All inspections: Cambridgeshire and Peterborough NHS Foundation Trust

During this assessment of Cambridge and Peterborough NHS Foundation Trust, the team visited the 136 Suite and Crisis and Resolution Home Treatment Team South (CRHT), both services are located at Mulberry 1 ward; Fulbourn Hospital in Cambridge; the Crisis Resolution Home Treatment Team North (CRHT) based at the Cavell Centre in Peterborough) and the FRS (First Response Service) based in Huntingdon.

We carried out this assessment due to receiving information of concern. We assessed 18 quality statements across safe, effective, caring, responsive, and well-led key questions and have combined the scores for these areas with scores from the previous inspection.

Date of on-site assessment, 7 and 8 August 2024.

During our assessment, we found concerns around:

The effectiveness of systems in place to share learning from incidents which resulted in a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Supervision, appraisal, mandatory training, and low staffing levels which resulted in a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings.

During this assessment of Cambridge and Peterborough NHS Foundation Trust, the team visited the community adults mental health locality teams for working age adults based in Peterborough North and South, Huntingdon and Cambridge North and South. We also visited the CAMEO South team, (Cambridgeshire and Peterborough Assessing, Managing and Enhancing Outcomes) early intervention psychosis service.

We carried out this assessment due to receiving information of concern. We assessed 20 quality statements across safe, effective, caring, responsive, and well-led key questions and have combined the scores for these areas with scores from the last inspection.

Date of on-site assessment, 12 & 13 June 2024.

During our assessment, we found concerns around:

The completeness and accessibility of patient care plans which resulted in a breach of regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The suitability of some equipment, facilities and premises which resulted in a breach of regulation 15 (Premises and Equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The effectiveness of systems in place to share learning from incidents which resulted in a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Mandatory training, supervision, appraisal and staffing levels were low which resulted in a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Cambridgeshire and Peterborough NHS Foundation Trust acute wards for adults of working age are based at the Fulbourn Hospital in Cambridge, and the Cavell Centre in Peterborough. The trust operated a 3-3-3 pathway model of assessment, treatment and recovery. The model consists of three days of assessment, three weeks of treatment and three months of recovery. Each acute ward had a designated function, providing services for adults aged 18 years old and over. During this assessment the team visited all six acute wards. We did not visit the psychiatric intensive care unit (PICU).

We looked at eight quality statements: learning culture, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, delivering evidence-based care and treatment, Independence, choice and control and equity in experiences and outcomes.

During our assessment, we found concerns around

Mandatory training, supervision, appraisal and staffing levels which resulted in a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The accuracy, timeliness and accessibility of patient information including risk assessments, care plans, handover notes and observation records which resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Maintenance and record keeping for some equipment which resulted in a breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings.

The acute wards for adults of working age are part of the mental health services provided by Cambridgeshire and Peterborough NHS Foundation Trust.

The five acute wards at Fulbourn Hospital and Cavell Centre, Peterborough provide assessment and treatment in an inpatient care setting for both adults admitted on an informal basis and patients detained under the Mental Health Act 1983.

Following a focussed inspection of Mulberry 2 ward in May 2022 we issued a Section 29a warning notice under the Health and Social Care Act against Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment:

The trust was not ensuring staff carry out patient observations in accordance with trust policy and National Institute for Health and Care Excellence (NICE) guidance in order to protect people from harm.
The trust did not inform the Care Quality Commission of a serious allegation of sexual assault on one vulnerable patient to another.
The trust was not ensuring there are robust, safe systems to protect patients from sexual harm when residing on this mixed sex ward.
The trust did not ensure patients bedrooms were cleaned to a safe standard, exposing patients to a risk of harm.

We inspected Mulberry 2 ward to follow up on the Section 29a warning notice.

We also inspected the other four acute wards at Fulbourn Hospital and Cavell Centre, Peterborough.

We also inspected areas of the well-led key question for the core service.

The provider submitted an action plan in response to the Section 29a warning notice and had addressed or was in the process of addressing all the identified concerns at this inspection.

We found enough improvement to remove the warning notice as the Trust had demonstrated that action had been taken to improve the safety of patients on Mulberry 2 and ongoing measures were in place to maintain this improvement.

We rated this service as requires improvement. We found:

The trust had taken steps to improve observations of patients on the ward including zonal observations. Observations hadn’t always taken place due to staff shortages, however we were assured the introduction of closed-circuit television and swipe access cards reduced the risk of patients entering the other gender bedroom corridors.
Staff could not always observe the bedroom corridors at the three wards at the Cavell Centre. Patients told us that patients of the opposite gender sometimes entered the bedroom corridor. The storage room for male and female patient possessions was located in the female bedroom corridor on two wards.
Staff did not always complete daily cleanliness checklists at the Cavell Centre.
Staff did not always complete the front sheet of observation records fully, so it was not clear who had undertaken the observation.
Staff did not always record which staff member had completed searches.
The Trust had not fully addressed and embedded all of the lessons learned from Mulberry 1 and 2 wards to the Cavell Centre wards.

However:

Staff on Mulberry 2 ward had completed enhanced observations training and the trust planned to deliver this across the other wards. Observation records had improved since the previous inspection.
The trust oversight of sexual safety at Mulberry 1 and 2 wards had improved. The trust had introduced a sexual safety project, co-produced with patients and was in the process of delivering sexual safety training to all staff on the wards.
The wards and patient bedrooms were all clean and tidy. Staff supported patients who had additional needs regarding cleanliness of their bedroom and checked bedrooms regularly.
The trust had completed audits including observation records and infection prevention and control audits.
Staff told us they felt supported by managers and morale was good within teams despite the staff shortages. The trust was actively recruiting to vacant roles.
Wards held regular governance meetings and had monitored progress against the action plan to meet the warning notice requirements.

Before the inspection we reviewed information provided by the trust.

During the inspection visit, the team:

Reviewed the environments of five acute wards;
Reviewed 21 care records including observation records;
Spoke with 11 staff including modern matrons, ward managers, clinical nurse specialists, nurses and healthcare assistants;
Spoke with 17 patients;
Reviewed one month of zonal observation records;
Reviewed training compliance rates;
Reviewed a number of audits, meeting minutes, policies and action plans.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with 17 patients and most patients told us they felt safe on the wards and staff managed any incidents well. Some patients told us that they had seen patients of the opposite gender in their bedroom corridors and that staff would escort them out.

Patients told us that there were regular staff shortages, but that staff were respectful and caring.

