Central and North West London NHS Foundation Trust

On this page

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant people were safe and protected from avoidable harm.

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

The service had a proactive and positive culture of safety based on openness and honesty. Concerns about safety are listened to. Safety events are investigated and reported thoroughly and lessons learned to continually identify and embed good practices.

All staff knew what incidents to report and how to report them. The service had 371 incidents reported within the last 12 months. The highest type of incident reported was admission, delay, transfer and discharge concerns. These were mainly due to staff reporting inappropriate discharges by a local acute hospital. The second type of incident reported was pressure ulcers, followed by medicine reconciliation concerns relating to hospital discharges and the physical deterioration of a patient. The service had 2 unexpected deaths within the last 12 months which were the result of unexpected traumatic falls. One fall took place at the same time as the referral to the service and had already occurred when the staff member arrived within one hour of the referral being received. One death was subject to an internal review to identify if there was any further learning for the service.

Staff reviewed incidents and deaths within the monthly staff meeting and in the quarterly governance meetings. Learning from incidents were shared and improvements to the overall safety of the service were reviewed by the team. For example, staff had recently identified the need to clarify the other services that the patient was receiving due to a patient thinking that they were under the district nursing service for their wound care, but they were not. Staff now ensured that all services that the patients received were discussed in the morning handover meeting.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff reviewed ongoing actions and learning from serious incidents, such as unexpected deaths in their monthly staff meetings and quarterly governance meetings. Staff informed us that they were debriefed and received support after a serious incident. Staff were supported when supporting palliative care patients.

The trust had responded to internal concerns about the service and identified several areas that needed to be improved. An action plan had been put in place to embed changes to improve the safety and communication within the service. The service had embedded learning from the investigations of unexpected deaths.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Incidents showed staff had sent a duty of candour letter to apologise if things had gone wrong.

The service worked with people and their partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. They ensured continuity of care, including when people move between different services.

A service-wide thematic review,covering the period Feb 2023 to November 2024 was conducted in early 2025. This review encompassed all three rapid access service pathways, Urgent Community Response, Discharge to Assess and Virtual Ward/Hospital at Home.

The review highlighted that further improvements were needed regarding escalation of concerns, use of NEWS2, triage and screening, communication, documentation, staffing, end of life planning and capacity and consent. Managers implemented these improvements through identified action plans and introduced specific steering groups. This had led to an overall improvement in patients’ quality of care and treatment that they received.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met by the service. The service had clear referral criteria outlined in their local standard operating procedure. The service only accepted self-referrals where the patient had been discharged within 48 hours of using the service and were re-presenting with the same presenting complaint.

Most referrals to the service were made by GPs, doctors within the CNWL single point of access service (SPOA), NHS 111, care homes and other allied healthcare professionals. Internal concerns raised in 2024 related to instances where individuals had not appropriately involved the responsible clinician in decisions about care relating to the patient, including patient discharge from the service. During this inspection, we saw that all staff had been given clear information that the responsible clinician must be involved in decision making and we saw this taking place.

The service allocated a clinician on duty each day to review and triage all new referrals and allocate them to the nursing or therapy pathway. The service only accepted referrals by telephone to ensure that the most important information was captured from the referrer, such as risks and clinical presentation. This saved time in going back and forth between the clinician and the referrer to obtain any information not captured in a referral form. The telephone referral was recorded on the patient’s care notes. The clinician on duty was a band 7 nurse or above and had completed training on triaging telephone referrals. Callers where signposted to other services where they did not meet the referral criteria. Staff used a specific urgent care response scheduling tool to review the capacity of the service each day, ensuring that staff with the right skill mix were available to visit patients at home. Joint therapy and nursing home visits were arranged for patients who required this assessment.

The clinician on duty had access to the care records systems that GPs used in Camden and systems used in two local acute hospitals, in addition to the trust wide records system. This meant that the clinician could access essential information about the patient across the four different record systems, to ensure that their needs could safely be met.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Staff worked closely with patients’ GPs and updated them on any treatment options discussed and interventions delivered. Feedback from one GP was that there had been instances where staff had not shared results from blood tests promptly or at all with the GP, which they should have done. During our inspection we saw that this practice had improved and is an area the service must ensure remains embedded. Patient discharge summaries were sent to the GP when they were discharged from the service. Staff worked closely with the other services that formed part of the rapid access services for Camden, such as the Hospital at Home team, discharge to assess team and other Camden community teams such as Care Link.

