East 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

Our overall rating of safe has improved to 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 had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

The service had two serious incidents for the period January 2025 – December 2025.

Staff reported all incidents that required reporting, including concerns about pressure ulcer care, welfare checks, deferred visits and delays in ordering urgent patient equipment. All pressure ulcers that were category 2 and above were reported as incidents.

For the month of December 2025, staff in Tower Hamlets community health service (CHS) reported 28 acquired pressure ulcers, including three unstageable ulcers and three category 3 ulcers. In Bedfordshire CHS, staff reported 80 acquired pressure ulcers. Of these, 13 were unstageable, two were a category 4 and 28 were suspected deep tissue injury (SDTI). In Newham CHS staff reported 27 acquired pressure ulcers, including two unstageable ulcers, two SDTIs and one category 4 pressure ulcer.

The service continually identified lessons learnt and embedded good practice. Managers and leaders discussed incidents during monthly team meetings, supervision and through trust lessons learnt briefings. Teams attended regular SWARM Huddles where they used the pressure ulcer reflective learning (PURL) tool to discuss pressure ulcer incidents that were a category 3 and above.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff confirmed they received a debrief and were supported by managers after deaths in service and serious incidents. Staff told us that there was a positive and inclusive learning culture within the service.

There was evidence that changes had been made because of feedback. For example, in the South District Nursing team (Bedfordshire) staff had undertaken further training following delays in reporting a death. For another incident, staff were reminded of weight checking prior to prescribing equipment. This helped to improve patient safety within the service. In Tower Hamlets CHS, staff had reported an incident after a miscommunication regarding a patient’s discharge and their medicines. As a result, staff conducted shared learning with the local acute hospital.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

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

The service had effective referral and admission processes to ensure all essential information was received so patients’ needs could be assessed and met safely. In Bedfordshire community health services (CHS), referrals were managed through the trust’s centralised single point of access, while the urgent community response (UCR) teams also accepted direct referrals from the East of England Ambulance Service. In Tower Hamlets and Newham CHS, referrals were triaged through a single point of access before being passed to local triage and assessment teams.

Most referrals were received from GP practices and acute hospital trusts. District nursing teams provided a wide range of care in people’s homes, including wound care, continence care, palliative care, diabetes care, lymphoedema management, medicines administration and support with self-care.

The service always had skilled staff available to assess patients. District nursing teams operated between 8am and 8pm, with an out-of-hours team providing overnight cover, ensuring patients could be assessed promptly when needed.

Staff worked with other health and social care services to ensure continuity of safe care, both within the service and when patients moved between services or were discharged. Referrals were reviewed daily and prioritised according to urgency. Urgent referrals were allocated directly to UCR teams, which supported people with needs such as intravenous antibiotics, end-of-life medicines, catheter blockages and falls. UCR staff attended daily allocation meetings to ensure referrals from the hospital were managed safely and in a timely way.

The service used systems to monitor waiting lists and support patients while they waited. In Bedfordshire community therapy teams, staff followed clear processes for people waiting longer than expected, including providing reassurance and advice on what to do if their condition changed.

Staff worked with people to understand what being safe means to them as well as with our partners on the best way to achieve this. The service 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 we make sure we share concerns quickly and appropriately.

Nursing staff received training specific for their role on how to recognise and report abuse. Staff received training in level 2 and level 3 safeguarding children and vulnerable adults.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff reported concerns for a patient’s welfare to the police after they suspected the patient was being financially abused.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff reported all category 3 and above pressure ulcers as a safeguarding concern.

Staff attended regular safeguarding huddles to support the early identification of adults with complex needs who may be at risk of harm and known to multiple services.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. In Bedfordshire CHS, staff had reported a safeguarding concern after a patient had been discharged from hospital with a complex pressure ulcer.

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

We reviewed 29 risk assessments and risk management plans during the assessment. Staff completed risk assessments for patients on admission using recognised tools and reviewed these regularly, including following incidents. Risk assessments included patients’ risk history, physical health risks, risks to self and clear risk management plans. Tools used included malnutrition universal screening tool (MUST), Waterlow and falls risk assessments.

Staff responded promptly to signs of deterioration in patient’s health. They used nationally recognised tools to identify deteriorating patients and escalated concerns appropriately. These included use of surface, skin inspection, keep moving, incontinence/moisture and nutrition bundle (SSKIN) for patients at risk of pressure damage and the national early warning score tool (NEWS2) to assess and manage physical deterioration.

Staff demonstrated a good understanding of individual patient needs and took action to manage risks. They completed pain assessments to identify the type and severity of pain and were knowledgeable about key risks, including sepsis, venous thromboembolism (VTE), falls and pressure ulcers.

Staff took photographs of peoples’ wounds and shared these with the wider team to monitor healing and support clinical decision-making, which was further reviewed through ‘skin matters’ meetings.

Patients and carers knew what to do if their condition deteriorated. They told us they would call 999, their GP or the urgent community response team if their condition worsened.

Staff carried out clinical observations and tests where required, including taking blood samples, measuring oxygen levels, completing electrocardiograms (ECG), neurological observations and baseline checks. Staff referred promptly to external professionals or contacted emergency services when appropriate.

Shift handovers and team meetings included all relevant information to keep people safe. Each district nursing team risk-rated their caseload and used a shared caseload spreadsheet to record patients’ risk levels, engagement plans and relevant mental health, social, cultural and personal information. This was updated weekly. During daily handovers, we observed staff discussing patients at higher risk, including actions such as welfare calls, follow-up after missed visits and sharing advice with patients about how to stay safe.

