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

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.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service a 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Patients told us they knew how to raise concerns, but that feedback was not always received well. Two of 4 carers we spoke with told us they knew of the complaints process. Family members we spoke with told us service actively sought feedback and felt they were kept informed, as much as possible.

Staff knew how to report incidents clearly in line with trust policy. Staff recorded incidents on an electronic incident reporting system. From July to September 2025, in total there were 20 incidents. Incidents included medication/prescribing errors, accidents, environment, and staffing. We reviewed these incidents, and they included how staff managed the incident, lessons learned and actions taken to embed learning.

Staff were de-briefed and received support after an incident. Patients were de-briefed after incidents in ways that supported their communication needs.

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.

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 patient’s needs could be met safely.

The consultant psychiatrists visited each patient prior to admission to assess suitability for treatment. There were 3 pathways that patients could follow: intervention, harm minimisation, and recovery. There was a clear criteria for people they would and would not accept. We reviewed 4 care records which evidenced multidisciplinary collaborative working and patient views.

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

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

Staff told us and care records demonstrated comprehensive discharge planning meetings where family, the MDT and external people involved in the patients’ care attended. Staff ensured that patients discharge to their local community teams were managed safely.

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 safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service 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 of staff trained to level 3 was 95%.

From July to September 2025 there were no safeguarding referrals completed by the service.

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

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 patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They 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. Patients and carers told us that staff met with them regularly to review care plans. Patients had signed their care plan and had a copy, and 2 out of 4 carers told us they also had copy of the care plan.

Where there were restrictions on patient’s freedom, these were discussed and recorded. The service had a list of prohibited items. 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.

Patients we spoke with said they felt safe on the ward.

Leaders we spoke with showed a good understanding of the management of risk including positive risk taking to reduce restrictive interventions. We reviewed nursing meeting minutes which demonstrated positive challenge and a reminder to regularly challenge any blanket restrictions. For example, removing fluids the night before weighing had been removed. Staff spoke about using restraint as a last resort and examples of interventions they would use to manage and de-escalate situations.

The trust held restrictive practice group meetings. We reviewed the minutes; however, we could not see reference to these meetings being held locally or that reducing restrictive practices for Ward S3 was discussed.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The ward is based within Addenbrookes hospital, which is not managed by Cambridgeshire and Peterborough NHS foundation Trust. Due to this maintenance issues within the ward are resolved by Cambridge University Hospitals (CUH) maintenance team. This often-caused delays and issues with repairs.

Staff, patients and carers all told us that the showers had been an ongoing problem and that recently there was only 1 shower working that all patients had to share.

Leaders had taken measures to support the maintenance of the showers by installing new pumps, changing the shower heads and having the heads descaled weekly to help with pressure and blockages.

The space available on the ward was not sufficient for group activities in a neutral space. They were often held in the dining room, which was anxiety provoking.

The ward did not have a sensory room.

Patients also told us there was insufficient space to facilitate all visits from friends and family. There was a family room outside of the ward area where children were allowed to visit.

The ward had access to a garden which was shared with other wards and owned by CUH. It was unkempt, however leaders told us that they were able to have input into the design of the garden. They told us they chose various types of seating, a summerhouse so people could use the garden when raining, raised beds and plants so that they can facilitate adaptable horticulture for people who can't stand for long periods. They described how they ensured various sensory aspects of it by choosing different plants with different colours and smells. For example, Buddleia to attract butterflies and scent.

The service was a mixed sex ward; at the time of our inspection there were 8 female patients and no males. Each patient had their own bedroom, bathrooms were shared. Patients were able to personalise their rooms. If a male patient was admitted, the ward was able to be segregated into separate male and female corridors and bathrooms. This promoted privacy and dignity.

People had a secure place to store personal possessions in their bedroom.

Staff carried out regular risk assessments of the care environment. Staff had mitigated the risks of ligature points adequately. All patients who entered the service had a thorough risk assessment completed prior to admission and had no current or recent ligature risks.

The ward had CCTV. Any blind spots were mitigated by convex mirrors.

The service followed policies, fire and safety practices on site including a fire risk assessment. There was a fire escape plan and fire action notices on the ward which showed the assembly point.

Staff had access to alarms for personal safety; however, some staff told us that on occasion there were not enough for all staff on shift.

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.

The service had enough nursing and support staff to keep people safe. At the time of our inspection S3 ward had capacity for 12 patients. Leaders had calculated the number and grade of nurses and healthcare assistants required based on patient’s needs.

In the 6 months prior to our assessment, staff sickness rates were low at 6.67% and in the same period turnover of staff was 7.79%. This equated to 2 staff, one of which had a fixed term contract that had come to an end.

Leaders always made sure staff received effective support, supervision and development. During this same period on average 93.66% of staff had received an appraisal and 95.83% of staff had received supervision.

The service had access to a range of specialists to meet the needs of people currently on the ward. Leaders told us they had secured funding to expand their team.

Staff had received appropriate mandatory training that met the needs of people. Staff compliance with mandatory training was 91% up to September 2025.

Staff compliance with learning disability and autism training was 100%. The ward manager was also sensory integration trained.

We scored the service as 2. The evidence showed some shortfalls. The service 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.

The floor in the kitchen felt sticky to walk on. One of the microwaves was rusty inside, and the button to open and close the door was broken.

The paint on the windowsill in the kitchen was flaking off and in very poor condition.

Some furnishings were not wipeable and a risk of infection control issue.

However, the trust had an Infection Prevention Control policy. This was reviewed regularly. During the visit we reviewed up-to-date cleaning records.

The service carried out infection prevention and control audits, which included checks on personal, protective equipment (PPE), handwashing, equipment, cleanliness and mattresses. We reviewed the audit for September to November 2025 and compliance was 100%.

Staff completed Infection, Prevention and Control training. Compliance in November 2025 for level 1 was 100% and for level 2 was 77.27%.

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, including when changes happened.

There had been no medication errors for 3 months prior to our visit in December.

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. 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 rarely used rapid tranquilisation.

The service reviewed people’s medicines regularly. People’s medicines were reviewed as part of their overall review of their progress at ward rounds. 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 the nursing office. There was an oxygen cylinder available which was in date.

However, we found some medications and supplements had expired. This could impact the quality and effectiveness of the medication. On the day of our inspection staff disposed of this medication and the pharmacist visited the ward the following day to review all medications. Patients and carers told us staff did not always explain medications given to them.