focusing on the learning themes from Pressure ulcer incidents post incident reviews. Staff were given the opportunity to practice the fundamental skills of wound care and pressure ulcer prevention and management with a focus on completing a wound assessment, wound imaging and making a referral, repositioning techniques, completing SSKIN bundle and pressure Ulcer Risk Assessment.

Action the Trust is taking

Quality improvement (QI) initiatives are underway to enhance patient safety in pressure ulcer prevention:

• The contract with Wabalogic ended in December 2024. The Trust’s TVN lead is working with a regional group to develop a regional encompass imaging policy. The TVN lead is working on a Standard Operational Procedure (SOP) to reflect the regional policy and guide staff on maintaining patient privacy, dignity and safety whilst capturing wound images on encompass via an app
• All registered nursing staff and non-registered staff working in hospital and community settings should complete the regional e-learning programme for Prevention of Pressure Ulcers in Adults for Registered Practitioners, every 2 years. All non-registered staff including nursing assistants, Health and Social Care (HSC) employed domiciliary care workers and Allied Health Professionals (AHP) support workers can access this e-learning programme
• There are plans to develop a community Tissue Viability Link Nurse group to offer the same opportunity for learning and networking
• The Tissue Viability team lead is collaborating with community nurse leads to develop a shared decision-making document to assist nurses in supporting patients to make an informed decisions regarding pressure ulcer prevention

Action the region is taking

The Tissue Viability Team actively participates in the Public Health Agency (PHA) Regional Pressure Ulcer Group alongside other Trusts to plan regional strategy, Key Performance Indicator (KPI) monitoring and improvement work in the area of pressure ulcer prevention.

• It is recognised now, that healthy women whose labours are prolonged or require caesarean sections are at increased risk of pressure ulcers. The TVN and maternity department developed and implemented the Trust Maternity SSKIN bundle including the PURPOSE T risk assessment tool. Regional collaboration began in 2023 and the maternity SSKIN bundle has been developed and implemented regionally on encompass
• Safeguarding criteria is being developed regionally to assist staff with decision-making in relation to appropriate referral to the adult protection team following a pressure ulcer incident
• The TVN team lead collaborated with the regional TVN leads to develop a pressure ulcer definition document. The recommendations in this document are designed to support a more consistent approach to the definition and measurement of pressure ulcers at both local and national levels across all trusts. This was implemented in April 2024
• The Regional Pressure Ulcer group have developed and launched an updated version of the Pressure Ulcer Prevention Information leaflet for patient and carers. This now includes QR codes; one that direct patients to a video explaining the risks of pressure ulceration and a QR code that direct patients to images of pressure ulcers. This is to assist patients to make informed decisions regarding pressure ulcer prevention and management.

Prevention of Venous Thromboembolism

Venous Thromboembolism (VTE) is a condition in which blood clots form (most often) in the deep veins of the legs. This is known as deep vein thrombosis (DVT) and sometimes the clot can travel through the blood circulation and lodge in the lungs causing a pulmonary embolism (PE).

Admission to hospital increases the risk of blood clots (DVT, PE); however, VTE can be preventable. To help prevent VTE in patients admitted to hospitals, a risk assessment is carried out at admission to determine the level of risk of developing VTE, and anti-clotting medicines are prescribed if appropriate.

The Trust is committed to achieving 95% compliance with the completion of the VTE risk assessment to ensure patients are provided with the most appropriate and safe care in the prevention of hospital-acquired VTE.

Between April and October 2024, the Trust achieved:

• 92% compliance with the completion of a VTE risk assessment within 24 hours of admission for patients to acute and community hospitals;
• 98% compliance with prescription of appropriate VTE prophylaxis

Cardiac Arrest Rates

A ‘cardiac arrest’ is where a patient requires chest compressions and/or defibrillation by the hospital resuscitation team. Evidence suggests that the number of hospital cardiac arrests can be reduced through earlier recognition and treatment of patients whose clinical condition is deteriorating. The compassionate care of those patients acknowledged to be nearing the end of their lives may also help to reduce the number of patients treated for cardiac arrests.

The chart below shows the yearly rate of reported cardiac arrests for Antrim and Causeway Hospitals (excluding Emergency Department, Intensive Care Unit, Coronary Care Units and Paediatrics). The Cardiac Arrest Rate is calculated by dividing the Number of cardiac arrests by the Number of deaths and discharges, and then multiplying by 1000.

Due to the implementation of the new encompass system in November 2024, the Cardiac Arrest Rate for 2024/25 is unavailable at this time.

Omitted and Delayed Medicines

Omission or delay of medicines can lead to harm for patients, particularly when “time critical medicines” are involved. Time critical medicines (TCMs) are those which need to be given “on time, every time” in order to control or treat certain conditions or disease, for example, drugs used to control Parkinson’s Disease and diabetes.

Consultant medical staff, pharmacy and nursing staff working in the Emergency Department at Antrim Area Hospital undertook a quality improvement project to reduce the likelihood of omitted and delayed doses of TCMs occurring. This involved focused education on TCMs within the ED, highlighting the importance of these medicines and the consequences to the patient if they are omitted or delayed.

Posters for the regional Know Check Ask campaign were placed in triage rooms to help equip healthcare staff with the knowledge and skills they need to be safe with medication, and in waiting rooms to encourage patients to Know Check Ask about their medicines, especially any TCMs.  The aim of the campaign is to increase awareness and understanding among staff and patients about the importance of using medicine safely.

‘Know, Check, Ask’ before you take medication urges Minister | Department of Health

An updated poster detailing the location of critical medicines in the hospital was displayed within ED clinical rooms to ensure accessibility of these medicines out of hours, reducing delay or omission of TCMs.

The ED pharmacists screen all patients in ED in the morning to prioritise those on critical medication, reconciling the medicines within 24 hours where possible, with urgent attention given to any TCMs that the patient may be taking, or requiring.

Insulin

Insulin is well recognised worldwide as a ‘high risk’ medication, which means if it is used incorrectly can lead to serious harm to patients. Prescribing, dispensing, administration and monitoring errors with insulin can lead to patient harm, which can significantly impact people’s health and experiences of using healthcare. Therefore, it is important that healthcare professionals take appropriate action to reduce the risk of errors when using insulin.

The Trust has an established multi-professional Insulin Safety Group which regularly reviews the risks associated with insulin use, proposing systems or process changes where appropriate. Other work of the Insulin Safety Group includes developing insulin-related policies, analysing reported medication incidents involving insulin, and developing staff training materials, all with the aim of avoiding errors in the use of insulin within the Trust.

