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
• Environmental sustainability – sustainable development

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust’s vision was ‘Together we will support our communities to live healthier lives’. The trusts’ purpose was ‘CPFT strives to improve the health and wellbeing of the population we care for, and to support and empower our citizens to lead a fulfilling life. The trust had 5 values: professionalism, respect, innovation, dignity and empowerment. These were known as the PRIDE values.

The trust’s strategy ‘Shaping Our Future was launched in 2023 to run to 2026 and consisted of 4 strategic priorities. These were: working in partnership to deliver best care, people at the heart of everything we do, system leader in innovation and research and making best us of our resources. Development of the strategy involved internal and external engagement. The trust strategy was supported by a number of enabling strategies.

Feedback from stakeholders noted that the strategy did not feel embedded or lived. They also noted it was not clear how the strategic commitments made in the plan had translated into operational and clinical delivery. The development of the plan was also prior to the ICS Joint Forward Plan and strategy and therefore alignment to system wide objectives could be stronger.

At the time of the inspection the trust was undergoing a refresh of its strategy, including the development of a High Performing Organisation Programme. This work was at an early stage. There was also a focus on the development of a new clinical strategy and a new equality, diversity and inclusion strategy. The trust was starting internal and external stakeholder engagement as part of the process. We heard how the Pharmacy and Medicines Optimisation strategy for 2025/28 was being developed, and how this reflected the work on the trust wide strategy with internal and external engagement and alignment with the Integrated Care System.

Leaders knew the trusts vision and values but there was less clarity around the current strategic objectives. Board priorities were noted to be descriptive with a lack of clear outcome measures. Leaders could also not consistently identify or describe how the implementation of the strategy had led to meaningful or measurable change within the trust.

We undertook 18 focus groups speaking to around 140 staff. Staff raised concerns around poor visibility of senior leaders. Staff described a culture of fear and reported incidences of bullying and of racial and disability discrimination. This was highlighted in the staff survey. Staff reported poor communication from senior leadership and feeling untrusted and undervalued. Staff also commented on the perceived poor management of change and lack of engagement and described a feeling of being ‘done to’. However, staff felt hopeful that the appointment of the new chief executive could bring about positive change and the trust had an action plan to address the culture within the trust.

The board acknowledged that historically leaders had not consistently demonstrated their commitment to compassionate and inclusive leadership. The culture within the trust had been very negative andequality and diversity had not been prioritised in board development sessions. There had also been a lack of commitment by leaders to promote inclusion within the trust.With the arrival of the new chief executive in October 2024 the trust had shown a renewed commitment to improving culture within the organisation and driving forwards a new equality and diversity agenda. However, there was significant continued work that needed to be undertaken in this area.

Trust governors reported there had historically been a culture of defensiveness around their engagement and a reluctance to hear their feedback. They also raised challenges around their external engagement with the local communities and also internally to facilitate service visits. However, they reported they were all engaged in the recruitment of the new chief executive and felt more positive about working with the trust moving forwards. They also reported good relationships with the non-executive directors.

Feedback from system partners commented on the significant changes in the executive leadership team over the past 2 years and the instability this had caused in building relationships and making delivery progress. CPFT was described by stakeholders as historically insular in its approach and defensive in acknowledging issues or opportunities for improvement. Stakeholders reported that their approach had been financially driven and as such, there had often been limited flexibility in meeting patient need within a system context. Conversely external stakeholders reported positive interactions with front-line staff acknowledging that communication with senior leaders needed to improve.

The trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. However, staff told us that historically they had not always felt that these issues were dealt with. Staff also raised concerns with us about the grievance process itself and how individual complaints were managed. A new behavioural framework (a product of the trusts ‘Shaping our Future Together’ programme, not to be confused with the trusts ‘Shaping Our Future’ strategy) had been co-produced with input from staff but was yet to be fully implemented.

The staff survey results indicated that there was more work needed to ensure staff were engaged and had positive working experiences. The 2024 staff survey results were not yet available at the time of inspection, but the trust results fell below average for all 8 areas of the 2023 staff survey. The number of staff reporting feeling burnt out sat just below the national average but a higher percentage of staff reported working additional unpaid hours (62.2% vs 57.5%).

We observed the trust’s board meeting, attended several governance meetings and reviewed minutes. These included the sub-committees of the board. In all meetings we saw leaders acting with integrity and respect. The trust supported accessibility by allowing attendance remotely where appropriate. Board papers were available in advance and following meetings subtitled recordings of the meetings could be accessed.

