Cambridgeshire and Peterborough NHS Foundation Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

Staff managed beds well. A bed was available when a young person needed one. Young people were not moved between wards except for their benefit. The design, layout, and furnishings of the ward supported young people’s treatment, privacy and dignity. Staff supported young people with activities outside the service, such as education and family relationships. The service met the needs of all young people – including those with a protected characteristic. Staff helped young people with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and identified lessons learnt.

This meant people’s needs were met through good organisation and delivery.

This service scored 79 (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 made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff regularly met with young people to understand their views on care and treatment. These discussions took place in one-to-one meetings with nurses and in multidisciplinary team meetings. Staff monitored young people’s presentation and discussed any changes at handover meetings and safety huddles. Young people were involved in decisions about their care and treatment. Care plans and risk assessments were person centred, holistic, and developed with young people.

The service provided therapeutic and recreational activities to meet the needs and personal interests of young people. A timetable of appropriate therapeutic activities was shared with young people. Young people participated in baking sessions, quizzes, played games and watched films.

Young people had access to psychology input either in groups or one-to-one sessions. Psychology staff ran a weekly dialectical behavioural therapy (DBT) group which was open to all young people. DBT is a structured therapy that supports people to manage their emotions and develop coping strategies. Psychology staff provided individual autism, ADHD and cognitive assessments, depending on the needs of young people.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff ensured young people had access to education and work opportunities. All young people could access the on-site school. The care was well integrated between services, teachers attended handovers and clinical meetings where appropriate to ensure they could provide the best education in the safest way to young people. The school developed individual attendance plans for young people and they were given a timetable depending on their plans and pathway.

Staff supported young people to maintain contact with their families and carers. Young people told us told us they were supported to maintain contact with the people who were important to them. With the young person’s permission, families and carers were included in decisions about care and were involved in care plans and risk assessments. Visits home were encouraged where possible.

Staff proactively worked with external agencies to support the continuity of care for young people while they were at the service, and in preparation for when they moved on from the service. Community child and adolescent mental health teams and young people’s local schools were invited to attend ward meetings. Staff made referrals for education, health and care plans (EHCP) to ensure young people would have the support they needed in place when they returned to the community.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. The trust submitted notifications to the Care Quality Commission in accordance with the requirements of their registration. The service also submitted safeguarding referrals to the local authority.

Leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Leaders attended monthly meetings where performance information was shared and discussed.

Staff ensured commissioners, families and carers were regularly updated about young people’s progress. They were invited to attend ward rounds and meetings. Carers told us they knew how to contact staff if they wanted an update on a young person’s progress.

Leaders created a care facilitator team for each young person and their carers. The team identified 4 key members of staff, including a member of the multi-disciplinary team, that young people and carers could go to. This was to ensure that carers received accurate and up to date information when they contacted the service. This process also supported carer’s views to be shared in ward round if they were unable to attend.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Young people participated in daily community meetings on the ward where requests and plans for the day were discussed. There was also a weekly “have your say” session, where young people could give feedback about the service and discuss improvement ideas. Young people told us the “have your say” sessions were productive.

The service actively sought feedback from young people and carers about their views of their care and treatment. Staff conducted monthly surveys of young people and carers to get their feedback about the service. Leaders used feedback to make improvements to the service.

Young people, relatives and carers knew how to complain or raise concerns. Young people said if they had any complaints, they would speak with nursing staff, their doctor or the ward manager. Leaders shared learning from complaints with all staff.

The service clearly displayed information about how to raise a concern in patient areas.Staff understood the policy on complaints and knew how to handle them. Each complaint was assigned to an individual investigator.

During the period November 2025 to May 2026 the service received 1 formal complaint. The complaint was partially upheld, and the complainant received a comprehensive response which included learning that had been identified.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service had sufficient medical cover day and night. A doctor could attend the ward quickly in an emergency and the ward was within a reasonable travelling distance to the local acute hospital.

Staff ensured young people had access to post-discharge care, including section 117 aftercare, child and adolescent community mental health and crisis services. Staff planned for young people’s discharge, which included good liaison with care co-ordinators.

The service was accessible to young people, including those with restricted mobility and wheelchair users. The ward was situated across one level with accessible washing facilities.

Delayed discharges were not always due to clinical reasons. Information provided by the trust showed there were 2 delayed discharges at the time of the inspection. Reasons for delayed discharges included placement identification and arrangements for Section 117 aftercare plans not being finalised.

We scored the service as 4. The evidence showed an exceptional standard. Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

Staff supported people with protected characteristics. For example, the ward had separate male and female bedroom corridors. The corridors were given different names such as watermelon, so that if any young people who were admitted to the service were transgender, they would not feel isolated or discriminated against.

Staff had developed a pathway for young people to access the local general hospital to best support the needs of young people. There was a consultant-to-consultant referral process, which meant that young people did not have to attend the emergency department and were instead given an appointment in the appropriate department. This was especially supportive to young people with neurodiverse needs, as it supported direct access to services they needed and reduced distress.

The trust recently launched a health equity strategy. Health equity means removing unfair and avoidable differences in health, access to care, experience and outcomes. The strategy was designed to demonstrate how the trust plans to ensure services are fair, inclusive and responsive — actively addressing inequalities in access, experience and outcomes.

The service admitted young people from diverse religious and cultural backgrounds. Staff asked young people about their religious and cultural needs when they were admitted to the ward. If required, staff supported young people to request culturally appropriate food. Young people had access to chaplains, who provided religious and spiritual care for young people.

Staff made adjustments to accommodate young people with diverse needs. Information was also made available in various formats to ensure accessibility. Information could be made available in different languages and staff had access to resources such as communication cards.

Staff were trained in equality, diversity and human rights. Staff compliance with this training was 96.8%. Staff also completed learning disability and autism training. Compliance with this training was 100%.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of young people with complex needs. The multi-disciplinary teams within the service were made up of a consultant psychiatrist, specialty doctor, nurses, healthcare assistants, family therapist, psychologists, social worker occupational therapist and other support staff.

The multidisciplinary team planned for each young person’s discharge. Staff ensured that appropriate arrangements were in place to support the young person’s mental health when they left the service. This included liaising with other professionals involved in the young person’s care to ensure they had appropriate accommodation to be discharged to and that a package of care was provided by local mental health services.