Insulin Safety Week 2024

The Trust participated in Insulin Safety Week (ISW) which took place from 1^st – 7^th July 2024. ISW is a national campaign to raise awareness of insulin safety, and this year, the Diabetes Team put the spotlight on “wearable diabetes technology”, highlighting some of the risks associated with using the devices. Wearable diabetes technology includes devices such as insulin pumps and continuous glucose monitoring devices, and are used by many people living with diabetes, especially as the devices offer the person the benefits of regulating and monitoring their blood sugar levels in real-time, with less need for finger-prick testing.

An Insulin Safety Bulletin was developed and issued by the Insulin Safety Group with the aim of raising awareness of insulin safety.

Other resources issued during Insulin Safety Week included links to insulin safety educational material, and an insulin safety quiz.

Insulin safety in a digital era – getting ready for encompass!

The Trust has a number of clinical policies governing the safe use of insulin. In readiness for the switch over to the new electronic prescription and medicines administration system, EPMA, (encompass), a number of these policies were updated so that staff could be guided through the safe prescribing and administration of insulin using the new system.

A number of members of the Insulin Safety Group were trained as encompass SuperUsers, and helped deliver diabetes and insulin-related training to other healthcare staff on the safe prescribing and administration of insulin in various scenarios e.g. Diabetic Ketoacidosis.

In the run up to go-live with encompass, the Diabetes Pharmacist met regularly with the Regional Diabetes Pharmacist Group to identify potential challenges with prescribing and administration of insulin in the new system, feeding back any key information to the Insulin Safety Group and the Diabetes Team. The Diabetes Team also met fortnightly to identify and address potential issues, and provided staff with valuable guidance and training in readiness for the new way of working.

Medicines Reconciliation

Medicines reconciliation is the process of compiling a complete and accurate list of all the medicines a person is taking. The ward clinical pharmacist completes medicines reconciliation for people admitted to and discharged from hospital, both of which are important steps in the patient journey.

On admission, the medicines reconciliation process:

• provides the information necessary to support safe prescribing decisions
• identifies adverse drug reactions
• identifies medicines that are no longer required
• optimises the prescribed medicines for the patient’s needs
• ensures timely and accurate administration of medicines.

On discharge, the medicines reconciliation process:

• provides a clear picture of what has changed during the hospital stay
• identifies important medicines information for transfer to the person’s GP.

Medicines reconciliation is recorded in encompass and this has provided the Trust with a mechanism to identify people who are awaiting a pharmacist to complete the medicines reconciliation process, and to monitor activity. In 2024/25, 70% of all patients admitted to wards and departments had their medicines reconciled and on the wards that have a ward clinical pharmacy service, 80-100% of patients had medicines reconciled.

Safer Prescribing of Opioid Analgesics in Surgery

Northern Ireland as a region has the highest prescribing of opioids across the UK and inappropriate opioid use is a concern for patient safety due to the risk of side effects, overdose and potential addiction.

Two quality improvement (QI) projects led by the Lead Surgical Pharmacist were undertaken with the aim of promoting safe use of opioid analgesics in surgery.

The first project had a specific aim of reducing inpatient use and discharge supply of codeine by 20% in the Surgical Elective Unit in Antrim Area Hospital.

To achieve this, the QI team took steps to reduce the reliance on opioids in managing post-operative pain, particularly at discharge. A new pain prescribing tool and a patient information leaflet were developed. The project proved to be a success with all improvement measures producing the desired outcome, exceeding the target of 20% reduction in the use of codeine.

The second project was an audit based in Causeway Hospital with the aim of identifying if opioid prescribing on surgical wards complied with the Northern Ireland Formulary guidance to use morphine in preference to oxycodone for a new prescription of a strong opioid. Guidance suggests that the ratio of morphine to oxycodone use should be approximately 60:40. A stepwise approach to opioid prescribing choices ensures that the patient receives the lowest and safest dose possible to achieve pain control without side effects. Findings showed that of the patients prescribed strong opioids, 92% were prescribed morphine and 8% were prescribed oxycodone, indicating good compliance with the guidance.

Supporting safe use of high-risk medicines

This year saw the introduction of new ways to educate and inform our patients about their medicines. Two Clinical Pharmacists working in the Emergency Department at Antrim Area Hospital developed a podcast aimed at reducing harm from high-risk medicines. The podcast was recorded in a conversation style and focussed on the questions most frequently asked about oral anticoagulant medicines. The podcast development was the second phase of a quality improvement project that had previously produced a patient education video on how to self-administer injectable anticoagulants.

The resources can be used in conjunction with face-to-face patient education to support greater knowledge and compliance with medication. A patient information leaflet is also available which contains a QR code for patients or carers to access the podcast on a smartphone. The podcast and videos have been made available for healthcare staff to access through the Trust intranet.

Another podcast series looking at many of the aspects of dementia care was developed by the Care of the Elderly multidisciplinary team. The Lead Pharmacist for Elderly Care contributed to the series by producing a podcast about how medicines can affect and trigger dementia. The podcast series is called ‘Pinch Me Pod’ and has been made available on a number of social media channels.

Theme 4: Raising the standards

The Northern Health and Social Care Trust is committed to raising the standards by putting in place robust and meaningful standards against which performance can be assessed, involving service users, carers and families in the development, monitoring and reviewing of standards.

Risk Adjusted Mortality Index

Risk Adjusted Mortality Index (RAMI) has been developed by CHKS (Caspe Healthcare Knowledge Systems, Ltd.) which is an independent provider of healthcare intelligence and quality improvement benchmarking services. RAMI is used to compare mortality more accurately between different groups of patients. The model predicts the expected number of deaths based on the mortality rate for similar patients who were admitted to hospital in England, Wales and Northern Ireland in the past five years. RAMI compares the actual deaths to the expected deaths to return an index out of 100. For any group of patients, a RAMI of 100 means that mortality was exactly in line with expectations; over 100 means more deaths occurred than would be expected, and below 100 means fewer than expected deaths. For example, if there were 110 actual deaths observed, and the expected number of deaths was 100 then RAMI would return a value of 110.

Funnel Chart showing RAMI variation for Northern Health and Social Care Trust and all English acute trusts (Nov 23-Oct 24)

Data excludes palliative care patients.

The chart above shows the relative performance of the Trust (blue dot) for the twelve months from November 2023 to October 2024 (the most recent available data) compared to all English acute trusts (the green dots) for the same period. The further a dot is to the right, the more patients the Trust treated during the year, and the higher up the chart, the higher the RAMI. Dots within the funnel are inside the normal limits of variation.