The trust’s board comprised of 7 executive directors including the chief executive and 9 non-executive directors including the trust’s chair. The executive team had individual portfolios covering all the necessary areas of work for the trust. These included patient safety, quality of care, risk management, performance, finance and organisational development. Some of the executive directors had very large portfolio’s, but they felt confident that they had the necessary support to enable them to have the capacity for these roles.

There had been significant instability in the trust leadership. NHS England reported that concerns had been raised around leadership and capability within the organisation following the departure of the previous chief executive in January 2024.

An interim chief executive had provided support until the appointment and arrival of the current chief executive in October 2024. At the time of the inspection the interim chief executive was still working for the organisation but was retiring imminently. The chief nurse was working in an interim capacity, having retired and returned to support the organisation for a year until a permanent person could be appointed. The chief finance officer was absent from work at the time of our inspection. A number of the executive directors including the chief operating officer and chief medical officer were in executive director posts for the first time in their career. There had also been changes in the non-executive directors as the chair had brought in people with an appropriate range of skills and experience. For example, the chair had recruited a non-executive director who was a recently retired GP and brought clinical and commissioning experience to the trust.

It was recognised by the trust that the trust board needed to stabilise and be supported to perform their roles. There was a board development plan in place with 5 sessions planned for 2025. The content of the sessions was appropriate and included topics such as Patient Safety Incident Response Framework (PSIRF), Patient and Carer Race Equality Framework (PCREF) and the clinical strategy. We heard that limited succession planning was in place at board level and a need for further individual tailored development support for some of the executive team.

Staff reported a lack of visibility of senior leadership and a lack of clarity around who senior leaders were and what they do. They described a disconnect between board level and frontline services. Staff also raised communication with senior leaders as a concern both from the bottom up and top down. They reported clinical leadership were kind and compassionate, but that historically there had been a lack of effective clinical leadership and voice at board level.

With the arrival of the new CEO a plan had been put in place to increase visibility of senior leadership. A programme of visits to services carried out by a non-executive director with an executive director were starting to take place. However, these were at an early stage and had not yet significantly improved visibility to staff teams.

The trust did have a Fit and Proper person policy, and we found records to be in line with the requirements.

Some staff expressed the view that certain leadership roles may not have been consistently advertised, and that recruitment policies and processes might not always have been followed.

There were 3 clinical directorates within the trust, adults and specialist mental health, children, young people and families and older people and community services. Appropriate clinical leadership (medical, nursing and management) was available in each directorate. We saw positive examples of integrated physical and mental health care within both the older people’s and children’s directorates. During the inspection we heard that the support from corporate services (finance, HR, data and insight) were variable impacting on the workload for directorate leaders.

There were also some positive examples of clinical leaders bringing about change within the organisation including the implementation of a robust learning from deaths review process by the deputy medical director. However, we also heard that the board had previously not promoted clinical voice and there was currently not a clinical strategy in place. With the new chief executive in post clinical voice was being prioritised, including significant work into a new clinical strategy.

There was evidence of individual executive directors being involved in partnership working, including the trust hosting the mental health learning disability and autism partnership within Cambridge and Peterborough. However, feedback from the system raised concerns about limited communication, awareness or understanding of the expectations of the trust as an organisation within the care system among senior leaders outside of the executive team. In system settings this resulted in senior leaders being unclear on the wider context, priorities or decisions that have been made and not being able to contribute effectively.

The trust had a freedom to speak up policy implemented in October 2022. There were 2 freedom to speak up (FTSU) guardians and 26 FTSU ambassadors across the trust. The lead freedom to speak up guardian reported directly to the chief executive. There was also a NED who supported the FTSU team.

The 2023 NHS Staff Survey showed that 69.26% of staff agreed with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was slightly higher than the national average of 68.1%. This was very similar to the previous years score of 69.28%, although there has been there has been a downwards trend in this since 2021 where they scored 72.09%. However, the survey also showed that only 53.3% agree with the statement ‘If I spoke up about something that concerned me I am confident my organisation would address my concern’. This is below the national average of 56.06% and again has shown a decline from previous scores of 58.29% in 2021 and 56.18% in 2022.

The latest FTSU up data from the trust showed that 117 cases were raised at the trust between April 2023 and March 2024. This sat in the middle of reporting numbers for similarly sized trusts in the East of England suggesting that some staff felt able to report concerns to the FTSU guardians.

During the inspection we heard about where there had been a cluster of concerns reported, and the actions taken by the trust to address these concerns. However, many staff we spoke with reported a ‘culture of fear’ to us, where they did not feel psychologically safe raising concerns including through formal mechanisms. Staff reported that they felt their concerns would not be heard or actioned and this undermined confidence in reporting. They also reported significant fear around the impact raising concerns had on their career progression. Staff also reported that they felt that using the FTSU process had no real impact on concerns and also raised issues around a lack of support in instances where FTSU concerns had to be taken to formal grievance processes.

