Cornwall Partnership 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

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We identified 2 breaches of the regulations in relation to deployment of sufficient staff who had received appropriate training and supervision, and physical health monitoring.

Requires improvement: The service did not have sufficient numbers of suitably trained or supervised staff. Processes to ensure physical health monitoring for people prescribed medicines were ineffective. The service did not have robust oversight of all risks related to people who used services. The service had insufficient therapeutic space for appointments.

However, the service managed safety incidents well and learned from these to improve practice. Staff supported people through their care and treatment, including when they transitioned to other services. Systems were in place to control and prevent risks of infection.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The adult community mental health service mostly had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify good practices.

The trust had implemented the Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. All managers told us about weekly incident review group meetings, in which all incidents, of any level of severity, were reviewed. They told us staff of any banding were able to attend, so that learning was shared across all levels of the organisation.

Managers told us there was a range of learning responses to incidents, depending on the situation. Responses included debriefs, restorative reflection, patient safety incident investigations and roundtable discussions. Debriefs took place after each safety incident to identify initial learning and support affected staff.

Most staff could provide examples of learning that had been shared from incidents and had led to improvements in the service. For example, in early intervention team (EIT) East, some staff told us that they had made changes to the discharge process following an incident in which someone who used services became aggressive when care was withdrawn. They told us the team now provided a more structured approach to planning people’s discharge, which involved staff encouraging people’s independence in the last year of a person’s time under EIT.

Most staff and managers told us the adult community mental health service had a ‘no blame’ culture and they felt able to ask for help or advice as needed.

Some staff told us learning from incidents, including safety incidents and safeguarding, was shared in monthly team business meetings. The meeting minutes were saved and accessible to any staff not present at the meetings. Staff also told us about regular newsletters, posters and round table discussions that kept them updated on learning from incidents.

All staff and managers we spoke to knew how to report incidents on the trust’s incident reporting system and knew what sort of incidents to report. Some staff told us the incident reporting system comprised a form in which they documented all information relevant to the incident and indicated the level of harm caused. This form was then sent to managers for review and further escalation as needed. They told us outcomes and learning from reported incident was later shared within teams.

In the 12 months prior to our inspection, the service had recorded 751 incidents across community mental health teams (CMHT), early intervention teams (EIT) and the mental health access and brief treatment team (MHABTT). Of those 751 incidents, the most reported type of incident was categorised as ‘access and flow’ with 180 incidents. Of the 180 incidents related to access and flow, a third (61) were reported by North Cornwall CMHT. The second most reported incident type was categorised as ‘clinical harm’, which was reported 141 times, and the third was ‘information and systems’, which was reported 134 times. The team with the highest number of total incidents reported was North Cornwall CMHT, with 141 incidents reported across a variety of themes.

All managers understood the duty of candour. The duty of candour is a legal obligation for healthcare providers to be open and honest with people who use services, or their families, when something goes wrong with their care or treatment and causes harm or has the potential to cause harm. All managers could give examples of times they had to implement the duty of candour, and how they involved and supported families during the investigation process and afterwards.

In the 12 months prior to our inspection, the adult community mental health service had recorded 24 incidents that met the threshold for duty of candour. We saw 3 duty of candour letters and each of them expressed condolences to the families of those affected. All 3 letters provided clear information about what had been discussed or agreed in previous conversations, the investigation process, and families were given information about additional support available to them. In 1 of the letters, a manager had confirmed that following their agreement in a previous conversation, they had referred the family member to the appropriate team for their own mental health support.

The trust had not received any Prevention of Future Deaths reports in relation to community mental health services in the 12 months prior to our inspection. The trust had not reported any Never Events in the 12 months prior to the inspection. Never Events are defined as wholly avoidable incidents.

The trust held bimonthly mortality review and oversight group meetings and bimonthly clinical review group meetings, in which learning was shared and actions to embed learning were agreed. We saw evidence the trust undertook Structured Judgement Reviews (SJR). SJRs are a way of learning from deaths of people using health services, even when no specific concerns have been raised.

The trust had a suicide prevention clinical review group. The group looked at suicide prevention and mortality review activity. It had created a suicide-specific incident risk mitigation form to support amore focused reflection aligned to the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH).

The adult community mental health service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They ensured continuity of care, including when people moved between different services.