The RAMI for the Trust for this period was 94.55 and compares to an English acute trust mean of 87.23. RAMI for the trust has been relatively stable over the past 12 months and shows a marginal decrease, however the RAMI for English acute trusts has been decreasing at a higher rate than the Trust so the relative position of the trust appears worse.

Emergency Readmission Rate

The 30-day readmission rate is a healthcare quality metric that measures the percentage of patients who are readmitted to a hospital within 30 days of being discharged from an initial hospital stay. The average readmission rate in 2024/25 (11.2%) increased slightly on the 2023/24 year average (10.9%).

Emergency Department (ED)

The following table shows Antrim and Causeway performance for the past three years for:

• Total number of attendances
• Percentage of patients seen and admitted or discharged within 4 hours of arrival at ED
• Number of patients spending more than 12 hours in ED
• Percentage of patients seen by a clinician within 1 hour of arrival
• Percentage of patients who did not wait to be seen
• Percentage of patients who re-attended within 7 days with the same complaint

Site	Year	Attendances	4 hrs	12 hrs	Seen <1 hour	Did not wait	Reattenders
Antrim	2022/23	94,900	45.69%	14,568	20.44%	5.78%	3.14%
	2023/24	100,163	40.02%	17,078	16.70%	6.92%	3.63%
	2024/25*	96,058	35.11%	19,919	18.15%	6.81%	3.51%
Causeway	2022/23	46,997	54.13%	5,911	21.96%	6.16%	4.39%
	2023/24	49,694	51.72%	6,164	21.88%	6.11%	4.70%
	2024/25*	48,175	49.86%	6,998	24.34%	5.70%	4.66%

*Data from November 2024 to March 2025 continues to be validated, due to the implementation of the new encompass system.

The following chart shows the percentage of patients who re-attended within seven days.

Actions taken to improve standards

Ambulatory pathways and the promotion of alternative pathways has led to a reduction in ED attendances on both sites. The Emergency Departments continue to be significantly affected by overcrowding with a deterioration in the 12-hour target. This has then affected the 4-hour target due to lack of clinical space to assess new patients. Actions to address this:

• Attendances – the Trust continues to promote alternative pathways to ED and is supported under the unscheduled care programme board
• 4-hour target – all patients are triaged and protected cubicle space on the ambulatory emergency care area of ED has been established to allow rapid assessment to stabilise and increase the 4-hour performance
• 12-hour target – the hospital is currently operating beyond capacity with a well-documented exit block. Flow is supported by our mature site co-ordination models, and working collaboratively with community care colleagues to maximise discharges and promote flow from ED
• Seen less than 1 hour – all patients are triaged and protected cubicle space on the ambulatory emergency care area of ED has been established to allow rapid assessment to stabilise and increase the 1-hour performance. This is seen in the increase in 1-hour performances
• Did not wait – both sites have seen a small reduction in the did not wait numbers. The division is working with corporate communications on messaging regarding our different streams inform the public and reduce the did not wait number
• Unplanned reattenders – the high frequent reattenders groups for both sites are meeting regularly to put care plans in place for these patients to reduce frequent reattenders. The consultant team on both sites review the reattenders in line with RCEM guidelines to ensure senior decision making

Reducing the risk of Hyponatraemia

The Trust continues to participate in the regional implementation programme in response to the 2018 Inquiry into Hyponatraemia-related Deaths (IHRD). The Trust’s IHRD task and finish group continues to review implementation of phase 2a and 2b of the programme, with 29 of the 37 actions relating to the Trust complete, and the remainder paused whilst awaiting further regional guidance during 2025 following the completion of consultation exercises on Duty of Candour / Being Open and the regional review of Serious Adverse Incident processes.

The Trust monitors ongoing compliance with corporate mandatory training for all intravenous (IV) fluid prescribers, with particular reference to prevention of hyponatraemia, as one of its key patient safety markers. The Trust IV Fluid Therapy steering group reviews IV fluid related incidents in order to identify themes and circulate transferable learning, and Trust IV fluid prescribing policies for both children and adults are being updated to reflect our transition to patient management and IV fluid prescribing via the encompass system.

Right Patient, Right Blood

The LearnPro contract for Right Patient, Right Blood (RPRB) eLearning ended on 31 March 2024. The regional training matrix has been reviewed. Training can now be accessed via Learn HSCNI or the ELearning for Healthcare platform. Currently there are no Blood Collection and Phlebotomy Pathway modules on the new platforms as these are being developed by the Regional Haemovigilance Team and UK wide. In the interim, Heatlhcare Assistants and Phlebotomists can complete the “Essential Transfusion Practice” module as an alternative or attend a classroom session with a Haemovigilance Practitioner. Support Services staff continue to attend face-to-face training sessions. A lack of medical RPRB assessors continues despite continued efforts by Haemovigilance and the Committee.

RPRB compliance is monitored continually by Haemovigilance via incident investigation and sample error monitoring. Several other Trusts have relaxed their policy of desisting repeat offenders. Once again, the Trust has resisted this, despite the implications on staff time, in the interests of transfusion safety and incidents where staff have been desisted are discussed within the meeting.

Identification and management of Sepsis within Emergency Departments

Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.

The Sepsis 6 bundle consists of the following elements: oxygen, serum lactate measurement, blood cultures, intravenous (IV) fluids, antibiotics and measuring urinary output.

Overall compliance with the Sepsis 6 bundle within Trust Emergency Departments was 19% between April and October 2024.

However, when the key treatment elements of Sepsis are separated out from this, the audits show that:

• 66% of patients received antibiotics within 1 hour of identification of Sepsis
• 67% received IV fluids within 1 hour of identification of Sepsis

The Trust is working with encompass developers to consider how this information can be reported going forward.

Cancer targets

The table below shows performance against the three cancer targets:

• Urgent suspected breast cancer referrals seen within 14 days
• Patients diagnosed with cancer who receive their first definitive treatment within 31 days of a decision to treat
• Patients urgently referred with a suspected cancer who begin their first definitive treatment within 62 days

	Target	2022/23	2023/24	2024/25
14 days	100%	29%	31%	10%
31 days	98%	93%	93%	90%
62 days	95%	35%	36%	29%

The 14-day target continued to be a challenge due to an ongoing capacity gap within the Breast Service, with 10% of patients being seen within this timeframe.

The 31- & 62-day performance deteriorated slightly in 2024/25. Overall, 90% of patients received their first definitive treatment within 31 days against a target of 98%. The 62-day performance was 29% against a target of 95% with delays to outpatient appointments and diagnostic interventions having the biggest impact.

