Central and North West London NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 had a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff we spoke to expressed there was a positive culture and felt proud to be part of the team.

Staff had the opportunity to contribute to discussions about the strategy for their service, through quality governance meetings.

The service had inclusive leaders at all levels who understood the context in which staff delivered care, treatment and support and embodied the values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Staff told us that leaders were visible in the service and approachable.

Leaders had a good understanding and oversight of the services they managed. They could explain clearly how the team was working to provide care and sought to improve the service where possible. Managers expressed that they were proud of the staff team and what they had achieved with the service developments over the last 2 years.

Leadership development opportunities were available within the trust, including opportunities for staff. Two staff had left the service to pursue leadership roles.

The service created a culture where staff felt that they could speak up and that their voice will be heard.

The service held a series of listening events for staff with the freedom to speak up guardian in 2024 to understand why there was a higher-than-average turnover of staff within the service.

Staff told us that the culture of the service was positive and had significantly improved since 2024. They were complimentary about their team and leaders and staff retention rates had improved since then. Information about the freedom to speak up guardian was in the staff induction pack.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Managers and staff had access to the feedback from patients and carers and used it to make improvements. For example, managers were in the process of updating the information leaflet to make this clearer in response to patient and carer feedback. Managers collated any patient and carer feedback received and shared this in the monthly staff team meetings.

Managers gathered feedback from staff during team meetings about what brings them joy at work, any ideas to improve the service and any desired training they wished to complete. Most recently, staff had expressed a desire for more social opportunities, better communication with GPs and training suggestions such as random case reviews and case-based learning. Managers acted upon feedback received to improve the service, such as introducing additional ‘bite sized’ training and cake competitions for staff.

The service valued diversity in the workforce. The service worked towards an inclusive and fair culture by improving equality and equity for staff.

Staff were able to apply to work flexibly. For example, flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. The service acted on the best information about risk, performance and outcomes.

Over the last two years the service had worked on making improvements to the quality, safety and governance off the service. Concerns about the safety and operation of the service, which had been shared internally, led to the implementation of a rapid access service steering group. This was a decision-making forum for clinical and operational issues, risk reviews and strategic and workforce matters and was responsible for the review and oversight of safety and quality of clinical care, as well as operational and governance systems. The steering group commissioned a thematic review of the service, created a specific rapid access service manager role, carried out an internal team culture review and formed workstreams to embed recommendations from the thematic review.

The thematic review analysed 16 incident learning reviews where a patient had deteriorated and/or died whilst under the care of the service, or had been seen by rapid access services. This was carried out by the trust’s Nurse Consultant Lead for deteriorating patients. The review highlighted 6 areas for improvement. These were around the escalation of deteriorating patients and the use of NEWS2. NEWS2 is a tool staff use to quickly assess how unwell a patient is by scoring their vital signs and triggering an appropriate clinical response. Other areas of improvement were around triage and screening, communication within UCR teams and external teams, documentation, continuity of care during out of hours end of life planning and capacity and consent.

Managers introduced three workstreams to implement the recommendations from the thematic review. One was a frameworks and policies group, responsible for reviewing the service’s standard and local operating procedures and implementing any changes, such as ensuring that roles and escalation pathways are clearly defined in the operating procedure. One was an autonomy of practice group, that was responsible for assessing and reinforcing roles and responsibilities of staff. This included reinforcing that there is a multidisciplinary team working approach when caring for a patient, but the GP or consultant must be consulted when making decisions as they hold clinical responsibility for the patient. Finally, a workforce group reviewed recruitment, retention, staff wellbeing and the learning and development of staff. A more robust training programme for staff had been developed and staff had received additional training. The workstreams were stood down in October 2025 and managers tracked progress of any remaining recommended actions still to be implemented. At the time of our inspection, 74 actions had been completed and 5 actions were recorded as in progress. Several groups that had been established to embed new ways of working were in place at the time of our inspection. For example, a staff wellbeing group and the documentation working group.