Referrals to community mental health teams (CMHT) were triaged and assessed by the mental health access and brief treatment team (MHABTT). Referrals to early intervention teams (EIT) were triaged and assessed directly by EITs. Referrals from home treatment teams and inpatient services were carried out as transfers of care.

Referrals to MHABTT came from GPs, other professionals and self-referrals. Qualified practitioners triaged all referrals within 24 hours and determined if a full assessment was needed. Where it was not needed, they signposted people to other services such as Talking Therapies or voluntary groups. Following this, routine referrals were assessed within 20 working days and urgent referrals within 5 working days. If an emergency response was needed, staff sent the referral to the mental health hub crisis teams.

Managers and senior leaders told us MHABTT received between 350 and 450 referrals a month from across the county. Of those, around a quarter were assed as needing CMHT support. They had also carried out a waiting list evaluation to understand people’s pathway, and how many had required crisis or emergency intervention.

CMHTs discussed referrals from MHABTT during multidisciplinary team meetings. They discussed if people met the criteria for CMHT care and treatment, of whether they required an outpatient appointment with a psychiatrist, or an assessment for psychology input. Some staff in EIT told us CMHT capacity had sometimes delayed being able to discharge people onto CMHT caseloads. However, their work to start planning discharge from EIT at least 6 months in advance, supported a smoother transition.

Some managers told us about improvements that had been made to the electronic system to record the stage people were at in the community mental health pathway, which had improved oversight of everyone referred to the service. The service’s ‘system optimisation project’ process document clearly explained the steps staff needed to follow to ensure people were correctly recorded in the system at each stage of their referral and treatment.

The service had a well-established partnership with a third sector organisation who carried out 6-week health and wellbeing interventions with people referred to MHBATT. The interventions covered a range of support people might need with their social, emotional, wellbeing, housing or financial situations.

People received 3-weekly wellbeing calls from duty workers whilst waiting to start treatment or be allocated to a key worker. The calls enabled the service to have contact with people whilst they were waiting, to check to see if they remained safe, if their level of need or risk had changed and to agree the frequency of future wellbeing calls. Senior leaders and managers told us they had recently introduced a renewed focus on wellbeing calls and had increased the commissioning of their third sector partner to include making wellbeing calls to people on CMHT waiting lists.

Learning From Patient Safety Events (LFPSE) data included 3 records from January and February 2026 of caseload reviews showing people who were ‘missed’ from the waiting list for assessment, having been referred to the service in October, November and December 2025. One of those people, who had been referred in December, had died in February, before the caseload review took place. The cause of death was unknown at the time of our inspection. The trust told us the service’s ‘Mental health access and brief treatment team operational procedure(MHABTT)’was updated after our inspection, to include the waiting list monitoring process. The monitoring process stated who was responsible for different aspects of monitoring the waiting list.

People who required clinic support for medicines were scheduled for monthly clinic appointments. The service sent a text message reminder a week before appointments.

In the 12 months prior to our inspection, the adult community mental health service completed 194 72-hour follow ups to people who were discharged from inpatient services. Managers told us it was rare to breach the 72-hour deadline. Data the trust shared did not state if there were any breaches.

In the 12 months prior to our inspection, there were 2 people who used services who required a follow up/contact, who were not seen or contacted. This meant the service did not know if those individuals’ needs or risks had changed since they were last in contact and therefore could not respond to any changing needs.

All teams had a duty worker system. A duty worker is responsible for managing and responding to allocated duty tasks for the day. Tasks typically include responding to emails and answering the phone to people who use services or professionals who need advice and support, along with contacting people to make wellbeing calls. Staff took it in turns to cover the duty worker role, to ensure teams could be responsive to any requests for support. The duty workers often saw and assessed people the same day if they visited the service in person or called the duty number.

Standard operating procedures had clear guidance for staff to follow if people did not engage in care and treatment. All staff we spoke to understood what they needed to do if somebody on their caseload did not engage with care and treatment. For example, if someone did not attend an assessment appointment for MHABTT, they were sent an ‘opt in’ letter. If they did not respond within 14 days, a discussion was held with the clinical leads to decide how to proceed. Nobody was discharged for not attending an appointment without having a clinical review first. In CMHTs and EITs, staff told us about how they responded to people not attending or engaging, which included making cold calls to people’s homes and contacting family and carers if appropriate.