Patients told us that the wards were clean.

We carried out this unannounced focused inspection of the liaison psychiatry service based at Peterborough City Hospital as part of a larger review of integrated care across the region. The inspection was focussed on the urgent and emergency care patient pathway and any barriers to discharge or transfer of patients with mental health needs out of the acute general hospital. We did not inspect all aspects of the key questions.

The liaison psychiatry service is part of the Cambridge and Peterborough NHS Foundation Trust mental health crisis service. The aim is to provide assessment, diagnosis and treatment for emotional and psychiatric problems for patients attending local general hospitals. Teams were based at Peterborough City Hospital in Peterborough, Addenbrooke’s Hospital in Cambridge, and Hinchingbrooke Hospital in Huntingdon. We only visited the liaison psychiatry service based at Peterborough City Hospital.

The liaison psychiatry service has two arms, the team who assess people with mental health concerns arriving at the urgent and emergency care department and the team who cover the Peterborough City hospital inpatients. The urgent and emergency care team role is front facing within the department assessing patients’ immediate needs and acts to gatekeep beds within the local mental health services. The inpatient arm of the service focusses on assessing and managing the mental health needs of those admitted to the acute hospital.

We did not inspect any other parts of the mental health crisis service or health-based places of safety core service at this time as they did not form part of the integrated care review.

We did not rate this service at this inspection as it was part of a review looking at urgent and emergency care systems. The previous rating of good for the mental health crisis service or health-based places of safety core service remains. We found:

The liaison psychiatry team were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the liaison psychiatry team immediately. Staff and managers managed the caseloads of the liaison psychiatry team well. The services did not exclude patients who would have benefitted from care.
The number of patients on the caseload of the liaison psychiatry service and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed.
Staff followed good practice with respect to safeguarding.
Staff working for the liaison psychiatry service assessed patients and developed holistic, care plans in collaboration with families and carers.
Managers ensured that staff received supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
The service was well led, and the governance processes ensured that procedures ran smoothly.

However,

Staff mandatory and required training in some areas was very low.
Staff clinically assessed and managed patient risk well but there was inconsistent assessment and recording of patient risk.
Staff had not fully reinstated clinical audit following cessation during the COVID-19 pandemic to evaluate the quality of care they provided.
The liaison psychiatry team included but did not have access to the agreed psychologist specialist required to meet the needs of the patients.

During the inspection visit, the inspection team:

Visited the liaison psychiatry service based in the urgent and emergency care department at Peterborough City Hospital.
Spoke with 17 staff members; including the service lead, doctors, specialist nurses, clerical workers and managers.
Observed one visit by staff to an inpatient who had been referred to the liaison psychiatry service.
Spoke with one patient.
Observed one handover meeting.
Reviewed five care records of people referred to the liaison psychiatry service.
Looked at a range of policies, procedures, meeting minutes and other documents relating to the running of the liaison psychiatry service.

We inspected Mulberry 2 ward, a 16 bedded mixed sex acute ward located at Fulbourn hospital, Cambridge.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services. We received information of an alleged serious sexual assault on Mulberry 2 ward in February 2022, the trust had not informed us of this.

Staff could not observe patients in all parts of the wards. There were no clear lines of sight into each of the bedroom corridors.

Staff had not ensured a patients’ bedroom was fit for purpose. We saw the bedroom was in a very poor condition, the floor was very heavily soiled with food and drink spillages. Dirty crockery and debris were visible, and the en suite toilet had dried faeces around the bowl and seat and urine stains on the floor.

How we carried out the inspection

Our inspection team was led by a CQC inspector.

The team included one CQC inspection manager and one assistant inspector.

Before the inspection visit, we reviewed information we held about the location.

During the inspection visit, the inspection team:

inspected the environment on Mulberry 2 ward
looked at six care and treatment records
looked at 24 significant incident reports
spoke with the ward manager, clinical nurse specialist, two senior staff nurses and a preceptor nurse
looked at six weeks of staff rotas
looked at the minutes of three clinical governance meetings and three business meetings
looked at mandatory training compliance rates.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services.

We inspected the trust’s three children and adolescent mental health wards based at Ida Darwin Hospital in Cambridge: Darwin, Phoenix and the Croft.

We did not rate all key questions of this core service, however, our rating for safe went down and is now requires improvement because:

There were not always sufficient staff at the service. There were significant vacancies for nurses, healthcare assistants and other support staff. For the two weeks ahead of our inspection there were many occasions where the staffing levels on the ward fell below the safer staffing levels set by the trust. The trust did not record all occasions when staff were moved during shift to accommodate cover arrangements, so it was not possible to be assured that there was sufficient staffing at all times. We noted occasions were leave was cancelled due to staffing levels and there were not always sufficient staff on Phoenix ward to accommodate physical intervention.
Not all staff had undertaken required mandatory training on Phoenix ward. Physical intervention training completion rates were 66% on Darwin, 44% on Phoenix and 32% on Croft.
The quality of care plans and risk assessments was variable and not all incident information had been captured. For two young people who had been involved in multiple potential self-harm incidents’ the risk of self-harm was recorded as low. Not all risk assessments had been updated following significant incidents. We noted incidents within contemporaneous records that had been included on the risk assessments.
Seclusion rooms on Darwin and Phoenix wards did not meet all of the requirements of the Mental Health Act code of practice.
Managers had completed and updated ligature point risk assessments of all wards areas however we found that these were not available to all staff.

However:

Most ward areas were clean, well maintained, well-furnished and fit for purpose.
There had been minimal use of physical intervention or rapid tranquilisation at the service in recent months. There had been no use of seclusion since August 2021. Physical health checks had been undertaken following restraint and rapid tranquilisation.
Staff knew what incidents to report and how to report them. Managers debriefed and supported staff after any serious incident and investigated incidents thoroughly. Children, young people and their families were involved in these investigations where appropriate. Staff received feedback from investigation of incidents and were included in learning discussions looking at improvements to care. There was evidence that changes had been made as a result of feedback.

