Cornwall Partnership NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good.

Good: Staff assessed the physical and mental health of all people who used services on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for people based on national guidance and best practice. Staff from different disciplines worked together as a team to benefit people. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and the Mental Capacity Act 2005.

This service scored 71 (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 maximised the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

The mental health access and brief treatment team (MHABTT) managed all referrals for community mental health teams (CMHT). Referrals to specialist teams including early intervention teams (EIT) were managed by the specialist teams. At the time of our inspection, the adult community mental health service was rolling out the use of a patient-rated scale satisfaction and outcome tool, which some teams had already implemented. The dedicated patient-rated scale assessment tool helped people who used services to identify how they felt about different aspects of their life, and what they would like help with. This helped inform people’s care plans.

We reviewed 20 care records of people who used services. Most records showed evidence of comprehensive assessments of people’s mental health needs. In 17 of the 20 records, we observed complete and in date care plans. The care plans reflected people’s needs identified in assessments, including specific treatment goals. The care plans were personalised, holistic and recovery focused.

Most of the care records we reviewed showed evidence of initial assessments of people’s psychical health needs. Of the 6 care records we reviewed from EIT East, all showed evidence of robust physical health assessments upon being accepted by the service.

We spoke with 14 people who used services. All of them told us staff understood their needs.

We observed staff carry out an initial assessment over the telephone. The assessment was comprehensive and covered a range of topics that affected the person’s mental health and wellbeing, including an overview of historic and current concerns. Staff asked what the person hoped to achieve and how they wanted the service to support them.

The service did not ensure all staff were trained in the Mental Health Act (MHA). However, the service planned and delivered people’s care and treatment with them, in line with current evidence-based good practice and standards.

The trust confirmed that MHA training was not mandatory for staff in the adult community mental health service. As a result, it was unclear how managers and senior leaders gained assurance that staff understood and could appropriately apply their duties under the MHA. However, there were clear policies and procedures for staff to follow to ensure people who were under Community Treatment Orders (CTO) had their rights upheld. A CTO is a legal order under the MHA that enables a person with a mental health condition to receive treatment in the community rather than in hospital, provided they comply with specific conditions, such as attending appointments and taking prescribed medication.

The trust’s MHA Office provided written information to people who used services and their nearest relative upon the start of a CTO. They also reviewed and audited people having their s132 rights explained to them on a three-monthly basis. The trust had appointed a new MHA manager at the start of 2026, who had developed plans to strengthen processes and audits of CTO rights being explained to people.

The adult community mental health service offered a range of treatment options suitable for people who used their services. Treatment interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE).

In the mental health access and brief treatment team (MHABTT), mental health and wellbeing practitioners carried out a range of short-term cognitive behavioural therapy-informed group and individual interventions. MHABTT clinical associate psychologists delivered a range of short-term group and individual psychological interventions such as emotional coping skills group and trauma stabilisation.

Staff and managers across the community mental health teams (CMHT) and early intervention teams (EIT), told us about the variety of psychological therapies and interventions people could access, which included family therapy.

In addition to psychological therapies, people could access medication. The service had consultant psychiatrists and nurse prescribers.

People could access support for functional skills, alongside social and employment opportunities. Some staff told us about the service’s employment support service.

Each team in the service was supported by operational and clinical leadership arrangements, including service managers, team managers, and clinical leads. The teams were multidisciplinary and comprised a range of professionals to support people receiving mental health care in the community. These included administrators, medical secretaries, support workers, healthcare assistants, occupational therapists, psychologists, mental health and wellbeing practitioners, clinical associate psychologists, consultant psychiatrists, physical health nurses, registered mental health nurses and social workers.

CMHTs and EIT had peer support workers. Peer support workers used their lived experience of mental health difficulties and recovery to support people using the service. Additional lived experience support was available through the service's community and voluntary sector partner organisations.

Staff maintained their expertise and skills to meet the needs of people who used services. Most staff and managers told us about continuing professional development (CPD) events. These took place regularly and included external speakers from other teams, services or organisations to increase staff awareness about a range of topics. Some staff and managers told us about monthly team business meetings. We saw evidence in team meeting minutes that staff were regularly updated on learning from incidents, complaints and good practice, and were informed of any planned changes to the service.

The service carried out a range of audits. These helped managers and senior leaders review how different aspects of the service were operating. For example, 6 months before our inspection, the service published an evaluation of the effectiveness of an emotional coping skills group for individuals with emotional regulation difficulties. The evaluation identified aspects of people’s experience of the emotional coping skills group that the service planned to use to inform improvements in its delivery of the group across the service.

The service mostly worked effectively across teams and services to support people, making sure they only needed to tell their story once by sharing their assessment of needs when they moved between different services.

The adult community mental health service worked well with different teams and services. Staff told us about other partners they worked with to support people who used services. These included social services, housing services, the probation service, educational establishments and drug and alcohol misuse services. We saw evidence in care records of communication with other agencies involved in supporting people, and of joint visits to people. This helped people reduce the need to tell their story multiple times as they accessed different teams.

Teams in the adult community mental health service held regular multidisciplinary team (MDT) meetings. MDT meetings included staff from different teams and services. Some staff and managers told us there was a regular slot in MDT meetings for staff from other teams such as home treatment teams, to attend. This supported effective sharing of information about people to plan transfers of care between services. It also helped create a shared understanding of different teams’ and services’ remits and ways of working. We observed handover and daily huddle meetings in which staff of all roles and grades contributed meaningfully to discussions about people’s needs, risks and progress.