For example, in Tower Hamlets community health services (CHS), staff discussed a patient who was not at home during a planned home visit and clearly followed the escalation process to ensure the person’s safety. Staff accessed the patient records at the local hospital to check if they had been admitted.

Staff detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of care environments. All areas we visited were clean, well maintained and fit for purpose. Team bases had fire risk assessments in place, and staff completed regular fire drills and alarm testing.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines, which staff checked regularly. Defibrillators were maintained and calibrated to ensure they were in good working order.

The service had sufficient specialist equipment to support safe care. Staff ordered equipment for patients through an external contractor. In Tower Hamlets CHS, staff told us equipment ordering had improved recently following previous delays.

Staff completed safety checks to ensure specialist equipment was appropriately maintained and calibrated. For example, urgent community response teams had access to falls raisers to support people safely from the floor. Staff had their own blood glucose monitoring devices used during home visits and calibrated these regularly.

Flu vaccines were stored appropriately and monitored to ensure correct temperatures were maintained. Anaphylaxis kits used by district nursing teams were in date and stored correctly.

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

The service had enough staff with the appropriate qualifications, skills, training and experience to keep patients safe and deliver effective care.

Vacancy levels across the service were generally low, with an overall nursing vacancy rate of 13%. Vacancy rates varied across localities, with lower levels in Newham (2%) and Tower Hamlets (1.8%), and a rate of 9% in Bedfordshire as of February 2026.

Some of the highest vacancies were in the North Bedfordshire community therapy service, where vacancies had reached 9.3%. This risk was recorded on the service risk register, and managers had active recruitment plans in place. Sufficient temporary staff were in post to ensure the service could operate safely.

In Newham CHS, the district nursing teams had five band 6 vacancies and experienced high turnover in band 5 roles due to long-term sickness and difficulties recruiting to district nursing posts, partly linked to limited access to specialist training.

Managers accurately calculated and reviewed staffing levels in line with national guidance. Senior leaders were developing a safer staffing tool to support workforce planning and ensure staffing levels reflected capacity and demand.

Increasing demand for community health services had led to rising caseloads for staff. In the mid Bedfordshire team, the service was planning to introduce a virtual ward from April 2026 without any additional staffing, which leaders were monitoring closely.

Teams shared responsibility for caseloads, alongside holding individual patient caseloads. There was no maximum caseload limit, and new referrals were allocated based on patient acuity and complexity. Multidisciplinary teams discussed patients daily during handovers to ensure safe and appropriate allocation.

Managers adjusted staffing levels daily in response to patient needs and used bank staff to cover short-term absences and support patient flow. Use of bank staff was limited wherever possible, and managers sought staff familiar with the service.

Staff were up to date with mandatory training, with an overall compliance rate of 91%. The lowest compliance was in patient handling training in Tower Hamlets (64%) and basic life support training (44%) in Newham Foot health team. Since the inspection these training courses had increased respectively to 73% for patient handling and 89% for basic life support. Managers told us was due to reliance on classroom-based training with limited course availability. Mandatory training covered areas including safeguarding, medicines administration, basic life support, conflict resolution and moving and handling. Staff also received Oliver McGowan training in learning disability and autism.

Staff followed clear personal safety and lone working procedures. Most care was delivered in people’s homes or in community settings. Staff carried mobile phones with an SOS application to track their location in an emergency. Unplanned night service teams visited patients in pairs to reduce risk, and staff checked in with base teams before and after visits to ensure their safety.

Staff assessed and managed the risk of infection, detect and control the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff followed infection control principles including the use of personal protective equipment (PPE) such as gloves, masks and aprons. Staff had received training in infection control and disposed of clinical waste safely.

We observed good infection control practices from staff when attending home visits. Staff used aseptic procedures including hand hygiene when providing wound care and catheter care.

Clinical areas were clean and had suitable furnishings. In clinical rooms for specialist services there was clean equipment and furnishings such as examination couches. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

The service used robust systems and processes to prescribe, administer, record and store medicines safely. Staff were appropriately trained and competent, and non‑medical prescribers prescribed only within their scope of practice.

Medication administration charts were completed accurately and included all relevant patient information, including allergies. These records were kept in patients’ homes, and we saw they were completed correctly during visits. Managers provided transcribing training to some nurses to support accurate recording of medicines and ensure safe administration in line with guidance and risk assessments.

Medicines, including controlled drugs, were not stored at staff bases, apart from staff flu vaccines. Staff completed regular stock checks of controlled drugs in patients’ homes.

Staff worked closely with pharmacy technicians to raise and manage any medicines‑related concerns and collaborated with other teams, such as advance care planning teams, when patients were prescribed controlled drugs. Pharmacy technicians were embedded within locality teams, and in Tower Hamlets CHS they carried out joint visits with diabetes community nurses to support patients with their medicines.

Staff reconciled and regularly reviewed patients’ medicines and provided clear advice to patients and carers. The service learned from safety alerts and incidents to improve practice. Following an increase in medication omissions in the South and Mid Bedfordshire teams, the service reviewed the role of unqualified staff in medicines administration and updated the medicines policy in collaboration with the pharmacy team to ensure a consistent and safe approach.

Staff followed national guidance to ensure patients had the correct medicines when they were admitted or when they moved between services.