This guide sets out what our inspectors and Mental Health Act reviewers look at when checking how providers implement the Patient and carer race equality framework (PCREF).
It applies to NHS mental health trusts and providers of mental health services in receipt of public sector funding.
PCREF supports trusts and providers to become actively anti-racist organisations. It does this by making sure they co-produce and implement actions to reduce racial inequalities within their services.
The NHS Standard Contract 2025-26 says providers of mental health services must implement PCREF. Trusts and services must develop plans to reflect their communities and demographics.
Trusts and providers must show how they implement, evaluate and achieve PCREF actions and outcomes.
What inspectors and Mental Health Act reviewers look at
We have a commitment to tackle inequalities and protect people's human rights.
As part of this commitment, we will look to see how providers implement PCREF. Evidence from PCREF also helps us prevent ill-treatment, a core function of our role within the National Preventive Mechanism.
Mental Health Act reviewers will look at PCREF to help understand if the rights of people detained under the Mental Health Act are being upheld. Reviewers may share what they find with inspectors to be looked at as part of our regulatory activity.
We will look at evidence related to PCREF when we make judgements about the quality of care. Failure to implement PCREF may indicate institutional racism or closed culture risks.
If providers and services cannot provide evidence that they are making progress in implementing PCREF, there may be an impact on their ratings.
Where appropriate, we may share what we find with other organisations, in line with our obligations and agreements. These organisations could include the provider, system partners and their regulatory counterparts, such as local adult safeguarding teams and integrated care boards.
When we look at how providers are implementing PCREF, we will use the following key questions and quality statements as a starting point:
- For services: Equity in experience and outcomes (under the responsive key question)
- For NHS trusts: Shared direction and culture (under the well-led key question)
If necessary, other key questions and quality statements can then be looked at. For example, evidence related to improving the wellbeing of racialised staff groups, promotion of workforce diversity and tackling bullying, harassment, discrimination and violence would sit under the Workforce equality, diversity and inclusion quality statement.
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What inspectors look at
The things we look at will vary as PCREF is context specific, but may include the types of questions and evidence below.
Service level assessments
Questions for before the inspection
The things we ask a provider before an inspection could cover:
- information about services using PCREF and how they apply the framework
- processes for working with local communities
- how the provider handles feedback
- the kind of information they collect.
Evidence we look at may include:
- PCREF action plan and self-assessment
- data and insight summary of risks from mental health services data set policies
- information from trusted community leaders and organisations
- Mental Health Act reviewer findings
- culturally rooted forms of feedback, such as those shared through trusted community intermediaries.
Questions for the on-site assessment
The things we ask people and carers could include:
- Do people have access to clear communication in ways that meet their needs?
- Do people say they are supported and are there any differences in responses based on ethnicity?
- Were people given the opportunity to develop an Advance Choice Document and individual care plans, and are there any differences in responses based on ethnicity?
- Do people think their care attends to their cultural needs?
- Do people feel that their ethnicity or culture has an impact on how they are cared for?
- Do people feel encouraged and supported to raise concerns, and are there any differences in responses based on ethnicity?
- Do people think the provider offers holistic care support, and are there any differences in responses based on ethnicity?
The things we ask staff could include:
- How involved are staff in the service’s approach to PCREF?
- What are staff doing to improve people’s experiences of care they receive and quality of life?
- How confident are staff to work in a way that is informed by understanding of racial trauma?
- How do staff reduce health inequities?
- What are staff doing to improve the ward environment and encourage meaningful activities that reflect people’s cultures and interests?
- How do staff ensure people are provided with information in line with their communication preferences?
- How are staff encouraging and enabling feedback, and how confident are they at supporting people who are raising concerns?
- Do staff think the provider offers holistic care support that addresses broader needs such as housing, employment, and financial stability?
Evidence we look at may include:
- Patient Reported Outcome Measure Surveys (PROMS)
- Patient Reported Experience Surveys (PRES)
- carer surveys
- staff surveys
- focus groups
- interviews
- staff equality networks.
NHS trust level assessments
Questions for before the inspection
The things we ask a provider before an inspection could cover:
- information about services using PCREF
- processes for evaluating PCREF
- how they respond to feedback
- the kind of information they collect
- who is the Board lead and what actions are being taken at Board level.
Evidence sources may include:
- CQC and provider engagement meetings
- CQC findings on PCREF from service level
- Board meeting attendance
- Board minutes review
- PCREF action plans and self-assessments, including co-produced outcome measures
- Mental health services data set.
Questions for the on-site assessment
The things we ask could include:
- How is the trust monitoring progress of their PCREF action plan?
- How is the trust working with local racialised communities to shape services?
- Does their strategy and vision foster anti-racism, cultural humility and stigma-awareness as core principles?
- How are staff trained on PCREF, cultural humility and ways to tackle mental health stigma?
- How are they using data to ensure accountability, transparency and action?
- How the trust works with partners across the system?
- How is co-production for addressing racial inequalities integrated into long-term care strategies?
- Are mental health services delivered in trusted, community-based settings that are accessible and culturally relevant?
Evidence sources may include:
- narrative explanations of outcomes data, including data around the use of the Mental Health Act, deaths reported to CQC, and inequality metrics
- feedback and complaints from people using the service, carers and culturally appropriate advocacy services
- Advance Choice Documents
- information around use of restraint, seclusion and segregation, including the type/frequency of restraint
- Core20PLUS5 mental health focus areas for adults and children
- discussions with the PCREF lead, senior leaders and Board members
- community partners
- member of triangle of care.
Regulations and standards
Although PCREF is not a regulation, failure to implement it meaningfully may reveal failings, especially where racial disparities persist. As such, evidence that a provider is failing to implement PCREF in a way that prevents negative impacts on people, communities and staff, could demonstrate a breach of regulations.
PCREF will be implemented in different ways depending on each trust or service. We have included some ways in which PCREF can relate to the regulations, but this is not a prescriptive list.
The regulations that could apply in this case, depending on the concern, are:
- Regulation 9: Person-centred care
- Regulation 10: Dignity and respect
- Regulation 12: Safe care and treatment
- Regulation 13: Safeguarding service users from abuse and improper treatment
- Regulation 17: Good governance
What Mental Health Act reviewers look at
Mental Health Act reviewers will use chapter 3 of the Mental Health Act Code of Practice as a starting reference when looking at people's experiences of racism. They will then consider other chapters or paragraphs if applicable.
Mental Health Act reviewers can see evidence of the way PCREF has been implemented by:
- speaking with people and their families to understand if experiences differ based on ethnicity
- hearing from Independent Mental Health Advocates about how people's cultural needs are met
- exploring advocacy referral rates and the provision of culturally appropriate services
- following up on relevant concerns raised during reviews through ward manager interviews and 'provider action statement' requests
- looking at how the provider supports people in raising concerns
- checking whether engagement with community groups is visible at ward-level.