The trust also had in a patient safety initiative called ‘Stop the Line’. The initiative was driven by proactive executive-led communication and encouraged staff at all levels to ‘call a halt’ to any proceeding that gave them cause for concern, from a safety or quality perspective. This aimed to be a non-confrontational way to pause proceedings and re-evaluate the situation with rapid escalation of issues to divisional leadership and the executive directors, with an executive response provided within 24 hours. However, staff gave mixed feedback with some reporting that the process was not supportive and that issues escalated were not resolved and were just deflected back to teams.

The trust monitored equality, diversity and inclusion in their workforce in line with the NHS Workforce Race Equality Standard (WRES).

In all 4 of the Workforce Race Equality Standard (WRES) NHS Staff Survey indicators (based on 2023 survey results), white staff at the trust reported notably better experiences than staff from all other ethnic groups. Compared to the national averages for staff from all other ethnic groups, staff at CPFT also reported poorer experiences in 3 of the metrics. These were harassment, bullying or abuse from patients, relative or the public in the last 12 months; harassment, bullying or abuse from staff in the last 12 months and discrimination from a manager/team leader or other colleagues in the last 12 months.

The 2022 WRES staff survey indicators showed a modest difference in experience of bullying, harassment or discrimination between staff of white heritage and staff with global majority (diverse group of people who are not considered white) backgrounds, in favour of staff of white heritage. Whilst the 2023 WRES staff survey indicators showed a significantly different experience of bullying, harassment or discrimination between staff of white heritage and staff with global majority (diverse group of people who are not considered white) backgrounds, in favour of staff of white heritage. Discrimination by managers was perceived more than 2 times higher by global majority staff than their white counterparts. White staff were also 15% more confident that the organisation provided equal opportunities to progress their careers than their global majority counterparts.

For 2023/2024, the WRES workforce indicators showed that ethnic diversity in staff groups was lower than the national average (20.5% vs 24.2%). However, this was a significant improvement of 5% from 2022/2023 when it was 17.4%. White staff represented 82.6% of staff at non-clinical management grades at band 8a or above. In clinical posts the percentage was slightly higher with white staff representing 89.9% at grades 8a or above, although greater diversity was seen in lower bands. The greatest diversity was seen in medical and dental staff where white staff make up 51.6% of the total staff group. Data for 2024 showed White staff are twice more likely to be appointed from shortlisting compared to BME staff.

There was also low ethnic diversity recorded within the board with only 12.5% of total board members coming from BME background compared to 20.5% in the organisation as a whole. There were no executive board members from a BME background.

Staff with long-term conditions or illnesses at the trust reported worse experiences in all 7 of the Workforce Disability Equality Standard (WDES) metrics from the 2023 NHS Staff Survey, compared to those without at the trust. They also reported worse experiences than the national average in 5 of the 7 metrics. However, 81% of staff with a long-term condition or illness said their employer had made reasonable adjustment(s) to enable them to carry out their work, which is similar to the national average. Of those who shared within the NHS Staff Survey 2023 that they had experienced discrimination, 19.9% experienced it on the grounds of disability which was an increase from 11% in 2019.

Between 2023 and 2024, staff with a long-term disability were more likely to undergo capability proceedings, but they were more likely to believe that the organisation offered fair career progression, than their non-disabled counterparts. They also experienced less pressure to come to work and more satisfaction with the extent the organisation values their work.

The trust Equality Diversity and Inclusion (EDI) team had a completed a 6 year look back at WRES and WDES data for the organisation (covering the period 2018 to 2023), which indicated very little improvement in metrics during the period. This suggested that to date strategies implemented had been ineffective at improving outcomes. However, this had been recognised, and this piece of work was being used to identify suitable improvement initiatives to form part of the new EDI strategy moving forwards.

The Patient and Carer Race Equality Framework (PCREF) is a new mandatory race equity and accountability framework for mental health trusts in England. The purpose of PCREF is to support trusts to improve racial inequalities in access, experience and outcomes of mental health care. The trust was preparing for the imminent implementation of PCREF through a number of strategies. This included setting up an advisory group open to trust staff, patients, carers, community members and community leaders interested in being involved in shaping the implementation of PCREF. Staff we spoke to were aware of PCREF and the plans for implementation, however there were concerns about the understanding and use of data as well as a lack of strategic drive behind implementation.