People who were discharged from CMHTs could be given a ‘green card’. This supported them to return directly to the care of a CMHT if their mental health deteriorated significantly in a certain period after being discharged from the service.

Some staff and managers told us there were sometimes challenges in transitioning people from children to adults’ community mental health services. This risk had been identified by the trust and recorded on its risk register. It was expected that an upcoming transition workshop would provide an update on progress towards the development and implementation of the transition pathway.

Not all staff had completed safeguarding training. However, the service had embedded a proactive safeguarding culture in which staff worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this.

Safeguarding training compliance varied across the adult community mental health service, which meant some staff had not completed the most recent training in safeguarding awareness and processes.

Across community mental health teams (CMHT), early intervention teams (EIT) and the mental health access and brief treatment team (MHABTT), excluding medical staff, compliance for safeguarding training averaged:

• safeguarding adults level 1 – 71%
• safeguarding adults level 2 – 58%
• safeguarding children level 1 – 71%
• safeguarding children level 2 – 61%
• safeguarding children level 3 – 74%

Safeguarding training compliance for medical staff across the service was 90% for safeguarding adults level 3 and 10% for safeguarding children level 3.

Staff completed Prevent training to help safeguard people who were vulnerable to extremist ideologies. Prevent is a UK government initiative aimed at stopping people becoming terrorists or supporting extremist ideologies by offering early intervention and community support. Across CMHTs, EITs and MHABTT, excluding medical staff, 86% of staff had completed basic Prevent awareness training and 88% had completed Prevent awareness training. Neither Prevent course was listed in the medical staff training data so it was unclear if medical staff had completed the training. We observed Prevent posters with guidance for staff to follow on notice boards.

The trust had a safeguarding adults policy and a safeguarding children policy. Both policies clearly outlined roles and responsibilities to safeguard people who used services, and their families, from harm. The policies included flowcharts for staff to follow safeguarding processes.

All staff and managers we spoke to told us about the importance of safeguarding in their roles, to keep people who used services, and their families, safe from harm. Most staff told us safeguarding played a significant part in their role and they assessed safeguarding risks and concerns at every assessment.

Most staff and managers told us common safeguarding concerns for people who used services included self-neglect, domestic abuse and exploitation. This was reflected in safeguarding data the trust shared for 1 February 2026 to 12 May 2026 for adult community mental health services and mental health crisis services and health-based places of safety. Data showed that of 87 Section 42 (safeguarding) enquiries made during that period, 33 were due to concerns about self-neglect and 21 were due to domestic abuse.

Teams had access to support from the trust’s safeguarding team. Some staff told us safeguarding leads sometimes visited teams to provide additional support to safeguarding champions. Some staff told us they could request safeguarding supervision if needed.

Most staff told us their teams had safeguarding champions who could advise on safeguarding concerns. EIT East shared their office with the safeguarding team, which some staff told us was helpful.

Most staff told us safeguarding was discussed during every multidisciplinary team (MDT) meeting or daily huddle. We observed MDT and daily huddle meetings in which safeguarding concerns were discussed and any necessary actions agreed.

Trust senior leaders worked with external agencies to safeguard people who used services. They attended quarterly Cornwall and Isles of Scilly Safeguarding Adults Board meetings and quarterly safeguarding subcommittee meetings.

Clinical leads attended multi-agency risk assessment conferences (MARAC) and multi-agency public protection arrangements (MAPPA) meetings to ensure robust multi-agency oversight of people’s risks. We saw evidence in people’s care records of liaison with MARAC when needed.

Most of the adult community mental health service worked effectively with people to understand and manage risks. However, there were inconsistencies in the oversight and management of people’s risks in community mental health teams (CMHT).

We spoke to 14 people who used services. All of them told us the service made them feel safe. We reviewed 20 care records of people who used services. In 17 of the 20 care records, we saw evidence of up to date, comprehensive risk assessments and crisis management plans that had been personalised. They contained tailored crisis plans that included supportive actions specific to the person. We also saw evidence in those 17 care records of risk assessments being updated in line with people’s changing risks.

