City and South Cambridgeshire Learning Disability Partnership

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

All services were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to people and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service managed safety incidents well.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to good.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff in services were able to clearly describe the processes in place to report incidents on Datix (Datix is a widely used web-based risk management and incident reporting software) and to share learning. Staff described how they raised and investigated safeguarding and serious incidents.

Staff told us incidents were recorded in case notes and reported via Datix, with clear post-incident learning. Practice was reviewed and adapted to improve outcomes following incidents. Staff described strong multidisciplinary working, particularly after serious incidents, with complex case discussions supporting shared learning.

There were 6 incidents reported between October 2025 and November 2025. We reviewed 3 incidents and examples of learning from them. For all 3 incidents actions were taken and lessons learnt. These included: team alerts shared at meetings; Datix reporting for all incidents (including serious incidents); discussions during supervision; mandatory training for all staff (including locums and temporary staff); and early legal support where needed.

However, it was not clear who had responsibility for reporting incidents to The Care Quality Commission (CQC). Following the on-site visit, this has been acknowledged and a process was being developed by Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) and Cambridgeshire County Council (CCC).

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We observed how referrals were initially brought to the weekly MDT, these were held in all 4 locations. The MDT were made up of different professionals, including health and social care staff. For each referral received, a joint decision was made on the best intervention for the needs of the individual. Staff told us all referrals were discussed, triaged, and urgent cases prioritised at MDT meetings.

Managers and staff told us countywide psychology service and occupational therapy referrals were also reviewed by the MDT for prioritisation, with urgent cases fast-tracked if risks were high. Leaders told us this was undertaken for all disciplines when necessary (for example, if a particular team had a staffing pressure). The MDT delivered specific interventions and discharged individuals once the intervention was completed. Individuals remained open to social care if required and could be rereferred if needed.

Cases were allocated to the most appropriate professional within the MDT. Joint assessments were carried out where appropriate. Staff could also signpost people and their carers to other relevant support if appropriate.

Staff and managers told us waiting lists were low for services and waiting lists were managed based on priority. High-priority cases were addressed first based on risks such as urgent needs or potential placement breakdown.

Leaders told us across all health professionals there were 189 people waiting across the county for health interventions predominantly for Speech and Language Therapy, Occupational Therapy and Psychology. 81 had been waiting over 18 weeks but only 8 of the people open for 18 weeks were not open to another discipline within the Learning Disability Partnership. Referrals were triaged at regular intervals. All health disciplines have an 18-week target.

We observed an MDT meeting. Referrals came from providers, and families. Staff told us most people referred were already known to services, with new referrals assessed to determine whether social care or healthcare intervention was required.

Decisions were based on professional judgement, supported by communication assessments, prioritisation lists, and written correspondence. Joint visits could be arranged depending on referral needs, and all cases including discharges were discussed within the MDT. Referrals received were for services such as speech and language therapy, art and music therapy, psychology, and occupational therapy.

Staff and managers told us waiting lists were low for services, physiotherapy currently had 4 people on the waiting list.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff had safeguarding training, knew how to make a safeguarding alert, and did so when appropriate. Overall, 94% of staff had received adult safeguarding level 3 training and 90% of staff had received children safeguarding level 3 training.

The safeguarding log for the county from between 2025 and March 2026 showed there had been 189 incidents of safeguarding reported. Leaders told us safeguarding enquiries were completed for all individuals known to the LDP, as well as those newly identified with a learning disability, across a range of settings including community services, residential care, and private homes. Data could be analysed at both team and practitioner level, enabling insight into trends such as types and locations of abuse. Staff explained that they were able to raise safeguarding concerns both through multidisciplinary team (MDT) processes and within their own team. Staff told us there were safeguarding leads in the County Council and the Multi-Agency Safeguarding Hub (MASH).

Staff provided examples of occasions where they had identified and raised safeguarding concerns.

Social care colleagues described how safeguarding referrals were triaged through the duty team. Safeguarding was routinely discussed as part of MDT meeting agendas, with concerns referred to the MASH team, recorded in case notes, and escalated to managers as needed.

Staff explained they would raise a notification of concern where a provider was not meeting their responsibilities and escalate to a safeguarding referral when more serious concerns were identified.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 5 risk assessments and risk management plans during the assessment. Plans were developed with involvement from the multidisciplinary team (MDT) to ensure they were easy read and understandable. We saw that plans were regularly updated. Staff told us risks were discussed at MDT, and it was decided if a formulation meeting was required. A formulation meeting is a structured discussion where professionals come together to share ideas of a person’s difficulties.

Staff explained an initial risk assessment was undertaken of every person at initial triage assessment. Staff told us risk assessments were completed based on the intervention that was being offered, for example moving and handling for staff being trained on supporting an individual with equipment.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Data received from the LDP showed the City and South location had completed a recent environmental risk assessment in February 2026 and actions were listed to ensure compliance with dates for completion. There was no receptionist but there were posters showing visitors who to call using an entry phone. There were useful information leaflets in reception for visitors, for example advocacy and occupational therapy.

There were rooms that staff could book for appointments, staff told us they carried out risk assessments and used two-way radios when they conducted interviews in these rooms for their safety. We observed the fire equipment had been serviced and there were comfortable chairs in the reception area.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff had received and were up to date with mandatory training. The training was appropriate for the people using the service. The overall mandatory training compliance was 95%. All staff had completed learning disability and autism training. Staff told us they were able to manage their caseloads.

At the time of assessment, the service had 7.2 full time equivalent (FTE) vacancies across the LDP, including 4 nursing, 2 speech and language therapists, 0.6 physio and 0.6 health admin.

Staff told us it was a county wide service, and they could share resources between the 4 sites to cover for each other. The average for staff turnover from April 2026 was 5%, which was within the LDP target of 10%.

However, there were incidents recorded of the service using agency and bank staff to cover absence and sickness. The staff sickness absence was 7.55%; This was above the LDP target of 4.35%.

One carer told us their relative had struggled to get a speech and language therapist, which was still an ongoing issue. Another carer told us the service was understaffed and had lacked a psychologist for a long time.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

During our visit we observed reception areas, waiting areas and toilets at the locations. We observed all areas that people who used services might access. They were all clean, had good furnishings and were well-maintained. There was antibacterial hand gel available for people and staff to use.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning.

The service did not hold medicines; the learning disability specialist consultant psychiatrist held a review with the person and then wrote to the persons' GP suggesting which medicine should be prescribed. Nurses told us they had a good relationship with the psychiatrists.

There were 5 psychiatrists working with the LDP, and they told us they worked closely within the multi-disciplinary team (MDT). They also told us that having social care in the team was helpful for joint working. The consultants visited people in their homes or in the office. There was a consultant rota for out of hours cover.

A carer told us the psychiatrist had been making fantastic suggestions, and their relative had responded well. Their relative needed a reduction in medication during the summer months, and staff were very aware of their needs at different times of the year.