Cambridgeshire and Peterborough NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We rated Effective as good. We assessed 3 quality statements. Staff comprehensively assessed people and completed and updated risk assessments. Staff used a range of recognised tools and worked together and with others, when assessing people’s needs. Staff supported patients with their physical health. However, not all patient records included a care plan.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Three people we spoke with did not have a care plan in place but 5 people did and were involved in setting their treatment plan and goals (1 person wasn’t sure if they had one or not). Of those people who had a care plan, they had been given the opportunity to contribute their views and input. Some patients told us about how staff spoke with them about their goals. People we spoke with told us they had good support with their physical health, including monitoring of potential side effects from medicines.

Staff told us when assessing a persons’ needs, they did this holistically, looking at social care needs, physical health needs, sensory needs, and identified with the person what their challenges were. Staff said they used a tool to assess a person’s degree of depression, and stress, staff said the Trust were moving towards using dialogue plus. Staff told us that patients had access to a physical health clinic to have their physical health needs assessed, patients could also access the clozapine clinic, patients were encouraged to attend regular physical health checks, and staff would support them to do this where required. Staff told us that where a patient was housebound, the team would visit them to completed physical health checks. Staff told us they encourage patients to have the support of their families and encourage family involvement where patients have consented to this, staff will introduce themselves to family/carers, explain how the service works and what they can expect from staff and answer any questions they may have. Staff at CAMEO South told us that patients are allocated to staff according to their locality or patch. Doctors, nurses and consultants could be involved in assessments and that joint assessments take place frequently. Staff hold planning meetings to organise the best approach.  Staff told us they use a range of different tools – for example, SCID (structural clinical interview guide), neurodiversity screening tools for Attention Deficit Hyperactivity Disorder (ADHD), autism. A staff member at CAMEO gave an example of how National Institute for Health and Care Excellence (NICE) Guidelines are followed and tools that are used to assess patients “at risk”. An example was also given of use of a social functioning scale that included housing needs, community integration and recreational activities.

Systems and processes for the recording of patients assessed needs were not fully effective. We looked at 17 patient records across the teams. Some staff told us their electronic patent record system was difficult to use for finding, recording and monitoring patient notes. We found the quality and completeness of patient records varied across teams. Not all records included a care plan. However, risk assessments had been documented and were up to date. Within the Cambridge Adult Locality Team we looked at 4 patient records, risk assessments had been documented but only 1 record had a care plan. Within the Peterborough Adult Locality Team we looked at 5 patient records of these 1 had a care plan, 1 had a care plan imbedded into the progress notes and 3 records had no care plan. Within the Huntingdon Adult Locality Team we reviewed 3 care records and found them clear and comprehensive with most care plans and risk assessments up to date. For the CAMEO South team, we looked at 5 patient records. We found nearly all records had at least one gap. Physical health monitoring was recorded well in all, in 2 we could not locate a crisis plan, in 1 we could not locate a comprehensive assessment, and another we could not locate a care plan.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

Some patients told us how staff worked together across teams and services so they do not have to repeat conversations.

Staff told us how well the teams worked and supported each, sometimes despite their heavy workloads. Staff spoke highly of their local service managers. Staff said that occupational therapists are now able to deliver more interventions due to a change from working as care co-ordinators and this had demonstrated positive results in helping service users move on. Staff told us they encouraged the sharing of information between services. Staff said that as a team they meet every day and were always given opportunities to discuss any daily business or anyone they were concerned about. Staff said that complex patient risks were taken to formulation meetings and regular Multi-disciplinary team meetings that included a range of staff and professionals coming together. Staff at CAMEO South described a good relationship with the forensics services and said they could easily contact them for advice and support.  Staff told us physical health checks took place regularly for patients on clozapine. In some General Practice (GP) areas in Peterborough, GP’s worked together with the locality teams and carried out home visits and yearly physical health checks. In Cambridge staff told us a private company carry out the annual health checks for their patients.  Peterborough locality team staff said they have face to face meetings once a month with the social work team. Some staff described good communications with the acute inpatient teams. However, some staff told us community mental health team managers no longer met formally with acute care managers. They used to have joint service line reporting meetings. Therefore, there was less information sharing about the patient journey through to acute inpatient admission.

We observed several meetings during our assessment including a referrals meeting; management meeting; multidisciplinary team meeting, a CTO meeting, a “zoning” meeting (for team awareness of high-risk service users) and a staff team meeting. We found that individual patient risks were routinely discussed. We attended the Cambridgeshire South Multidisciplinary Team morning. The team worked collaboratively, discussions were patients centred and the team problem solved together across all roles. At the Cambridge locality “zoning” meeting, we found evidence of good liaison and working relationships with crisis team, housing providers, and social services. Out of area patients and those in the local acute Trust for physical health conditions were discussed. At the referrals meeting we saw discussion of a patient who was being referred on from the CAMEO service to the Huntingdon Adult Locality Team service. The patient’s history was given and an explanation of support that would be required. A range of suitable professionals attended. It was clear that the CAMEO South service knew the patient very well, including the mother too. Relevant questions were asked by the Doctor and they gave everyone an opportunity to ask further questions. Support was also considered for the main carer.

We saw there were meeting structures in place which enabled members of multi-disciplinary teams to work together including staff from within the Trust and external partners. We viewed staff team meetings and saw discussions took place about how staff inter-faced with wider teams.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not receive any feedback on this quality statement.

Staff told us people’s outcomes were monitored through supervision, caseload reviews, audit processes, clinical meetings and discharge discussion meetings. Staff told us that when outcomes were not being met for the patient, they looked at other things that could be offered, looked at any barriers, they had discussion as a team, and ensured it was monitored. Staff said the service worked hard to help people progress through the service. Staff told us outcomes were a work in progress within the electronic patient recording system, staff felt they could monitor outcomes closer when they used an alternative system. A Consultant Psychologist shared examples of evidence-based audits, as well as ongoing work to integrate outcome measures into the electronic patient recording system.

The service collected data on waiting times, referrals, discharges and follow ups. We saw from staff meeting minutes that these were regularly discussed. There was a programme of audits, including for example, caseloads, waiting lists and supervision. Work was being undertaken to integrate outcome measures into the electronic patient recording system.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.