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.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

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 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 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.

The trust’s senior leadership team had successfully communicated the trust’s vision and values to staff and leaders in the service. Leaders knew and understood the trust’s vision and values and how they were applied in the work of their team. Service leaders and the multi-disciplinary team developed their own values for the service, which were in line with the trust values. The service’s values were respect, safety and discovery and were based on the principle of least restrictive practice which was embedded throughout the service.

Leaders ensured staff were connected with the values of the service. Leaders discussed values with staff in team meetings, supervision and annual appraisals. Values and behaviours were also shared with young people.

Staff had the opportunity to contribute to discussions about the strategy for their service. Leaders planned away days for the nursing team and full multi-disciplinary team. Staff reflected on practice and shared learning during these sessions. A young person who was previously admitted to the service provided a training session to staff about their experiences of being an inpatient on the ward.

Young people had the opportunity to be involved in discussions about the service. Staff routinely sought feedback from young people and actively encouraged them to make suggestions. The weekly “have your say” meetings gave young people the direct opportunity to share feedback, suggest improvement ideas and influence service delivery.

Staff described a positive working culture within the service and spoke highly of their colleagues. They told us they had confidence in their team and trusted their colleagues.

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.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the service they managed. They were aware of service performance and were aware of challenges faced by the service. They collaborated with one another and other staff to develop solutions or mitigations and were supported by management at provider level.

Staff felt supported by leaders and told us that they were approachable and engaged well with them. Leaders were visible within the service and had the experience, capacity, capability, and integrity to ensure that the organisational vision could be delivered, and service risks were well managed.

There was a positive culture across the service. Staff told us they could speak freely and they felt their suggestions were listened to. Staff felt their opinions were valued. Reflective practice was available to all members of staff to promote a supportive culture of development.

The trust supported staff development. The trust had processes to support staff through nursing and occupational therapy apprenticeships. The trust also ran a leading and learning event.

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.

The service had a freedom to speak up process if staff wished to raise concerns confidentially. The trust had a freedom to speak up guardian and staff could find details about the freedom to speak up process in the trust policy. Staff told us they felt they could raise concerns with their managers and that they would be dealt with appropriately.

Leaders collected data surrounding themes raised from freedom to speak up cases. Cases were addressed and escalated appropriately, with advice and support provided when needed.

Leaders collected staff feedback. We reviewed a summary of the 2024 and 2025 staff survey results. The service demonstrated the most improved score in a speaking up indicator; 87.2% of staff said they would feel secure raising concerns about unsafe clinical practice in 2025 compared to 58.1% in 2024.

Young people had the opportunity to provide feedback about the service. They knew how to raise concerns and received a response. Staff facilitated regular “have your say” meetings and community meetings on the ward, which were dynamic and gave young people the opportunity to give feedback and receive updates about progress or changes following their feedback.

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 trust had an equality, diversity, and inclusion (EDI) strategy which had 4 overarching strands: culture, reporting, workforce and engagement. The strategy aligned with the trust’s values.

The trust had a range of equality, diversity and inclusion networks that staff could access. These included an ethnic minority network, disability and long-term conditions network, parents and carers network LGBTQ+ network, menopause support group and armed forces network. These groups provided supportive and informative networks for staff.

The trust employed a diverse team of staff from international backgrounds. Employment practices promoted equality of opportunity.

Leaders put reasonable adjustments in place for staff members to help them carry out their role. For example, staff were able to request flexible working arrangements and some staff had workplace passports which were reviewed in supervision.

The trust completed a Workforce Disability Equality Standard (WDES) report to assess progress against metrics focused on disability equality. The trust also completed a Workforce Race Equality Standard (WRES) report. Both reports showed there had been improvements, but there was still work to do to improve experiences of disabled staff members and black and minority ethnic (BME) members of staff. The reports set out priority areas for improvement with action plans with allocated leads and defined timescales.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes, and shared this securely with others when appropriate.

Meetings at team and management level followed a clear structure to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Clinical governance meetings discussed multiple topics including safeguarding, mandatory training, audits and feedback from young people and carers. Any actions were emailed to all staff following the meeting.

Staff maintained and had access to a service risk register. The risk register was up to date and included operating as a standalone unit, sexual safety, environment and building works. The risk register included a score for the severity of each risk and control measures to mitigate against harm, as well as a named member of staff as the risk manager. The risk register was reviewed monthly.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. For example, clinical staff completed audits of documentation, medicines management and therapeutic observations on a monthly basis.

Leaders had access to information to support them with their management role. This included information on performance, staffing and patient care. The electronic system used by the service allowed leaders to have access to information such as whether care plans, physical health checks and legal status were up to date. They also had access to information on staff training compliance. Service performance was discussed in governance meetings.

The service had plans for emergencies that could cause disruption to service delivery. The service had a business continuity plan in place. The plan identified the processes to be followed in the event of a number of different emergency scenarios.

However, some of the data held about the service was unreliable. For example, some of the training data held by the trust showed inaccuracies. Figures for staff compliance with safeguarding training was not up to date. The system had not updated when a staff member had left the service. The system also indicated a member of staff needed to complete a certain training course that they were not actually eligible to complete, which further obscured the figures.

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 worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Service leaders engaged with external stakeholders such as commissioners and the local authority. Staff developed and maintained effective working relationships to support young people’s care and maintain their safety. Leaders developed positive working relationships with other general adolescent units within their local provider collaborative. Teams could ask questions and share best practice. Feedback from stakeholders described thoughtful and person-centred working.

Leaders were transparent with stakeholders about performance. Leaders shared service performance data with the provider collaborative.

Staff worked in partnership with families. The service had a head of patient and parent involvement who worked closely with families and young people, sought their views and encouraged them to share feedback about the service. Staff updated the admission packs for young people and carers following feedback they had received. Staff had developed links with local caring agencies. They worked to maintain those links so they could signpost families to these services that provided additional support.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were actively involved in quality improvement and innovation projects to constantly improve the service. Staff were involved in a culture of care initiative. Part of this work included the service’s least restrictive approach to care. Medical staff carried out a review of the model of care used within the service, and the impact it had on young people’s care. Data showed that the number of admissions to the service increased and the length of stay decreased. Self-harm and restrictive practice reduced, and there was consistent improvement in young people’s clinical outcomes.

The service developed expertise and competence in the assessment and treatment of young people with complex disordered eating and eating disorders. The service’s approach was in line with least restrictive practice and values-based healthcare. Interventions provided holistic support from a system approach. Staff developed expertise in nasogastric (NG) feeding, and the service developed close links with an intensive day therapy provision. The dietician had expertise in avoidant/restrictive food intake disorder (ARFID). Staff were skilled in meal support and provided group or individual meal support, depending on the needs of the young person. Staff worked collaboratively to improve patient experience when attending the local acute hospital. Staff also worked collaboratively to provide transition support when young people approached adulthood.

Leaders were in the process of developing an eating disorder pathway. Leaders worked collaboratively with colleagues from a local acute hospital and other community organisations to develop a pathway to tackle some of the barriers young people with disordered eating faced; such as long waits for treatment and increased length of stay in acute beds even though clinically ready for discharge. The aim of developing this pathway was to improve consistency and outcomes for young people.

The service was in the process of participating in an accreditation scheme and had recently undergone a peer review for the Quality Network for Inpatient CAMHS (QNIC). This accreditation scheme was led by led by the Royal College of Psychiatrists and focussed on improving care for young people as accredited services must meet certain standards.