Cambridgeshire and Peterborough NHS Foundation Trust

Updated 9 December 2022

• 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.

Updated 5 September 2019

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.

Updated 21 June 2018

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

Updated 21 June 2018

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

Updated 5 September 2019

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.

Updated 5 September 2019

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.

Updated 31 March 2022

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

Updated 5 September 2019

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.

Updated 21 June 2018

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

Updated 13 October 2015

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.

Updated 13 October 2015

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.

Updated 21 June 2018

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

Updated 21 June 2018

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

Updated 22 July 2022

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.

Updated 13 October 2015

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.

Updated 21 June 2018

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

Updated 9 December 2022

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.

Updated 5 September 2019

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.