Independent Quality Assurance Review Cornwall Partnership NHS Foundation Trust and NHS Cornwall and the Isles of Scilly Integrated Care Board StEIS 2016/19955 Final Report 31 January 2023

To ensure improvements are sustained, the Trust should continue to implement actions to improve the timeliness of Duty of Candour contact and to monitor and report on this to the Quality Assurance Committee.

The Trust must test, through routine supervision processes and ongoing thematic review of incidents, that the issues raised by this case do not recur.

The Trust should ensure it is able to demonstrate changes in staff behaviour arising from the new competency based training, within its agreed bi-annual cycle of audit (see Recommendation 10).

The ICB (former CCG) should carry out the planned review of information sharing across the health and social care system (including health visiting) with regards to children’s safeguarding within the stated time frame, and formulate and progress an associated action plan which is overseen by the relevant ICB (former CCG) assurance mechanisms.

The Trust should ensure that staff understand and undertake their responsibilities for reporting safeguarding concerns when a patient reports historic abuse.

The Trust should update the Adult Safeguarding Policy, at the next opportunity to i) refer to the criminal exploitation of young adults in relation to County Lines related abuse and ii) include specific reference to historic abuse.

The Trust should undertake further case review work to evidence that support for patients under duress due to criminal exploitation is being addressed in care plans.

The Trust must complete its planned audit work to provide assurance that actions are having the required impact.