How we carried out the inspection

Reviewed the environment of all wards
Spoke with the service director, service manager and modern matron for the child and adolescent mental health service
Spoke with the deputy ward manager and clinical team leader for Darwin and the nurses in charge of Croft and Darwin wards
Spoke with key stakeholders including the East of England Provider Collaborative
spoke with four other staff
spoke with three children and young people and joined a community meeting on Darwin Ward
spoke with two young peoples’ parents
looked at care and treatment records for five young people
reviewed incident and physical intervention records
reviewed staffing rotas for the three wards
reviewed observation records
and reviewed a range of policies and procedures, data and documentation relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection

Our rating of this service stayed the same. We rated it as good because:

All wards were clean, well equipped, well furnished, and well maintained and managers had completed environmental risk assessments. Staff followed good practice in medicines management and monitoring of effects of medication on people’s physical health. The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm.
Staff completed mental health assessments at or soon after admission and assessed patient’s physical health needs in a timely manner. Care plans were personalised, holistic and recovery orientated and updated regularly. There was evidence of effective working relationships with other care teams. Staff understood their roles and responsibilities under the Mental Health Act 1983 and supported patients to make decisions on their care for themselves.
Staff attitudes and behaviours when interacting with patients were discreet, respectful and responsive, providing patients with help and emotional support and advice at the time they needed it. Staff involved patients and their carers in care planning and risk assessment, care plans were written in patient focused language and evidenced the patient voice.
The service met the needs of all patients who used the service and helped patients with communication, advocacy and cultural and spiritual support. Daily bed management meetings took place to review bed pressures, availability of beds and options for patient transfers. Wards had enough rooms for patients to access individual sessions with nursing staff, to receive visitors or to participate in ward-based activities. Staff supported patients to maintain contact with their families and carers and invited them to attend ward reviews where appropriate. The service treated concerns and complaints seriously and acted on these.
Staff told us that senior managers were visible on the wards and they knew who senior staff were. Staff knew and understood the trust’s vision and values and said they felt respected and supported by their managers and that morale was good. Staff we spoke with knew the trust had a whistle blowing policy which they would use if they needed to. Governance meetings and local risk registers were in place, staff were able to contribute to these.

However:

At this inspection the trust had not made improvements in respect of some areas found at the previous inspection.
The layout of the psychiatric intensive care unit’s seclusion room could pose a safety risk to patients and staff. This was because staff had to enter the room to support patients to use the ensuite facility or to open the blind. Staff at the Cavell Centre moved patients across the hospital in restraint holds to access the seclusion room at PICU putting patients and staff at increased risk of injury. At Fulbourn there were occasions where patients had been secluded in rooms other than a designated seclusion room, Staff had not ensured that incidents of seclusion had been recorded in line with the Mental Health Act Code of Practice.
Staff had failed to enforce the trust’s patient search policy. We found tobacco, cigarette papers and a lighter in a patient’s bedroom on the treatment ward at the Cavell centre. This posed a fire risk to patients and staff. In addition, at Fulbourn hospital site, staff permitted patients from Mulberry 2 to smoke directly outside the ward. This was against the trust’s no smoking policy.

We rated the service as good because:

The service provided mandatory training in key skills to all staff and made sure most staff had completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service controlled infection risk well. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff assessed risks to patients, acted on them and kept good care records. The service managed patient safety incidents well. The service used systems and processes to safely manage medicines.
The service provided care and treatment based on national guidance and evidence-based practice. Staff assessed and monitored patients regularly and gave pain relief in a timely way. All those responsible for delivering care worked together as a team to benefit patients. Staff supported patients to make informed decisions about their care and treatment and followed national guidance to gain patients’ consent.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers, and supported them understand their condition and make decisions about their care and treatment.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and received the right care in a timely way.
Leaders had the integrity, skills and abilities to run the service. Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

Diagnostic imaging support was not consistently available during opening hours across all sites.

We rated community services for adults as good because:

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service managed patient safety incidents well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used monitoring results well to improve safety.
The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well. The service controlled infection well and the service had low number of infection incidents.
Staff kept detailed records of patients’ care and treatment, they completed and updated risk assessments for each patient and removed or minimised risks. The service used systems and processes to safely prescribe, administer, record and store medicines.
The service provided care and treatment based on national guidance and evidence-based practice. Staff gave patients practical support and advice to lead healthier lives. Staff regularly checked if patients were eating and drinking enough to stay healthy and help with their recovery. Staff assessed and monitored patients regularly to see if they were in pain and requested pain management reviews in a timely way.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported patients to make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The service planned and provided care in a way that met the needs of local people and the communities served. It was inclusive and took account of patients’ individual needs and preferences. People could access the service when they needed it and received the right care in a timely way.
The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. It was easy for people to give feedback and raise concerns about care received.
Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. All those responsible for delivering care worked together as a team to benefit patients.
The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Managers used a systematic approach to continually improve the quality of its services. The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Staff were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

The service did not have robust assurance processes in relation to infection prevention and control audits. The service completed annual hand hygiene audits and did not have any formalised assurance processes in place.

Our rating of this service improved. We rated it as good because:

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to be assessed. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

Waiting times from referral to treatment start exceeded 18 weeks for 24% of patients.

Our rating of this service stayed the same. We rated it as good because:

All patient areas of the wards were clean and tidy. Clinic rooms at S3 ward were fully equipped with accessible resuscitation equipment and emergency drugs, and clean and well maintained.
There were sufficient staff to meet the needs of the patients. Overall, staff knew about any risks to each patient and acted to prevent or reduce risks. Staff identified and responded to any changes in risk to, or posed by, patients promptly. Staff used physical intervention rarely. Staff took part in de-escalation techniques and proactive preventive interventions, which included how to safely restrain a patient with low body mass index. There were effective systems in place for safe management and administration of medication.
Services provided a range of treatment in line with best practice guidelines. Overall, there was a holistic approach to assessing, planning, and delivering care and treatment to people who use services. Staff assessed the physical and mental health needs of all patients on admission. The service had access to a range of specialists to meet the needs of the patients. Staff held regular multidisciplinary meetings to discuss patients and improve their care. Staff had a robust understanding of mental capacity and consent. We found clear records around consent to treatment and mental capacity requirements.
We observed positive and caring interactions between staff and patients on the wards and in the community. Staff had a good rapport with patients. Staff involved patients and gave them access to their care plans. Staff contacted family members about joining multidisciplinary meetings, ward rounds, or care programme approach meetings.
Beds were available when needed to people living in the catchment area. Staff ensured they did not discharge patients until they were ready. The trust ensured facilities promoted recovery, comfort, and dignity. Patients on wards had their own bedroom, which they could personalise. Staff provided a range of information on treatments, local services, patients’ rights, how to contact CQC, and advocacy. We saw information on how to complain displayed around the service.
Leaders, at local level, had the right skills, knowledge, and experience to lead their teams. Staff reported they felt supported by leaders. Staff were offered the opportunity to give feedback and input into service development. S3 ward was accredited by the Quality Network for Eating Disorders.

