Cambridgeshire and Peterborough 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

We rated Safe as requires improvement. We assessed 6 quality statements. Learning from incidents was not fully embedded. Some staff held high caseloads. The service had high sickness rates and some teams had high nursing vacancy rates. Managers had not ensured all staff were kept up to date with mandatory training, supervision or appraisal. We had concerns about the safety of the environment at offices where staff met with patients. These included, fire safety, buildings maintenance, and out of date equipment. However, staff knew how to protect people from abuse and neglect. Staff completed individual risk assessments. Staff knew what safety incidents to report and how to report them. Most patients were seen within waiting time targets and staff had processes in place for monitoring patients on waiting lists.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients we spoke with told us they had never had to raise a concern. All but one person said they would feel comfortable to raise a concern if they needed to do so.

Most staff were able to explain how safety incidents were reported and shared within their own teams, staff gave an example of a safety incident and how this was managed. Staff told us that patients were informed and de-briefed after any incidents, staff said the person closest to the patient would discuss the incident with the patient if appropriate and offer a de-brief, staff told us that sometimes it may be more appropriate for a manager to speak to the patient and family, but it depended on what the patient preferred. Clinical staff and managers knew the process for investigating incidents and sharing learning. Some staff were able to describe how they escalated incidents and how these were shared in governance meetings and major learning by emails. However, whilst some staff could share local learning examples from incidents and risks, not all staff could share any learning or changes at an organisational level and said it was usually slow to be shared. Staff told us they felt confident raising concerns and concerns being managed at a local level. However, they did not have this confidence in more senior management, and said at overall Trust leadership level, there was no transparency, and they had no faith that processes would be followed. Staff have used an internal incident review process called “Stop the Line” to raise concerns but they told us this takes a long time to action and felt that community teams’ concerns were neglected. Not all staff were aware of the learning from a serious incident the Care Quality Commission were aware of and the Trust had told us about.

There were systems in place for the recording of incidents, and sharing lessons learnt. However, these were not fully embedded in practice as not all staff we spoke with were able to give examples of learning from incidents from the wider organisation or knew about any early learning from a serious incident that took place within the service. Incident data for the previous 3 months showed that incidents were recorded against different category types and injuries. We saw examples of monthly communications for staff on learning from risks, incidents and complaints. These included themes, recommendations and good practice examples including those identified from rapid review incidents. We saw that serious incidents and complaints were standing agenda items on the monthly governance meeting agenda and that these included lessons learnt and recommendations following incidents and complaints. However, we viewed staff team meeting minutes and saw discussion of incidents and complaints varied between teams. For example, we saw that the Huntingdon Adult Locality Team included incidents and complaints as a standing item within their staff team meeting agendas. The service had mandatory training courses for staff on the Patient Safety Incident Response Framework (levels 1 and 2). All teams had received training on level 1, except for Huntingdon Adult Locality Team with a training compliance rate of 67%, this was below the service target. The compliance rate for level 2 training, for 3 teams fell below the service training target.

Patients and carers we spoke with told us that information sharing between professionals took place.

Staff gave mixed feedback on their caseloads and whether they were manageable. Staff told us that when patients were waiting to be seen, staff communicated with them and offered them support whilst they waited. Staff could escalate to the home treatment team and crisis team for patients needing an urgent service. However, some staff told us that it was sometimes difficult to refer patients on to crisis teams. Staff told us that discharge planning occurred at the point of admission. Staff told us that when patients were being discharged to another community service or hospital, they share information in a timely manner. Staff had to rely on verbal handovers as they did not have access to their systems. If a patient required another service urgently and there was a wait, staff said they would escalate this to their manager for support. Managers said that recovery coaches were available to patients on discharge offering 6 to 12 weeks support at this point of transition from the locality teams. Staff told us the electronic patient record system they used did not link well with information when a service user was a patient in acute inpatient services. However, information from primary care and acute (emergency) care was available on the system. A staff member in Huntingdon team told us that many GPs won’t take patients requiring a depot injection therefore they have to stay open to a mental health team. This meant there could be a delay in discharge for this patient group. When patients went into prison the locality teams were not informed when they were discharged and described communication with prison services as sometimes difficult to have good two-way information flow. Whilst the Peterborough team had joint meetings with acute inpatient and crisis colleagues managers in Cambridge told us that there was no joint working with other teams. This had previously happened and we were told staff felt that this was a loss.