The service used a rating system to manage the number of referrals received for the day to ensure that patient needs could safely be met.If the service is closed for all referrals, including both same-day and next-day referrals, this would be rated as black. This had happened twice in the last 12 months, with this escalated to senior managers and notification to the Integrated Care Board (ICB). Staff told us that they felt confident to escalate concerns about referrals and capacity when needed.

The service worked with people to understand what being safe means to them as well as their partners on the best way to achieve this. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure they shared concerns quickly and appropriately.

Staff received training specific for their role on how to recognise and report abuse. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. At the time of our assessment, 95% of staff had completed Safeguarding Adults level 1, 2 and 3 training. The compliance rate for level 1 and 3 Safeguarding Children training was 95%.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them, including making a safeguarding referral. Staff gave us examples of where they had raised a safeguarding concern with the local authority safeguarding team after visiting a patient at home due to an untreated pressure ulcer or where a patient did not have electricity.

Staff ensured that current safeguarding concerns were discussed in the daily handover meeting and staff knew who to inform if they had concerns, such as their designated safeguarding lead.

The service worked with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Staff reviewed patient risk daily at morning handovers and shared key information to keep patients safe when handing their care over to others. There were three separate handover processes that took place each morning. All staff attended the first handover meeting, which was a formal escalation and discussion meeting focusing on patients who required review by the Hospital at Home team due to clinical deterioration, identified areas of concern, or diagnostic uncertainty. As staff worked with increasingly unwell and complex patients, this provided additional medical oversight of discussions, from a consultant geriatrician.The nursing/paramedic team and the therapy team then each undertook their own dedicated handover as part of the UCR and Discharge to Assess pathways.Following this, the Hospital at Home team conducted its own separate handover.We observed the therapy and nursing handovers, and saw staff discussed necessary information to keep patients safe.

Where staff noted that a patient’s physical health deteriorated, they escalated this when necessary. Staff had received additional training on recognising the deteriorating patient in response to learning from the thematic review and a serious incident, where concerns should have been escalated quicker.

As well as a review of how risks were managed for all patients being seen by the service that day, we did an in-depth review of 2 risk assessments and care records during the assessment. Staff completed risk assessments for patients on admission, using a recognised tool, and reviewed this regularly, including after any incident. Staff knew about and responded to specific risk issues appropriately. Staff escalated concerns appropriately, such as concerns relating to sepsis, falls and pressure ulcers. Immediate concerns were escalated to the London Ambulance Service, in line with the service protocol.

Staff used a range of tools to detect clinical deterioration in patients. During our inspection we observed staff using the National Early Warning Score (NEWS2) as a scoring system to identify clinical deterioration in patients. Staff also used the Glasgow Coma Scale (GCS) to measure any decreases in patient consciousness and the Multi-factorial Risk Assessment for Falls (MFRA) to assess patients who were at risk of a fall. The service had responded to concerns about the use of NEWS2 in specific examples and reviewed their use in these instances. The review recognised this as one of several appropriate tools to use for patients in this setting to identify deterioration in health.

Staff could enter flags on the patient record system to alert the team to any known risks about the patient or their environment. Staff followed an escalation process for patients who did not answer the door and were uncontactable.

The service detected and controlled potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Staff did regular risk assessments of the care environment. Staff visited patients in their own home and assessed their environment. Staff gave examples of escalating environmental concerns to the local authority safeguarding team where they had assessed that the patient’s environment is unsafe to receive care in.

Staff carried a basic observation kit to visit patients. Staff disposed of clinical waste safely. Staff used sharps bins to safely dispose of needles.

Staff did not carry oxygen or resuscitation equipment, due to the scope of the service. Nurses and paramedics carried BLS‑appropriate equipment, including anaphylaxis kits. As a community service, if an emergency occurred, staff started basic life support (BLS) and called emergency services who attended with appropriate equipment.Staff described the London Ambulance service as very responsive, and patients were not left waiting for a long time in the community. Staff received regular training on providing basic life support (BLS).

Staff often visited patients alone in their own homes. The service had systems in place to monitor staff safety. The service used an electronic system to monitor the real time location of staff, overseen by the clinician on duty. This duty clinician monitored the time each staff member spent in each patient’s home. Staff told us that the system worked well to keep them safe.

Staff identified when patients required certain equipment to keep them safe and meet their needs whilst in the community. Staff could provide patients with some immediate equipment, which was stored in their stock room, such as dressings. Other larger equipment was ordered to be delivered to the patient’s home, such as pressure relieving mattresses (to prevent patients developing a pressure ulcer). This was ordered through an equipment company.

