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

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 Good. At this assessment the rating has remained Good.

Good: This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
For example, a video and advice was circulated to all Cavell Centre staff after an intruder was in the building on 2 occasions.
Staff reported incidents clearly in line with trust policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by the ward manager. In the last 12 months, there were 121 incidents in total. Incidents included patient on staff aggression, assault, contact with an object and self-harm. There were 66 incidents classified as no harm, 53 incidents of low/minor harm and 3 incidents of moderate harm. We reviewed these incidents, and they included how staff managed the incident, lessons learned from incidents and actions taken to embed learning.
Staff were de-briefed and received support after an incident. People were de-briefed after incidents in ways that supported their communication needs.
 

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored.

The service’s referral and admission processes ensured that all essential information about the patient was received to ensure the patients’ needs could be met safely. However, there were not clear exclusion criteria detailing which patients they would and would not accept for admission. We reviewed 5 care records which evidenced multidisciplinary collaborative working and patient views.

They made sure there was always continuity of care, including when people moved between different services.

Risk assessments and treatment plans were updated and reflected current risks and needs.

Staff told us about comprehensive discharge planning meetings where family, the MDT and external people involved in the patients’ care attended. Staff said that there could be delayed discharges due to issues securing accommodation. Staff ensured that patients discharge to their local mental health teams were managed safely.

From September 2024 to June 2025 the service had 10 admissions.

Of these 10 admissions, 4 people had delayed discharges. These delays were due to challenges finding placements for them. Plans were in place to prevent emerging or future delays. For example, early discharge planning, weekly multidisciplinary team oversight, and closer partnership working with social care and providers.

The service 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, whilst ensuring support was in the least restrictive way.

Staff received training in safeguarding at levels 1, 2 and 3 and staff kept up to date with their safeguarding training. The compliance rate across all levels was 100%.

Safeguarding learning was also shared in various forums including staff meetings, reflective sessions and supervision.

The provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments for people on admission and reviewed these regularly, including after any incident. Staff told us they involved people and carers in care planning and risk assessment. People and carers told us that staff met with them regularly to review care plans and positive behaviour support plans, they felt they were included in care and treatment and able to contribute. People had signed their care plan and had a copy, carers also told us they had a copy of the care plan.

Where there were restrictions on people’s freedom, these were discussed and recorded. The service had a list of prohibited items. The service had an easy read version of the blanket restrictions and prohibited items in place. People did not have unrestricted access to outside space, however, staff facilitated access to the garden. Carers told us their relative was safe on the ward and staff managed safety well.

People we spoke with said they felt safe on the ward and that restrictions on the ward made sense.

Staff we spoke with showed a good understanding of the management of risk and reducing restrictive interventions. Staff spoke about using restraint and seclusion as a last resort and examples of interventions they would use to manage and de-escalate situations, staff were aware of people’s positive behaviour support plans and referred to this, staff said they found them helpful.

The trust held restrictive practice group meetings. We reviewed the minutes; however, we could not see reference to whether The Hollies was discussed. There was a blanket policy that the ward must use cardboard cutlery, however there had been no risk assessment to determine the risk level around this for individuals. Staff told us this policy had been in place since COVID19 and that it had not been reviewed since.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was a mixed sex ward; at the time of our inspection there was only 1 male patient. However, if a female was admitted they explained they would put signs on the doors of the bathrooms and lounges stating whether they were for male or female use. There were 3 gardens and 3 lounges which could also be divided by sex.

Staff regularly reviewed the environment, identified and managed ligature risks and mitigated risks quickly to keep people safe. The ward had easy access to information on environmental risks, this included a map of hotspot areas. Staff we spoke with knew about any potential ligature anchor points and knew where ligature cutters were located. Staff could describe mitigations taken to reduce risk to people’s safety. We saw from staff meeting minutes that ligature audits, and their findings, were shared and discussed.

At the time of our inspection 91.67% of eligible staff had completed ligature management training.

The ward did not use CCTV. Therefore, they could not use this to review safety incidents.

As there was only 1 person who was on 1:1 observation staff could observe them in all parts of the ward. The ward also had convex mirrors to support their view of the ward and mitigate some blind spots.

Staff had easy access to alarms for personal safety.