At the time of our inspection, the service had clear governance structures in place. This included processes to learn from incidents and complaints, analyse staffing numbers and training needs, review supervision data, evaluate patient and carer feedback and discuss safeguarding concerns. Information was discussed with staff in the monthly staff team meetings and the quarterly rapid access service quality governance meetings. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. This information fed into the trust’s divisional board.

Staff had access to the information they needed to carry out their roles. The service used an electronic confidential patient record system. Staff ensured that incidents were recorded on the service’s incident reporting system. Information was in an accessible format, accurate and identified areas for improvement.

Managers had access to information to support them with their role. This included information on the performance of the service, staffing and patient care. Managers shared performance and outcome data with the commissioners of the service. Managers monitored the number of referrals and had oversight of the performance of the service, including outcomes. The average length of stay for the service was 2 days and the service received 115 referrals in December 2025, with 97 seen within 2 hours. The service had received 358 referrals in January 2026, with 356 patients discharged from the UCR service back to the ongoing care of their GPs or onto other services.

Managers monitored audits in senior manager meetings and quality governance meetings to check improvement over time. These included hand hygiene audits, documentation audits and the safe handling of medicines audits. Managers said that this could be further improved by having oversight of audits in one place, such as an audit dashboard for the service.

Managers maintained and had access to the risk register. There were 2 risks listed on the risk register for this service. These were staff vacancies and national-level concerns associated with the equipment company.

Managers continued to monitor staff vacancies which had reduced from 23.7% to 15%. Managers also monitored staff feedback and any incident in relation to the new provider who were responsible for providing equipment for patients under the service.

The service had a business continuity plan in place for emergencies for example, adverse weather or a flu outbreak. Managers planned for winter pressures.

Staff had access to the equipment and information technology needed to do their work, including laptops and applications on their mobile telephones. Managers recognised that there could sometimes be a delay to the telephone system, so there were plans in place to address this.

The service worked in partnership with other services to meet the needs of patients.

The service had a strong sense of integrated working with the other services that were under the Rapid Access Services. The service had also formed partnerships and integrated working with local services in the community. Staff had also received training form the local mental health crisis team about how to help patients who may be experiencing a mental health crisis.

Senior managers engaged with appropriate external stakeholders and had close working relationships with commissioners. They attended the North Central London Urgent Community Response Delivery Group.

The service was working to further strengthen the relationship between UCR and Camden GPs. The service had produced a newsletter for Camden GPs to promote the service with them. They had also worked collaboratively with GPs to improve the patient discharge summaries, actions for the GP were now highlighted in yellow to ensure that these were not missed by GPs.

The service focused on continuous learning, innovation and improvement across the organisation and the local system. The service encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The service actively contributed to safe, effective practice and research.

The service had implemented an ongoing training programme in response to the thematic review to promote continuous learning and development for staff in addition to their mandatory training. Staff had received training on delirium, palliative care, deteriorating patients, patients experiencing a mental health crisis, human factors, mental capacity and audits for risk assessments.

Staff were due to receive training on caring for patients with learning disabilities, pressure ulcer assessment tool, 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.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Staff had successfully applied and received funding for two butterfly handheld ultrasound machines. This meant that patients could now receive a non-invasive procedure to test for urinary incontinence and avoid unnecessary catheters.

Staff had a quality improvement project to increase the number of referrals from ethnic minorities into the service by 50% to better reflect the borough demographics for Camden. The service recognised that most referrals received were from White British patients, despite this group representing 49% of Camden’s overall population. The service recognised that individuals from other ethnic backgrounds may not have equitable access to the service. The service planned to address this by improve the recording of ethnicity on referrals and further promote the service to local GP practices.

Staff participated in national audits relevant to the service and learned from them. Staff had oversight of audits and these were discussed in the quality and governance meetings.

Staff identified topics for further development and learning and these were implemented by the service. For example, staff had received training on their roles and responsibilities in attending investigations and hearings.

Innovations were taking place in the service. Managers had been nominated for a Health Service Journal award for their New Starter Road Map. This was a guide to encourage managers to help motivate and engage new staff waiting to come into their posts within the service. This included actions to complete from the first day up until their 6-month review. Managers told us that this had improved the experience of new staff and overall staff retention within the service.