However:

Although staff on the wards had undertaken environmental ligature assessments, that for S3 ward had not considered risks in the garden area. Also, the garden back gate had been left unlocked. We raised this with managers during the inspection. Neither community eating disorder services had undertaken environmental risk assessments, although these were in development. The Cambridge community eating disorder service had identified risks in the patient toilet areas and staff were aware of these.
The clinic rooms at the Phoenix Centre were disorganised and required cleaning and there were no cleaning records at the Cambridge community eating disorder service. In addition, the clinic room at the Cambridge community eating disorder service did not have disposable gloves or aprons.
At S3 ward not all staff were routinely aware of lessons learnt from serious incidents across services.

Our rating of this service stayed the same. We rated it as good because:

Staff assessed the care environment annually for potential risks. Patients who were assessed as being at high risk were always individually risk assessed and supervised in the clinical areas. Staff had access to personal alarms on site in the clinical rooms.
Thirty seven of the 43 care plans we reviewed were holistic, personalised and recovery orientated. Thirty-seven of the patients had received a physical health check. Where necessary, staff referred patients to their weekly physical health clinic for regular monitoring.
At the time of the inspection, all the workforce in this service had received training in the Mental Capacity Act Level 1 and 89% in the Mental Capacity Act Level 2. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.
Staff that we spoke with were discreet, respectful and responsive to patients. We observed staff providing practical and emotional support and advice to patients and working flexibly to meet their needs. They understood the individual needs of patients and supported patients to understand and manage their care and treatment.
Staff saw urgent referrals quickly, including the same day if required and non-urgent referrals within the trust target time. The service provided a daily duty cover system and all new referrals were reviewed by the duty cover worker.
The systems and procedures in place ensured that premises were clean, safe and well-staffed. Patients were assessed and treated well and referrals and waiting times were managed well. Incidents and complaints were reported and investigated, and lessons learned were effectively cascaded to the teams.

However:

Not all mandatory training had been completed to the trust’s target of 95% completion. Four courses had failed to exceed 75% compliance.
At the Fenland team we found that staff had not kept patient records updated, this included five out of eight risk assessments.

We rated safe as requires improvement and effective, caring, responsive and well-led as good. In rating the trust, we took into account the previous ratings of the nine core services not inspected this time. We rated the trust as good overall for well-led. We rated all of the core services that we inspected on this occasion as good overall. Following this, and taking our previous ratings into account, all bar one of the 16 core services delivered by the trust are rated good overall.
We found that leadership was good across the trust. Executive directors and directorate leads were known to most staff and visited services regularly. They provided leadership and the board encouraged feedback from all levels of the organisation. Local leadership across the trust was visible and effective. Staff felt supported by their leaders. The trust supported staff to develop their leadership skills and staff had opportunities for career progression. The trust recognised staff success through individual staff and team awards. Staff morale was good across services that we visited and staff felt respected, supported and valued.
The service had enough staff to care for patients and keep them safe. Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision, and opportunities to update and further develop their skills.
Staff understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. The service controlled infection risk and managed medicines well. The service managed safety incidents and learned lessons from them. Staff collected safety information and used it to improve the service. Patients across the trust told us that they felt safe.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. Staff involved patients and those close to them as partners in their care and treatment. We received positive feedback from those patients, families and carers that we spoke with about the care and treatment received from staff.
The service engaged well with patients and the community to plan and manage services. Trust staff worked well with each other and external organisations to provide care and treatment. The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and, in most cases, did not have to wait too long for treatment. Bed management processes were effective and included daily bed management meetings. Discharge planning was a core part of any inpatient admission.
The services met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. Staff provided a range of treatment and care for patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported them to live healthier lives. Individual care plans were reviewed regularly and reflected patients’ assessed needs, were personalised, holistic and recovery-oriented. Staff monitored the effectiveness of care and treatment. Treatment was delivered with the legal framework of the Mental Health Act and Mental Capacity Act.
Staff had been involved in the development of the trust vision and strategies and, overall, knew of plans to develop their service. Staff were clear about their roles and accountabilities. Managers discussed the values with staff in supervision and appraisals and recruitment processes were based on the values. Staff knew the trust values and demonstrated these in the care that they delivered to patients.
The trust had a cohesive governance framework and structure. Service managers attended directorate clinical governance meetings, which fed into the trust wide governance meetings. Local governance meetings discussed team issues, such as incidents, safeguarding, staffing concerns, and identified and shared learning from incidents. Managers fed this learning back to front line staff and patients through team meetings, supervision and learning bulletins. Risk registers were in place at trust, directorate and team level. Staff could escalate concerns and submit items to the trust risk register. Senior trust staff reviewed the trust risk register and non-executive directors openly challenged issues through board and governance meetings. Leaders ran services well using reliable information systems.
The trust had committed to improving services by learning from when things went well and when they went wrong, and promoted training, research and innovation. The trust had participated in national improvement and innovation projects and undertook a wide range of quality audits and research. Quality improvement was developing across services. The services treated concerns and complaints seriously, investigated them and learned lessons from the results. Patients told us they knew how to complain.

However:

At our inspection of 2018, we had some concerns about the safety at the acute wards. We told the trust that they must address concerns and meet regulation. At this inspection, we found that some of our concerns had not yet been fully addressed. The trust had not ensured that seclusion practice and environments met the requirements of the Mental Health Act Code of Practice and were fully safe. Staff had failed to enforce the trust’s patient search policy in relation to smoking at wards. The trust’s smoke free policy was not being operated at all wards.
While the trust had worked to address ligature risks in inpatient services there remained some environmental concerns. At ward S3 in the eating disorder service, an environmental ligature assessment was in place but had not included the garden area. In addition, we found the garden back gate was unlocked. There were also concerns regarding the risk of possible patient absconsion from the garden at the PICU. The clinic rooms within some eating disorder services were messy and grubby and required some essential equipment.
Staff at the health-based place of safety at Fulbourn Hospital did not complete or update risk assessments for patients whilst in their care. The service also was not meeting the Royal College of Psychiatrists’ recommendation for doctors assessing patients in the health-based place of safety within three hours. The trust had only one health-based place of safety. When this was in use patients remained in rooms in the local acute trusts.
Staff supervision rates and the recording of, were not monitored on a consistent basis by all team managers.

The summary for this service appears in the overall summary of this report.

