Cornwall Partnership NHS Foundation Trust

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• 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

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We identified 1 breach of the regulations in relation to governance. The score of 1 for the quality statement ‘Governance, management and sustainability’ limits the key question rating to requires improvement.

Requires improvement: Governance processes were not always effective at providing robust oversight of performance and risks. However, leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued and felt able to raise concerns. The service worked well with partners to support people’s needs and share learning. Staff and people who used services had opportunities to participate in research and quality improvement projects.

This service scored 62 (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 had a shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and their communities.

The trust’s values of respect, compassion, honesty and teamwork were reflected in the teams in the adult community mental health service. Some managers told us about work they had carried out to embed positive team cultures. In the mental health access and brief treatment team (MHABTT) for example, it had been recognised that remote working created additional challenges to sharing information and staff feeling connected to one another. Therefore, they held online and in person events to talk about values.

Senior leaders had successfully communicated the trust’s vision and values to staff. Staff across all teams in the adult community mental health service worked in a way that supported the aims of the trust’s clinical strategy 2025-30. For example, the strategy identified key objectives which included developing a culture of continuous learning, improvement, research and innovation. Staff in all teams we visited told us about their recent external accreditation experiences and how positive they found the experience. In community mental health teams (CMHTs) in which staff and managers told us they did not think they would achieve accreditation this time, they spoke positively about how the process helped them to identify what was working well and areas for improvement.

Some staff and managers told us the trust’s strategy included ‘getting people outdoors’. The objective in the clinical strategy was to deliver half of the clinical care they provided outdoors, or in non-traditional spaces. Some staff told us examples of groups and sessions that were delivered by the service, or the service referred to, that provided this. For example, some staff told us about a ‘healing with nature’ team that staff referred people to. Some staff in the early intervention team (EIT) East told us about surfing sessions and beach litter picks they hosted for people who used services.

Staff had opportunities to contribute to discussions about the strategy for their service. For example, some from across CMHTs told us about changes that had been made and continued to be made to the complex emotional difficulties pathway. It had previously been a standalone service, but had recently become part of CMHTs. They told us they had shared their concerns with managers and senior leaders about how they could ensure continuity of care for their client group. Not all changes to the pathway had happened at the time of our inspection, however senior leaders told us they were aware of staff concerns and were working with them to address concerns and make sure people who used services remained well supported.

Staff were invited to share their feedback on national guidance that would affect them. We saw a May 2026 trust-wide digital newsletter encouraged staff to engage with the Security Industry Authority’s national consultation on the Terrorism Protection of Premises Act 2025 (Martyn’s Law) draft guidance and attend a webinar to understand what the implications could be for organisations when the law comes into force in 2027.

Most staff told us about the supportive nature of their teams. They told us staff of all bands and roles supported each other, and that they had a strong focus on teamwork.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

All managers and senior leaders spoke to us with honesty and openness and expressed a focus on ensuring staff and people who used services were safe and well supported. They expressed pride in the work teams were carrying out in challenging circumstances.

Senior leaders showed a good understanding of the adult community mental health service, its challenges and plans to address any concerns. All managers told us senior leaders were aware of the operational challenges their teams faced and were supportive rather than punitive in response. Some staff told us trust directors frequently attended their continuing professional development (CPD) days, so were aware of progress being made within the service.

Some managers told us they felt senior leaders shared their core values and were passionate about ensuring staff could deliver good care.

Staff told us their teams were led by approachable, supportive and compassionate team managers and clinical leads. Some staff told us their managers were the best they had ever had.

Some managers and senior leaders we spoke to told us they had developed their career within the adult community mental health service or trust.

Some managers and senior leaders told us about the compassionate leadership programme they had recently completed. They told us the programme helped support the trust’s commitment to embedding a culture of compassionate leadership.

The service created a positive culture where people felt that they could speak up and that their voice would be heard.

The trust had a freedom to speak up policy that explained the different ways staff could raise any concerns they had, including through the Freedom to Speak Up Guardian. A Freedom to Speak Up Guardian works alongside the trust’s senior leadership team to ensure staff have the capability to speak up effectively and are supported appropriately if they have concerns regarding patient care. The policy explained what staff could expect at different stages of raising a concern and explained staff’s rights in relation to making a protected disclosure. Making a protected disclosure is sometimes called “whistleblowing”.

