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

We rated Safe as Requires improvement. We assessed 6 quality statements. Learning from incidents was not fully embedded. The service had high sickness rates and vacancy rates for registered nursing staff. Managers had not ensured all staff were kept up to date with supervision, appraisals and mandatory training. Caseloads between the 2 Crisis and Resolution Home Treatment (CHRT) teams varied. However, staff knew how to protect people from abuse and neglect. Staff completed individual risk assessments. Staff knew what safety incidents to report and how to report them. Most patients were assessed and seen within Trust target times. Staff completed and updated thorough risk assessments.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients and carers we spoke with told us they had never had to raise a concern or complaint and felt safe using the service.

Staff knew how and when to report incidents. However, not all staff were aware of serious incidents or how learning from incidents across the wider organisation had been actioned to make changes or improve services. Staff were not able to describe formal systems within the Trust to share lessons learned or themes or trends arising from incidents. Staff told us they were supported with debriefs following incidents. Staff from the First Response Service told us they got support after taking a difficult call and gave example of psychology support after a serious incident.

There were systems in place for the recording of incidents, and sharing lessons learnt. We saw examples of monthly communications for staff on learning from risks, incidents and complaints. These included themes, recommendations and good practice examples including those identified from rapid review incidents. We saw an example of a complaints log for the First Response Service, there had been 4 complaints in the last 3 months, 3 related to access to services and 1 was about attitude of staff. There had been no complaints received for the other 3 teams during that time. We saw that serious incidents and complaints were discussed at directorate governance meetings. We reviewed both staff team business and governance meeting minutes and saw discussion of incidents and complaints took place. However, these formal mechanisms to share learning from incidents were not fully effective as not all staff we spoke with were able to give examples of learning from incidents. We reviewed team level incident data for the previous 3 months. This showed that incidents were recorded against different category types. We saw staff recorded immediate actions that had been taken. The service had mandatory training courses for staff working within the Crisis and Resolution Home Treatment teams on the Patient Safety Incident Response Framework (levels 1 and 2). Of the 4 teams, 3 were up to date with this training however, the compliance rate for level 1 and 2 training fell below the service training target for Crisis and Resolution Home Treatment North team.

Patients and carers told us there was effective communication between services.

Staff gave mixed feedback on their caseloads and whether they were manageable. They told us they could work across teams to support if needed. Staff said there were processes in place for monitoring patient risk and keeping people safe. They said they took part in daily handover discussions. Staff at Crisis and Resolution Home Treatment South team described using a smart board that listed each patient to priortise their daily work according to individual level of need. Staff we spoke with could not describe clear criteria for referral into the Crisis and Resolution Home Treatment teams or provide details of how many referrals were declined . Staff said that the availability of inpatient beds could be a pressure at times. If no beds were available patients remained on the team caseload. Sometimes patients were placed out of their own area if a bed was not available closer to home . Crisis and Resolution Home Treatment staff were gatekeepers for inpatient acute beds, staff told us this took up a lot of their time. Staff in the 136 Suite described good liaison with the local Emergency Department and police. Staff told us that a Police Joint Response Car was set up in 2022 with the aim of ensuring people in mental health crisis received appropriate care and support to reduce unnecessary detentions under 136 Suite . This initiative was staffed with staff from the First Response Service. Staff from the First Response Service told us they had good relationships with the physical health 111 team. Crisis and Resolution Home Treatment teams and First Response Service said they worked well together to look at the patient pathway and First Response Service worked to avoid people needing to get to the Crisis pathway. However, staff told us timely responses to referrals to Approved Mental Health Professionals (AMHPs) for a mental health act assessment was an issue.

We did not collect the evidence to score this evidence category.

The service had operational policies and procedures in place to support safe systems, transitions and pathways. There had been no use of restrictive practice in the last 6 months. The Crisis and Resolution Home Treatment teams’ operational policy set out the referral and eligibility criteria, referrals and assessment process and discharge procedures. The Trust provided referral and assessment data. Most people could access the service when they needed it and received the right care in a timely way. We reviewed waiting times data supplied by the Trust. Whilst most patients were seen within the Trust target times some people were waiting longer to be seen. Data showed for both Crisis and Resolution Home Treatment teams and the First Response Service that the average wait from referral to assessment was 1 day. This meant most patients waiting received an assessment within the Trust target of 24 hours. However, a small number of patients waited longer than the target time with the maximum wait for Crisis and Resolution Home Treatment team North was 12 days and South was 9 days. For the First Response Service the maximum wait was 13 days. We clarified the data with the Trust. They told us this was a data recording issue, and the data provided was incorrect. Data showed for both Crisis and Resolution Home Treatment teams the average wait from assessment to treatment was 1 day, this was within Trust target. The number of people on team caseloads varied between teams. Data showed the caseload for Crisis and Resolution Home Treatment team North was 25 and for Crisis and Resolution Home Treatment team South this was 9 (as of 8 August 2024). There were meeting structures in place to ensure staff interfaced between services including Crisis Resolution and Home Treatment teams, First Response Service, Community Mental Health teams, CAMEO, psychiatric liaison and inpatient acute wards to share information about patients and discuss referrals.

Patients and carers we spoke with did not report any safeguarding concerns. Patients told us they felt safe using the service and that staff helped them to keep safe. Patients we spoke with told us staff discussed individual rights under the Mental Capacity Act (MCA).