Our rating of the trust stayed the same. We rated it as good

We rated safe as requires improvement and effective, caring, responsive and well-led as good. In rating the trust, we took into account the previous ratings of the five services not inspected this time. We rated the trust overall for well-led as good.
At this inspection, we rated seven core services as good, one specialist mental health service (The eating disorder service) as good and two core services as requires improvement. In rating the trust, we took into account the previous ratings of the four services not inspected this time. Therefore, following this most recent inspection, 12 of the trust’s services are rated as good, and two as requires improvement.
The trust managed patient safety well. Staff had recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support. The trust applied the Duty of Candour appropriately. Those serious incident reports reviewed included clear communication with and attempts to communicate with family and carers throughout the investigation process. Staff had training on how to recognise and report abuse and applied it. The trust had effective systems for identifying risks and planning to eliminate or reduce them. The trust was committed to improving services by learning from when things go well and when they went wrong. Staff training and service development was prioritised.
Staff kept clear records of patients’ care and treatment. Care and treatment records were clear, up-to-date and available to all staff providing care. The trust provided care and treatment based on national guidance. Patients had access to psychological support and occupational therapy. The physical healthcare needs of inpatients’’ with mental health needs were met. Patients in community health services benefitted from the support provided by staff.
Trust staff worked well with each other and external organisations to provide care and treatment to patients based on national guidance. Bed management processes were effective and included daily bed management meetings.
Staff completed Mental Health Act paperwork correctly. There was administrative support to ensure these records were up to date and regular audits took place.
Systems for the safe management and administration of medicine were in place. Incidents and errors within the pharmacies were reported and investigated and shared at team meetings to ensure consistency across different sites. The pharmacy team reviewed serious incident reports when medicines were involved. The trust had subscribed to the Choice and Medication website to support patients including at the point of discharge.
Positive feedback was received from those patients, families and carers spoken with about the care and treatment received from staff. Patients told us that they felt safe across the trust.
The trust promoted a person-centred culture and staff involved patients and those close to them as partners in their care and treatment. Staff provided positive emotional support to patients.
Local leadership across the trust was strong, visible and effective. Executive directors were known to staff and visited services. They provided inspirational leadership and the board encouraged feedback from all levels of the organisation. Staff were particularly positive about the chief executive’s approach. The responsiveness of the trust to issues raised during the inspection was immediate.

However:

There were a number of environmental issues that prevented the trust from offering safe services. The current ward ligature risk assessments did not address all the potential ligature risks on the wards. The environment in which the LD and autism community intensive support team saw patients had areas that patients could access that were unsafe. Wards had some outstanding maintenance tasks. Staff environmental checks on the wards were not thorough. Staff did not effectively implement the trust’s smoke free policy on some wards. The trust took immediate action to address these concerns once these were identified.
Staff did not always record information thoroughly. Staff supervision rates and the recording of; were not monitored on a consistent basis by ward managers. Some seclusion records were incomplete and these did not reflect the interventions provided by staff during seclusion episodes.
In the specialist community mental health services for children and young people, the trust did not routinely monitor the risk of those young people waiting to receive treatment. Staff had not followed the trust policy on the recording of risk. The trust had not ensured that staff followed their new access policy on patients who did not attend appointments. Patients, who failed to attend appointments, were not followed up. Some staff were not aware of their responsibilities under the Mental Capacity Act and relating to capacity assessment and Gillick competencies.
Managers did not monitor the arrangements in place for the safe management of alarms, keys and access cards. Staff were taking these away from the hospital which meant that these could be misplaced and access gained by unauthorised persons.

We gave an overall rating for long stay/rehabilitation mental health wards for working age adults of good because:

Patients we spoke with were very positive about the wards and the care they received from staff and told us they were involved in their care, were listened to and treated with kindness and respect.

Staff morale was high with staff positive about the leadership of both the trust and their line managers. There were good systems in place to monitor staff performance and the productivity of the ward.

There was good management of risk, learning from incidents and complaints. Staff shortfalls were managed safely with an active recruitment programme for staff vacancies. Staff were up to date with mandatory training and were able to undertake further training; for example, four nurses had trained in tissue viability and wound management.

Patients had a full range of activities.

However:

There was a general lack of psychology input which meant staff did not always have sufficient input to help them manage more complex and challenging patients.

Oak 4 did not have a dedicated low stimulus/de-escalation area.

We rated wards for older people with mental health problems as good because:

Wards were generally clean and safe. Furnishings and clinic rooms were well maintained. Environmental risks were managed in line with the needs of individual patients.

The service had a good safety record with 21% of incidents recorded over a 12 month period as resulted in ‘low harm’ and staff had received feedback from investigations across their directorate.

Wards made use of dementia friendly, reminiscence material and activities to meet the needs of the patients.

Care records showed there was a good response to physical healthcare needs and assessment. Staff showed a good awareness of individual patient needs and how to meet them. There was access to specialists where required. Patients were complimentary about the support they received.

Staff were observed to interact with patients in a responsive and respectful manner and showed a good understanding of patient’s needs. Staff reported positive job satisfaction and high morale and had been able to undertake development and leadership opportunities. Staff were well supported by their managers/matrons and were empowered to raise concerns

However

There were clear arrangements for ensuring that there was single sex accommodation on the majority of wards. However, improvement was needed to ensure that arrangements for managing mixed sex accommodation at Maple 1 ward were followed to ensure the privacy of patients.
Some staff were unclear about what constituted restraint and how this should be recorded.
Formal assessment and recording of capacity to consent for care and treatment on both informal patients and those subject to Deprivation of Liberty safeguards (DoLs) were not clearly recorded or evidenced by decision specific rationale.

We did not give an overall rating of the eating disorder specialist services as we only inspected part of the service:

Parts of the wards on S3 and the Phoenix Centre could not easily be seen. However, staff tried to mitigate and manage this by ensuring they were well positioned, enabling them to monitor and observe patients.
The wards could accommodate males and females without compromising the patients’ privacy or dignity.
We saw no ligature points in patient areas.

Medicines were stored appropriately in the clinic room on both wards. Both clinic rooms were well stocked, clean and well equipped with resuscitation equipment and emergency drugs.

Most staff confirmed that they had received mandatory training. Clinical supervision was offered. Staff appraisals were all completed and in date.

Physical health checks were completed at the point of admission and were comprehensive. Risk assessment and care plans were very detailed. They had been updated and reviewed. Care assessments had been completed and uploaded onto the electronic system.

NICE guidelines for eating disorders were followed for inpatient and community services.