The trust had 30 freedom to speak up champions across the trust, some of which were based in teams in the adult community mental health service. For example, there was a freedom to speak up champion in the mental health access and brief treatment team (MHABTT). Champions were trained to support colleagues to raise concerns through the freedom to speak up process, or signpost to other teams or processes as needed.

All staff and managers we spoke to were aware of how to raise any concerns they had, including approaching the Freedom to Speak Up Guardian. Some staff and managers told us about issues they had raised within their teams and how these had been resolved.

Most staff and managers told us their teams had a supportive and open culture in which they felt they could share their opinion or raise concerns without fear of repercussions.

The trust produced an annual freedom to speak up report, which gave an overview of concerns raised through the freedom to speak up process. In the freedom to speak up annual report 2025 – 2026, the adult community mental health service was not included as one of the areas having raised the most concerns.

The service valued diversity in its workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust had 4 equality objectives that supported its efforts to become a more inclusive organisation. It undertook equality monitoring of its staff and reviewed its Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results. WRES and WDES data are only available at trust-wide level. The trust had developed WRES and WDES action plans that aimed to achieve an inclusive culture, diverse workforce and eliminate discrimination.

Staff in the adult community mental health service could access the trust’s 8 staff networks: Allies; Armed Forces; Carers; Ethnic minority; Faith; Gender equality; LGBTQ+; and Long term conditions and disabilities. The networks had peer support sub-groups staff could also access. There were staff network champions in the teams we inspected.

The trust had a flexible working policy which explained the process for staff to follow if they wanted to make a flexible working request.

Some staff told us about reasonable adjustments that had been put in place to help them carry out their role.

Governance processes across the adult community health service were not always effective. They did not always ensure the service had a good understanding of people’s risks and needs, or actions staff should complete. Performance data did not always reflect operational reality.

At the last inspection in 2022, we identified a breach of regulations relating to governance processes within community-based mental health services for adults of working age. We told the trust it must ensure governance systems provided robust oversight of the service and that identified improvements were acted upon in a timely manner. At this inspection, we found governance arrangements remained ineffective in several areas and did not consistently provide oversight of quality, safety and performance.

Governance processes were not always consistently followed, meaning senior leaders did not always have a clear understanding of people’s risks and needs, and some performance data did not accurately reflect operational practice. Although senior leaders recognised weaknesses and had begun implementing improvements, these were not yet fully embedded. Staff also described some governance processes as unclear and difficult to use.

Oversight of physical health monitoring was not always effective. Monitoring and escalation of abnormal physical health results was not consistently evidenced within care records, and the service did not routinely audit compliance with physical health checks. We reviewed records where people had not received physical health monitoring in line with trust guidance. Although the trust had introduced new oversight processes and added a risk relating to antipsychotic prescribing to its risk register shortly before inspection, these actions were recent and their effectiveness could not yet be demonstrated.

Trust policies did not always provide clear guidance for staff. For example, the trust’s Guidelines for the Use of High Dose Antipsychotics contained contradictory information regarding the frequency of physical health monitoring. This lack of clarity was reflected in records, where people receiving high-dose antipsychotic treatment had not always received 3-monthly physical health monitoring.

Caseload management arrangements lacked clarity, and data provided by the trust was not fully reflected in policies and procedures. Caseload reports contained large numbers of 'blank' entries, which the trust advised represented people not allocated a key worker. However, this category was not clearly defined within the service’s standard operating procedure or caseload management guidance. On 14 May 2026, 1,076 people were awaiting allocation to a key worker and a further 665 records appeared as 'blank' across other caseload categories. While leaders had recognised concerns regarding caseload management and added this risk to the trust’s risk register in November 2024, improvement work remained ongoing.

Oversight of waiting lists was limited. The trust could not reliably determine the date treatment pathways began within its electronic systems and was therefore unable to accurately measure waiting times from assessment to treatment. In addition, psychology waiting list data was not recorded consistently across teams, limiting the trust’s ability to identify trends and risks. Although waiting lists had been included on the risk register since October 2023 and risk ratings had reduced, some people continued to experience lengthy waits.

