Cambridgeshire and Peterborough NHS Foundation Trust

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• 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 requires improvement. At this assessment the rating has changed to good.

The ward was safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to young people and themselves well. Staff understood how to protect young people from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This meant people were safe and protected from avoidable harm.

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 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.

Staff reported incidents clearly and in line with the trust policy. Staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed and addressed appropriately according to the level of severity. Between December 2025 and May 2026, 690 incidents were reported across the service. During this timeframe, self-harm was the most common incident theme, with 569 incidents reported. There were 11 incidents of disruptive or aggressive behaviour and 12 medication incidents.

Leaders investigated serious incidents thoroughly using the Patient Safety Incident Response Framework (PSIRF). Staff reviewed closed-circuit television (CCTV) footage as part of the investigation process to identify areas of improvement and good practice. Leaders reviewed incidents and any emerging themes or trends. Learning and actions were collated and shared as part of a monthly review of all incidents across the service in clinical governance meetings. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Staff met to discuss learning from incidents which was shared in a variety of ways. Staff told us they received regular communications about learning from incidents via email. If an incident took place on the ward, it would be discussed in handover, and staff told us they received debriefs and reflective practice sessions following incidents. Staff took part in daily safety huddles and leaders told us they called nursing huddles as needed to address urgent concerns or needs.

Staff understood the duty of candour. They were open, transparent and gave young people and families a full explanation if things went wrong. The trust had a duty of candour policy which provided information on the trust’s standards and expectations in relation to the duty of candour.

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 trust’s referral and admission processes ensured that all essential information about young people was received to determine if their needs could safely be met. Young people were admitted from within and outside the county of Cambridgeshire. Referrals often came from community settings. Eligibility requirements were that young people were between 13 and 17 years of age and required support with their mental health in an inpatient setting.

Referrals into the service were managed by the provider collaborative. Referrals were sent to the service for their clinical opinion. The clinical team reviewed new referrals to ensure they could meet the needs of the young person and maintain the safety of all other young people on the ward. Leaders said they were mostly supported if a decision was made not to accept a referral. There was a policy in place for out of hours referrals, whereby an on-call consultant would review the referral along-side the nurses.

Staff involved all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge. Other agencies involved in the care of young people were invited to attend ward rounds and could attend virtually if that was preferred. Carers were also invited to attend ward rounds and share their views.

Staff ensured that young people’s discharges from the service were managed safely. Discharge planning began at a young person’s first ward round. Young people were often discharged back home to be followed up by community child and adolescent mental health services (CAMHS) or discharged to supported or independent accommodation in their local community. Staff liaised with the appropriate services to ensure robust discharge plans were in place. Young people had periods of trial leave before they were discharged.

Staff told us that transition to adult services was one of their main challenges. They cared for young people from different counties across the area covered by the trust, as well as young people from out of the area. Staff reported variation across different areas, with differing referral criteria and varying levels of support being offered. For example, some areas had youth teams which meant young people were managed by those teams until the age of 24. Leaders told us they communicated with the provider collaborative to flag when a young person was approaching transition to adult services. Staff carried out timely referrals to adult services. Staff reported concerns that adult services were not engaged early enough to support effective transition planning for young people, resulting in transitions that were not always seamless for young people.

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.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff completed level 2 training in safeguarding adults and compliance was 100%. Staff completed level 3 training in safeguarding children. Data sent by the trust showed compliance with this training was 80.6%. Evidence provided by the trust after the inspection showed that compliance with level 3 safeguarding training had increased to 96.8%. There was a trust safeguarding team who managed all safeguarding data and referrals.

Leaders had weekly safeguarding meetings with the trust safeguarding team where appropriate actions and liaison with other agencies were planned and discussed. The trust safeguarding team provided staff with safeguarding supervision and training that was tailored to safeguarding young people. Leaders had oversight of safeguarding referrals and reported on the number of referrals through trust governance processes.

Staff gave examples of how to protect young people from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. Staff gave us examples where they had raised safeguarding concerns relating to disclosures from young people. Staff followed the trust safeguarding policy which provided clear guidance on how to respond to safeguarding concerns.