All eating disorder services had good links with Addenbrooke’s Hospital for physical healthcare, including access to paediatrics for young people at the Phoenix Centre.

Detained patients had appropriate documentation in place, as required, and in line with the Mental Health Act and Code of Practice, including consent to treatment forms, section 132 rights and section 17 leave.

Patients told us that staff were kind, caring and supportive when they were experiencing difficulties. Patients were involved in their care and treatment and attended meetings to discuss decisions about their treatment and dietary plans. Patients told us that their families were involved too. On admission to the wards patients and families were given an admission pack which had information on treatments, patient rights and how to complain.

We saw a wide range of rooms on both wards; all rooms were fit for purpose and fully furnished. There were quiet areas on the wards and rooms where patients could meet visitors.

However

S3 and the Phoenix Centre had difficulty when using bank or agency staff because of the special needs of the patients and the support required at meal times.

When a patient required blood tests on S3 there was no direct link to the computer system at Addenbrooke’s for staff to make a request on-line. There had been incidents when names were entered incorrectly on the computer system at Addenbrooke’s.

At the Phoenix Centre we saw that capacity and consent had not been assessed and recorded on admission in line with the code of practice.
In order to maintain patients’ safety the Phoenix Centre, as a temporary measure, only admitted one patient per week. This was because of the staffing levels and the acuity of patients.

At times, on S3, meal choices were limited, popular food ran out and there was a lack of choice for vegetarians.

The service was rated as requires improvement overall because.

There was evidence that the service was unable to meet the needs of an expanding population with some services experiencing increasing referrals for which they did not have the capacity to meet. Services had been commissioned based on 2010 population figures which were not representative of the population today. The population had increased by 11% and there had been an increase in the transient population who came for seasonal rural employment. As a result the service was struggling to meet the demand for children and young people’s services in a safe manner.
This was particularly evident in speech and language therapy (SALT) where low staffing levels and increased referrals had resulted in an inability for the service to meet demand.
Community nurses were unable to update electronic care plans in a timely manner due to workload.
There was a lack of robust data collection to facilitate national comparators for service improvement.

However:

There had been a change in trust management over the preceding eighteen months which had had a positive effect on the staff working within the directorate who expressed positivity about the future of the service.
There was a positive incident reporting culture with evidence of sharing and learning from incidents being shared with staff. There were established systems for safeguarding within the children and young people’s service which was reflected across the trust.
Multi-disciplinary teams worked well together to deliver holistic care for children and actively involved parents and carers.
Staff were passionate about the service they provided to community children and young people. The service planned and provided safe individualised care using a family friendly inclusive approach.
New young parents were particularly well supported by the family nurse partnership initiative and by health visitors who tailored home visits to meet individual needs when needed.

We rated the forensic inpatient/secure ward as good because

Staffing levels were safe and recruitment was in progress for vacancies. The ward was also awaiting 3 staff nurses to start. Staff were up to date with mandatory training. Staff were trained in and aware of safeguarding requirements.

There was an effective incident reporting system in place and there was learning from serious incidents. All staff knew how to report an incident.

Comprehensive assessments were completed in a timely manner. Care records showed personalised care which was recovery oriented. Physical healthcare needs were considered during admission and patients’ had access to the same. Risk assessments were recorded and updated regularly. The ward used HCR-20 and the trust risk assessment processes. All patients were assessed prior to going on leave.

Medicines were managed safely and there was learning from medication incidents.

Staff were respectful and caring when they spoke with people.

Managers monitored performance and addressed any issues. Staff had received appraisals. All staff said they could raise issues with their manager if required and action would be taken. Clinical and managerial supervision was taking place for qualified staff. Staff knew who the senior managers and executive directors were.

Staff were aware of the trust’s vision and values and could describe them. They had met the chief executive who had worked on the ward. They said they felt supported by the board members and senior management. Staff said they had raised issues with the chief executive and felt they had been heard and action had been taken. Staff said morale was high.

All staff had access to appropriate alarm system and support from other wards when required. All staff inducted into the unit in order to access keys.

The ward was awarded the recovery award for 2015.

However:

The seclusion room was placed away from main area of the ward on the male side of the ward and did not have en-suite facilities. Access to a toilet meant taking the patient out of the seclusion area.
There was no record of supervision for unqualified staff.
There were some blanket restrictive practices on the ward.
The food was rated as poor by patients.

We rated wards for people with learning disabilities and autism as good because:

Interview rooms were fitted with panic buttons. Staff and visitors to inpatient wards were provided with personal safety alarms. All areas were clean and well maintained. Cleaning records were up to date and demonstrated that the ward environments were regularly cleaned.

Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report any abuse. Staff were supervised appraised and had access to regular team meetings. Staff received the necessary specialist training for their role. On both inpatient wards bank staff were regularly deployed to ensure the required higher staffing levels were maintained for the patient group.

Patients and their relatives told us that staff were very positive and respectful. Staff demonstrated that they understood the needs of the patients well. Patients and their relative were involved in their care planning where appropriate. Patients had access to advocacy services.

There were a full range of rooms and equipment to support the assessment, treatment and care of children and adolescents. Patients and carers language needs were met with the assistance of interpreting services. Patients’ individual communication systems were used and understood by staff. Patients knew how to make a complaint and staff processed complaints appropriately.

Staff knew how to use the whistle blowing process to raise any concerns. Staff had opportunities for leadership development. Staff were offered the opportunity to give feedback on services and input into service development through the annual staff surveys. The trust used key performance indicators to gauge the performance of the team and developed action plans where there were issues.

The trust took immediate action to respond to our concerns identified on IASS ward around the single sex accommodation. Improvements were made at the time of our inspection.

We rated the Darwin Centre and The Croft Child & Family Unit Mental Health Wards as good because:

Both wards were clean and there were dedicated cleaners employed. The furnishings were clean and in good repair. The clinic rooms were well equipped with resuscitation equipment, emergency drugs, fridge and tools to monitor physical health.
Staff reported that there were good systems in place to share learning from incidents across the Trust. Staff told us that they knew how to report incidents and were supported after incidents had occurred on the wards.
All care plans were comprehensive, up to date and reviewed weekly at the ward round or after an incident. They included patient views, with a full range of problems and needs. Patients had copies of their care plans. We saw evidence of physical health care checks being carried out on admission and there was evidence on all care plans that this was being reviewed.
Staff confirmed that they had received mandatory training. Clinical supervision was offered and staff attended regularly. Staff appraisals were all completed and in date. Staff reported good morale and were supported by their colleagues. Governances systems were in place and managers had access to trust data and used this to gauge the performance of the team.
Staff were trained in and had a good understanding of the MHA, the Code of Practice and the guiding principles. Consent to treatment and capacity requirements were adhered to and copies of consent to treatment forms were attached to medication charts where applicable. Section 132 rights were being given two weekly and recorded in line with the trust policy.
Patients told us staff treated them with dignity and respect and felt staff were approachable. We observed interactions with staff, patients and families. We found that staff communicated in a calm and professional way. Staff showed an understanding of individual needs of the patient. We found that patients were actively involved and participated in their care planning. Patients gave feedback on the service they received on monthly patient/parent feedback forms.
There was a full range of rooms and equipment to support treatment and care on the ward. There were quiet areas on the wards. The outside space was used. Patients were involved in choosing colours of the walls and art work.
The Trust had used QNIC Guidance and professional judgement to set core staffing levels.