NICE Guidance

The role of the National Institute for Health and Care Excellence (NICE) is to improve outcomes for people using the National Health Service (NHS) and other public health and social care services. One way they do this is by producing evidence-based guidance and advice for health, public health and social care practitioners.

A wide range of different resources published by NICE are used by the Trust in the development and review of policies and guidelines. Examples include clinical guidelines, public health guidelines, antimicrobial guidelines, technology appraisals and clinical knowledge summaries, which are utilised by Trust staff in the development and review of Trust policies and guidelines. Once the Trust policies are approved, they are disseminated for reference by staff and are available within the Trust Policy Library.

The Department of Health (DoH) endorses the implementation, monitoring and assurance of NICE Clinical Guidelines and Public Health Guidelines. A total of 7 newly endorsed NICE Clinical Guidelines, and 10 updates to previously published Clinical Guidelines were received during 2024/25. A total of 66 NICE Technology Appraisals and 3 NICE Technology Appraisals not recommended were issued during 2024/25. There were 2 new Public Health and 1 Antimicrobial guidelines endorsed in 2024/25.

NICE COVID-19 Rapid Guidelines have been developed in collaboration with NHS England and NHS Improvement and a cross-specialty clinical group supported by specialist societies and Royal Colleges to assist with the active management of people with suspected and confirmed COVID-19 in a number of clinical areas.

No NICE COVID-19 Rapid Guidelines were published during the 2024/25 financial year. However, there was an update to 1 previously issued NICE COVID-19 Rapid Guideline.

All such guidelines and related updates published to date have been issued to divisions within the Trust and confirmation sought regarding dissemination and implementation being taken forward, where applicable. Services identified any implementation issues.

Regular update reports were provided to relevant Committees and Groups within the Trust’s Integrated Governance and Assurance Framework Committee Structure.

International, National and Regional Audits

Clinical and social care audit is a way to find out if care and professional practice is in line with standards, and informs care providers and service users where a service is doing well and identifies what is not working with the aim of changing it. This allows quality improvement to take place where it is most needed and as a result improve treatment, care, safety and service quality for service users.

Trust staff have continued to engage in clinical and social care audit work, including international, national and regional audit projects.

International and national clinical or social care audit projects provide an opportunity to measure practice and services against evidence-based standards, using validated tools enabling comparison and benchmarking with other HSC Trusts and Hospitals elsewhere in the UK.

Such audits are managed or led by another organisation, with the Trust, along with other organisations, contributing to the audit. The lead organisation is responsible for reporting on the audit outcomes; however, the Trust recognises the importance of identifying learning and introducing any necessary improvements within the Trust.

During the 2024/25 financial year clinical teams contributed to a number of specific audit projects and service evaluations including:

• Alcohol related LivER disease audiT: ALERT-UK
• BAOMS BOS (British Association of Oral and Maxillofacial Surgeons & British Orthodontic Society) Orthognathic Prom project
• Blood transfusion in women with heavy menstrual bleeding – BROWNIE project
• MAMA – Management of acute appendicitis in pregnancy
• National Audit of Care at the End of Life (NACEL) – Round 5 (includes Antrim and Causeway Hospitals and Community Hospitals)
• NHS Benchmarking Exercise Programmes for Older People (BEPOP): improving exercise interventions for older people living with sarcopenia and frailty (wave 2)
• NHS Benchmarking 2024 Managing Frailty Project
• The National Unilateral Nipple Discharge Study – NUND
• PANDA-PATRN (Paediatric and Neonatal Database of Airway Management & Paediatric Anaesthesia Trainee Research Network) 2025
• Prescribing Observatory for Mental Health (POMH) – Opioid medications in inpatient mental health services
• Prescribing Observatory for Mental Health (POMH) – Use of Clozapine
• Society for Acute Medicine Benchmarking Audit – SAMBA 2024
• Surveillance and Care for Hepatocellular Carcinoma: A National Evaluation
• UK Parkinson’s Audit

The Trust also contributes to National Confidential Enquiry into Patient Outcome and Death (NCEPOD) audits. NCEPOD audits contributed to during 2024/25 include:

• Rehabilitation following Critical Illness
• Blood Sodium Study
• Emergency Paediatric Surgery
• Acute Limb Ischaemic

The above audits have provided an opportunity to review patient management, outcomes, safety and clinical effectiveness. A number of these audit projects are ongoing. The results generated from these audits will help inform clinical practice and improve patient care. For example, the NHS Benchmarking Exercise Programmes for Older People (BEPOP). The audit seeks to determine and promote the exercise training characteristics associated with positive outcomes for resistance exercise for older people living with, or at risk of, sarcopenia or physical frailty.

Regional Audits

The Trust continues to participate in regional audits with fellow Trusts and other lead organisations. Regional audits participated in during 2024/25 include:

• Blood Platelet Wastage Audit
• Renal Podiatry Audit
• Interstitial Lung Disease (ILD) Audit

Additional Audit Programmes

In addition to participation in international, national and regional audit programmes, the Trust also has a mandatory clinical and social care audit assurance programme. The programme content is directed by audit assurances or monitoring required by external organisations and internal Trust obligations for example, learning from serious adverse incidents, complaints, litigation or to provide assurance over new policy or guidance. Clinical and social care professionals are also involved in a range of audits at service/departmental level.

The Trust’s Clinical and Social Care Audit and NICE Implementation Committee monitors progress with projects and the implementation of recommendations and learning following project completion. An annual clinical and social care audit report for the 2024/25 year will be produced during 2025.

Theme 5: Integrating the care

Integrated Care System

The new Integrated Care System (ICS) continues to be embedded throughout the region. It is a single, joined-up system, which includes many statutory and non-statutory partners coming together, to assess our current health and social care provision and how our resources can be used to best effect. The main vehicle by which the ICS will be delivered is the Area Integrated Partnership Board (AIPB). There are five AIPBs, each covering a HSC Trust area. In 2024/25 the Northern AIPB was established in shadow form and began to meet. The membership is drawn from a wide range of partners, including GPs, Community Pharmacists, local elected representatives, community and voluntary sector organisations, carers and Trust staff. The AIPB is tasked with developing a plan which will address the health and social care priorities in the Northern Trust area. To this end it has agreed the three priority areas on which it will focus; children and young people, obesity and smoking cessation.

Trust/GP Partnership

The Trust/GP Provider Partnership continued to meet regularly throughout 2024/25 and has progressed with its agreed work plan. This has included the rollout of the encompass system, and the launch and implementation of Working Well Together principles document, enabling excellent communication and collaborative working across the Primary and Secondary care interface, which is vital for optimising access to appropriate and timely care for patients and improving outcomes. It also supports a more efficient use of staff time and medical resources, as demand for Health and Social Care services continues to grow. The Partnership’s focus during 2025/26 will increasingly move to the rollout of the Primary Care Multi-Disciplinary Team (MDT) across the Northern Area.