Leaders told us that the trust board was committed to providing a workplace that was free from discrimination, promotes equality of opportunity, fosters good relations, and provided an environment that was inclusive for patients, carers, visitors, and staff and puts ‘people at the heart of everything we do’. Over the past 12 months the trust had focussed on embedding equality, diversity and inclusion in its workforce policies and procedures. The trust were developing a new EDI strategy and co-producing a new behavioural framework with staff (a product of the trusts ‘Shaping our Future Together’ programme, not to be confused with the trusts ‘Shaping Our Future’ strategy), but these were yet to be fully implemented.

The trust acknowledged the slow progress and had a WRES Improvement Plan 2024-2025 aligned with the EDI Improvement Plan. This outlined action the trust will take to respond to the WRES and achieve improvements against the following themes: discrimination, bullying and harassment (links to the anti-racism working group), recruitment and selections, disciplinary HR processes, compassionate and inclusive leadership an improving the experience of ethnic minority staff. As part of this the trust was currently embedding cultural ambassadors to support employment processes and practices that involve staff who have a protected characteristic. However, staff fed back that the current resource was not sufficient to meet demand.

Staff networks had been built to promote equality, diversity and inclusion. The trust had 6 staff networks. Each staff network had an executive sponsor, however network leads reported limited visibility and input from their executive sponsors. Network leads commented on the limited protected time they were given for their roles as well as very limited budgets. They also raised concerns about the staff being able to attend meetings due to staffing pressures.

There were 5 sub committees of the board. These were quality and safety, people and culture, business and performance, audit and assurance, and renumeration. The board met 6 times a year and the sub-committees fitted in with these meetings. Key risks and updates were shared in a report from each sub-committee to the board. The non-executive directors (NEDs) were aligned to the sub-committees and also attended meetings which they did not chair to get a broader understanding of the work of the trust. A previous governance review had highlighted the numbers of committees sitting beneath the sub-committees and the need for these to be consolidated and the trust was committed to making these changes.

The current Board Assessment Framework (BAF) was introduced a year ago and was reviewed monthly. The BAF aligned to strategic priorities and recorded 9 principal risks. All recorded risks included the dates added and the executive owner and described current actions in place to mitigate. There were 2 current risks that were over 12 months old. All showed no change on the risk score at the latest review. In the last quarter a risk had been added to the BAF relating to the trusts ambition to be a leader in research not being realised. This noted lower levels of research in the Peterborough area and the lack of infrastructure.

The trusts operational risk register (ORR) brought together risks with a current risk score of 12 or above (as dictated by current trust risk tolerance thresholds), and/or pose a significant risk to delivery of the trust’s strategic objectives, or risks that cannot be mitigated at directorate level. The ORR informed the Board Assurance Framework (BAF) maintaining oversight of significant risks which, if they materialise, may affect the strategic direction of the trust. Risks on the ORR were those which had been escalated and accepted by the trust board sub committees as risks which required senior ownership, scrutiny, and support in mitigating. The ORR was overseen by all sub board committees i.e. the quality and safety, business and performance and people and culture committees. A significant ongoing risk identified on the ORR was the lack of ECT provision in the south of CPFT’s geographical patch.

Directorate teams and services were held to account through a monthly patient safety meeting where they reviewed the content of a quality and safety report. Any exceptions requiring escalation that were identified were then taken to the performance risk executives (PRE). Outcomes were then fed into the appropriate subcommittee through the operational report.

Staff both during and prior to our assessments of frontline services told us the trust did not have always effective governance systems and escalation processes to ensure services were safely staffed. Staff recruitment and retention impacting on the consistency of staffing was identified as a significant risk during the inspections of services. However, at the well led review we found this was reflected on the board assurance framework, that mitigations were in place and improvements were gradually happening. The latest board papers showed turnover as 12.26%; vacancies at 9.03%; sickness as 5.31%. Bank and agency fill rates are just under 94.33%. The most significant workforce challenges were medical with consultant psychiatrists having a 17% vacancy rate. There was ongoing recruitment for these posts continuing with a number of offers and new starters expected.

A number of actions were in place to mitigate the ongoing staffing issues. These included reviewing the staff benefits and rewards, bespoke recruitment plans for directorates, ongoing international recruitment, centralising the support worker ‘new to care’ recruitment, promoting flexible working, working with system partners to access housing, reviewing the vacancy control processes and working with the ICS on a long-term work-force plan.

The trust had a comprehensive operational performance report. It highlighted areas of risk such as inpatient flow (out of area placements, delayed discharges), waiting lists and mental health DNAs. The data was presented clearly making use of run charts and data also related back to the individual directorates. There were concerns about whether data was sufficiently timely with performance data at the latest meeting noted to be 3 months out of date. The trust told us of the need to ensure that operational data presented to the sub committees and Board had been through a governance process in order to provide the necessary level of data quality assurance. The trust told us the data would have been used initially as part of the Directorate Performance and Risk Executives Committees. There were also concerns about whether the documented actions were sufficient.

