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

Since the last inspection, improvements had been made to the ward environments to enhance patient safety. Staff completed risk assessments of ward areas and mitigated risks they identified. Wards and clinic rooms were clean, tidy and fit for purpose. Staff knew how to protect people from abuse and neglect. They knew what incidents to report and how to report them. Managers had investigated these incidents and took immediate actions. However, systems in place to learn lessons from incidents were not fully embedded across the wards. The service had high nursing vacancy rates. Managers attempted to fill gaps on shifts with the use of bank and agency staff. Managers requested and booked staff familiar with the service, so staff knew the patients’ risks and needs. Managers had not ensured all staff were kept up to date with mandatory training, supervision or appraisal. Patient records, were not always complete or regularly updated, including risk assessments following incidents. There were gaps in records for the calibration of some equipment, fridge temperatures and ward cleaning rotas.

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 were given the opportunity to raise concerns with staff at daily community meetings. We saw examples of meeting minutes where patients had raised issues. However, the minutes did not record what action had been taken as a result of the feedback given. Most carers we spoke with knew how to raise a concern or complaint, should they need to. However, some carers told us that they felt they hadn't been listened to when they raised a concern or that they did not feel confident action would be taken.

Staff we spoke with knew what incidents to report and how to report them. Whilst staff could give examples of individual incidents on the ward they worked on and immediate action taken as a result, most staff we spoke with were unable to give clear examples of learning from incidents that had happened at other wards or locations. Managers told us and staff confirmed, they were offered debriefs following incidents. Staff were aware of the Freedom to Speak up Guardians and knew how to raise a concern should they need to. However, staff on 3 of the 6 wards were not up to date with mandatory Freedom to speak up training. Staff talked to us about their lived experience of racial discrimination in the workplace. Some staff told us they had received verbal racial abuse from patients. Whilst staff knew how to raise these concerns and knew how to contact the speak up guardians, they did not feel reporting them would result in change.

Whilst there were systems in place for the recording of incidents and immediate actions taken, the service did not have fully effective processes in place for lessons from incidents and complaints to be widely shared and learnt across wards. We viewed staff team and governance meeting minutes and saw that incidents and complaints were not routinely discussed or shared. We saw examples of monthly communications for staff on risks, incidents and complaints learning. However, these were limited in content and did not include themes. It was not clear from staff we spoke with, or from team meeting minutes, that these communications had been cascaded to teams or embedded in practice on the wards. Incident data for the previous three months showed that incidents were recorded against different categories and levels of harm. We saw from the incident log that managers had investigated incidents and taken immediate action.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke with 10 patients of which, most told us they felt safe on the wards. During the assessment, we saw community meetings for patients and staff took place on each ward, which included discussions about safety and well-being. Ward meetings based at Peterborough Cavell Centre had standing agenda items asking patients if they felt safe on the ward or if they wanted to raise any issues or concerns about the environment. We spoke with 6 carers who told us that they felt their person was safe at the hospital and they knew how to raise safeguarding concerns if they needed to. Carers told us that they felt safe when visiting the wards.

During the assessment we spoke with staff members, including ward managers, nurses, healthcare assistants and members of the multidisciplinary team. Staff knew how to make a safeguarding referral and how to escalate concerns. However, not all staff we spoke with knew the safeguarding leads. Staff could describe examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to recognise adults and children at risk of or suffering harm and worked with internal departments and external agencies to protect them.

During the assessment, we observed patients being supported by staff who understood how to protect people from harm. Staff took steps to safeguard patients and reduce the risk of incidents or harm. We saw staff quickly and appropriately de-escalate a potential incident between patients. We saw posters displayed on wards giving information about how to contact the Independent Mental Health Advocate. However, 2 patients we spoke with told us they did not have advocacy in place. We saw information about patients’ rights displayed on the hospital wards and patients confirmed they had been given information about their rights under the Mental Health Act.

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 hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if the Local Authority had been made aware. Staff were not kept up to date with mandatory safeguarding training. Training compliance figures showed that 5 out of 6 wards fell below the service training target for at least one mandatory safeguarding training module.

Patients told us they felt involved in making choices about their treatment and were aware of their care plan. However, not all patients had been given a copy of their plan. Most carers we spoke with told us they felt involved in care and treatment decisions. Carers were invited to multidisciplinary ward round meetings which they could attend in person or virtually.

Staff we spoke with demonstrated a good understanding of the management of risk and reducing restrictive interventions. Staff told us how they minimised risks where they could not easily observe patients and could describe procedures for therapeutic observation of patients. Most staff knew their patients’ individual risks and needs well.