Staff knew how to recognise young people, adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff submitted safeguarding referrals to the local authority appropriately via the trust safeguarding team. Staff told us when young people were admitted, there were sometimes ongoing safeguarding concerns that the local authority was already aware of. Staff worked with external services involved in the young person’s care to ensure they were protected from harm throughout their admission.

All the young people and carers we spoke with told us they or their loved ones felt safe on the ward.

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 and seclusion 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.

During an inspection in 2022, the trust had the following breach: The trust must ensure that risk assessments and care plans include all relevant information and are reviewed and updated following any significant incident or patient concern. During this inspection, this had improved. Risk assessments and care plans were up to date, contained accurate information and were reviewed regularly, including after an incident or a new concern.

Staff completed risk assessments for each young person on admission using a recognised tool, and reviewed them regularly, including after any incidents. We reviewed 4 young people’s records during the inspection. All records contained a crisis plan, were individualised and gave staff clear guidance on how to manage ongoing risks. All records included appropriate risk management plans and showed evidence of collaboration with other relevant professionals and stakeholders. Records demonstrated a proactive approach to assessing and managing risk.

There was evidence of young people and carer involvement in all records we reviewed. All records showed that young people were involved in their risk assessments; they identified their triggers and protective factors. Carers were also involved in this process. Young people and carers were offered a copy of their care plan. Young people were given the opportunity to participate in their ward round reviews. All care plans we reviewed were personalised to the individual.

Staff identified and responded to any changes in risks to, or posed by, young people. Staff used de-escalation techniques to initially respond to escalations in young peoples’ risk and followed best practice in managing risks. Staff responded to risks appropriately by reviewing management plans, medication, observation levels and access to leave. The multidisciplinary team (MDT) discussed incidents and changes to young peoples’ risks at handover meetings, huddles and ward rounds.

One young person spoke to us about their experience of being restrained by staff. They told us that while it was not a pleasant experience, they recognised the reasons why it happened and they felt that staff ensured it took place for the shortest time possible. The young person told us they had access to debrief sessions following the incident.

Staff followed provider policies and procedures when they needed to search young people or their bedrooms to keep them safe from harm. Staff searched young people when they returned from leave based on individual assessment of risks.

Staff and leaders were aware of blanket restrictions on the ward. Meetings were held to review blanket restrictions and to discuss how to reduce them. There were processes in place to report on any new restrictive practices. For example, staff discussed restrictive practices in safety huddles.

Levels of restrictive interventions were consistent with other similar services. Between November 2025 and May 2026, the service had no recorded incidents of prone restraint. Prone restraint is where the person is restrained facing the ground. During the same period there had been 19 instances of rapid tranquilisation across the service, and 29 incidents where physical intervention was required.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During an inspection in 2022, the trust had the following breach: The trust must ensure that seclusion rooms meet the standards set out in the Mental Health Act code of practice. During this inspection, this had improved. There was now a clock that young people could see. All other areas of the seclusion room met the required standards. The seclusion room allowed clear observation and two-way communication. Room temperature could be controlled from outside of the room and it had toilet facilities.

Staff completed thorough risk assessments of all ward areas and removed or reduced any risks they identified. For example, staff completed a ligature risk assessment. This was a comprehensive document, covering all areas of the ward including external areas. Mitigations included observation levels and ligature reduced fixtured and fittings. Staff conducted daily environmental checks of the ward.

The service complied with NHS guidance on delivering same-sex accommodation. The ward was a mixed sex ward with a higher proportion of females to males. There were separate bedroom corridors for males and females with separate bathrooms. There was also a room that could be utilised as a single-sex lounge. Leaders discussed and reviewed the use of this space with the young people, to ensure it was used in a way that was preferred by the young people.

The ward environment was bright and welcoming. There was lots of artwork on display that had been created by young people who had previously been on the ward. There was a mirror in the female bedroom corridor which had positive affirmations around the outside. These had been compiled by another young person. Young people were able to personalise their bedrooms with photographs, their own bedding and soft toys if they wanted to.

Staff carried alarms, which were tested daily. Young people had easy access to nurse call systems in their bedrooms and all other ward areas.

Leaders ensured fire risk assessments were completed. The fire risk assessment was last reviewed in June 2025. Staff undertook fire drills and the fire alarm was tested weekly. There was an emergency action plan for staff to follow in the event of a fire.

