Cambridge Park - Community Inpatient Unit (CIU)

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service remains in breach of the legal regulation in relation to the way people’s medicines were managed. It is also in breach of the legal regulation in relation to safe staffing of the service.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Systems to identify and learn from safety issues were in place, but they were not always used effectively to support continuous improvement. Audits and action plans were completed; however, they did not always clearly demonstrate that identified actions had been fully addressed and embedded into practice. As a result, learning was not always translated into sustained improvements in care delivery. For example, several medicines-related concerns identified during this assessment were the same as those found at the previous assessment, indicating that improvements had not been consistently achieved or maintained.

The provider 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. Systems and pathways were in place to support people’s care and safety, with people experiencing effective and coordinated care. Discharge planning and communication with other healthcare services worked well. The service had identified additional opportunities to further improve coordination during transitions between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. The service used safeguarding principles effectively to help keep people safe from abuse and avoidable harm. Staff understood their safeguarding responsibilities, knew how to recognise and report concerns, and were confident that appropriate action would be taken when needed. This helped to promote people's safety, wellbeing and rights.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service balanced risks with people's independence by supporting them to make choices and engage in their rehabilitation. Staff worked with people to understand what they could do for themselves and what support they needed. A health professional employed at the service told us, “People come here when they are vulnerable and unwell, our role is to ensure they are involved and understand their admission.” Risks were managed in a way that helped people regain skills, build confidence and remain as independent as possible while staying safe. A person using the service said, “I am really scared to go home but the staff, all of them, pop in and chat this through with me”.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. The environment was maintained through an ongoing programme of repairs and improvements. Fire wardens on each shift supported fire safety arrangements. However, staff did not consistently recall taking part in regular fire drills. Fire drill records from December 2025 and April 2026 identified gaps in staff confidence regarding their emergency responsibilities. The records did not evidence follow-up action to address these issues or embed learning. We were not assured that fire safety arrangements were effective. We discussed this with the registered manager, who took action to improve oversight of fire safety preparedness to ensure staff understood their role in the event of an emergency.

The provider did not always ensure there were enough qualified, skilled and experienced staff to consistently meet people's needs safely. Staff were recruited safely and the required pre-employment checks were completed before they began work. The provider told us they operated a baseline staffing model, including a direct care staff ratio of 1:6 alongside nursing, therapy and advanced clinical practitioner support. They also used a dependency tool to assess people's needs and inform admission decisions, including pausing admissions where dependency levels were considered too high. Although people's needs were assessed individually, we saw limited evidence that this information was routinely used to review staffing levels across the service. Staff reported occasions when staffing pressures affected their ability to complete all aspects of care, particularly for people with more complex needs. Internal audits also identified that people were not always repositioned as required, increasing the risk of pressure damage. There was no registered nurse routinely available overnight; however, an on-call Urgent Care Team provided support and, where appropriate, follow-up intervention for people with acute or complex needs outside normal nursing hours. While there is no requirement for a registered nurse to be present overnight, providers must ensure there are enough suitably skilled staff to meet people's needs safely. The provider monitored calls made to 999 and used this information in discussions with partner organisations regarding patient pathways and discharge arrangements. However, the provider was unable to demonstrate how people's assessed needs, dependency levels, incidents, service demand and requests for additional medical support were consistently analysed and used to inform formal reviews of staffing levels, skill mix and workforce deployment. As a result, we were not fully assured that staffing arrangements were routinely reviewed in response to people's changing needs and trends in clinical incidents.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The service had infection prevention and control (IPC) processes in place, with PPE (Personal Protective Equipment) available throughout the service. However, IPC practices were not always applied consistently. We found dirty laundry bags which were not sealed, and damaged chairs which could not be cleaned effectively. We also found toiletries in communal bathrooms, despite guidance for staff outlining these should not be shared to reduce the risk of cross-infection. The registered manager addressed these concerns during the assessment. They told inspectors that IPC audits, which had previously been completed annually, were being increased to every three months to strengthen oversight and support ongoing improvement.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The service had systems in place to safely store, administer and record the use of medicines. However, these were not always followed. Medicines Administration Records (MARs) did not include a photograph of the service user which increases the risk of medicines being given to the wrong person. People’s preferences of how they wanted their medicines to be administered were not recorded. The quantities and stocks of some medicines were incorrect. Therefore, we could not be assured that the correct doses of medicines had been administered as signed for by staff. This included one service user prescribed an anticoagulant, a medicine which prevents blood from clotting as quickly as normal. Anticoagulants should be taken at the same time each day. If a dose is missed this puts the service user at risk of blood clots, which can lead to serious health issues. Instructions for medicines which should be given at specific times were not available. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was not available to staff. In line with best practice when there was an option to give a variable dose, e.g. 1 or 2 tablets, the actual dose given was recorded. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. However, the service did not have individual risk assessments in place for people who were prescribed paraffin-based skin products, these products present a risk due to their flammable nature. Some people were prescribed a medicine administered via a patch which needs rotating to different areas of the body, as recommended by the manufacturer. There was a process in place to indicate the site of application to prevent the patch being placed on the same site too frequently.There were appropriate arrangements in place for the management of controlled drugs and staff completed regular balance checks. Fridge temperature records, to ensure the safe storage of medicines, were completed in accordance with national guidance. Medicines were stored in clinical rooms and service users’ bedrooms. However, temperatures were not being monitored in people’s bedrooms to ensure they were being stored within the manufacturers recommended range.