Staff had reported 19 incidents in the last 12 months about this company regarding equipment issues or delays.These had been part of a national issue with the company. Staff and managers had told us that this had improved since a new company had taken over this contract and these types of incidents were declining.

The service made sure there are enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that meets people’s individual needs.

The service had calculated the number and grade of nurses and therapists needed for each shift in accordance with national guidelines. This was agreed and reviewed with the local integrated care board. The service had a whole time equivalent of 38.54 staff.

Referring doctors remained the responsible clinician for individual patients. This was either a GP or the doctor from the Single Point of Access Service. Staff we spoke with understood this and during our inspection we saw these doctors being consulted appropriately about plans for care. Staff also had informal access a consultant geriatrician from the trust Hospital at Home service.The partnership with the local acute hospital related to improved pathway working and systems integration, in line with the service specification.

This doctor attended the morning meeting during the week, where patients for that day and treatment plans were discussed. This was to provide medical input to the group but did not replace the responsibility of care, that remained with the referring doctor. This doctor was not available during evenings and weekends. During these times, staff could contact the out of hours urgent care GP service for advice using a direct telephone number. Although staff told us they could receive advice in a timely way using this system, managers recognised that this was a potential gap and were working on forming a partnership with a local acute hospital, so staff could access a consultant geriatrician for advice and support during out of hours times.

The service had reducing vacancy rates. Managers had initially added vacancy rates to the risk register in May 2025 due to a 23.7% vacancy rate. This has since reduced to 15% with three vacancies across the nursing/paramedic and therapy staff and one staff member on maternity leave. There were two band 7 nurses that were recently recruited to the service and were going through the onboarding process. The vacancy rate was expected to fall to a further 2.9% once the new staff had started working within the service and one staff member due to return from leave at the end of March 2026.

Managers were able to access bank staff who were familiar with the service when required, the service did not use agency staff. Due to the level of expertise required, there were a limited number of bank staff who were suitable to work within the service, managers therefore offered bank shifts to regular staff to cover the vacancies and maternity leave. They ensured that staff did not go beyond the working time regulations of 48 hours a week.

The service had low sickness rates, sickness rates had reduced from 6.5% in January 2025, to 2.9% in December 2025. The service had reducing turnover rates. Staff turnover had reduced from 31% in January 2025 to 23.7% in January 2026. Managers had created a service specific development project to address the high turnover of staff and to understand any pressures that staff faced, including gathering feedback from staff exit interviews. Managers held a series of listening events through anonymised surveys and team away days and introduced a rotational role so staff could experience working within the different services within the Rapid Access services. Staff had also left the service due to promotion in other roles.

Staffing levels and skill mix were reviewed daily by the clinician on duty to ensure that there were enough nursing and therapy staff to meet patients’ needs and keep them safe. This was also discussed in the morning handover meeting. If the service was ever at full capacity, the clinician could close the service to further referrals for the day and escalate this to senior managers for review, directing referrers to use alternative services, such as the London Ambulance Service. This had occurred twice within the last 12 months.

The service had enough nursing and support staff to meet the demands of the service. Staff received appropriate training to support the client group. We identified that staff had an awareness of when and how to escalate concerns and refer patients on to services that better met their care needs.Staff were highly skilled, with most bringing experience from a range of environments including accident and emergency, intensive treatment units (ITU), high dependency units (HDU), and London Ambulance Service (LAS) backgrounds.

Managers gave new staff a full induction tailored to their role before they started work. Managers made sure all bank staff had a full induction and understood the service. New staff and bank staff were given an induction booklet and a new starter checklist. This ensured that new staff competencies were checked and staff were aware of the essential policies and procedures to work within this service.

Managers supported staff to develop through yearly, constructive appraisals of their work. At the time of our assessment, completion was 87.9%. Managers recognised that this was below the trust wide target of 90% and had put in plans to improve this.

Managers supported nursing and therapy staff to develop through regular, constructive clinical and managerial supervision of their work. Staff received both clinical and managerial supervision every 2 months. At the time of our assessment 90% of staff had received clinical supervision and 97% of staff had received managerial supervision.

We reviewed a sample of clinical supervision records, and these showed that line managers reviewed skills and competencies with staff. Staff also had the opportunity to discuss training needs with their line manager and were supported to develop their skills and knowledge.