The clinic room was fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

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.

During an inspection in 2022, the trust had the following breaches: The trust must deploy sufficient numbers of suitably qualified, competent, skilled and experienced persons who receive appropriate training as is necessary to enable them to carry out the duties they are employed to perform, and the trust must ensure that all relevant staff receive training in physical intervention including the de-escalation of incidents. During this inspection, this had improved. The service had enough suitably trained staff to keep people safe, and staff were appropriately trained in physical intervention and de-escalation.

Data provided by the service identified 2.4 whole time equivalent (WTE) nurse vacancies and 4.2 healthcare assistant (HCA) vacancies. Discussion with leaders stated that there were in fact no vacancies as staff had been redeployed to this service from a nearby child and adolescent mental health service (CAMHS) within the trust that had closed. At the time of inspection, these staff were in the process of being permanently redeployed, therefore they were not yet reflected in the figures.

Leaders ensured the ward was sufficiently staffed. On occasions where staffing requirements were not fulfilled, there were processes in place to mitigate the risks and escalate further if required. Agency staff use was low, and regular staff would often work additional hours or bank shifts to ensure needs were covered.

Staffing levels allowed young people to have regular one-to-one time with their named nurses.

There were enough staff to carry out physical interventions, for example, observations and restraint safely. Staff compliance with conflict resolution training was 100%. Compliance with physical intervention training was 88%. Physical intervention training was featured on the service risk register, so leaders had oversight of progress with compliance for this training. Evidence provided by the trust after the inspection showed that compliance with physical intervention training had improved to 95.5%.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role.

Staff had received and were up to date with appropriate mandatory training. Overall compliance with mandatory training was 94.67%. The training was appropriate for the patient group using the service. Staff also had access to specialised training outside of their mandatory training, such as eating disorders, and meal support training. Evidence provided by the trust after the inspection showed that overall compliance with mandatory training had increased to 95.5%.

Leaders told us they provided staff with supervision. The trust policy required staff to have supervision once per quarter, however leaders told us staff usually received supervision on a monthly basis. Staff completed annual appraisals. The completion rate for appraisals was 75%. Evidence provided by the trust after the inspection showed that compliance with appraisals increased to 85.7%.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service conducted a number of infection prevention and control (IPC) related audits as part of the trust’s audit programme. Staff carried out regular audits of mattresses and resuscitation equipment.

Housekeeping staff cleaned the ward on a daily basis. Some additional cleaning tasks were carried out by clinical staff. We observed that the ward was clean and furniture and décor were in good condition. Young people and carers shared feedback that they found the environment to be clean.

Staff followed the IPC policy, including handwashing. Staff could access personal protective equipment (PPE) as required. Staff compliance rate for level 2 infection prevention and control training was 93.5%.Evidence provided by the trust after the inspection showed that compliance with level 2 infection prevention and control training had increased to 100%.

However, there were some gaps noted in the clinical staff cleaning records in the weeks before the inspection, which indicated some ward areas and equipment were not consistently cleaned on a daily basis. This had been picked up by leaders and shared with staff in a team governance meeting.

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.

Staff followed systems and processes to prescribe and administer medicines safely. Staff kept a record of all medicines dispensed on a medicines administration record. There were no controlled drugs present at the time of the inspection.

Staff reviewed each young person’s medicines regularly and provided advice to young people and carers about their medicines. Medicines were reviewed as part of an overall review of young peoples’ progress at ward rounds. Staff provided information about possible side-effects. Young people were involved in discussions about medication and care planning. All young people we spoke to told us their medicines were managed well and that they understood any changes made.

Staff completed medicines records accurately and kept them up-to-date. We reviewed the medicines charts for 10 young people. Records we looked at were clear and accurate. An effective electronic system was used by the service for administrating medicines, which minimised the possibility of errors occurring.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge, in the clinic room. Staff monitored room and fridge temperatures daily, and there was a process in place for staff to follow if temperatures were outside of range.

The service ensured young people’s behaviour was not controlled by excessive and inappropriate use of medicines. All young people received doses of medicine within the level recommended in the British National Formulary (BNF).