Audits of care records did not always lead to improvements across the service. An audit in November 2025 showed concerns with care records not always having up to date risk assessments in the North Cornwall community mental health team (CMHT). Although most records we reviewed showed evidence of up to date risk assessments, 3 of the 4 records we reviewed from Carrick CMHT has significant gaps, suggesting that learning from the audit had not led to service-wide improvements in the quality of care records and risk management.

Data recording systems were burdensome and did not always support effective oversight. Staff and managers described difficulties with supervision recording systems, resulting in low reported compliance rates despite most staff stating they received regular supervision. Staff also reported challenges with the electronic care record system, including information being stored in different locations, creating a risk that important information could be overlooked. Senior leaders acknowledged these issues and had introduced training to improve staff use of electronic systems.

Some senior leaders and managers were not confident safeguarding activity was fully reflected in incident reporting data, as they told us staff did not always record safeguarding concerns on the trust’s incident reporting system. They told us this was partly due to the system being difficult to use, reducing assurance that safeguarding data accurately reflected activity across the service.

Staff awareness of environmental and safety arrangements was inconsistent. In 3 teams, some staff were unaware of security alarms within clinic and consultation rooms despite having received local induction. Training oversight was also not always effective. Although overall mandatory training compliance was mostly above 80%, compliance in some key subjects, including safeguarding and basic life support, was low in several teams. Additionally, Mental Health Act and Mental Capacity Act training were not mandatory, limiting assurance that staff could consistently fulfil their responsibilities under the legislation.

Environmental risk management did not always result in timely action. For example, the March 2026 ligature audit for the Caradon CMHT building found that actions identified in audits completed in 2022 and 2024 had still not been addressed because of funding constraints. As a result, not all known risks within the environment had been mitigated.

Incident investigations were not completed within expected timescales. We reviewed 3 patient safety investigation reports and found all exceeded NHS England's expectation that learning responses should be completed within six months. The investigations were approved between 9 and 13 months after the incidents occurred, delaying opportunities to identify and implement learning.

However, senior leaders demonstrated a good understanding of many of the risks affecting the service and had taken steps to address them through risk registers and improvement plans. We saw examples of some effective governance arrangements, including a staffing continuity process that enabled services to safely manage periods of high sickness and workforce turnover. The trust was also developing business intelligence dashboards and reviewing data collection processes to improve the quality, consistency and usefulness of performance information. Its five-year strategy also recognised existing concerns regarding data quality and included actions to address them.

The service understood its duty to collaborate and work in partnership, so their services work seamlessly for people. They shared information and learning with partners and took a lead role in the region to collaborate for improvement.

Teams across the adult community mental health service had a strong focus on working in partnership with other teams, services and voluntary, community and social enterprise (VCSE) organisations. Staff and managers were aware of the importance of working in partnership with other organisations to keep people safe and well supported. Some staff and managers in the early intervention team (EIT) East told us about awareness and health promotion work they carried out with local education establishments and at large events.

Staff and managers across all teams told us about VCSE groups they regularly worked alongside or referred people to. They told us this helped ensure people could access services that supported them with a range of physical, social, financial and wellbeing opportunities.

We observed a multi-agency transition event (MATE) which was attended by staff from the service alongside other professionals, experts by experience, VCSE organisations and primary care staff. Managers and staff from the service told us MATE aimed to strengthen community-led approaches to mental health and wellbeing, reduce barriers to support and encourage meaningful connections. Staff told us MATE helped them understand what else was available to people they supported, so they could refer people on when the time was right to transition from secondary mental health care.

Teams invited external speakers to their continuing professional development (CPD) events. Some staff in the early intervention team (EIT) East told us about their recent CPD event in which staff from local charities attended to talk about the support they could provide for people who used services.

Most staff and managers told us about the importance of making connections with local groups and organisations. For example, some staff told us about opportunities they could support people to engage with, such as a local, world-famous horticultural attraction.

Service leaders engaged with external stakeholders such as commissioners and Healthwatch to share information and collaborate for improvement. For example, senior leaders attended bimonthly Cornwall area prescribing committee meetings, in which medicines safety, guidance and best practice were discussed. Area prescribing meetings were also attended by staff from the integrated care board (ICB), the local acute trust, Kernow local medical committee and Healthwatch Cornwall.

