Coventry and Warwickshire Partnership NHS 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 assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We identified concerns relating to involving patients to manage risk, safety of environments and equipment, staff training, management of infection prevention and control and medicines optimisation practices.

However, staff demonstrated a positive approach to learning from incidents.

The service was in breach of regulation 12 for safe care and treatment at the service.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The Trust had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff attended monthly practice development days and protected learning times and told us these provided an opportunity to share learning from incidents.

Leaders ensured safety was a top priority that involved everyone, including staff as well as people using the service. Staff told us they learnt from incidents through debriefs, safety huddles, team meetings, supervisions and sharing of safety alerts. Swanswell ward manager told us about a ligature tool being piloted on their ward. This involved staff completing a checklist after ligature incidents to ensure all learning was captured. The checklist guided staff to review all aspects of the incident and consider what to do differently in future, including a focus on staff assessing how to take positive risks.

Staff did not overlook or ignore risks. They were dealt with willingly as an opportunity to put things right, learn and improve. Edgwick ward manager told us about an absent without leave (AWOL) incident whereby the patient was able to remove part of the garden fencing and leave the ward. The ward manager took action to reinforce the fence to prevent further incidents. We spoke with a leader who shared learning from a serious incident on Hearsall ward, improvement actions were implemented, including a new signing in/out procedure for restricted items.

Leaders ensured incidents were appropriately investigated and reported. The weekly incident oversight group reviewed all incidents rated as moderate harm or above and decided whether they needed a rapid review or input from other teams, for example, infection, prevention and control (IPC) or Health and Safety (HS). The Trust reported 1536 incidents at the acute and PICU wards for this location between 1 October 2024 and 30 March 2025. The most common incident type was patient assaults on staff at 399, followed by patient self harm incidents at 305. The Trust implemented actions to address the high level of staff assaults, including offering guidance through the criminal justice system, encouraging staff to challenge inappropriate and illegal behaviours and supporting staff to look at preventative measures for patients at risk of sexual offending. We reviewed 8 incident records; staff reported incidents correctly and managers investigated when required. Ward managers completed ‘after action learning’ reviews following incidents and discussed these with staff. We reviewed an incident whereby staff had not sourced a prescribed medication for a patient on Beechwood ward, managers implemented actions to ensure staff were aware of the escalation procedures to follow in the event a patient has no supply of a prescribed medication. On Quinton (previously Westwood) ward we saw a poster displayed with learning from a recent physical health incident on another ward. Quinton ward manager shared evidence that incident rates reduced from an average of 30 to 10 per month. This followed work on completing rapid reviews and ‘after action learning’ reviews, alongside debriefs with patients which linked into the patients’ care plans.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff learned lessons from safety incidents or complaints, resulting in changes that improved care. Examples included the Trust updating their therapeutic observations and engagement policy, improved training for staff, improved processes for managing AWOL events and a new learning from incidents process, including the completion of rapid reviews and after action reviews. Leaders implemented the Patient Safety Incident Response Framework (PSIRF). This approach encouraged greater learning for staff and people using the service. However, some nurses and Healthcare Assistants (HCAs) told us learning from incidents on other wards was not always shared.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received prior to admission to determine if the patient’s needs could safely be met. Although staff on one ward raised concerns about potentially inappropriate admissions, we did not find this on other wards and were assured by the Trust processes in place. These included a bed management team that met with ward managers and other leaders twice a day to review potential and current admissions. Ward managers were able to share any concerns about a potential admission. Senior leaders advised there were escalation procedures for staff to follow if they felt their concerns about an admission were not being considered. The Trust advised they would be supporting staff to better understand the admission process and how to determine if an admission is clinically inappropriate. Leaders told us ward managers supported each other and would discuss options including the most appropriate ward and whether other patients could be moved to facilitate an admission. Staff told us information about new admissions was shared in handovers, safety huddles and recorded in care notes. Staff on Spencer ward raised concerns about status of the ward continually changing between male only, female only and mixed, they said this resulted in a high turnover of patients. Staff followed mixed gender guidance when the ward was mixed.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. This included staff liaising with the police, prisons, accident and emergency departments and the Trust health based place of safety, crisis and home treatment teams. The service recognised the importance of keeping patients within their communities and close to family and friends. Senior leaders told us they had processes in place to prevent the need to send patients out of area for an acute or PICU bed.

There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. Beechwood ward manager told us about working with the probation service to ensure a successful discharge for a patient with a forensic history. Sherbourne ward manager told us about supporting a patient with history of multiple admissions. Staff identified a suitable step down placement and worked with the placement provider to create a transition plan for a successful discharge. However, Sherbourne ward manager told us there were 2 patients experiencing delayed discharges due to waiting for medium secure beds, this was out of the control of the Trust. On Beechwood ward we observed a multi-disciplinary team (MDT) meeting where 14 patients were reviewed. We saw evidence of positive practices in relation to newly admitted patients (ensuring immediate needs were met and support put in place) and active discharge discussions and actions in place to enable a smooth transition through the service. The team discussed risks for each patient and how they might impact once they were in the community, for example, a patient with a forensic history and how they ensured they were not discharged to a community where they were at risk of abuse. We observed a best interest meeting on Beechwood ward. The doctor and discharge coordinator were focused on removing barriers to the patient’s discharge and made sure the external attendees (from the local authority) were fully informed of the potential impact on the patient should their discharge be delayed.