Of the 3 care records we reviewed which did not have up to date, comprehensive risk assessments and crisis management plans, all were from Carrick CMHT and we observed a range of concerns. One of the 3 care records did not contain any risk assessment, and the crisis management plan was last updated in November 2024. Another of the 3 care records contained a risk summary which highlighted staff must attend visits in pairs due to risk of weapons, but there was no risk assessment present, and the crisis management plan was 10 years old. The last of the 3 care records did contain an up-to-date risk assessment, but the crisis management plan was from September 2024. Additionally, the record showed the person had called the duty worker in March 2026, requesting a call back which did not occur. A key worker visit was then arranged for April 2026, but this did not take place due to the key worker being on leave. At the time of our inspection in May 2026, records showed the person had not been seen by anyone in the service since February 2026, despite contacting the service to say they needed more help.

The adult community mental health service carried out an audit of risk assessments and management plans for people under the care and treatment of North Cornwall CMHT, which was published in November 2025. The audit reviewed 35 care records from a total caseload of 265 people. The audit showed that while 83% of care records reviewed included a risk assessment, only 46% of the reviewed care records contained an up-to-date risk assessment and only 37% had a clearly identified lead healthcare practitioner responsible for risk review.

We observed multidisciplinary meetings in which staff discussed concerns they had about people’s current or changing risks. Discussions were robust, person-centred, and included input from a range of professionals. People who used services were rated red, amber, or green (RAG) according to their level of risk. Most staff and managers told us that anyone could be discussed at multidisciplinary meetings, regardless of RAG rating.

Some staff and managers told us that psychology staff offered guidance to staff to carry out risk formulation for complex cases. Risk formulation uses information about a person’s history, mental state, environment, protective factors and context, to create a structured understanding of their potential for harm and help guide management strategies. Senior leaders told us there was a team reviewing how formulations were done in relation to suicide and self-harm, in line with NHS England’s Staying Safe from Suicide guidance.

During our inspection, senior leaders told us the trust had agreed a new approach to clinical prioritisation based on risk, impairment on life and severity of presentation. Senior leaders told us teams would be phasing out the RAG system as it started to use the new approach.

Staff used a variety of tools to assess people’s risks. The trust told us staff used the National Confidential Inquiry into Suicide and Safety in Mental Health safer services tool to assess risk with people who used services. We saw evidence of this in care records, where we saw staff completed holistic risk assessments with people who used services. They identified individual risk factors and protective factors and created collaborative safety plans. We also saw evidence in care records of staff completing a patient-rated satisfaction and outcome tool with people, which included a question about personal safety.

The trust told us about other risk assessment tools that staff used. For example, the Domestic Abuse, Stalking and Honour-based violence (DASH)tool was used to identify high-risk victims of domestic abuse, stalking, and honour-based violence. The sexual safety risk assessment tool was used to assess risks relating to sexual safety, including vulnerability to exploitation or risk of harm to others.

Improvements were needed to ensure community mental health teams (CMHTs) provided safe and therapeutic environments. However, the service detected and controlled potential risks in the care environment.

The adult community mental health service was based in different buildings and offices across the county. Most buildings were leased, older properties. At the time of our inspection, the local council had recently closed several resource centres the trust had used for individual and group sessions, which affected service provision. However, some staff and managers told us they were able to book other locations if needed, such as community centres. Senior leaders told us that lack of clinical space was one of the biggest risks for the service.

CMHTs were based in buildings with secure entry systems and secure staff-only areas. Clinic and consultation rooms had alarm buttons on the wall. In Restormel CMHT, most staff told us there were no room alarms, but some other staff told us there were alarms and showed us individual alarms that could be worn. We observed alarm buttons in all rooms. Some staff at Restormel CMHT said that if an incident occurred downstairs in the reception, clinic or consultation areas, staff from upstairs could ‘usually hear the commotion’ and would come downstairs quickly to support. Some staff at Carrick CMHT told us there were no alarms in the reception area, and staff who worked in this area did not receive training to de-escalate situations.

In Restormel CMHT there was a consultation room with CCTV in it, which was used by pairs of staff when seeing anyone who presented as high risk.

Some staff told us the consultation rooms in Restormel CMHT were not soundproof, which disrupted sessions and caused distractions.

In Restormel CMHT, there was no resuscitation trolley or emergency equipment or medicines onsite, although medicines clinics were held there. However, staff knew where the nearest defibrillators were in the community.