We did not collect the evidence to score this evidence category.

The service had a range of operational policies and procedures to support safe systems, transitions and pathways. Most people could access the service when they needed it and received the right care in a timely way. However, not all people were seen within target times. Staff monitored waiting times at waiting list review meetings and referrals meetings and knew their caseloads. We observed a weekly waiting list review meeting and saw staff coming together as a team to discuss individual patients and allocated a risk rating according to need. We viewed waiting times data supplied by the Trust. Whilst most patients were seen within target times some people were waiting longer to be seen. Data for CAMEO teams showed most patients waiting time to assessment was within 4 weeks. For CAMEO north, 91% of people were seen within 4 weeks and CAMEO south, 83%. This varied for locality teams with between 24% to 60% of patients waiting time to assessment within 4 weeks. Whilst most patients had a first contact across the community mental health teams, within this timeframe for the Peterborough Adult Locality Teams, less than half the patients had received a first contact and these teams had the maximum number of days waiting. Individual caseloads varied across teams and individual clinicians. Data showed the number of patients on clinical team caseloads within CAMEO team services ranged from 1 to 18. For Community mental health locality teams, the Peterborough Adult Locality teams had the highest caseload for a clinician at 32. We saw Doctors caseloads were high. These ranged from 37 in Huntingdon Adult Locality Team to 229 in Peterborough locality team. We saw from risk registers that some teams had identified long waiting times. For Cambridge this was waits for psychology and in Peterborough team, waits for allocation to a care co-ordinator. The risk register for CAMEO teams showed difficulty in transferring patients to locality teams due to their staffing levels.

Patients and carers we spoke with did not report any safeguarding concerns. Patients told us staff helped them to feel safe.

Staff had a good understanding of safeguarding, if they had raised a safeguarding concern, they could explain the process for doing this. Staff told us they had social work leads in the teams and had good and close working relationships with the local safeguarding teams. Staff were aware of safeguarding procedures for both adults and children and were able to share examples in this area. Staff had a good understanding of the Mental Capacity Act and knew how to apply this in their work. Managers told us and staff confirmed they check patients understanding and adapt to their individual needs to keep people safe.

During our assessment we observed patient focused meetings where staff discussed safeguarding matters. Staff discussed whether service users had children and whether there were any safeguarding issues. For example, 1 service user who had been detained had a dependent child and staff followed up with local safeguarding team. At another meeting, we heard that a safeguarding had been actioned recently due to concerns regarding modern slavery.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. We saw evidence that there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service had a comprehensive local safeguarding procedure and a range of policies to protect adults and children. As part of the assessment, we reviewed the service safeguarding log which included the total number of safeguarding requests made to the Trust central safeguarding team. All staff were up to date with mandatory training for safeguarding adults and children up to level 2. Except for Peterborough South Adult Locality Team, with a training compliance rate of 66.7% which fell below the Trust training target. Staff were not kept up to date with mandatory training for safeguarding adults and children level 3. Training compliance figures showed that 4 out of the 6 teams we visited fell below the Trust training target of 85% for level 3 safeguarding adults and 5 out of 6 teams were below target for safeguarding children level 3. Staff were kept up to date with training on the Mental Capacity Act. All teams were compliant with both level 1 and level 2 training.

Patients we spoke with told us that staff worked with them to help understand risky behaviour and make plans to cope with these. Staff spoke with patients about their risks and how to keep safe.