All teams across the service had effective multidisciplinary working relationships. In all morning huddles and zoning meetings we observed, staff from all disciplines contributed fully. Staff collaborated effectively, showing respect for each other's opinions and encouraging contributions from the wider team. They also respectfully and professionally challenged each other when opinions differed. Staff displayed a solid understanding of the needs and risks of people on their caseloads and communicated these effectively.

We saw evidence in care records that staff updated people’s GPs, for example after medical reviews or outpatient appointments with consultant psychiatrists. We also saw examples in care records of staff carrying out joint visits with other teams such as home treatment teams.

The adult community mental health service worked with other teams and services to share learning and best practice. For example, once a month the weekly incident review group would include staff from crisis and inpatient services. Some staff told us there were monthly best practice meetings for different professions. These provided opportunities for staff to share learning that helped improve support for people who used services.

Staff and managers across the service told us about how they were working to improve how they worked with other teams and services. For example, some staff and managers told us about work being done with primary care networks to make sure they understood the referral criteria for community mental health teams (CMHT).

The trust had worked with the Devon, Cornwall, Isles of Scilly Health Care Providers and Devon and Cornwall Police to develop a Right Care, Right Person protocol. Right Care, Right Person is an agreement between policing, health and other relevant partners that sets out the principles around the Right Care, Right Person approach which aims to ensure that individuals in mental health crisis are seen by the right professional.

The service supported people to manage their health and wellbeing so they could maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

The adult community mental health service promoted healthy lifestyles. In the early intervention team (EIT) East, we saw posters for, and some staff told us about, a range of groups they ran for people who used services. These included walking, pool, cycling and beach days.

Across the service, people could be supported to access a range of interventions that supported their physical and mental health and wellbeing. For example, there were yoga groups people could engage in.

Some staff in community mental health teams (CMHT) told us they liked to encourage people to be active and would sometimes walk with them or signposted them to groups such as gardening groups. Some staff told us they had referred people to the council’s Healthy Cornwall service to support a range of physical health needs.

In EIT East, some staff had recently qualified as personal trainers. The team was finalising plans to provide personal training and nutrition sessions.

The trust had 2 peer support leadership roles, one of whom was leading a project called Healing by Nature. Some staff and managers told us this was a co-produced green health hub embedded within community mental health services. The project used lived experience leadership, relational practice and nature-based interventions to support recovery, prevention and workforce wellbeing.

Some staff told us that the biggest concern for many people on their caseload were smoking and diet. They told us they referred to smoking cessation support and provided meal planning support to guide them to make healthier choices.

Some staff told us they regularly discussed diet and exercise with people.

One person who used services told us they had experienced physical health problems in the past year. They told us their keyworker had been helpful in supporting them with these concerns, including linking in with their GP.

The service routinely monitored people’s care and treatment to continuously improve it.

The adult community mental health service routinely monitored people’s care in a way that enabled them to assess how effective it was and make necessary improvements. Most staff and managers told us about the range of outcome measures they used. These included nationally recognised ratings scales that assessed the severity and impact of people’s symptoms.

Most managers told us about the focus the service had on patient-reported outcome measures (PROM) to help identify what was working well from the perspective of people who used services.

The trust had a live business intelligence dashboard that was reported on at monthly senior leadership meetings. Senior leaders told us it was an ongoing project working to develop accurate reporting and recording. The intention was to regularly audit outcomes once reporting had been refined.

The service had recently introduced a patient-rated satisfaction and outcome tool. We saw evidence of it being completed in most of the 20 care records we reviewed.

We saw evidence in some care records of side effects rating scales being used for some people who were prescribed Clozapine. We also saw evidence in care records of people who had been supported to successfully reduce their medicine prescriptions.

Staff in the adult community mental health service did not have to complete Mental Capacity Act (MCA) training, however they demonstrated a good understanding of the need for people to consent to care and treatment.

Most staff and managers told us that people’s capacity and consent were considered throughout their time with the service. Most staff in the early intervention team (EIT) East told us consent was discussed frequently with people who used services. All staff told us consent was established as part of every assessment. Some staff told us they always considered people’s capacity to consent. The trust confirmed that MCA training was not mandatory for staff in the adult community mental health service. As a result, it was unclear how managers and senior leaders gained assurance that staff understood and could appropriately apply their duties under the MCA, including recognising when an individual lacked capacity and ensuring decisions were made in accordance with MCA principles.

We asked to observe care and treatment during our inspection. All staff considered individuals’ mental health and wellbeing, before seeking consent to observe when clinically appropriate. Where people declined to have their care and treatment observed, staff respected their wishes.

We observed 4 people receive depot medication during clinic appointments. In all 4 cases, staff reviewed documentation with people, including confirmation of their consent to share information with family members, partners, and approved contacts such as GPs and hospitals. During one of the clinic appointments, staff took additional time to explain what consent to share information meant, which supported the person to confirm who they were happy for certain information to be shared with.

We reviewed 20 care records of people who used services. In 18 of the 20 records, people’s consent to care and treatment and consent to share information was complete. In 1 of the 20 records, the section on consent was incomplete and, in another record, there was no evidence of consent ever being discussed or recorded. We saw evidence in records of consent being sought by staff to make referrals to other services, such as the foodbank.