However:

We saw a number of potential ligature areas at the Darwin Centre.
The bedroom and bathrooms on Croft Unit were not gender specific. However, all bedrooms were family rooms so it was not possible for bedrooms to be single sex. The bathrooms were unisex so children can change the gender prior to using the room, but this does not fully meet the expectations in the code of practice.
The seclusion room on the Croft Unit did not meet the required standards for seclusion defined within the Mental Health Act 1983: Code of Practice. The Darwin Centre did not have a seclusion room however the staff were using an intensive nursing area (INA). We were told by staff they did not seclude patients but the description staff gave of how the INA was used constituted seclusion as defined in the Mental Health Act 1983: Code of Practice. The INA environment did not meet the safety specifications for a seclusion room as outlined in the Code of Practice.

We rated Cambridge and Peterborough NHS Foundation Trust specialist community mental health services for children and young people as requires improvement because:

Interview rooms used by therapy staff were not fitted with alarms or viewing panels on the doors.

Insufficient levels of staffing affected the referral to assessment and treatment times in community mental health teams. This was up to 62 weeks for some young people, with further delays for some treatments.
Referrals to the ADHD service had been suspended due to lack of staff.

Risk assessments were not present on all electronic records and risk assessments were not always reviewed when the young person’s situation changed.
We saw no evidence in the notes that consent and capacity was being discussed with young people or recorded.

Managers and staff told us that whilst supervision was offered to all staff no records were available to demonstrate this.

However:

The trust told us that funding has been sourced in order to address the long waiting list and recruit more staff.

Young people waiting for treatment were prioritised according to their risk.
Treatment programmes were bespoke and based on the case formulation of the young people and were in accordance NICE guidelines

We observed staff communicating with young people in a kind and respectful manner. Staff were observed to be sensitive to the needs of the young people and when speaking about them showed good knowledge of their problems and how they could help them.

Managers had access to trust data to gauge the performance of the team and compare against others. Key performance indicators (KPIs) were used to gauge performance. The KPIs that we saw were in an accessible format.

Staff were open and transparent with young people and their families.

We gave an overall rating for mental health crisis services and health-based places of safety as good because:

The trust had set safe staffing levels and these were followed in practice. Cover arrangements for sickness, leave and vacant posts meant people who used the service could be kept safe.

Risk assessments were undertaken at initial assessment and updated regularly. Lone working protocols were in place. Incidents were reported and learning from such incidents was used to improve the service.

Comprehensive holistic assessments and care plans were completed and reviewed in a timely manner.

Multi-disciplinary teams and inter-agency working were effective in supporting people who used the service.

Staff were experienced, received supervision, appraisals and specialist training for their role. Staff were trained in and had a good understanding of the MHA and MCA.

Staff treated people who used the service with respect, listened to them and were compassionate. They showed a good understanding of people’s individual needs.

Target times for assessment were set and met. This meant urgent referrals were seen quickly by skilled professionals. Proactive steps were taken to engage with people who found it difficult or were reluctant to engage with mental health services.

People who used the service knew how to complain. Concerns and complaints were handled appropriately and findings acted upon.

Good governance arrangements were in place, which supported the quality, performance and risk management of the services. Key performance indicators were used to gauge performance.

There was effective team working and staff felt supported by this. Staff knew how to use the whistleblowing process and could submit items to the risk register.

There was a commitment to quality improvement and innovation.

However:

Some medication was not signed in or out when delivered by staff to people living in their own home and some medication was not transported using secure bags or cases.

Some areas in the health-based place of safety could not be observed. Staff were aware of these and had taken mitigating action to ensure people who used the service were observed at all times. Facilities in the health-based place of safety did not promote privacy and dignity.

People using the services provided by the CRHT teams had limited access to psychological therapies and there were no psychologists working within the teams.

Interpreters were available but there could be a delay in accessing them in a crisis.

Staff’s knowledge of the organisation’s values and vision was inconsistent.

We gave an overall rating for community-based mental health services for older people of good because:

The support provided by older persons CMHTs, CRHTs, day therapy service and memory clinic was thoughtful, respectful and considered patients individual needs. The teams worked closely with carers and relatives and with other agencies. Teams were appropriately staffed, and where there were vacancies appropriate arrangements were in place to manage these.

Risk assessments were undertaken on every patient during the initial assessment. This information was reviewed regularly. However, in one instance we found that the risk assessment had not been updated. All incidents were reported and staff had opportunities to discuss and learn from these. However, managers at some sites did not have access to detailed information relating to incident reporting within their team and two staff reported that when reporting incidents they were not always clear how to rate the incident.

Comprehensive assessments were completed in a timely manner, and care records were up to date. However, a small number of care records did not evidence that patients had been given a copy of their care plan. Some care plans were not recovery orientated, did not consider holistic needs or contain the patients’ views. One patient we spoke with told us that they were not aware of the out of hours arrangements for contacting services.

Staff were using NICE and other best practice guidance. Each team was made up of the full range of disciplines, who were regularly supervised and supported to undertake appropriate training. Staff demonstrated a good understanding of the MHA and MCA. Urgent referrals were seen quickly and non-urgent referrals within acceptable timescales.
The trust had effective governance procedures in place. Key performance indicators were used to gauge the performance of individual teams, and staff had the ability to submit items to the directorate and trust risk registers. Staff spoke highly of their managers and their supportive teams. Staff were open and transparent with patients when things went wrong. Some teams were involved in innovative research programmes. Whilst a wide range of information leaflets were available at each site we visited, these were not available in a range of formats or languages.