Staff we spoke with could describe how they worked to manage individual patient risk. Staff told us they had a centralised risk assessment tool on their electronic patient records system, and said this would be completed when patients come into the service and was reviewed at least 6 monthly, or sooner if there were any changes to risk. Staff said they involved people to manage risk by having direct conversations and being transparent with what the concerns were, staff said it was important that they were sensitive but also open and transparent with patients and carers. Staff told us they worked collaboratively with patients and wrote care plans and risk assessments together, building a plan around the persons voice and what the persons goals were. One member of staff gave an example of a person that had traumatic experiences of inpatient services. Staff unpicked this with them and found out from them what they would like staff to do. After doing this piece of work, the person had a relapse but felt confident to call the team and talk to them, which avoided the person having a crisis. The person gained confidence in managing situations and in the team.

There were policies and arrangements in place for identifying patients at higher risk or in urgent need. The service had structures in place for staff to meet to discuss complex patient risks including for example, formulation meetings, multi-disciplinary team meetings, daily handover meetings and “zoning” meetings (for team awareness of high-risk service users), brainstorming time, peer support and supervision. We observed some of these meetings during our assessment and found that individual patient risks were routinely discussed. As part of the assessment, we reviewed 17 patient records. Staff completed risk assessments for each person when coming into the service using a standardised tool and updated these regularly.

Patients reported a clean and confidential environment. However, one patient told us it sometimes there was sometimes difficulty in booking a room for an appointment.

During the on-site assessment staff raised a number of concerns regarding the environment. These included difficulty in booking patient interview rooms due to a lack of space; staff safety issues including access to panic alarms in some locations and lone working arrangements, continuous maintenance issues and out of date equipment. The Chesterton office at Cambridge was shared with other patient groups. Staff told us about an incident which had occurred as a result of this. Staff based at the Chesterton office did not have access to a panic button or portable personal alarm when seeing patients alone in interview rooms. Staff demonstrated an alarm system which was switched off and told us this was because it was faulty and that they did not know how it should operate. There was some confusion amongst staff as to whether the building was a team base only and that Union House should host all patient appointments, which had a portable personal alarm in each interview room. Staff based both at Cambridge and Peterborough told us there was not enough meeting space, and they had constant issues trying to book rooms. Whilst staff demonstrated a good understanding of personal safety and risks, systems in place were inconsistent both across and within teams. At Cambridge most staff said there were systems in place to keep them safe which were discussed and reviewed regularly in meetings. Staff said that if they are in someone’s home and do not feel safe, they can ring the office and there is a phrase they can use to alert them. However, staff based at Peterborough reported they did not always feel safe walking from the car park to the office. No alternative arrangements were in place for staff who had protected characteristics. Staff told us there are daily hand over meetings to establish who is working from home and the office. Duty relies on what is written in staff outlook calendars. Staff based in Peterborough told us there were continuous maintenance issues.

At the onsite inspection we observed equipment that were out of date. Within the Peterborough Adult Locality Team premises, we found out of date dressings and flu jabs. We had some concerns regarding fire safety during our inspection. The floor plan at Cambridge teams' site did not show fire exits . We raised this with the Trust and were assured on 2 August 2024 that the Trust’s Fire Safety Officer had completed a visit to the site and found that the fire extinguishers had all been serviced and it appeared that the wrong label may have been read at the time of the visit. This still meant they had not been serviced in a timely manner. At the Huntingdon Adult Locality Team site we saw some basic equipment supply for staff were delayed and we saw some building repairs were needed. The Trust informed us on 2 August 2024 that the building repairs had since been completed. We found some staff areas and storage cupboards were freely accessible and we were concerned of the potential for an unauthorised person to access this. A fire blanket in the staff kitchen did not have an in date annual service sticker. However, fire extinguishers had recently been serviced. Whilst at Peterborough Adult Locality Teams we were told that a recent discovery of reinforced autoclaved aerated concrete (RAAC) resulting in a loss of office space. This meant there was a lack of interview space for patients and staff areas. Whilst visiting the South CAMEO team, we found some expired items in first aid kits, including face masks used by staff. We observed rooms available for patient appointments were used as physical health care rooms, and therefore not suitable therapeutic environments.