In addition to the ORR there was also a quality report. This monitored a wide range of mental health and physical health incidents as well as mortality and patient experience including complaints. The trust also produced a people and agency report which included a wide range of workforce data. The data included in these reports was noted to be more timely.

The system fed back concerns around to be a lack of data sharing with the integrated care board on core contract delivery that would enable a system overview of risk, performance and outcomes. Clinicians in our focus groups also reported how they were struggling to get data pulled from the trust to provide feedback to NHSE for projects.

The trust had a guardian of safe working hours, reports were delivered to the board quarterly. Currently at the trust working practices for trainees continued to be safe. The trust had arrangements in place to complete medical appraisals and revalidation. An annual report highlighted 31 missed appraisals from 153 doctors. The trust noted that more trained medics were needed to carry out appraisals.

The Nursing and Midwifery Council and General Medical Council had both provided feedback about the trust and had not highlighted any concerns. The trust was referring individuals as needed as part of its fitness to practice procedures.

The pharmacy team had clear and effective systems for governance, management and accountability. The medicines governance group (MGG) was effective in overseeing medicines related incidents and risks. Following an internal audit review of medicines management, the MGG also monitored the implementation of the recommended actions across all inpatient areas. The medicines safety officer (MSO) role had been vacant for over 18 months. However, the trust was recruiting to fill this role, which would also include antimicrobial pharmacist responsibilities. Despite this gap, the team had continued essential work. They reported quarterly on medicines-related incidents, shared learning and published a medicines bulletin.

Robust arrangements were in place to ensure that the trust discharged its specific powers and duties according to the provisions of the Mental Health Act 1983. The medical director was the executive mental health law lead for the trust. In addition, there was a non-executive director, a head of mental health law and a mental health law clinical lead. The mental health law policy and practice group met bi-monthly and was chaired by the mental health law clinical lead. The group submitted a bi-annual report to the quality and safety committee. The latest quarterly report produced by the mental health law policy and practice group provided data about activity in relation to the use of the Mental Health Act, examples of which were the number of detentions by section of the Mental Health Act, out-of-area placements and the ethnicity of detained patients. The data showed that people from Black and other minority ethnic groups were disproportionately represented among detained patients. The head of mental health law and the clinical lead were exploring further data collection with the team leading on the trust’s patient and carer race equality framework (PCREF). Concerns raised in the CQC Mental Health Act monitoring reports were considered by the mental health law policy and practice group. Actions taken to address these were reported on.

The trust had arrangements in place to monitor its compliance with the Mental Health Units (Use of Force) Act which came into effect in 2022. The trust had a lead to oversee the work to monitor and reduce the use of restrictive interventions. The trust had published its policy and provided information for patients on their rights. The trust had training certified as compliant with the Restraint Reduction Network Training Standards. The trust monitored the use of restrictive practices in line with the NHS digital mental health services data set through a violence, aggression and restrictive practice ligature reduction group. However, compliance with training on prevention, management or violence and aggression was at 71% which meant there was a risk of staff using restrictive practices inappropriately or incorrectly.

The trust had a focus in 2023/24 on improving the sexual safety of people using services. This is included face to face training for all MH inpatient staff; sexual safety policy; leaflets to use to support conversations. The trust continued to monitor sexual safety incidents. In 2023/24 the trust also focused on reducing preventable harm for older people with falls prevention work for inpatients. This included improving the guidance on falls screening, developing a falls dashboard to identify patient specific needs, and adding a falls safe audit to support clinicians.

After a long period of financial stability, the trust had become exposed to turbulence which was impacting the delivery of its plans. Its financial plan for 2024-25 required significant reductions in spending on agency staff and out of area placements, both of which it had struggled to achieve. The trust told us that it expected to achieve its financial targets in 2024-25 with support from the integrated care board. Feedback from external stakeholders noted that the trust needed to ensure the focus on financial grip and control was recognised as an organisation wide necessity and not solely an issue for the finance team.

At the time of the inspection, the substantive chief finance officer (CFO) was unavailable. An interim CFO had been appointed for a 3 month period to steer the finance function through the end of year processes and oversee the development of financial plans for 2025-26. There had been a high level of staff turnover in the finance department and a risk had been identified in consequence about the loss of corporate memory and resilience.

The external auditor had stated that that the trust accounts for 2023-24 gave a true and fair view. They made no published specific recommendations in their value for money opinion on the trust’s arrangements for financial sustainability; governance and value for money.

For 2023-24, the internal auditor had given an opinion of partial assurance on the operation of the systems of internal control within the trust stating: “The organisation has weaknesses in the framework of governance, risk management and control such that it could become inadequate or ineffective”. Just prior to the inspection a potential fraud case referred to police was being investigated.