Restormel CMHT did not have sufficient clinical waste bins. We observed the bed in the clinic room was full of clinical waste bags underneath it. We raised this concern with the manager and senior leaders, who explained the new depot clinic had only been introduced the week before our inspection, and adequate clinical waste bins would be provided.

The adult community mental health service carried out a variety of environmental risk assessments. We saw all buildings had environmental, health, safety and security inspections, which included action plans to address any concerns noted. Concerns included those most staff told us about, such as the tired appearance of some buildings. Buildings also had fire risk assessments and water risk assessments. Any patient-facing buildings had ligature point risk assessments. Ligature points are locations or fixtures from which someone could secure a ligature, for example a belt or shoelace, creating a risk of self-harm. The trust told us it was developing an improved environmental risk assessment process and tool and a new health and safety oversight framework.

The trust had a lone working policy which stated each job role’s responsibilities regarding staying safe when working alone. Most staff across teams told us about lone working practices they followed, which included keeping calendars updated, signing in and out and letting the duty worker know when they had safely left a visit or appointment. We observed staff following the lone working processes when making visits during our inspection.

The trust’s estate strategy 2023 – 2030 acknowledged the significant challenges caused by the age, ownership and suitability of its estate. The strategy set out the trust’s commitment to future-proofing its estate to meet the needs of people who used services and staff. Most staff in Restormel CMHT told us they would soon be moving location to nearby premises that would be shared with other mental health teams. However, some staff told us they were concerned that room availability for group and individual sessions would be more challenging in the new building, and that there was insufficient office space for all the staff that would be based there. Some staff told us they were originally meant to move to the new premises over a year before our inspection.

The service still did not always have enough suitably trained and supervised staff. There were challenges across the service with low staffing levels in some community mental health teams (CMHT) and low rates of training, supervision and appraisal.

At the time of our inspection, the trust was carrying out a review of its mandatory training and associated policies and processes. The service aimed to achieve over 85% compliance in mandatory training courses. Overall team training compliance for the adult community mental health service, excluding medical staff, was 81% in May 2026, and there were low rates of compliance in some core and mandatory training courses across teams. In May 2026, overall training compliance for medical staff was 80%, with low compliance in some training courses. Staff had not always completed the most up to date training to ensure they could safely and effectively fulfil the requirements of their role.

There were lower rates of compliance in the following teams and training courses (excluding medical staff):

Caradon CMHT:

• Personal safety awareness 72%
• Autism and learning disability e-learning 61%
• Resuscitation level 2 – adult basic life support 56%

Carrick CMHT:

• Personal safety awareness 74%
• Autism and learning disability e-learning 68%
• Infection prevention and control level 2 69%
• Resuscitation level 2 – adult basic life support 47%

Countywide Early Intervention Team:

• Autism and learning disability e-learning 74%
• Safeguarding adults level 3 64%
• Infection prevention and control level 2 63%
• Resuscitation level 2 – adult basic life support 66%
• Safeguarding adults level 2 73%
• Safeguarding children level 2 71%
• Safeguarding children level 3 72%

Kerrier CMHT:

• Freedom to speak up part 1 70%
• Autism and learning disability e-learning 60%
• Understanding sexual misconduct in the workplace 70%
• Infection prevention and control level 2 47%
• NHS conflict resolution 65%
• Preventing radicalisation – prevent awareness 71%
• Resuscitation level 2 – adult basic life support 45%
• Safeguarding children level 3 57%
• Medicines management 50%

North Cornwall CMHT:

• Autism and learning disability e-learning 73%
• Infection prevention and control level 2 67%
• Resuscitation level 2 – adult basic life support 69%
• Safeguarding children level 3 73%

Penwith CMHT:

• Autism and learning disability e-learning 64%
• Understanding sexual misconduct in the workplace 73%
• Infection prevention and control level 2 58%
• Resuscitation level 2 – adult basic life support 47%

Restormel CMHT:

• Autism and learning disability e-learning 72%
• Infection prevention and control level 2 67%
• Resuscitation level 2 – adult basic life support 72%

Mental health access and brief treatment team:

• Autism and learning disability e-learning 68%
• Autism and learning disability tier 1 13%
• Safeguarding adults level 3 50%
• Infection prevention and control level 2 62%

In May 2026, compliance for medical staff was low in the following training courses:

