Central and North West London NHS Foundation Trust

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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated as Good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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

The service maximised the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

The service obtained information about the patient’s initial needs from the point of referral. Staff subsequently visited patients to complete a full face to face assessment of their needs.

In the records we reviewed, we saw that staff completed a comprehensive clinical assessment of the patient in a timely manner after acceptance to the service.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff gave examples of where they had used alternative communication techniques, such as an electronic tablet, to communicate with a patient.

Staff had received specific training in November 2025 on the deteriorating patient in response to improvements identified in the thematic review and incident learning reviews. This was delivered by a clinical expert in that field and staff gave positive feedback about this training. When patients showed signs of deterioration, staff escalated these appropriately and promptly. Staff used appropriate national tools to assess and escalate any physical health concerns, such as the National Early Warning Score (NEWS2).

The service planned and delivered people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

The service followed national guidance to ensure that appropriate patients requiring an urgent response were triaged and seen within 2 hours. Patients that were triaged as less urgent were seen within 2-4 hours within the same day.

Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and best practice. Patients received pain relief soon after requesting it. We saw that staff prescribed, administered and recorded pain relief accurately.

Staff completed a full assessment and used tools to assesses the patient’s needs in line with best practice and national guidelines. Staff used the Purpose-T assessment to assess the risk of patients developing a pressure ulcer, the community sepsis screening tool and a top to toe assessment to evaluate the patient’s entire body to detect any abnormalities that would need care and treatment.

The service worked well across teams and services to support people. They shared their assessment of needs when people moved between different services.

Staff worked closely with Camden GPs, as they held the overall medical responsibility for many patients under this service. Staff sent a discharge summary electronically to the patients’ GPs, outlining the actions undertaken and any ongoing actions required. Senior clinical staff had access to the electronic record systems used by GPs and the two local acute hospitals, all of which used different record systems. This ensured that vital patient information was not missed when assessing and treating a patient.

Managers were in the process of implementing a system to try and improve communication with GPs. This operated as a direct messaging service whereby staff could share vital patient information with GPs. This addressed communication barriers that staff faced when trying to directly contact GPs.

Staff worked closely with other teams within the Rapid Access services and other services to meet the needs of patients. Other services included district nursing services, podiatry teams, palliative care teams, speech and language therapists and care services.

Staff attended daily multidisciplinary meetings to discuss patients and improve their care. Patients were discussed in an initial multidisciplinary meeting overseen by a consultant geriatrician and triaged into either the nursing or therapy pathway depending on their needs. Nursing and therapy staff then attended separate handover meetings to discuss patients in detail. Before this inspection, we received information that there were times when the UCR team had disagreed with the referring consultant about a plan of care, and the process to resolve this was not sufficient. During this inspection we saw that this had been identified as an area for improvement and communication and management of this had been improved. This remained an area for the service to ensure was managed appropriately, to ensure safe patient care was not impacted.

In handover meetings, staff reviewed each patient’s case, including their history, reason for referral, medications, observations completed and family circumstance. They had also introduced a review of what other services a patient was receiving, which had been identified as an area for improvement. Handover meetings were also an opportunity to adjust the list of visits in accordance with patient need and priority.

We observed the therapy handover meeting and saw that staff were using the Situation background, assessment, recommendation and decision (SBARD) approach and template to review each patient and agree a clear set of actions. We observed the nursing handover meeting and staff also used the SBARD approach to review each patient and set actions, although this was notably shorter than the therapy handover. We could not initially see that the SBARD template was being used to record each patient during the nursing handovers, however we were later provided with additional evidence to show that staff were using the template.

Staff had strong working relationships with the local acute hospital teams, local authority social services teams, district nursing teams and palliative care teams. Therapy staff from a local acute hospital attended the morning urgent community response therapy handover to have a joined-up approach in caring for patients in the community, who may already be known to the hospital.

The service supported people to manage their health and wellbeing. The service supported people where possible to live healthier lives.

Where appropriate, staff gave patients and carers advice so they could self-care. Risk factors, where identified upon the initial assessment, were highlighted to patients, carers and their normal care providers so additional support could be given, such as risks associated with smoking and alcohol use.

Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs. Staff gave examples of third party or voluntary organisations that patients were signposted for support such as Age UK.

Staff completed assessed patients’ hydration and nutrition as part of the ‘head to toe’ assessment, ensuring that patients had enough to eat and drink, monitoring food fluid charts when required. Staff used the nationally recognised tool called malnutrition universal screening tool (MUST) to monitor patients at risk of malnutrition.

The service had an effective system in place to routinely monitor people’s quality of care and treatment and to continuously improve it.

Managers recorded the outcomes of the service monthly to monitor patient’s quality of care and treatment. This was measured against the national expected targets of the service set out by the commissioners. For example, the service aimed to see 70% of patients within the 2-hour response time per month. The service often exceeded this and saw about 80% of patients within the 2-hour response time.

Outcomes for patients were positive, consistent and met expectations. The service was able to evidence that it had enabled patients to stay within the community longer and avoided a potential hospital admission. In December 2025, 208 patients had avoided a hospital admission.

The quality and safety of the service was monitored by the quarterly quality and governance meetings, the monthly quality steering groups and the monthly staff meetings. Information was shared with the divisional quality and safety committee.

Staff carried out a comprehensive programme of repeated audits to check improvement over time. These included hand hygiene audits, documentation audits and the safe handling of medicines audits. Managers monitored information from the audits to improve care and treatment and these were reviewed in the quality governance meetings.

The service told people about their rights around consent and respected these when they delivered person-centred care and treatment.

The service identified as part of their thematic review that assessing and recording mental capacity assessments could be improved within the patient records. The service had taken steps to improve this by providing face to face Mental Capacity Act training to staff in June 2025. The service reviewed the quality of mental capacity assessments through a monthly documentation audit of patient records.

Staff gained consent from patients for their care and treatment in line with legislation and guidance and recorded this in the patient’s records. Staff took all practical steps to enable patients to make their own decisions.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff did this on a decision-specific basis with regard to significant decisions. If patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Staff recognised the challenges around capacity and consent, particularly when a patient was unwell and refusing hospital admission. Staff gave examples of where they have assessed a patient’s mental capacity and found that they had capacity to refuse to go to hospital and were choosing to make an ‘unwise decision’ in accordance with the principles of the Mental Capacity Act.

Staff could describe and knew how to get accurate advice on the Mental Capacity Act and the this formed part of their mandatory training. At the time of our assessment, staff had completed 96% of their mental capacity act training.