The trust had a major capital development taking place with the integrated children’s hospital. Full capital had not yet been resourced for this project but robust plans were in place to meet the target.

Staff raised concerns to us about teams losing control of their budgets and incidences of having promised funding withdrawn. They also noted that director posts seemed to be filled much quicker than clinical posts and raised a lack of communication about posts which were not to be filled.

There was effective oversight of cybersecurity and information governance at the trust. There had been no cybersecurity incidents recorded. The trust had completed the NHS England data security and protection toolkit, a self-assessment tool which found they were largely compliant and were addressing outstanding areas where further work was needed. The trust also had a digital transformation strategy which included the role out of electronic prescribing across the trust. Staff did however raise concerns that poor technology and aging devices significantly impacted productivity in clinical areas.

The trust board recognised the need to prioritise and strengthen its partnership working. Feedback from some system partners noted that the trust had historically tended to be insular in its approach and defensive in acknowledging issues or opportunities for improvement.

The trust was in segment 3 of the NHS England Oversight Framework, which meant it was being supported to address concerns which needed to be resolved. An improvement board was in place that met every 6 weeks, and an improvement plan had been developed with the trust scoping the support and resources needed for delivery. The trust board were engaged with the work to make the necessary improvements including plans to review the future organisational design of the trust and its alignment with emerging integrated models of care.

The trust strategy included addressing health inequalities as part of enabling strategies, however senior leaders recognised that further work was needed to understand inequalities and meet the needs of specific communities across the trusts footprint. However, there were some examples of where services had been developed or adapted to make improvements for vulnerable communities. One example was the children’s and young people’s physical health integration project. Another the virtual ward being developed for Clozapine initiation and monitoring in more deprived areas of the patch.

Healthwatch reported regular engagement with the trust through children’s and young people's forums across the patch but said its engagement with the trust’s head of patient experience was in its early stages.

The trust was a key partner in the East of England provider collaborative alongside 5 other partner trusts. The collaborative commissions specialised mental health services including children and young people inpatients and admission avoidance schemes, adult eating disorder inpatients and admission avoidance and secure mental health services. Feedback noted that over the last 3 years, the collaborative (with the trust as a key participant) had significantly reduced waiting times (admissions take place when clinically required) as well as the number of people in inpatient treatment through providing viable alternatives. The collaborative reported a strong and mutually respectful working relationship between the trust nursing director and the collaborative Head of Quality. The collaborative was also noted to undertake significant co-production with service users and carers being key participants in clinical design and delivery groups as well as the collaborative board.

The trust’s governors told us they felt supported to fulfil their roles. There were joint development sessions with non-executive directors and governors as well as service visits. There was an annual member meeting that took place yearly. There was also a drive from the new chief executive to enhance governor engagement and redevelop the membership strategy.

The trust worked in partnership to safeguard people. Mental health statutory social work with adults whose main presenting needs were associated with their mental health was delivered by the trust under partnership agreements with Cambridgeshire County Council and Peterborough City Council, under section 75 of the national Health Service Act 2006. Quality assurance and governance arrangements included the monitoring of the local authorities legal and policy frameworks. All safeguarding concerns were received and managed via the respective local authority adult safeguarding services. This ensured that all concerns regarding adults at risk were effectively and safely addressed. This included all aspects and sources of harm, including physical and psychological abuse, and exploitation. Board papers reported that there were 600-650 safeguarding referrals being made each month. The majority of these were complex and 64 external safeguarding reviews were taking place.

The trust also had a section 75 partnership agreement with Cambridgeshire County Council and Peterborough City Council for Approved mental Health Professional (AMHP) provision under the Mental Health Act. The AMHP team had 3 hubs across the geographical area covered by the trust. Recruitment was ongoing and additional work was being carried out to increase availability. There was a challenge to cover some of the specialist work, for example, with people with a learning disability, and the team were looking at a targeted recruitment strategy.

There were a number of multi-agency policies and protocols, for example, the section 117 after-care policy, which involved local authorities, the Integrated Care Board and the trust. The system partners were in the process of developing additional standard operating procedures to replace the current policy with a new joint policy. The trust had service level agreements (SLA) with local NHS hospitals.

The pharmacy team works closely with other partners in the system. For example, the integrated care system (ICS) identified high prescribing of broad-spectrum antibiotics in minor injury units. To address this, the pharmacy team participated in an audit and confirmed that independent non-medical prescribers were following current guidance on antimicrobial prescribing. The team is also close to meeting the ICS target of referring 20% of discharged patients to the discharge medicines service (DMS). The DMS is a community pharmacy service that helps patients who need extra support with their medicines after leaving the hospital. The trust regularly received updates on these referrals from the ICS.