Primary Care MDT

The Primary Care MDT Programme is central to the Department of Health’s commitment to transform Health and Social Care services. The MDT model is key to stabilising and strengthening Primary Care services to ensure they can continue to provide high quality care to our communities, now and into the future. The MDT Programme boosts the capability and capacity for early intervention, prevention and wellbeing for our population, and as such is an important enabler for the neighbourhood model of healthcare.

To date, Primary Care MDTs have been introduced across all 17 Practices in the Causeway GP Federation, with all having access to at least one element of the MDT team. The MDT Practice based Professionals provide a range of interventions and support to their practice populations. This additional capacity has provided 60,292 additional consultations for Causeway GP Federation patients in 2024/25.

Roll out of MDT Implementation Plan for 2025-33 will see the MDT model expanded out in full across all 4 GP Federations in the Northern Area over the next 8 years. Implementation will proceed in two phases:

• Phase 1 will run from 2025/26 – 2028/29 and will see MDT completed in the Causeway GP Federation and expanded to the East Antrim GP Federation area
• Phase 2 will run for a further four years from 2029/30 and will see MDT complete in the remaining 2 GP Federation areas Mid Ulster and Antrim/Ballymena.

Community Care

Podiatry and Speech and Language Therapy Premises

The new purpose-built site for the provision of care by Allied Health Professional Services, Podiatry and Paediatric Speech and Language Therapy, was officially opened in June 2024. It is located on the Cookstown site beside Westlands Residential Home.

The modular building, known as Cookstown Community Clinic, was the result of significant investment and planning. There was much excitement for the two services to have the opportunity to work in a professional shared space collaboratively. The new building has bright, airy clinical spaces for both the Paediatric Speech and Language Therapy and Podiatry service users, with shared waiting areas and onsite parking. There is a separate reception area and facility for charts securely locked on site.

Initial feedback from service users has been extremely positive and it is pleasing to see the different programmes of care integrating with Community Care and Children’s Services in a shared space.

National Audit of Care at the End of Life 2024-2025

Trusts across Northern Ireland commenced Round 5 of the National Audit of Care at the End of Life (NACEL) in July 2024. This is a comparative audit of the quality and outcomes of care experienced by the dying person and those important to them within acute and community hospitals. Audit results will be used to improve the quality of care. NACEL will finish in June 2025 and results from Northern Ireland will be known in October 2025.

Advanced Cancer Toolkit

The Trust’s Macmillan Palliative Care Service Improvement Team, worked very closely with local service users, to co-develop an online Advanced Cancer Toolkit, after a service user identified a gap in resources for people living with advanced cancer. The toolkit, from the title to the content, was service user led. The focus of the toolkit is on quality of life – how to live as well as possible. There are practical local resources. Alongside this, various professionals across oncology and palliative care, working with the service users, developed videos that provide information on physical, social, psychological, emotional and spiritual well-being. At the NI Allied Health Professionals (AHP) and Health Care Scientists Awards, 2024, this project won the Award for Excellence in Cancer Care and was recently showcased for the PHA Human Library Project. Following the NI AHP Award, the DoH and NICaN (NI Cancer Network) approached us to work with them in developing it into a regional resource. It will continue to grow but is now giving tailored, evidence-based health and well-being information and resources to local people living with advanced cancer, at any stage from diagnosis on. The lived experience of people with advanced cancer is evident from start to finish.

New Bereavement Call Service for the Macmillan Specialist Care Unit

The Macmillan Volunteer Coordinators have developed a new Bereavement Comfort Call Service to offer additional support for families, whose loved one has died in the Macmillan Specialist Palliative Care Unit, at Antrim Hospital. This team of Bereavement volunteers have received specific training necessary for this supportive role. Calls are made on a weekly basis and guided by the Volunteer Coordinators who support the volunteers in liaising closely with the Macmillan Unit’s social worker. This role offers the next of kin a comfort call after 4 weeks to offer their condolences to the family. During these phone calls the volunteers within this team explain about the Bereavement Support Service, offer a listening ear and a safe confidential space to chat. They also direct the family as required to a range of useful resources that can be of additional help and support. This exceptional team of volunteers have, since late November 2024 to March 2025, completed over 100 calls with positive feedback from the next of kin for this timely, supportive call following bereavement of their loved one.

Development of a Palliative Care/Learning Disability Working Group

Research shows that people with learning disabilities are living longer. This means that they can experience a range of palliative conditions, often diagnosed late. Research also shows that they want to be involved in palliative care, end of life choices and bereavement conversations. A survey completed by the Trust during covid highlighted that palliative care and learning disability professionals lacked confidence in supporting people with learning disabilities when they have palliative needs. There was a lack of training and knowledge about services, resources and approaches in this important area. A Palliative Care / Learning Disability Working Group has been formed across services, professions and sectors. The initial event held was a speed networking event to form networks and increase knowledge of services across professionals, videoed for future staff. The group continues to work on new projects including the introduction of a new evidence-based end of life toolkit and the creation of an accessible bereavement booklet for service users.

Compassionate Communities Work

The role of caring for people through serious illness, dying, death and grief was once widely recognised as being centred in the community. However, as palliative and end-of-life care services have advanced to make significant improvements in quality of life for individuals with serious illness and their families, society has come to view responsibility for death and dying as primarily that of healthcare professionals. This shift has led to communities feeling less confident, knowledgeable, and prepared to provide compassionate support around end-of-life. The Trust has a Compassionate Community working group, crossing Trust, statutory and voluntary sectors, working together to empower people to support one another through serious illness, dying, death and grief.

Two key initiatives this year were:

• The introduction of ‘Death Positive Libraries’ in Cookstown, Draperstown and Magherafelt. Libraries can offer readers practical information on planning for end of life, guidance on how to have tender conversations about death and dying, and provides people with an opportunity to develop a greater understanding of living through the realities of a health crisis
• The issues of loneliness and succession planning are identified within the farming community. The Trust partnered with rural networks, using food, the arts and a key expert in succession planning, to provide important information in planning ahead, alongside the opportunity for the attendees to make new connections. It was positively received and has provided a template for future events regionally

Compassionate Schools Working Group

The Specialist Palliative Care Team collaborated with two schools in pilots to improve the awareness of palliative and end of life care, bereavement and grief. The sessions aimed to help improve understanding, how grief can affect people, how they can support one another and some strategies to help for their own personal grief. The Specialist Palliative Care Social Worker worked with Cruse to provide a Grief Ally session, followed by an art project to design the Specialist Palliative Care team bereavement card.