The design, maintenance and use of the facilities and premises were not always suitable to meet the needs of patients. The Trust provided a Fire Risk Assessment for the Chesterton building. However, this was completed on 24 June 2024, after the inspection when we raised concerns that staff could not locate a fire risk assessment on site. We saw on the risk register for Cambridge Locality Team that a red emergency bag did not contain an oxygen tank, this risk was raised in November 2023. We saw from evidence provided by the Trust that potential ligature risks were identified within all team risk registers. However, we did not receive a ligature risk assessment when requested, whilst on-site. We viewed 1 ligature risk assessment on-site for the Peterborough Adult Locality team and saw this had not been updated recently and had a creation date of 21 April 2021. We raised this with the Trust and were told that led by the Trust’s Deputy Chief Nurse and the Ligature Risk Reduction Group, the requirements for community sites would be considered. This was in line with Trust policy that did not require the completion of ligature risk assessments in community settings. We also saw from risk registers that risk assessments, for example, security of property, fire, building maintenance and first aid equipment, had been identified as potential risks across all teams. The register stated these risks were mitigated by ongoing review of environments through quality assurance visits.

Most people using the service told us that they saw the same care co-ordinator at appointments, and that their care co-ordinator had a good understanding of their needs and explained their treatment clearly. However, they had noticed a reduction in the frequency and length of appointments with staff due to perceived low staffing levels. Some patients described staff as being “overstretched”.

Not all staff said they felt the service was safe and that they individually held a lot of risk. Staff said there were not always enough qualified, skilled, and experienced staff on shift, staff in Cambridge also told us it was difficult to recruit and retain staff, retention was difficult as staff said they were under so much pressure, staff said there was a lot of sickness and they felt they were always one away from patient care being compromised. Some staff told us that waiting lists were long and felt that people weren’t getting the help they needed. Staff told us that due to these things they had felt overwhelmed and stressed at work, staff said they had witnessed people upset and crying because of the pressure and feeling unsupported by senior leaders at overall Trust level. Staff told us that team managers worked hard to support staff and patients and tried to do as much as possible for the well-being of the team and to prioritise the resources they had. Staff told us they felt less supported by Trust level senior leaders and there was a lack of communication with Acute inpatient wards and Crisis teams, so referrals would continue to come in, assessments would be completed and then people would sit on waiting lists. Peterborough based staff told us there were enough qualified, skilled and experienced staff on shift, but not always in the building due to space, staff told us this can be a concern when there are high risk people on site, but staff said managers supported them. Staff said annual leave is planned for, and they never felt like they struggled with staffing. Staff within Huntingdon told us their caseloads were manageable. Staff reported having induction, regular supervision and support from their managers. However, staff reported that training beyond compulsory/mandatory training were impossible to access due to budgetary pressures. Most staff we spoke with told us they received regular supervision and appraisal.

During the inspection we observed 4 patient appointments. Prior to the appointments the team had contacted the patients to gain consent for CQC to be present, this consent was then sought again at the start of the appointment. We observed that the appointments took place at the correct time and the required staff were present. We saw that staff knew their patients well and engagement was good.

Vacancy rates for qualified nurses across the service teams ranged from 11% to 65% . At the time of inspection, the highest vacancy rate for qualified nurses was within the Cambridge Adult Locality Team. Managers told us Cambridge was a challenging area to recruit to, due to the high cost of housing in the area. The service had high sickness rates. All teams, apart from CAMEO teams, had a sickness rate higher than the Trust target. The service had low staff turnover rates. Due to staffing gaps, managers used bank and agency staff to fill shifts. Managers mostly used bank staff and kept the use of agency staff to a minimum with only 1 out of 262 shifts in a 6 week period we looked at filled by an agency staff member. The service had a comprehensive mandatory training programme in place with modules to meet the needs of staff and patients. However, training compliance figures showed that not all staff were kept up to date with mandatory training. Out of a total of 34 modules, 16 (47%) had compliance rates that fell below the service target for at least one service team. We were still not assured that all staff received regular supervision. We viewed supervision rates for all teams and saw these were lower than the service compliance rate for 3 teams. However, staff we spoke with told us they did receive regular supervision. Staff did not always receive an annual appraisal of their work. We reviewed appraisal rates which were lower than 70% for 2 of the teams.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.