The appointment of a non-executive director with a background in general practice had led to an increased understanding and work across the community care - primary care interface, to the benefit of patients.

The trusts received about 20 complaints a month and had around 300 patient and advice liaison service (PALS) contacts per quarter. The top areas for complaints were access to and quality of care. Issues were noted in the time taken to respond to complaints. From September to November 2024 no simple complaints had received a response in 30 working days and only 13-20% of complex complaints had received a response within 50 working days. The trust had identified that most of the delays had occurred in the quality checking phase and were training an additional 100 people to be able to address complaints. At the point of onsite inspection 39% of complaints were classed as overdue. People were also not always satisfied with how their complaints had been handled, with concerns being raised to CQC that processes were not effective. Our onsite review of complaints noted that lessons learnt from complaints were not consistently recorded.

The involvement of people who use services and carers in developing and evaluating improvement appeared to be at an early stage in the trust. A lead for service user experience had a very broad portfolio and had made positive progress with the limited resources available for this work. A participation and partnership forum had been established in 2018. It consists of service users and carers. They provide support to which had helped to provide input to consultations, review patient and carer information and attend some governance committees, the development of surveys as required and involvement in specific projects. They had developed a survey to collect feedback from patients, but this had low completion rates of around 10% and was being reviewed.

The trust board was not routinely hearing feedback from people who use services. In the last year only 1 board meeting had heard directly from people who use services or their carers. Co-production throughout the trust was limited and not happening routinely in areas such as service redesign, quality improvement, quality assurance, staff recruitment and development.

There was a lack involvement of people who use services with the exception of the children’s and young people’s directorate. This directorate had a dedicated involvement lead. A young people’s forum was established in 2023 with a membership of about 40 young people who were paid for their involvement work. This group had supported the design of the young people’s home treatment service. They were also co-producing a youth leadership programme with external partners.

The trust employed around 32 peer support workers across its teams. The trust also had 180 volunteers, but only a small number of these were people with lived experience of using services.

Work with carers was also at an early stage. The trust was using the triangle of care and had identified named carers for people using services across 80% their adult and older patients. They were also introducing carer leads across services, but there were challenges keeping this information up to date. A carer programme board was in place with links to external organisations supporting carers.

The trust aspired to progress as a world-leading research organisation for mental health and community physical healthcare. The Windsor Research Unit worked with local, regional, and international partners to ensure maximal benefit from research. This collaboration aligned with trust and integrated care system (ICS) clinical priorities. The unit team delivered studies and clinical trials for a range of mental health and physical health conditions, neurodegenerative conditions, intellectual disabilities, rare conditions and COVID-19. We saw evidence of innovative and exciting research aimed at improving the lives of patients. The opportunity to be involved in research continued to be a draw for clinical staff wanting to work at the organisation.

However, there was a variation between research opportunities across the trust. Research was more focused in the Cambridge area and further development was needed in Peterborough. This disparity was identified on the trusts board assurance framework.

CPFT was also a University of Cambridge teaching trust. The trust had a draft clinical innovation strategy and there was a research and development dashboard at an advanced stage of development.

Quality improvement (QI) work at the trust appeared to have slowed. There were examples of QI work currently being undertaken at the trust including a pilot taking place on some inpatient wards to improve the quality of patient care. However renewed work needed to be put into the direction and drive in this area.

The trust was an active member of the Royal College of Psychiatry College Centre for Quality Improvement. The trust had wards and teams in 9 quality networks for inpatient CAMHS, adult community mental health teams, crisis intervention services, eating disorder services, ECT, forensic, acute mental health inpatient services, perinatal services and learning disability inpatient services. Two of the services ECT and 1 acute inpatient ward were fully accredited.

During 2023/24 the trust participated in 13 national clinical audits and 5 national confidential enquiries which covered the relevant health services provided by the trust. The trust also completed 94 local clinical audits. Actions from these audits were documented in the trusts annual quality account.

The trust had implemented a new process for learning from deaths. A mortality team was in place with a mortality manager, mortality specialist reviewer and mortality officer. Oversight of the team was held by the deputy medical director. Structured judgement review (SJR) processes are used when looking at the deaths. The trust was currently completing 12-15 SJR’s a month. Some of the themes had included physical health in detained patients, the importance of good documentation and communication. There was a learning from deaths group forum with bi-monthly in-depth learning sessions open to all clinicians. A 7 minute briefing was also shared across the trust which included how learning had been implemented. SJR’s were benchmarked monthly by department and directorate. Around 85% of SJR’s at the trust were currently being recorded as good or above.