An interactive workshop, called ‘Lessons from an Elephant’ for year 8 pupils, developed by Tracey Stewart Specialist Palliative Care Dietitian, in collaboration with Dunclug College, Ballymena was held in June 24. The workshop used the theme of elephants and focused on food and memories to raise awareness of palliative care, grief, loss and bereavement, and to help pupils begin to develop coping skills should anyone close to them die now or in later life. The pupils also completed art work to form a memory mural for display within the college. Feedback from staff, parents and pupils described the workshop as a very worthwhile and valuable experience.

Following the success of these pilots, the Palliative Care Service Improvement Team have set up a Compassionate Schools Working Group across Trust, voluntary, statutory organisations including Marie Curie, Cruse, the Education Authority and service users. An initial survey with schools has highlighted areas of collaborative work for group over the coming year.

Cookstown Health Centre Treatment Room Redesign

Cookstown Health Centre is a Trust-owned building accommodating the Mid Ulster Health Care GP Practice. The Trust, working collaboratively with the Practice, have completed a re-model of the Treatment Room within the Health Centre. Mid Ulster Health Care, is an evolving forward planning diverse Practice. The New Treatment Room will complement and enhance diagnostics and care delivery.

The demographic needs of the Practice population provided a vital role in the Treatment Room design. This will result in a safer more effective streamlined service. The new layout provides 4 separate treatment areas with increased space, disabled access and bariatric equipment and will also enhance infection prevention control compliance. This extension and re-design will improve privacy for service users, improved accessibility for all patients, family and carers and deliver a better experience for both staff and patients using the service. The Trust, in collaboration with the Mid Ulster Health Care GP Practice, will continue to provide compassionate care with our community in our community.

Integrated Care in District Nursing

Population health profiles have been developed in several District Nursing teams, as an extension of the Neighbourhood District Nursing Pilot Model. Population profiles involve District Nursing teams reaching out into their local community e.g. connecting and engaging with GPs, Primary Care Multi-Disciplinary Teams (social workers, physiotherapists, pharmacists, and mental health practitioners), community and voluntary groups and integrating with the local Borough Council.

Integrating the care of community clients involves linking with health and social care professionals and reaching out to wider community groups and social prescribing. Below are some examples of this improvement work in action:

Alcohol and/or substance misuse – integrated working with District Nursing Service

NI Drug and Alcohol Connection Team (NI DACT) hosted an awareness event of drug and alcohol misuse in June 2024 and invited District Nursing to attend. District Nurses present were able to network with agencies and gather useful information to share with their patients and their carers.

Strong links have been made with the Trust’s Consultant in Addiction Psychiatry whilst case studies have been shared regionally as part of the Extension of Community Healthcare Outcomes (ECHO) network.

• Diabetes and insulin management in partnership with a patient with alcohol misuse
• Palliative care – Delivering compassionate care while mitigating risks of a person living with advanced cancer and an ongoing heroin addiction

Local Rural Community Hub

Getting to know a local rural community hub was the focus of a District Nurse team leader in Ballymena and how it could lend support to patients to become more active and reduce loneliness. It is essential that District Nursing Services work closely with community hubs as they have invaluable local knowledge of the terrain, weather conditions and the community in general and a valuable asset to advance social prescribing for District Nurses. A reciprocal relationship can develop and thus support the funding of these groups.

Ongoing integrated working with community services colleagues attending the Rural Conference in April 2024 which raised awareness of key rural health and wellbeing issues for clients.

Bags of Taste – East London Integrated Community Group

Marion Orr, Neighbourhood District Nurse attended a field trip In East London as part of the International Forum on Quality and Safety in Healthcare in April 2024; learning of the importance of collaborative working in communities and how healthy eating can be promoted with low-income families / ageing population and encouraged by health care professionals.

Northern Ireland Picture Archiving and Communications System (NIPACS)

On 7 November 2024, the Trust went live with NIPACS+ Phase 2 for Additional Imaging Specialties (AIS):

• Cardiology
• Ophthalmology
• Obstetrics
• Dental
• Endoscopy
• Medical Photography

The NIPACS+ solution provides a single integrated enterprise imaging solution for HSCNI comprising a Radiology Information System, Picture Archiving and Communication System and Vendor Neutral Archive, which covers 28 sites across Northern Ireland.

This implementation paves the way for a more efficient healthcare system enhancing day to day workflows by streamlining access to medical images and reports, enabling faster decision making, reducing repeat scans, strengthening coordination between departments and improving patient care.

The Regional Programme Team worked closely with the Trust’s Project and AIS Teams in preparation for go-live across the Phase 2 Imaging Specialties.  All teams worked collaboratively to ensure a smooth and safe transition across all specialties into NIPACS+.

Mental Health

Crisis planning within Mental Health Services has been enhanced through a number of initiatives. These include:

1. The embedding of a purposeful admission statement for all acute psychiatric admissions
   

A purposeful admission statement was introduced throughout urgent mental health services (Crisis Resolution & Home Treatment and Mental Health Liaison Service) in 2023/24. This introduction of the statement was supported by HSCQNI and is now being reviewed in partnership with the HSCQNI for consideration of further scale and spread within a second Trust. The Statement ensures that all service users, carers and staff understand why a decision has been made to either admit to hospital or provide home treatment. The use of the statement has successfully ensured a 12% reduction in admissions thereby ensuring capacity for those who require an inpatient bed. It has also ensured that Home Treatment is utilised effectively and emphasises the importance of community care. Work is now ongoing on how the statement can support inpatient services to plan appropriate interventions.

2. The introduction of the Regional Safety Planning tool across acute mental health services

Acute Services including urgent mental health services (Crisis Resolution & Home Treatment and Mental Health Liaison Service) and inpatient services continue to support the implementation of the Regional Safety Plan. This plan is now routinely provided to all service users presenting in Crisis and who are identified as being at risk of self-harm or suicide. The plan supports individuals to identify supports when in crisis and aims to enable individuals to draw upon the same when experiencing a crisis.

3. Review of Urgent Mental Health Services and introduction of enhanced Crisis Services at Causeway ED

The Trust has commenced an internal review of our urgent mental health services (Crisis Resolution & Home Treatment and Mental Health Liaison Service) with the aim of establishing an overarching single urgent mental health service to support improved accessibility and crisis planning. As part of the ongoing review the services have successfully achieved funding for the recruitment of staff to provide 24/7 cover at Causeway ED (previously an on-call model from 22:00-07:00). It is envisaged that this 24/7 model will ensure all service users presenting to both ED sites can receive timely mental health assessment within 2 hours. The model is anticipated to commence from October 2025.