Staff had a good understanding of safeguarding, they could explain the process for doing this. Staff were all aware of when and how to make a safeguarding referral and knew who their safeguarding leads were. Staff told us, that safeguarding was regularly discussed in team meetings and they had access to quarterly supervision with the safeguarding team. Staff had a good understanding of the Mental Capacity Act (MCA) and knew how to apply this in their work.

We saw in records that patients had safety plans which were co-produced with staff . We saw in staff meeting minutes that safeguarding matters were routinely discussed in team meetings.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. We saw evidence that there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service had a comprehensive local safeguarding procedure and a range of policies to protect adults and children. As part of the assessment, we reviewed the service safeguarding log which included the total number of safeguarding requests made to the Trust central safeguarding team. Staff were kept up to date with mandatory training for safeguarding adults and children level 2 and level 3, except staff who worked in the 136 Suite, with a training compliance rate of 67% for safeguarding children level 3. Staff were kept up to date with both training on the Mental Capacity Act and Mental Health Act.

Patients told us that staff completed risk assessments and discussed these with them. They said staff helped patients to understand risky behaviours and worked with them to create a plan to cope with them.

Staff we spoke with were aware of risk issues and completed thorough assessments. Staff said they involved people to manage risk and collaborated with patients to co-produce care plans. They told us they assess risk daily and where a risk was identified they visit in pairs. We observed staff assessing risks on a home visit. We saw how they actively involved the patient during the visit. They checked the patients’ own thoughts on how safe they were feeling that day.

There were operational policies and processes in place for identifying patients at elevated risk or in urgent need. As part of the assessment, we reviewed 15 patient records. Staff completed risk assessments for each person when coming into the service using standardised tools and updated these regularly. We saw from records that staff co-produced care plans with patients.

We did not collect the evidence to score this evidence category.

Staff told us most appointments took place at patients’ homes or in local facilities and not at Trust offices. Patients in Peterborough could have appointments in the visitor’s room at the Cavell Centre. Meeting spaces we visited were clean and tidy and suitable for the needs of the patient. Some staff told us they did not always feel safe at work and staff described lone working arrangements that were not consistent across the teams. Not all staff had access to a Trust telephone and had to use their personal telephone. This meant that staff did not have access to panic buttons or check in apps on their mobile phones and would need to ring the office if there was an issue. The Trust had one 136 Suite in Cambridge. Staff told us that this was not sufficient to meet the demand on the service and the size of the area covered.

When we visited the 136 Suite, we saw this had an outdoor space with a wire mesh fence. This meant it was visible to all passers-by and therefore we were concerned about the privacy and dignity of patients. We observed the medicines cupboard at Crisis and Resolution Home Treatment team South was open for all staff to access instead of being locked. We saw the first aid bag at the Cavell centre, Peterborough had items missing, including for example plasters, shears and burns dressings. The contaminated sharps box in Mulberry 1 had a hole in the top and posed a potential infection control risk. We observed staff safely attending a home visit, 2 staff members attended this visit.

We reviewed risk registers and saw the teams had recorded and considered general environmental risks. For example, fire safety, security of property, infection control and kitchen areas. There were no concerns identified that required immediate action, all current risks were categorised as low. The risk registers did not include any potential ligature risks that may be present at Trust premises . Staff safety and lone working arrangements were included in the Crisis and Resolution Home Treatment operational policy. The Trust has a lone working policy. Staff were signposted to the “Working Alone in Safety - Guidelines on the Prevention and Control of Violence and Code of Practice” policy, from within the service operational policies.

Patients and carers told us that staff were well trained and experienced. They said staff were supportive and responsive.

Staff told us that recruitment was challenging with high vacancy rates. However, they felt this was improving as vacancies were reducing. Staff said there had been a lot of sickness. Managers tried to use regular bank staff to cover any vacant shifts. Staff said they could support other teams if there were gaps in rotas. Most staff we spoke with told us they received regular supervision and appraisal.

On the day of the site visits we observed there were suitable numbers of staff on shift to meet the needs of the patients. During the site visit we observed Crisis and Resolution Home Treatment staff in the Cambridge office were not overly busy with appointments or calls. This meant we were not fully assured that staff were effectively deployed across the service.

We saw from data provided by the Trust that the service had high vacancy rates for registered nurses for all the teams except for the 136 Suite. For Crisis and Resolution Home Treatment South the vacancy rate was 51%, for Crisis and Resolution Home Treatment North this was 32% and for the First Response Team this was 42%. The service had high sickness rates. All teams, apart from the 136 Suite team, had a sickness rate higher than the Trust target. Due to staffing gaps, managers used bank and agency staff to fill shifts. Managers mostly used bank staff and kept the use of agency staff to a minimum. In the 3-month period prior to our inspection there were between 5 and 65 shifts unfilled across the teams. We reviewed incident data for the 3 months prior to our assessment. During this time, the Crisis and Resolution Home Treatment South team reported 8 occasions where staffing levels were inadequate. On these occasions we saw that Crisis and Resolution Home Treatment North supported these shifts or they were filled by bank staff. Crisis and Resolution Home Treatment North had not reported any staffing level incidents for the same period. We saw from Crisis and Resolution Home Treatment teams risk registers that safer staffing and workforce capacity had been identified as high risk for the service. All the services had low staff turnover rates, below the Trust target. There was a comprehensive mandatory training programme in place with modules to meet the needs of staff and patients. Training compliance figures showed that most staff were kept up to date with mandatory training. However, there were some courses within the teams where compliance fell below the Trust target. For example, medical emergency response, basic life support and medicines management. We reviewed supervision rates for all teams and saw these were lower than the Trust compliance rate for all teams. Appraisal compliance rates for all teams were also low.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.