A quarterly mortality and learning from deaths report was produced and the trust continued to monitor its progress in meeting the requirements of the National Guidance on Learning from Deaths – in terms of its recording, monitoring and triangulating data. Further work was ongoing to improve learning across the organisation. This included taking departmental mortality reviews out to staff as well as looking at patient and carer involvement in the review process.

There was an annual learning from lives and deaths – people with a learning disability and autistic people (LeDeR) report to the quality and safety committee. This is a Cambridgeshire and Peterborough system report. In 2022/23 there were 54 deaths of people with a learning disability within Cambridge and Peterborough, the median age was 60 which was 2 years below the national average. Of these 54% of the deaths were avoidable. Not all of the deaths included in this local system report are of patients known to, or receiving care from CPFT services. The trust told us that after each in-depth learning from deaths case review, a 7-minute briefing is shared across the trust, which includes how learning has been implemented.

The trust implemented the patient safety incident response framework (PSIRF) last year. There were 2 full time PSIRF investigators employed at the trust. There were 5 local priorities for the first year, these were: deaths by suicide of those who had 2 or more contacts in the year prior to their death, any service user leaving a mental health unit outside of agreed care planning arrangements resulting in moderate or greater harm (i.e. Absent Without Leave also know as AWOL), delays in assessment and deterioration for a patients physical health leading to moderate or greater harm, self-harm of an inpatient resulting in moderate or greater harm or resulting in admission or treatment in a general hospital and inpatient sexual safety incidents leading to moderate or greater physical or psychological harm. Priorities for the upcoming year are currently out for consultation. Part of this consultation process engaged service user collaborative groups.

In the first year 1 patient safety incident investigation (PSII) had been completed, and another was close to completion. Two further investigations involved the use of PSII principles. One of the trusts ongoing priorities recognised in the annual quality account was embedding the use of PSIRF across the organisation.

There were other examples of innovative work to improve patient safety. For example, the domiciliary medicines management service helped people in the community manage their medicines safely and independently at home. Staff shared an example of how they empowered a person with Parkinson’s disease to take control of their medicines by optimising their regimen. The service had received positive feedback from service users and their families, and staff had been nominated for awards. The team was also piloting an innovative model with the intermediate care team.

The Healthy IO, an innovative wound management project started by community nursing teams at the trust had developed a wound app, Minuteful. The introduction had seen consistency and accuracy of wound measurements improve, with standardised wound recording supporting best practice and patient flow. The project had been shortlisted for 3 national awards.

A pioneering partnership involving the trust, Cambridge Neuroscience and award winning game developer Ninja Theory had also recently received a prestigious research award for their collaboration. Ninja Theory, the Cambridge based BAFTA award winning video game developer worked with staff and students from the trust’s RCE wellbeing hub and Cambridge Neuroscience to create a best-selling game in which the protagonist had psychosis. The trust’s staff and those with lived experience of the condition offered advice to the creative team during development of the game.

The trust had a Green Plan, in line with national guidance, which was published in 2022 following calculation of the trusts’ carbon footprint. Leaders acknowledged this plan was due to be updated and had a clear idea of the future direction of the trusts journey to net zero. There was governance in place to ensure performance against targets and a board level lead for net zero. The trust board was updated on the Green Plan progress within the annual report, for which different departments across the trust fed in their progress. Leaders acknowledged, in the future, it could be beneficial to have a group meeting around sustainability more regularly than they currently do, to ensure net zero goals are tracked more consistently throughout the year.

The trust had clinical teams providing different services in inpatient, community and primary care settings across a large geographical area. This was identified as a challenge for engagement in the net zero goals, as communicating to staff across the organisation was difficult. There were clear plans to change this in the future, and there is an understanding of the importance of engaging and educating clinical staff on sustainability. Staff were supported to attend courses relating to environmental sustainability externally, but currently there were no internal courses available to trust staff. There was support for staff to become involved in research and quality improvement projects which have a sustainability focus, with examples outlined.

The trust was clearly engaged with the ICB around sustainability, with acknowledgement of their contribution to the ICS Green Plan and examples of engagement in ICB wide sustainability projects including medicine use and reduction of waste. The trust contributed to the national data return on their emissions and were committed to national initiatives for reducing emissions in the NHS for example within medicines, estates and procurement.

Within some areas, such as medicines, there was a clear understanding of where reduction in emissions could be achieved, and the trust has been successful in these initiatives. For example, introduction of electronic prescribing, which has led to reduction in medicines waste and reduction in travel between wards. However, there were challenges around other areas of focus such as travel and procurement, which made up the majority of their carbon footprint. This had been identified by leaders as an area of focus moving forwards.