Cambridgeshire and Peterborough NHS Foundation Trust

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 Good. At this assessment the rating has remained Good

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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. Staff knew the trust vision and values.

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.

Staff and people told us that leaders were visible on the ward, approachable and engaged well with them. Managers said they received good support from senior leaders.

Senior leaders were skilled, experienced and knowledgeable. Experienced leaders had a strong understanding of the service they managed. They checked staff competencies and ensured staff were supported at work.

Staff told us they found the ward manager approachable and supportive.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of the term ‘freedom to speak up’ and what this meant. Staff said they felt confident in speaking up and raising concerns, staff told us they felt listened to and where there was learning this was shared amongst staff.

The trust had policies in place that were in line with best practice guidance for freedom to speak up, whistleblowing and complaints.

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 service had an equity, diversity and inclusion policy and strategy in place to guide staff in ensuring that people were treated fairly. All staff completed training in equality, diversity and inclusion.

The trust had 6 staff networks where members worked with the trust to understand the needs of the communities and shape improvements. These networks were the ethnic minority, wearing 2 ats (disability and long-term conditions) parents and carers, LGBTQ+, menopause support and armed forces. Feedback from staff, patient surveys, equality networks and data from the Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standard (WDES) were used to inform trends and make improvements.

Leaders had taken action to review and improve the culture of the organisation in the context of equality, diversity and inclusion. An anti-racism working group had been implemented to provide platforms for open communication and support.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders attended regular governance meetings for safety, audit, quality and governance. The trust discussed and addressed key areas of performance, risk, culture and workforce. Minutes showed areas of concern were identified and actions taken to learn and improve.

Leaders completed regular audits on the ward.

Staff said they had regular team meetings, handovers between shifts to discuss any issues or risks and attended multidisciplinary team meetings. Staff felt the wards were well organised and managed. Staff were able to give examples of the checks they had participated in to ensure the safety of the wards such as security checks, observations, audits and checks of equipment. Staff gave feedback that they received regular supervision and appraisals. However, on reviewing files we were unable to locate some supervision records.

The trust held a risk register which we reviewed. All risks were identified with risk scores, controls, mitigations with assurance and action review dates. Staff said they could make suggestions to add to the risk register which would be escalated.

Staff knew how to deal with complaints and safeguarding concerns. Leaders ensured any lessons learnt were shared with staff.

However, staff voiced frustrations that trust policies mostly focussed on mental health and not people with learning disabilities and autism.

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 service worked well with other agencies; there were established relationships with the intensive support team and other departments within the Cavell Centre where the ward is based.

Leaders and staff developed and maintained effective working relationships to support patient care and maintain their safety.

Staff invited family members and external professionals to meetings so they could discuss any issues and receive any updates about people’s / their family member's care and treatment.

Staff had access to regular team meetings on the wards. Staff were able to propose, exchange and discuss ideas in terms of good practice.

The service manager sought feedback from staff make improvements.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service focussed on continuous learning, innovation and improvement across the organisation. Regular audits, ongoing monitoring and actions drove improvement across the service

The consultant psychiatrist had completed a quality improvement project about sexual experience in a learning disability ward; this supported the ongoing development and promotion of good practice through continuous learning.

Staff told us there were learning development opportunities which can be facilitated provided it would benefit the patient group.

Staff told us local learning was shared via team meetings, governance meetings, and by email. The trust also sent out lessons learnt, these included what happened, identified learning and actions required.