The service had policies to follow fire and safety practices on site. There was a fire escape plan and fire action notices on the ward which showed the assembly point.

The ward did not have a dedicated seclusion or de-escalation room. Leaders told us that the Cavell Centre had 1 seclusion room for all the resident wards and that patients could be secluded in their bedrooms whereby they would follow seclusion guidance.

Each person had their own bedroom and en-suite bathroom, which they could personalise. People had a secure place to store personal possessions in their bedroom.

The ward had a range of rooms and equipment to support treatment and care. The ward had a quiet room and quiet areas people could use; these areas echoed due to the nature of the sparse area which was low stimulus for the patient group. The ward had a room where visitors could come and meet people, there were alternative rooms off the ward to use if a child was visiting. The ward had multiple communal living rooms, leaders told us they could separate them into male and female by attaching removable signs to the doors.

We reviewed the wards maintenance log. Issues were identified and reported, however the log had not been fully completed with confirmation of the issue being resolved.

The service had enough nursing and support staff to keep people safe. At the time of our inspection The Hollies had capacity for 6 people. Leaders had calculated the number and grade of nurses and healthcare assistants required based on people’s needs.

They did not always make sure staff received effective support, supervision and development. At the time of our inspection 66.7% of staff had received supervision.

The service had access to a range of specialists to meet the needs of people currently on the ward. There had been a vacancy for a speech and language therapist since 2022. However, they could access this within community services.

Staff had received appropriate mandatory training that met the needs of people. Staff compliance with mandatory training was 95.8% at the time of our inspection.

Staff compliance with The Oliver McGowan mandatory training on learning disability and autism was 100%.

Leaders supported permanent staff to develop through yearly, constructive, comprehensive appraisals of their work. At the time of our inspection, 96.2% of staff had received an appraisal.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some furnishings were worn and a risk of infection control issue. The ward kept up-to-date cleaning records, but we found some gaps in the data suggesting several areas of the ward and clinical area had not been cleaned on occasion.

However, the area was visibly clean and tidy.

Staff maintained equipment well and kept it clean. The service followed their infection control policy, including hand washing. The service carried out infection prevention and control audits, which included checks on personal, protective equipment (PPE), handwashing, equipment, cleanliness and mattresses.

Staff completed infection, prevention and control training. Compliance in October 2025 for level 2 was 95.83%.

The trust had an Infection prevention control policy, which was reviewed regularly.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There were specific systems in place for the management of controlled drugs and medicines that were liable to be misused.

Medicines were stored appropriately. Medicines cupboards were locked when not in use. Medicines prescribed for individual people were labelled and stored correctly. Staff kept up-to-date information about stock. Details of pharmacy contacts were displayed for staff to see easily. Staff knew how to dispose of medicines and associated equipment safely. Staff kept accurate records of medicines. Sharps bins were available on the ward and were marked with the date of opening, as needed.

The service ensured people’s behaviour was not controlled by excessive and inappropriate used of medicines. The ward had not utilised rapid tranquilisation for 3 years.

The service reviewed people’s medicines regularly and provided advice to people and carers about their medicines in line with their medications policy. People’s medicines were reviewed as part of their overall review of their progress at ward rounds. Staff provided information about possible side effects. People were involved in discussions about medicines and care planning. Pharmacists carried out medicines audits. The clinic room was clean, orderly and fully equipped.

Equipment to support physical health care was available, regularly cleaned, audited and calibrated in line with manufacturer guidance.

The service had emergency equipment available. Its location was clearly marked in clinic rooms. There was an oxygen cylinder available in the clinic room which was in date. Records showed staff carried out regular checks of the defibrillator and resuscitation equipment.

Staff accurately recorded administration of medicines. However, staff did not always follow good practice in medicines management in line with national guidance. The daily room and fridge temperatures were not always recorded or issues relating to the temperature escalated or resolved in a timely manner. This could impact the quality and effectiveness of the medication.

We noted occasions where medicines were not administered as prescribed. We saw lessons learnt and reflections after these incidents. For example, a short guide had been created on ‘Handling To Take Out’s (TTO’s) and leave medication’ after an error had occurred. This was shared via email to the team. Support was given to staff and measures put into place to reduce the risk of this in future.