Lithium Pathway

A Mental Health and Learning Disability (MHLD) Lithium Implementation group was established in May 2023 in response to learning from Datix and SAI incidents which identified gaps in blood monitoring along with delays in discharge letters being provided to GPs.

The rationale for this oversight group is to ensure robust, consistent and timely processes are in place along with appropriate governance arrangements in relation to the initiation and monitoring of service users prescribed Lithium treatment within MHLD services.

The Lithium Pathway determines how care is managed across MHLD services and ensures lithium treatment is prescribed and monitored in accordance with the following best practice:

• HSC Regional Lithium Care Pathway (January 2018)
• NICE CG185 ‘Bipolar disorder: assessment and good practice standards’
• The Prescribing Observatory for Mental Health (POMH-UK) Quality Improvement Programme (2019): 7f -Monitoring of patients prescribed lithium
• The Trust’s Lithium Initiation and Monitoring Care Pathway – Regional Guidance

To ensure lithium process are consistently and robustly applied across MHLD services regular auditing of the Lithium Pathway will be implemented using the approved audit tool once the Lithium report build is available on encompass.

To support staff adherence to the Lithium Pathway, online mandatory Lithium training is available for all Trust staff with compliance rates monitored.

A Trust Divisional Lithium Standard Operating Procedure/Guidance is currently being developed which recognises that engagement with primary care is key.

Social Work Performance

The Social Work Governance, Workforce Development and Training department is directed to submit an annual statutory function report, addressing the following critical areas:

• Statutory function arrangements currently in place to ensure the safe and effective delivery of social work and social care services across the Trust
• A detailed assessment of the Trust’s performance in delivering statutory functions with efficiency and effectiveness during the reporting period
• A summary of any areas where statutory functions have not been fully or appropriately discharged.

The Trust retains full accountability for exercising statutory functions as authorised under the Health and Personal Social Services (Northern Ireland) Order 1994. The Trust must ensure robust systems are maintained to monitor, assess, and continuously improve the quality of social work services and the conditions under which they are provided.

Statutory Function reports must be submitted biannually to the Trust Board, detailing both Annual and Interim compliance. Mechanisms are established within the Trust to ensure that professional leadership, control, and oversight of statutory functions are regularly reviewed.

To ensure executive-level oversight, the Executive Director of Social Work & Assistant Director for Social Work Governance are required to present regular updates and strategic briefings to Governance Committees and the Trust Board. These must highlight any emerging risks impacting the effective delivery of statutory functions.

Divisional, Corporate and more recently the Principal Risk Register is also utilised to capture specific issues pertaining to the delivery of statutory functions (referenced throughout this year’s report). This process is utilised in order to identify the regional and local challenges, mitigations and monitoring in place to address these challenges and to notify Trust Board on how these challenges have been appropriately managed including the escalation to the Strategic Planning and Performance Group (SPPG).

On the 7 November 2024 the Trust implemented encompass within adult social care services. Due to ongoing regulatory reporting issues, workflow issues and ongoing user familiarity the Trust can only provide general provisions data for the period 1^st April 2024 to 7^th November 2024. In order to maintain local assurance, the Trust has established a number of manual data sources aligned to the general provision data sets. Due to the inability to validate all manual counts from an information system it has been agreed via the regulatory reporting sub group that the Trust will submit general provisions data via legacy reporting systems.

There are three core themes across both Adults and Children’s services that currently affect our compliance with statutory functions:

1. Inappropriate Placements in Adults and Children’s Services

On occasions the Trust is unable to meet the demands for specialist bed-based placements within our Adult Services programmes, this results in bespoke placements being designed within a community setting, trackers are in place to monitor these arrangements closely. The continued and growing pressure on the looked after children system and in particular on the availability of placements has resulted in an increase in the number of children in inappropriate placements.

2. Workforce Challenges

Social services have experienced significant workforce pressures during this reporting period which have impacted on the capacity of the Trust to discharge statutory duties. The current workforce arrangements present a significant challenge. This is also in the context of increasing demand for services. Recruitment of social work staff in particular areas of social services is difficult. Where teams are staffed well there is a disproportionate number of newly qualified staff. The Northern Trust has put in place strategies to recruit and retain staff including introducing new recruitment pathways, different skill mixes, additional administrative support, and mentoring / coaching networks for frontline social workers.

3. Unallocated Cases
   Older Peoples & Physical Disability Services

SPPG have indicated that they will work alongside Trusts during 2025/26 to identify compliance data and targets in relation to unallocated cases in older people’s services. The current action plan requires Trusts to provide SPPG with detail regarding contingency arrangements in place to cover workload safely and mitigate any impact on unallocated cases, waiting lists or timely response to referrals or investigations.

Children’s Services

There have been some reductions in unallocated cases within Looked After Children (LAC), Gateway and Family Support service areas, the reduction of 28 cases is a direct result of workforce vacancies being filled by newly qualified social worker graduation from universities.

An improvement plan is in place for all unallocated case activity within the Northern Trust.

In addition to three areas above there are a number of programme specific issues that continue to impact our compliance with statutory functions.

Approved Social Work (ASW)

The report indicates there is an increase in Approved Social Work (ASW) assessments this year compared to last. The body of the report sets out the impact of this including ASWs being required to wait with a patient for exceptionally long periods of time until a bed is available and difficulties with handovers to and between the day time service and the Regional Emergency Social Work Service (RESW). The Northern Trust ASW service has remained under pressure during the reporting period. Whilst the number of local referrals has not increased significantly, the number of admissions has increased. The ongoing mental health bed crisis coupled with NIAS / PSNI interface issues has resulted in protracted waits on numerous occasions. The ASW lead in the Northern Trust is continuing to work alongside SPPG and the Department of Health (DoH) to explore solutions to these issues.

Unmet Need for Domiciliary Care

The Trust continues to have a significant level of unmet need for Domiciliary Care. At the end of March there were 844 service users awaiting a full care package and 444 awaiting a partial care package. This level of unmet need spans all programmes of care with older people being the largest group affected. Maximising capacity in domiciliary care is a core focus for the Trust Community Care Division and reform work continues to take place within one of the new DoH Social Care Reform Collaborative work streams.

Adult Safeguarding

Whilst the Adult safeguarding service has seen an increase of referrals during this reporting period the delivery of statutory functions continues to be met. The greatest number of referrals received relates to older people followed by people with dementia and adults with learning disabilities. The Trust has a governance structure and reform board in place to monitor adult safeguarding arrangements and deliver improvements.

