East London NHS Foundation Trust

On this page

• 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

Our overall rating of effective has stayed the same. Community Health Services for adults were rated as good.

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.

We reviewed 29 care and treatment records. Staff completed a comprehensive physical health assessment of the patient in a timely manner. Staff gathered detailed information at the point of contact and during face-to-face home visits, to ensure all presenting needs could be identified and met. For example, in the urgent community response team (Bedfordshire), we observed staff collating all the patient’s relevant information as part of their telephone triage assessment.

Staff developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery oriented. Staff updated care plans when necessary. Patients who presented with additional needs or disorders in their mental health were referred to other appropriate mental health services. In Tower Hamlets, the teams had a mental health nurse embedded within the service to guide and assist staff with patients who had mental health needs. For patients who needed extra support with housing or social care needs, the teams had care navigators to assist patient with this.

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

Staff provided a range of treatment interventions suitable for the patient group. The interventions were those recommended by and were delivered in line with guidance from the National Institute for Health and Care Excellence (NICE). The teams supported patients to manage physical health symptoms at home to reduce hospital admissions and readmission.

Staff used nationally recognised clinical pathways to support effective management of long‑term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), and Asthma.

Staff had piloted a Telehealth service in Newham CHS. This was a remote monitoring service consisting of care support workers and advanced practitioners working with people diagnosed with long term medical conditions such as diabetes, high blood pressure and heart problems to help them monitor, manage and control their own health. This was delivered using a full vital sign monitoring service, an SMS service to monitor vital signs or reviewing patients by telephone once a month. This service was due to be rolled out to Tower Hamlets CHS.

Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and best practice. Staff completed pain assessments for those patients that required it, specifically patients who were end of life. End of life patients received pain relief soon after requesting it.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients. The Community Health Service (CHS) was made up of nurses, occupational therapists, speech and language therapists and physiotherapists. Care navigators were embedded in the teams to support with social aspects of care and linking in with housing and benefits.

Managers supported staff to develop through regular, constructive clinical supervision. Staff had opportunities to discuss training needs with their line manager and were supported to develop their skills and knowledge. Where performance concerns were identified, managers acted promptly to support improvement. In the Bedfordshire single point of access team, managers supported staff by listening to a sample of recorded calls to provide feedback and oversight.

Supervision compliance remained below 80% across all three community health services between October 2025 and January 2026. Tower Hamlets CHS reported the lowest compliance, with supervision recorded at 42% in November 2025. By January 2026 compliance had improved across all geographies: Bedfordshire CHS reported 76%, Newham CHS 73%, and Tower Hamlets CHS 77%. Since the inspection, the trust reported an increase in supervision compliance. Newham and Tower Hamlets reported an increase of 88% and Bedfordshire an increase to 84% as of August 2026.

Managers also supported staff development through annual appraisals, and these were helpful for their role and ongoing development.

Managers gave all new staff a full induction tailored to their role before they started work. As part of their induction, district nurses completed ‘skills and drills’ training that was specific to community nursing. Staff at all grades had a competency book to complete, with the required competencies, such as bladder care, catheter care and wound care.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Staff were given the opportunity to complete prescribing courses to support them with their development. In the mid Bedfordshire community therapy team, an occupational therapist assistant had been supported to complete training in occupational therapy.

In Newham CHS, nurses attended sharp debridement in wound management training to help manage complex, hard to heal wounds that required debriding. Other specialist training included safe and effective use of catheters, continence and motivational interviewing to encourage professional curiosity. In addition, advanced nurse practitioners completed further training in analysing blood results.

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

Staff worked effectively across teams and services to support people, making sure they only needed to tell their story once by sharing their assessment of needs when they moved between different services.

Staff held regular, effective multidisciplinary meetings to discuss patients and improve their care, including when clinical tasks were delegated or when people were referred between services. Complex patients were discussed in designated ‘red, amber, green’ (RAG) meetings to identify and manage specific risks. The urgent community response teams also attended daily allocation meetings with the local acute hospital to review and prioritise new referrals.

Staff worked well together, and managers and teams were supportive. We observed strong joint working across district nursing teams, occupational therapists, tissue viability nurses, physiotherapists, podiatrists, and healthcare assistants. Nursing teams worked closely with the therapy colleagues to provide holistic care, particularly for people with sudden acute illnesses.

Staff worked effectively with external agencies when required. Community health service teams collaborated closely with local acute hospitals, particularly discharge teams, to support timely and safe discharge. In Bedfordshire CHS, staff also worked closely with the ambulance service to coordinate care.

In Newham CHS, as part of the Telehealth programme, staff met weekly with the heart failure team and GPs to review patients’ results and ongoing needs.

Staff also worked in partnership with local care homes and primary care services. In Tower Hamlets CHS, the clinical director and lead physiotherapist developed a podcast and webpage to support GPs and raise awareness of the community health services. This helped to improve shared understanding of services and support continuity of care for patients.

Staff referred patients for mental health assessments when they identified signs of mental ill health. In Tower Hamlets CHS, mental health nurses were embedded within teams to provide specialist guidance and support to staff.

Staff supported people to manage their health and wellbeing so they could maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives – for example, through participation in smoking cessation schemes, healthy eating advice, managing cardiovascular risks, screening for cancer, and dealing with issues relating to substance misuse. The service provided relevant information promoting healthy lifestyles and support. For example, we saw a care plan in the Bedfordshire CHS team where the patient had been educated on the signs of an infection following an amputation.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition. Staff used the malnutrition universal screening tool (MUST) to monitor patients at risk of malnutrition and obesity.

Staff provided patients with pressure ulcers with specific nutrition and hydration advice to support wound healing and improve their overall recovery.

Specialist support from staff such as dietitians and speech and language therapists were available for patients who needed it.

Staff monitored people’s care and treatment to continuously improve it and to ensure that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service participated in relevant national clinical audits. Community therapy teams used recognised outcome measures, including the Bartel Index for transfer of care and the community dependency index (CD). However, clinical leads told us these standardised measures were not always meaningful for community health services. The trust was therefore exploring the development of its own outcome measures. Staff also told us they used patients’ individual goals and choices to help measure outcomes.

Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time. Audits included care planning, infection control, palliative care, medicines charts and informal carer details. Managers used information from the audits to improve care and treatment, such as improvements needed in the recording of medicine charts and skin checking.

Managers shared and made sure staff understood information from the audits. Managers looked at trends and outcomes of audits every three months.

Staff told people about their rights around consent and respected these when delivering person-centred care and treatment.

Nursing staff received and kept up to date with training in the Mental Capacity Act and Deprivation of Liberty Safeguards.

Staff gave patients all possible support to make specific decisions for themselves before deciding a patient did not have the capacity to do so. Staff observed and recorded that patients consented to visits from the community health teams.

There was a clear policy on the Mental Capacity Act, which staff knew how to access. Staff understood mental capacity and were aware of how physical health conditions can affect capacity. Staff worked under the principle that capacity is always assumed and where they queried a patients’ capacity this was discussed as a team.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. Staff asked patients to sign a consent form before taking photographs of their wounds. When one patient in Tower Hamlets CHS chose not to give consent, staff respected their decision. This showed that patients had control over their care and that staff supported their right to make their own choices.

When patients could not give consent, staff made decisions in their best interest, taking into account patients’ wishes, culture and traditions. Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision. We saw capacity assessments that was time and decision specific for the patient based on their care and treatment.

Managers monitored how well the service followed the Mental Capacity Act and made changes to practice when necessary. The trust had done a lot of work to ensure that staff understood the MCA and how it impacted on the care and treatment of patients.