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 meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

The service had a shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in their day-to-day work. The trust had a set of values which were: professionalism, respect, innovation, dignity and empowerment.

The trust had a 5-year strategy in place that set out it’s ambition ‘in delivering outstanding, whole-person care, building strong partnerships, fostering a compassionate culture, and embracing innovation through research and digital transformation’. The trust also had clinical and health equity strategies in place.

The provider 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 spoke positively about local leadership and felt supported by them, both personally and professionally.

Leaders had the skills, knowledge and experience to perform their role and a good understanding of the services they managed. Leaders had oversight of team performance and were aware of the key challenges affecting delivery.

Staff reported that local and senior leaders were visible within the service, with executive team leaders visiting the ward routinely. However, patients did not feel that leaders were always visible on the ward.

Leadership development opportunities were available for staff and a band 5 to band 6 leadership programme was offered to staff wanting to develop leadership skills.

The service created a positive culture where people felt that they could speak up and that their voice would be heard.

The trust had a Freedom to Speak up policy and Freedom to Speak up Guardians (FTSUG) in place. A Freedom to Speak Up Guardian (FTSUG) works alongside the trust’s senior leadership team to ensure staff have the capability to speak up effectively and are supported appropriately if they have concerns regarding patient care.

Staff understood how to raise concerns and said they felt comfortable doing so. They were aware of the service’s whistleblowing policy and knew how to access support from the Freedom to Speak Up Guardian.

The service valued diversity in its workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust had an equality, diversity and human rights strategy in place that set out expectations of inclusive leadership and equality priorities.

The trust undertook equality monitoring of its staff and reviewed its Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results. WRES and WDES data were only available at trust-wide level.

The trust had 6 staff networks in place: Ethnic Minority Network, Wearing 2 Hats Network (Disability and Long-Term Conditions), Parents Carers Network, LGBTQ+ Network, Menopause Support Group, and Armed Forces Network. These aimed to provide a more inclusive and supportive culture for staff.

Leaders supported staff who had received abuse based on protected characteristics to report incidents to the police and had a good working relationship with the police liaison officer who worked with the trust. Staff had received training in racial abuse and hate crimes.

The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We reviewed examples of the business and clinical meeting minutes. There was a clear framework outlining what must be discussed at staff and team meetings to ensure essential information, such as learning from incidents and complaints, was shared.

The service had clear governance processes in place to review and take action on the results of audits, incidents and complaints.

The trust had a risk register at service level that accurately reflected the current risks. Managers and staff could access the risk register and raise concerns when required.

The service had plans in place for emergencies including a continuity and emergency response plan that included loss of space, staff, systems and supplies.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 worked as part of the provider collaborative which enabled sharing of best practice, joint quality improvement initiatives, and regular forums to discuss learning.

The service was in the process of implementing a sensory pathway including a full sensory assessment and plan for each patient.