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 changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were systems in place for the recording and reporting of incidents. The service used the Patient Safety Incident Review Framework (PSIRF) for investigation of serious incidents.

The service reported 120 incidents in the 6 months before inspection, with 5 of these resulting in moderate harm and 115 resulting in no or low harm.

The service used an electronic incident reporting system, and staff knew what incidents to report and how to report them. The service used the Patient Safety Incident Review Framework (PSIRF) for investigation of serious incidents.

Staff discussed incidents, including any outcomes and lessons learned at monthly ward business clinical meetings and the trust’s monthly quality and safety group. Staff could give examples of changes made as a result of lessons learned, including a change in security procedures for sharp objects. Staff received a debrief after any incident.

The trust also held a monthly clinical learning forum for staff to discuss any learning from incidents, complaints or complex cases. Key messages for staff were also included in the adult mental health services newsletter.

Staff were up to date with mandatory trainingon the Patient Safety Incident Response Framework (PSIRF) with 100% of staff having completed level 1 training and 95% having completed level 2 training.

The trust provided examples of how they met their duty of candour, giving patients an explanation and apology when something went wrong.

The service worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. They ensured continuity of care, including when people move between different services.

The service worked closely with the community forensic team to ensure effective continuity of care. The consultant psychiatrists worked across both the ward and community team, and staff from the community team completed in-reach work with patients approaching discharge. Staff from the community team held groups based in the community for patients with section 17 leave from the ward.

The service had an outreach liaison worker in post who supported patients to prepare for discharge including applying for documents, bank accounts and financial support.

The trust had an admission, transfer and discharge policy in place. The service had a clear admission and exclusion criteria and referrals were made through the provider collaborative central referral point.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. There were clear systems, policies, and practices in place to ensure people were protected.

The service had made 91 safeguarding referrals in the 6 months prior to inspection. Staff discussed safeguarding issues and outcomes of referrals in the monthly business clinical meetings.

Staff were up to date with mandatory training for safeguarding adults and children, with training compliance rates of 95% for safeguarding children level 3 and 100% for safeguarding adults level 3. Staff knew how to identify safeguarding risks for patients and who to contact if they had concerns.

The service did not always use least restrictive practice. However, staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 6 patient records and saw that staff involved patients to complete a through, individualised risk assessment on admission to the service and reviewed these regularly including after any incident. Risk assessments included risks to patients such as falls, choking and self-harm, as well as risks posed to others.

Staff involved patients completing risk assessments and risk management plans.

Whilst we saw that staff completed individual risk assessments for patients to have access to sharp items and internet access, the ward had a restriction on access to the 2 ward tablets and phone. Patients were only allowed access for half an hour each evening and staff were unable to explain why there was such a short period of time allowed for patients. This meant that patients could not maintain contact with friends and family as often as they liked.

The trust reported 11 incidents of restraint in the 6 months before inspection, with 6 of these incidents resulting in seclusion and 2 resulting in rapid tranquilisation. The trust reported 1 of these was a prone restraint. The service reviewed incidents resulting in restrictive interventions as part of the violence, aggression and restrictive practice group meetings.

Staff told us they reviewed ward restrictions including the use of vapes with patients and co-produced a policy around these. However, the minutes from the violence, aggression and restrictive practice group did not include a review of blanket restrictions.

The provider detected and controlled potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service completed regular risk assessments of the environment including ligature risk assessments, clinical environmental risk assessments, site specific risk assessments and trust wide risk assessments.

The layout of the ward areas meant that staff could not observe patients in all parts of the ward due to the bedroom corridors not being in line of sight of the staff office. The service had mitigated this as much as possible with the use of mirrors and closed-circuit television (CCTV) in the corridors.

All bedrooms were single-occupancy and patients were issued with wristbands that enabled them to unlock their bedroom doors independently. Each bedroom was equipped with a nurse call system, allowing patients to request assistance when required. Bedrooms had en-suite w.c and shower facilities with additional bathrooms on each ward for patients who preferred to have a bath.

The service complied with mixed sex accommodation guidance with separate bedroom corridors for male and female patients and a female only lounge space. The main lounge area, dining room and garden were for both male and female patients.

The service only had 1 laundry room which both staff and patients raised as a concern, as female patients did not like having to share laundry facilities with male patients. All patients felt that there was not enough washing machines for the number of patients on the ward.

The seclusion room allowed clear observation and two-way communication, had toilet facilities and a clock.

The clinic room was not clean, with visible dust observed on some equipment. Only one item of equipment had an ‘I’m clean’ sticker to show that it had been cleaned since it’s last use. The clinic room was cluttered with boxes and outdated paperwork that needed to be tidied away. The floor was dirty and we found a medicine tablet on the floor next to the bin.

However, the clinic room was fully equipped with accessible resuscitation equipment and emergency drugs.

The provider made sure there were enough qualified, skilled and experienced staff. However, they did not always receive training, supervision and appraisal within trust targets. They worked together well to provide safe care that met people’s individual needs.

Managers calculated the number and grade of nurses and healthcare assistants required for each shift. The service used an electronic system to calculate staffing requirements for each shift dependent on patient numbers and acuity.

The service had low numbers of vacancies with 1 nurse vacancy that was in the process of being recruited to, and 1 activity co-ordinator post that was out for advertisement. When required, managers used bank staff to cover vacant shifts and maintain safe staffing levels.

However, patients told us that section 17 leave was often delayed due to lack of staff availability. Patients did not think there was enough staff to cover people going out on leave.

Staff had received and were up to date with most mandatory training with 92% of staff being up to date with all training sessions. However, 6 training sessions had less than the trust target rate of 85% compliance. These included 57% of staff having up to date ligature management training and 63% of staff having up to date sexual safety training.

Staff sickness rates were 7.5% which was above the trust expected rate.

Staff were supported through regular supervision with 72% of staff having received managerial supervision in the month before inspection. However, 70% of staff had an annual appraisal in place against a target of 95%. Following the inspection the trust provided additional information to show that the appraisal rate had improved to 94% in August 2026.

The service did not always assess and manage the risk of infection, detect and control the risk of it spreading.

The clinic room was not clean with visible dust and only 1 piece of equipment had an ‘I’m clean’ sticker to show it had been cleaned since last use. However, the ward areas were clean and well maintained.

Male patients told us that there was an issue with ant infestation in their bedroom corridor. They told us that they were distressed by having ants in their beds and waking up in the night with ants crawling on them. Staff told us that they were working with a pest control company to address the problem but that it was an ongoing issue as they couldn’t use ant powder on the ward.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems and processes were in place to ensure the safe prescription and administration of medicines. The service used an electronic prescribing system which was effective.

However, medicines were not always stored safely. Staff had not checked the fridge temperature on one date and the room temperature on several dates. Some medicines need to be stored within temperature range to ensure they are effective. We found 3 pots of creams for skin conditions that had been opened but did not have the date opened and when they should be used by recorded. These creams should be used within 3 months of opening otherwise they lose effectiveness and could increase the risk of skin irritation or bacterial infection.

We reviewed 10 medicines records and saw that all medicines had been administered as prescribed.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

Nursing staff responsible for the administration of medicines were appropriately trained with 100% of staff having completed up to date medicines management training.

Patients told us that they were involved in discussions about their medicines but did not always feel they were listened to by doctors.