Cambridge Park - Community Inpatient Unit (CIU)

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service remained in breach of the legal regulation in relation to governance and oversight of the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider promoted a clear shared vision and positive culture. Staff spoke about a strong team approach and a focus on supporting people to regain their independence. However, they told us that staffing pressures, inconsistent communication and limited time to read care plans sometimes affected how consistently this approach was put into practice.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager was visible and approachable, and staff told us they were supportive, helped on the floor when needed and were easy to talk to.

The service used a live dashboard to monitor performance, risks, incidents, audits, feedback and action plans, supporting both local and organisational oversight. However, key information was not always readily available to the registered manager, including information relating to maintenance and external safety checks. As a result, we were not fully assured that governance information was being used effectively to provide comprehensive oversight of the service, support timely decision-making and drive improvements. The registered manager was receptive to feedback and intended to explore ways to strengthen their oversight and access to key information.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider created a culture where staff could be confident their concerns would be heard and acted on consistently. Staff said they would raise concerns with the manager and felt action would be taken, and one staff member said, “If I raised a concern to the manager they would take action.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider promoted workforce equality, diversity and inclusion. Records showed the service completed relevant employment checks, health declarations and assessed whether reasonable adjustments were needed as part of recruitment processes, Staff files included evidence of one-to-one meetings, supervision records and appraisals. Staff said any health issues were supported, and said they felt treated well at work.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had established governance arrangements in place. The service carried out audits, maintained action plans and the registered manager completed daily walk-rounds to monitor quality, safety and performance. However, governance systems were not always effective in providing leaders with sufficient oversight of risks, quality and performance. While systems were in place to monitor the quality and safety of the service, they had not consistently identified, addressed or sustained improvements in relation to medicines management, fire safety, maintaining accurate and detailed records, and some issues identified at previous assessments remained. In addition, audit processes did not consistently demonstrate whether actions had been completed, extended or formally closed, reducing their effectiveness in monitoring improvement and ensuring accountability. Although governance structures and quality assurance arrangements were established across the organisation, including external review through the ISO 9001:2015 framework, we were not fully assured that these systems were consistently effective in identifying concerns and driving timely improvements within the service. The registered manager recognised this and planned to strengthen audit oversight to better evidence progress and completion of actions.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider demonstrated partnership working. Staff described positive multidisciplinary working with nurses, therapists and social care teams. One staff member explained, “Communication works well. We have a therapist in handover, we have multidisciplinary team meetings, and we talk to the social care team.” However, we saw little evidence of the involvement of the local community within the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The provider had systems in place to support learning, innovation and continuous improvement, and there was evidence that learning was shared and acted upon. For example, infection prevention and control (IPC) audits had increased from annually to quarterly, damaged equipment was being replaced through a planned programme, and lessons learned from incidents, such as falls, were used to improve practice. The registered manager told us that action plans were developed following audits and investigations, learning was shared during team meetings, and additional training was provided where concerns were identified. However, the provider could not always demonstrate the effectiveness of these arrangements. Audits and action plans did not consistently show whether actions had been completed, sustained or what improvements had been achieved. As a result, we were not fully assured that learning and improvement initiatives were consistently embedded, monitored and used to drive continuous improvement across the service.