The service had a Use of Force Act Implementation & Restrictive Interventions Oversight Group and a policy on the use of restrictive practice. Its aim was to help staff act in a safe manner with a focus on using the least restrictive option available. As part of the assessment, we reviewed incident data. In the previous three months, a total of 34 incidents of restraint (on 17 individual patients) were reported to the Trust reporting system. Of these, 9 resulted in the use of rapid tranquilisation and 9 in an episode of seclusion. There were no incidences of long-term segregation reported. Staff described processes for handover between shifts, we found that practice differed between locations. For example, staff on Mulberry ward 1 did not always keep an updated copy of handover notes that included current plans and risks. This meant that bank staff and new staff did not always have the most up to date essential information about the patient. We observed a handover on Mulberry ward 1. We requested to review copies of the last month of handover notes however, staff told us that night staff overwrite the current handover sheet, and the ward did not keep previous copies. Staff on the treatment unit at Cavell Centre kept comprehensive up to date handover sheets that contained essential information. For example, observation levels, food and fluid needs, medication, physical health and current risks. Staff told us that printed copies of handover sheets were only available to permanent nursing staff, healthcare support workers could only access electronic copies on the shared drive. Bank staff we spoke to said they could access handover copies from a nurse if they needed to. Staff completed risk assessments for each patient on admission, using a recognised tool. As part of the assessment we reviewed 11 patient records, we found that risk assessments were not always updated in care records to reflect elevated risk or details from incidents.

We spoke with 10 patients, all except one told us the wards were clean and tidy. Most patients told us that they felt safe on the ward. Carers told us the ward environments were clean, tidy and felt safe when they visited.

Staff we spoke with knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff assessed environmental risks to patients and took action to reduce risks where possible.

We observed all wards to be clean, safe and well furnished. In response to a previous CQC inspection of acute wards in 2022 the Trust had initiated a sexual safety project that included actions to improve the environment. We saw that each ward had a line-of-sight environmental improvement plan. During the site visit we saw that improvements to the wards including the installation of CCTV and increased use of mirrors to reduce blind spots had recently been completed. Whilst this work was underway, line of sight risks were mitigated with patient observations. The Trust had also installed locked doors to the gender segregated bedroom corridors however, on the day of the site visit these were not fully operational due to the wrist fobs not being available. Staff completed zonal observations to prevent patients accessing the opposite gender corridors. We checked the clinic rooms on 4 wards and found they were fully equipped, with accessible resuscitation equipment and emergency drugs and all necessary equipment to carry out physical health checks and ongoing health monitoring. However, we found 2 clinic rooms did not have calibration records for equipment including electrocardiogram machines, thermometers and oximeters. The equipment was out of date for calibration by 4 months. Records viewed on Mulberry 2 ward had shown the fridge temperature used for storing temperature controlled medicines had been out of range on 3 occasions in the last 3 months. We found that 3 wards did not have cleaning records completed, however all rooms were visibly clean and tidy.

The service held environmental and ligature risk assessments for wards areas and removed or reduced any risks they identified. Staff completed and regularly updated thorough risk assessments of all wards areas, we saw examples of these. The provider had a process in place in line with its therapeutic observations and engagement policy to carry out patient observation. During the assessment we reviewed patient observation records. We found observations were recorded in the patients care records. However, we found in 1 patient record on Oak ward Recovery unit that their observation levels had been reduced from continuous to intermittent observations with no reason recorded. Another patient had their observation levels increased without clear rationale. We found there were 4 missed observation recordings on 1 patient’s care records on Mulberry ward 1. Staff told us that electronic observations were not always recorded in a timely manner due to poor internet connection in some areas of the hospitals. The service had implemented a programme of sexual safety training however, Training compliance figures showed 4 out of 6 wards fell below the service training target.

We spoke with 10 patients who told us that there were enough staff to always be visible and approachable in communal areas. Patients and carers told us that staff were generally kind, caring and supportive.

Managers reported that staffing had been challenging however, this was improving across the service. Staff told us that the use of bank and agency staff was reducing and that most temporary staff worked regular shifts. Staff we spoke with knew their patients and their needs well. Managers were able to adjust staffing levels to meet the needs of the patients on the ward. Managers told us they tried to ensure regular bank and agency staff were booked when required. Patients had access to a multidisciplinary team including for example, medical staff, nursing staff, support workers, activity co-ordinators, occupational therapists and psychology.

As part of the assessment, we observed all 6 wards. Our observations showed that on both days we visited the services there were enough staff to complete therapeutic observations and to actively engage with patients.

The service had high vacancy rates. At the time of inspection, the vacancy rate for qualified nurses was 41% and for Healthcare Assistants 19%. The service had a sickness rate of 5.90% and turnover rate of 2.93%. Managers used bank and agency staff to fill shifts to cover sickness, absence or vacancies. Managers tried to book regular bank and agency staff, when required. As part of the assessment, we reviewed ward staff rotas and found over a 6-week period that not all shifts were filled. The service was proactive in recruitment including the use of overseas recruitment, internal staff development and preceptorships. There was an ongoing recruitment campaign in place. 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 39 modules, 22 (56%) had compliance rates that fell below the service target. Examples of essential mandatory training that was overdue included basic life support, ligature management, physical interventions and medical emergency response. Managers did not ensure that staff received regular supervision. We viewed supervision rates for all wards and saw these were low. Staff did not always receive an annual appraisal of their work. We reviewed appraisal rates which were at 70% or lower for 3 of the 6 wards.

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.