Staff at all levels had opportunities to share learning with organisations in the region and trust senior leadership took a lead in working with partners across the region. For example, the trust’s chief executive chaired the South West Mental Health Learning Improvement Network and there were several communities of practice staff could join depending on their discipline. The improvement network and communities of practice brought together staff from across the region, working in other healthcare and educational organisations, to share learning and good practice.

The trust had established processes in place to inform and share patient safety incidents with external agencies and third-party organisations such as commissioners, other care providers, emergency services and the council. Senior leaders told us all incidents, irrespective of the level of harm caused, were shared. Any updates or responses were recorded and learning from them was shared. Staff also notified the council of isolated incidents, quality concerns and compliments for adult care services.

The trust’s patient safety incident investigation process supported early identification of relevant external stakeholders and system partners. Where appropriate, stakeholders were invited to participate in investigations and encouraged to contribute throughout the process.

Senior leaders attended the ICB’s monthly patient safety meetings, in which incidents requiring multi-agency review and input were presented and discussed.

The service focused on continuous learning, innovation and improvement across their organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Across all teams we inspected, staff and managers told us there was a focus on continuous improvement. ‘Building a culture of continuous improvement’ was one of the trust’s key objectives in both its clinical strategy and five year plan 2026 - 2031. To support this, the trust had a quality improvement strategic delivery plan 2026/27 to 2029/30.

The trust’s recently created quality improvement team had developed a learning improvement network and had plans to hold in-person events every 4 months to bring together multiple stakeholders in a shared learning environment. The quality improvement team also offered introduction to quality improvement training and quality improvement coaching training, which was available to all staff in the adult community mental health service.

Some staff told us about quality improvement projects they were working on. For example, in the early intervention team (EIT) East, staff were working on a project that aimed to bridge the gap for people who wanted to return to work but were not quite ready yet.

Some staff in EIT East told us about a recent quality improvement project the team had undertaken with NHS England around delivering a programme to support family carers. They told us this was co-produced with family carers, who they asked what they wanted to know about. Family carers identified 5 topics, and from that the team created information leaflets about each topic. The information was shared across the trust through QR codes so people could access the leaflets or print copies for themselves. Staff told us that they were building on from the positive response to the leaflet project by now working to set up a carers group. The team was due to present their work at the Royal College of Psychiatrists’ 2026 Annual Early Intervention Conference.

There were other quality improvement projects underway that related to the adult community mental health service. For example, there was a quality improvement project aiming to improve Clozapine workflows, and another to gain Triangle of Care accreditation.

At the time of our inspection, the EITs had achieved the Royal College of Psychiatrists Early Intervention in Psychosis Network accreditation. Staff and managers in EIT told us how positive the experience of accreditation had been, and how they valued not just the accreditation, but also being part of a quality network.

At the time of our inspection, all CMHTs had signed up for the Royal College of Psychiatrists ‘accreditation for community mental health services’ (ACOMHS), and most had been peer reviewed. Staff and managers across teams told us they found the peer review useful to help identify areas of good practice alongside areas for improvement.

Staff and people who used services had opportunities to be involved in research, particularly in EITs. The trust’s research team attended EIT multidisciplinary meetings to inform staff of the latest research projects and pilots. EITs were participating in a university virtual reality pilot, in which staff could support people with graded exposure exercises using a virtual reality headset. The Kernow at risk mental state (KARMS) service was participating in a research project with a university in which people could participate in a trial looking at using cognitive behaviour therapy for insomnia.

Teams participated in national audits such as Prescribing Observatory for Mental Health (POMH) UK audits on the use of antipsychotic medication for relapse prevention in patients with a diagnosis of Schizophrenia, improving the quality of valproate prescribing in adult services national review form and the use of clozapine national review form. They had also participated in the National Confidential Inquiry into Suicide and Safety in Mental Health audit into suicide by people under mental health care.

In the 12 months before our inspection, the trust had completed numerous internal audits including: clozapine prescriptions; evaluating the effectiveness of a dialectical behavioural therapy skills group in individuals with emotional difficulties; access to treatment for patients with obsessive compulsive disorder; evaluating the use of Compassionate Minds Group (CMG) within a CHMT to reduce psychological distress and improve self-compassion; and ‘Healing by Nature’, a trauma informed relational health hub within Cornwall’s lived-experience-led peer support service.