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

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.

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.

We scored the service as 3. The evidence showed a good standard. The service 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 told us they felt valued by their team.

Professional standards were upheld through clear expectations of staff conduct and ongoing training.

However, according to the most recent staff survey, only 38.5% of the team felt that team members understood each other’s roles.

We scored the service as 3. The evidence showed a good standard. The service 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.

Senior leaders were skilled, experienced and knowledgeable. Experienced leaders had a strong understanding of the service they managed. They checked staff competencies, identified any risks and ensured mitigations were put into place.

Staff told us they found the ward manager approachable and supportive. However, staff told us leadership above service manager level were not visible.

We scored the service as 3. The evidence showed a good standard. The service 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 ward displayed a ‘freedom to speak up’ poster on the noticeboard.

The trust had policies in place that were in line with best practice guidance for freedom to speak up, whistleblowing and complaints. There had been 1 concern raised for the last 12 months. An investigation was underway at the time of our visit.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

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 equality networks where members worked with the trust to understand the needs of the communities and shape improvements. These networks were Ethnic Minority, Wearing 2 hats (Disability and long-term conditions) Parents and carers, LGBTQ+, Menopause Support and Armed Forces.

To support staff with their individual spirituality there were Heart and Soul volunteers in place, specialist chaplains and peer workers.

The service had a professional advocate service which delivered restorative clinical supervision to staff to support them with their emotional wellbeing. Data from the Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standard (WDES) were used to inform trends and make improvements.

We scored the service as 3. The evidence showed a good standard. The service 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 act on the best information about risk, performance and outcomes, and share 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, audit, 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 gave feedback that they received regular supervision and appraisals.

Staff maintained and had access to the risk register. All staff were able to escalate their concerns if needed.

Staff had access to the equipment and information technology needed to do their work. Staff said these systems worked well.

The service had a business continuity plan in place for emergencies. This plan covered areas such as power failures and disease outbreaks.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Managers and staff worked with other services, both within the trust and the broader community, to share information and learning. 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.

We scored the service as 3. The evidence showed a good standard. The service 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 contribute to safe, effective practice and research.

The service had been successful in gaining the Quality Network for Eating Disorders Accreditation (QED) for May 2025 to January 2028.

The Consultant Psychiatrist actively took part in research and Quality Improvement projects, inviting other members of the team to be involved.

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 require.