• Autism and learning disability e-learning 67%
• Autism and learning disability tier 2 40%
• Self-harm and suicide intervention for mental health services 0%
• Infection prevention and control level 2 40%
• Resuscitation level 2 – adult basic life support 40%
• Safeguarding children level 3 10%

Not all staff had opportunities to discuss their performance and training needs with their manager, to reflect on and learn from practice, receive personal support and identify opportunities for professional development. Managers told us supervision data would not be reflective of the numbers of staff who had received supervision as the system required staff to register their supervision on an electronic system, which most staff told us they found difficult, or forgot to do. Most staff told us they regularly had management and clinical supervision and could request it more frequently if they needed.

The trust’s clinical supervision policy stated all staff should have line management supervision every 3 months, clinical staff carrying a caseload should have caseload supervision every 6 weeks and all clinical staff should have clinical supervision every 3 months.

However, average supervision compliance between February and April 2026 was low in the following teams:

Carrick CMHT 59%

Countywide Early Intervention Team 71%

Penwith CMHT 72%

Restormel CMHT 44%

The trust told us they did not audit training and supervision compliance, however both were reported monthly through mental health directorate delivery and performance meetings.

Most staff told us they received annual appraisals. However, data from April 2026 showed rates of completed appraisals were low in most teams across the service, which meant not all staff had the opportunity to discuss their performance, training needs and career goals. Appraisal completion rates in April 2026 were:

• Carradon CMHT 47%
• Carrick CMHT 28%
• Countywide Early Intervention Team 77%
• Kerrier CMHT 50%
• North Cornwall CMHT 92%
• Penwith CMHT 71%
• Restormel CMHT 25%
• Mental Health Access and Brief Treatment Team 72%

Most teams in the adult community mental health service had high rates of staff sickness, above the trust’s target sickness rate of 4%. Between May 2025 and April 2026, average full time equivalent absence rates per team were:

• Caradon CMHT 7.04%
• Carrick CMHT 9.42%
• Countywide Early Intervention Team 5.34%
• Kerrier CMHT 10.00%
• North Cornwall CMHT 3.87%
• Penwith CMHT 9.62%
• Restormel CMHT 15.13%
• Mental Health Access and Brief Treatment Team 7.00%

Teams across the community mental health service had experienced significant staffing challenges in the 12 months before our inspection. At the start of 2026, 3 teams in the community mental health service had staffing percentages in the 40s. Two other teams were between 50% and 64%. The service had used its escalation system to implement staffing continuity plans. One of the teams with low staffing levels was the mental health access and brief treatment team (MHABTT), and the trust explained the staffing challenges contributed to a backlog of assessments at the start of 2026. When we visited Restormel CMHT on 12 May 2026, the team was operating at 62% staffing. Managers and senior leaders told us the challenges were a result of vacancies and high levels of staff sickness in some teams.

In the 12 months prior to our inspection, the service recorded 53 incidents of ‘short staffing’. Between February and March 2026, the service reported 7 learning from patient safety events (LFPSE) incidents in which staff reported insufficient staff numbers to safely support people on waiting lists.

Managers and senior leaders we spoke to had a good understanding of staffing challenges, including issues that were unique to their trust, such as the lack of affordable housing for people they recruited from out of the county. Senior leaders told us about initiatives to address staffing challenges, including apprenticeships, developmental roles, links with local universities, the introduction of flexi workers, and changing roles to adapt to candidate feedback. Managers and senior leaders told us recent recruitment meant various roles were at various stages of the onboarding process across the service.

The service used bank or agency staff to cover shortfalls in staffing. Data showed in the 3 months prior to our inspection, all bank or agency staff shifts were filled. Shifts were filled to cover sickness, vacancies, annual leave, training, special leave and to provide additional staff, which would have reduced disruption to the service from staff absence.

In April 2026, the trust had a total of 3.55 full time equivalent (FTE) vacancies across the adult community mental health service, against an establishment of 201.01 FTE. Although there were vacancies across all teams, there were roles in all teams across the service, in which there were higher numbers of contracted staff than the establishment figures. Establishment figures are the number of staff the service has calculated it needs.