Carers Assessments

Carers play an important role in the provision of care and support they provide to a family member or someone close to them. The Trust remains committed to the promotion and uptake of carers assessments, using a standardisation of approach of the Northern Ireland Single Assessment Tool (NISAT) and Carer’s Conversation Wheel, across all Programmes of Care. The need for improved recording and reporting of carer’s assessments is recorded within the Northern Trust’s local statutory function action plan.

Annual Care Reviews

The report illustrates that the Trust continues to face challenges in this area. Non-compliance by the Trust in ensuring that service users receive timely annual reviews is recorded within our local statutory function action plan; this area continues to be an issue. The cause is largely workforce related due to the staff vacancies coupled with increased workloads, increased referral levels along with the prioritisation of adult safeguarding, hospital discharge and Mental Capacity Act work. The Trust welcomes the new guidance from DoH on Care Management reviews but due to trade union engagement the Trust cannot implement these changes immediately.

Increase in Looked After Children

At the 31 March 2025, there were 865, an increase of 62, young people. Inevitably the increase in looked after children has resulted in increased demand for suitable placements.

The Trust’s previous statutory function report highlights an increase in kinship placements as positive and in line with legislation, policy and research findings. The Trust continues to support children to remain with family or friends. This trend has changed the face of foster care as kinship carers often want different and/or more intensive support. Given the demand in respect of kinship placements, the Trust has 50 kinship carers with no allocated social worker with a further 57 kinship carers awaiting assessment at the 31^st March 2025.

Workforce Initiative – Retention Strategy: Professional Mentoring Pilot

High caseloads, resource pressures, and burnout are widely recognised drivers of attrition in social work. However, many professionals continue to thrive and build long-term careers within the Trust. Drawing on new research led by the University of East Anglia (UEA), the Trust is piloting a “theory of change” model aimed at improving retention through strengthened professional identity and peer support.

Legacy Mentoring

A cornerstone of the pilot is the introduction of “legacy mentoring”. This model matches experienced, often late-career, social workers with those at the beginning of their journey. By sharing their expertise, legacy mentors reinforce a sense of purpose, build resilience in early-career staff, and foster a culture of continuity and care.

Northern Trust Pilot Implementation

The Trust, in collaboration with the DoH, Queen’s University Belfast, and the other HSC Trusts, will test key recommendations from the theory of change. The pilot will focus on:

• Scaling the Assessed Year in Employment (AYE) mentoring scheme for early and mid-career staff
• Launching dedicated social work Schwartz Rounds
• Piloting legacy mentoring as a key retention tool
• Enhancing team leader capacity to support identity formation within teams
• Embedding specialisms into career pathways

This work aligns with national efforts to support workforce wellbeing and builds on positive feedback from the Trust’s Social Work mentoring scheme.

World Social Work Day Conference

Over 200 social workers, managers and senior leaders from across the Trust came together recently to celebrate World Social Work Day.

The annual event was opened by Chief Executive, Jennifer Welsh, and Executive Director for Social Work, Maura Dargan, and the theme for the day was ‘Strengthening Intergenerational Solidarity for Enduring Wellbeing’.

Speakers for the day included Diane Taylor from the HSC Leadership Centre; Romav Ali from Journey of Hope Refugee; Matthew Taylor, Mental Health Campaigner; Lisa Morrison, Independent Training Consultant and Emily Wilson, Young Onset Dementia Researcher.

Those in attendance also heard from Mayor of Mid and East Antrim Borough Council Councillor, Beth Adger who shared her personal experiences of being a foster parent. Attendees also heard from Lynne Rowntree and Nicola Dorrian-Clark from Quilts for Care Leavers NI and Helen McVicker from Northern Ireland Social Care Council. Comedian Paddy Raff finished off the day on a lighter note.

The event was closed by Chair, Anne O’Reilly, who thanked all of the inspirational guest speakers and everyone for attending.

At the event social work staff across divisions who were nominated for the Regional Social Work Awards 2025 were also acknowledged. A total of 19 Social Workers from the Trust were nominated by their colleagues and managers, and two staff were shortlisted for the regional finals in March 2025.

Recognition and Rewards

• 7 Social Work Managers have successfully completed Level 3 Quality Improvement qualifications
• 64 Social Workers are set to receive Professional in Practice (PiP) awards during this reporting period
• Lorraine Boyd and Clare McGrath were recognised as finalists at the Regional Social Work Awards

Lorraine Boyd, Integrated Care Social Worker, was nominated for the Spirit of Social Work Award. Colleagues commend her compassion, work ethic, and dedication to mentoring students and newly qualified staff.

Clare McGrath, Principal Practitioner for Ethnic Minorities, was nominated for the Co-Production Award for her inclusive, relationship-focused work with individuals at risk of isolation and exploitation.

These recognitions spotlight the exceptional contribution of Trust staff and elevate the public profile of social work as a life-changing profession.

Annual Health Checks

Trust Healthcare Facilitators (HCFs) were notified in June 2024 that there was a change to the payment for the Learning Disability Health checks. This appears to had a direct impact on figures for the year 2024/25. Trust HCFs have continued to engage with GP practices and by doing so they have ensured that the GP registers for people with learning disability are kept up-to-date. In doing so, some practices have not carried out health checks, they are seeking more support from HCFs to complete these. At times HCFs are being requested to complete annual health checks without any input from the GP practice.

The HCFs completed some health checks across the Trust, either in service users’ own homes or in a clinic setting. Other settings are considered depending on the service users’ needs and wishes.

During the reporting period, 1022 health checks were completed by GPs of which 332 were completed with support from HCFs. Staffing levels from April – August 2024 there was only two HCF’s working with one off on maternity leave.

The HCFs continue to liaise with GP practices and work closely with them to ensure that annual health checks are completed in a timely fashion.

The HCFs complete one-to-one health promotion sessions via referral from the community learning disability services. Group work has been completed in adult centres, bases and supported living units.

HCFs continue to collaboratively work with the breast screening service in identifying people with learning disability who require reasonable adjustments. HCFs are currently building links with Abdominal Aortic Aneurysm screening to ensure uptake from the learning disability population.

Area	Total Health Checks completed	Completed with HCF support
Larne, Carrick & Newtownabbey	174 (25.4%)	79 (45%)
Causeway	410 (39%)	164 (40%)
Magherafelt	465 (54.8%)	89 (19%)

 

Northern Health and Social Care Trust Annual Quality Report 2024 to 2025 in PDF