Managers made sure staff had the opportunity to attend monthly team meetings or had access to full notes when they could not attend.

Managers identified poor staff performance promptly and supported staff to improve.

Staff had received and kept up to date with their mandatory training, with a 96% completion rate. The mandatory training was comprehensive and met the needs of patients and staff. Staff had also completed 92% of their local mandatory training, which was specific to this service. Training included dementia training, deteriorating patients (NEWS2), medicines administration competency, mental capacity act training and preventing pressure ulcer training. Managers monitored supervision, annual appraisals and mandatory training using an electronic system and alerted staff when something needed completing.

Managers made sure staff received specialist training for their role. Learning form incidents and the thematic review had identified areas of improvement in terms of certain clinical areas. Staff had received training on delirium, human factors, palliative care, mental capacity, risk assessments and deteriorating patients. This were delivered by clinical experts in these subject areas. Staff spoke positively about this training. Staff were due to receive training on caring for patients with learning disabilities, bowel management and heart failure and pharmacological management. Training was delivered by experts in that subject area; these were internal and external to the staff team. The service also planned to introduce staff competency frameworks for these subject areas.

In the event of a risk of infection, the service would detect and control the risk of it spreading and share with appropriate agencies promptly, in line with trust policies. The service visited patients in the community, either in their own homes or in a care home or supported living environment. Staff reported any infection control risks to the relevant agencies.

During our assessment, we observed a staff member visiting a patient within their own home. Throughout the visit, the staff member demonstrated good infection prevention and control practices, including remaining bare below the elbows. Equipment was checked and cleaned before each visit.

Staff compliance with infection, prevention and control training was 96% and 100% in their quarterly hand hygiene audits.

Staff kept up to date with national guidance and information about any current outbreaks of infectious diseases, and these were discussed during the monthly team meetings. For example, staff recently reviewed information about the outbreak of Marburg disease in Ethiopia.

The service had received a peer review from the Divisional Assurance Response Team within the trust (but external to the service) to identify if there were any areas that the service could improve on. They identified that there were some areas concerning Infection, prevention and Control, such as cleaning and decluttering their storage rooms. This had been escalated to the estates team, to ensure that this was part of their normal cleaning schedule from now on.

The service made sure that medicines and treatments are safe and meet people’s needs, capacities and preferences. Staff reviewed and provided advice to patients and carers about their medicines.

Staff followed national practice to check patients had the correct medicines when they were admitted or they moved between services, including discharge from an acute hospital. Staff spoke positively about the support from the pharmacy team within the trust.

The service did not supply or dispense medicines; prescriptions were prescribed through the electronic prescribing system and collected by patients from pharmacies. GPs could see what had been prescribed as they used the same prescribing system. Staff ensured that patient records were updated and had access to a dashboard which showed what had been prescribed. Staff only carried adrenaline for anaphylaxis and IVs required for the furosemide pathway when visiting patients in the community.

Half of the staff were qualified as non‑medical prescribers and attended a non-medical prescribing quarterly conference held by the trust.

The service had a system to audit medicines to ensure that medicines were being prescribed, stored, recorded and disposed of in line with national guidance and local policy. Internal compliance audits for the service included safe and secure handling of medicines and an annual FP10 prescription audit, and these were over 95%. These audits were analysed in a trust-wide quarterly report.

One third of staff had completed phlebotomy training and collected patient blood samples when required. Patient bloods were tested for Urea and Electrolytes for kidney function, a C-reactive protein (CRP) to measure protein produced by the liver and a full blood count to assess the number of red and white blood cells. Other required interventions would be referred back to the patient’s GP or original referrer.

Staff learned from national patient safety alerts and incidents to improve practice. Updates were discussed in the monthly staff team meeting. Staff ensured that penicillin allergies were correctly listed in the patient electronic prescribing system following a recent patient safety alert.

During our assessment, we noticed that staff were not storing individual labelled patient blood samples in a dedicated box or bag within the car used by staff. This meant we could not be assured that samples were being kept at the correct temperature in the car, particularly as it was common for staff to see multiple patients and for the samples to remain in the car in-between patient visits. In response to this, the trust ordered one box for each of their lease cars in accordance with their collection and management of microbiological specimens policy. This did not apply to staff who used public transport; therefore the service was developing a local standard operating policy on safely transporting blood on public transport. Following this issue being raised at the time of inspection, the service implemented a local operating procedure to ensure samples were being kept at the correct temperature.