Overall we rated this core service as ‘good’ because:

We received positive feedback from patients about the care they received and found that staff across the service were committed to providing good quality care to the patients.
We found positive multidisciplinary work and observed that staff were caring, compassionate and supported patients.
Patients received regular one to one time with staff
The bed management system was effective, ensuring that patients receive timely access to services when they required it.
The leadership was visible and proactive on all of the wards.

However:

Staff had assessed ligature points on all wards. However, the low level of staff at night on Poplar ward meant that patients could potentially access ligature points without the notice of staff.
The clinical rooms for Oak 1, Oak 2 and Oak 3 wards were not fit for purpose and did not comply with infection control guidance.
The nursing and medical staffing levels on Springbank ward were poor.
There were a number of concerns relating to Mental Health Act 1983, specifically consent to treatment (Section 58) and practice which amounted to seclusion.

We gave an overall rating for community based mental health teams for adults of working age as good because:

The teams worked to a lone working practice protocol. Staffing levels were safe and recruitment was in progress for vacancies. Staff were trained in and aware of safeguarding requirements and showed they used the referral process. Staff had received and were up to date with mandatory training. Caseloads were managed and re-assessed regularly and were discussed in supervision.
There was an effective incident reporting system in place and there was learning from serious incidents. All staff knew how to report an incident.
Risk assessments were recorded and updated regularly. Comprehensive assessments were completed in a timely manner. Care records showed personalised care which was recovery oriented. Physical healthcare needs were considered during assessment and during treatment. Outcome measures were used to evaluate the effectiveness of care and treatment. The teams were looking at how to implement other outcome measures for all disciplines. Medicines were managed safely and there was learning from medication incidents.

Staff were respectful and caring when they spoke with people. People said they felt involved in their care planning and treatment and this was documented in the care record.

Teams were meeting the five day standard for seeing urgent referrals and the eight weeks for routine referrals. Actual times for adult locality teams were 3-4 days for urgent and 3-4 weeks for routine. The Peterborough locality team provided extra clinics to address a large number of unmet referrals to ensure waiting time targets were met.

Managers monitored performance and addressed any issues. Staff had received appraisals and said a new format had recently been introduced to improve structure. All staff said they could raise issues with their manager if required and action would be taken. Clinical and managerial supervision was taking place. Staff knew who the senior managers and executive directors were. Staff were aware of the trust’s vision and values and could describe them. They had met the chief executive and executive and non-executive directors. They said they felt supported by the board members and senior management. Staff said they had raised issues with the chief executive and felt they had been heard and action had been taken. Staff said morale had improved greatly over the last 12-18 months, since the trust had re-organised services and improved leadership and accountability.

However:

There was no evidence medical equipment, such as weighing scales and blood pressure monitoring machines had been checked and re-calibrated according to the manufacturer’s instructions. Apart from Peterborough locality where equipment had been recently calibrated.
Buildings did not have alarm systems fitted in rooms where staff saw people. The Huntingdon team were in the process of fitting alarms. Wisbech and Peterborough locality teams had personal alarms for use in the building. The buildings for the early intervention teams (CAMEO), Huntingdon and Peterborough locality team also required re-decorating in areas. The buildings for the CAMEO teams and Huntingdon locality team did not provide sufficient space to see people. People had to travel distances for appointments at Wisbech because of geographical area. The south CAMEO team base had no separate reception in a shared building. People were escorted around the outside of the building to access the waiting room. The trust has an estate strategy to look at alternatives.
The locality teams did not have direct access to the system providing results of blood tests, which might cause a delay in clinicians being able to adjust medication or arrange for further tests if required.
Consideration of mental capacity assessment was not always recorded.
The early intervention teams had moved to a two year model of engagement from a three year model. The NICE (National Institute for Health and Care Excellence) recommendation is a three to five year model.
There was no policy for failed visits or for when people did not attend appointments. Although staff were able to describe how they risk assessed and tried to engage with people.
Staff reported a delay in referrals reaching the early intervention teams because of the introduction of the assessment and referral centre (ARC). Staff in the locality teams also told us about the need to improve the ARC process. A review of the role of ARC was underway. Staff reported carers’ assessments were taking four to six weeks unless urgent. Young carers were also assessed, working with CAMHS staff. Carers could access money from social care when eligible.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated Cambridgeshire and Peterborough NHS Foundation Trust as good overall because:

Services were effective, responsive and caring. Where concerns had arisen the board had taken urgent action to address areas of improvement.
Staff treated people who used the service with respect, listened to them and were compassionate. They showed a good understanding of people’s individual needs.
Admission assessment processes and care plans, including for physical healthcare, were good.
The board and senior management had a vision with strategic objectives in place and staff felt engaged in the improvement agenda of the trust. Performance improvement tools and governance structures were in place and had brought about improvement to practices.
Morale was found to be good in most areas and staff felt supported by local and senior management. There was effective team working and staff felt supported by this.
The trust had undertaken positive engagement action with service users and carers.
A good range of information was available for people and the trust was meeting the cultural, spiritual and individual needs of patients.
The inpatient environments were conducive to mental health care and recovery.
The bed management system within adult and older people’s services was effective.
Information systems were in place to ensure effective information sharing across teams.
Services were using evidence based models of treatment and made reference to National Institute for Health and Care Excellence (NICE) guidelines.
The trust had an increasingly good track record on safety in the previous 12 months. Effective incident, safeguarding and whistleblowing procedures were in place. Staff felt confident to report issues of concern. Learning from events was noted across the trust.
The trust had met its targets required under the Department of Health’s ‘Positive and Proactive Care: reducing the need for restrictive interventions’ agenda. There had also been a decreasing level of restraint and seclusion in the previous 12 months.
Medicines management was effective and pharmacy was embedded into ward practice.
Arrangements were in place to ensure effective use of the Mental Health Act and Mental Capacity Act
There was a commitment to quality improvement and innovation.

However:

We had some concerns about restrictive practice in some areas of the trust. However, the trust was engaging in work to reduce these episodes. In addition not all environments where people were secluded were appropriate.
Staffing issues in some community children’s teams and acute services were affecting waiting targets.

There were clear arrangements for ensuring that there was single sex accommodation on the majority of wards. However, improvement was needed to ensure that arrangements for managing mixed sex accommodation at Maple 1 ward were followed to ensure the privacy of patients.

There were ligature points in some inpatient services and observation should be improved in some areas.
Not all patients had easy access to psychological therapies.
Consent to treatment procedures needed improvement.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

These reports, under our old approach to inspection, involved us assessing a whole provider against the standards we expect.

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