The trust had a recruitment and onboarding policy which stated that all new employees must attend a Corporate Welcome Day on their first day with the trust, followed by an induction programme. Once in their new teams, staff were required to have a local orientation, which included an overview of the team and its role and function, along with an introduction to departmental guidelines, policies and procedures. The trust had a separate temporary worker policy for bank or agency staff. Bank staff were required to attend the Corporate Welcome Day. Managers were required to ensure bank and agency staff were given a local induction if they had not worked in that area before.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

All premises and equipment we observed on our inspection were clean. Furnishings were in good condition.

Some staff told us the buildings were cleaned ‘all the time’ and one person who used services told us the premises were always clean and tidy.

The trust had an infection prevention and control role and responsibilities policy which laid out the expectations for all staff, private contractors, locum, agency staff and volunteers. We observed staff followed the policy when delivering care. We observed clinical care being delivered and staff followed infection prevention and control measures in both the preparation and administration of medicines. We observed staff followed good hand hygiene practices, washing their hands properly and using and disposing of gloves appropriately. We also observed staff clean the area after each person.

Staff had access to hand washing stations and personal protective equipment.

We observed hazardous waste cleaning kits were available in reception areas.

The service did not make sure that medicines and treatments were always safe and met people’s needs, capacities and preferences. The service did not have reliable processes to ensure that physical health monitoring and side effects were consistently followed up and acted upon.

The service did not always manage medicines safely. Staff did not always complete or record physical health monitoring in line with National Institute for Health and Care Excellence (NICE) guidance. When staff requested GPs to complete checks for people prescribed antipsychotic or mood stabiliser medicines, these were not always followed up to make sure they happened. In some cases, physical health information was not clearly recorded in people’s records. For example, we found incomplete high dose antipsychotic treatment (HDAT) forms for people prescribed above the recommended maximum dose. These medicines require increased monitoring due to a higher risk of side effects.

The service did not have a clear system to track all people taking medicines that required additional monitoring. Some teams kept records of people taking medicines that required additional monitoring; however, these records were not always complete and were not consistently used across the service. This meant the service could not always be assured that people taking these medicines were monitored safely or that there was effective oversight of processes and record-keeping.

Staff did not always act promptly when physical health results indicated a potential risk. We saw evidence results were not always reviewed in a timely way, and there was no clear evidence of follow-up action, increasing the risk of harm to people.

Following our inspection, the trust took immediate action to review processes and strengthen communication and oversight of physical health monitoring across the multidisciplinary team. However, these actions were implemented at a local level and were not part of a coordinated, trust-wide approach. There was limited evidence that the trust had identified or built on good practice in teams where physical health monitoring and follow-up processes were already working well and risks were effectively managed.

Medicines reviews were not always carried out on time. Some people had not had their medicines reviewed despite ongoing risks or concerns about side effects.

Records showed staff did not consistently use side effect rating tools in line with trust policies, so it was not possible to determine whether symptoms had improved or worsened.

Medicines were stored securely, and staff carried out regular checks and audits. However, we found in some teams record keeping for supplying medicines to people were not always being completed.

Staff handling medicines completed the trust’s medicines management awareness training, however compliance varied across the service. Although some teams had high rates of training compliance, including Carradon CMHT at 100%, other teams in May 2026 had low rates. Kerrier CMHT had 50% compliance and North Cornwall CMHT had 67% compliance in medicines management awareness training in May 2026.

We saw the depot clinic in Restormel CMHT did not have an emergency medicines kit, and staff told us they did not take emergency medicines kits when administering medicines in people’s homes. The trust told us they were currently reviewing their policy relating to emergency medicines, to make sure they balanced the risk of potential anaphylaxis with the additional burden of maintaining emergency medicines kits.

However, we saw evidence the service reported medicines-related incidents and learned from them. In the 6 months prior to our inspection, the service reported 37 medicines incidents. Incidents ranged from missed medicines to instances where people tried to harm themselves using medicines, and national recalls of medicines. There was evidence that incidents were reviewed, appropriate actions were taken, and learning was identified and shared where relevant to support improvement in practice.

The trust had monthly Medicine Optimisation and Safety Committee meetings. We saw meeting minutes which showed evidence of discussion about changes to policy, areas of concern and sharing of good practice that related to the adult community mental health service.

The trust had a medicines policy which described the procedures and good practice that staff in the service were expected to follow. These included prescribing, supplying and administering medicines and covered the legal and professional standards that were expected of different staff groups.