Staff planned and organised care and support with people, together with partners and communities in ways that ensured continuity. Staff told us they liaised with community teams and patients’ families to support patients’ transition into and through the service. Leaders implemented post discharge processes to ensure people were followed up once back in the community. Staff ensured relevant information was shared with community teams to support patients’ discharge and continuity of care. Managers told us the discharge coordinator would attend MDT meetings to support patient discharges. Staff described how helpful this role was and said the coordinator would sort out funding and housing issues and had good knowledge of services and support available within the community. Staff also told us the discharge coordinator had a good understanding of mental capacity and in-depth knowledge of the court of protection processes and would support patients and families to navigate these.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

There was a strong understanding of safeguarding and how to take appropriate action. The Trust reported an overall compliance rate of 93% for levels 1-3 of safeguarding adults and safeguarding children training completed by staff. Staff spoken to were able to describe different safeguarding scenarios and the action they would take. Staff shared examples on four wards of action they took to safeguard patients. These included staff supporting a patient who lacked capacity with managing their money, support to a patient who disclosed domestic abuse and support to patients who were financially abused. They told us for any safeguarding concern they would speak with the patient to gather more information, report internally and externally and discuss with the MDT to ensure actions were taken to protect the patient. Staff actions included reporting to the safeguarding team, reporting to the police, moving patients’ bedrooms and increasing patient observations. Staff told us they also discussed safeguarding concerns in daily safety huddles. Senior leaders told us all ward managers completed bespoke training on reviewing and managing safeguarding concerns delivered by the Trust safeguarding team. However, we reviewed care records for 1 patient on Sherbourne ward and saw 2 incidents where the patient was physically assaulted by another patient. Staff had not raised a safeguarding alert for either of these incidents.

Most patients were supported to understand safeguarding, what being safe meant to them, and how to raise concerns when they didn’t feel safe, or they had concerns about the safety of other people. We spoke with 27 patients; most told us they felt safe and were able to tell staff if they didn’t feel safe. One patient told us they didn’t always feel safe. We asked 3 carers of patients at the service if they thought their relative was safe, all answered yes.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. Managers told us the Trust implemented new processes for safeguarding. These included an automatic alert sent to ward managers when staff reported a safeguarding concern followed by email reminders to ensure managers took appropriate action. The Trust created a dashboard to capture all safeguarding alerts and actions taken. Ward managers and matrons reviewed the dashboard in their weekly meetings and discussed open cases and any outstanding actions. Any safeguarding remaining open for a long time due to complexity would be reviewed and updated in the ‘professionals leadership assurance group’. Senior leaders told us ward managers were required to review all safeguarding alerts within 48 hours and decide if all required actions had been taken or whether the case needed escalating. Staff told us the Trust safeguarding lead would visit regularly, and they were able to access their support for safeguarding concerns.

Safeguarding systems, processes and practices mean that patient’s human rights were upheld and they were protected from discrimination. Staff did not apply blanket restrictions without justification. Staff gave examples of how they reduced the use of restrictive practices, these included a reduction in levels of patient observations on Swanswell ward and a reduction in the use of rapid tranquillisation. The Trust reported 294 incidents involving the use of rapid tranquillisation between 1 October 2024 and 31 March 2025. Edgwick PICU recorded the highest use at 107, Beechwood acute ward reported the lowest with 1. The Trust reported a 50% reduction in the use of rapid tranquillisation on the PICU wards between 3 September 2023 and 6 October 2024. The Trust did not provide data from this period to compare with the data requested for this assessment.

Patients were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 and their rights under the Equality Act 2010. The Trust reported 98% of staff received level 1 and level 2 training in the Mental Capacity Act (MCA). Staff had a good understanding of the MCA. Staff on Spencer ward told us patient consent was discussed in MDT meetings. Staff told us they completed a capacity to consent form for patients on admission. Staff on Sherbourne ward shared an example of supporting a patient who lacked capacity in relation to managing their money. On Hearshall ward, we saw evidence in care records of staff completing MCA assessments in relation to physical health conditions and medication. The Trust had a policy on the MCA, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the Trust regarding the MCA, including deprivation of liberty safeguards. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. They did this on a decision-specific basis with regard to significant decisions. We observed a best interest meeting on Beechwood ward. The team discussed the patient’s lack of capacity in relation to a specific decision and options as to how best support the patient and meet their mental and physical health needs. The doctor included views expressed to them by the patient’s mother. The service had arrangements to monitor adherence to the MCA. Staff audited the application of the MCA and acted on any learning that resulted from it. Staff told us the pharmacy and MCA teams completed audits of MCA compliance. Managers created a flow chart from completed audits to help improve practice.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Most patients told us they were informed about risks and how to keep themselves safe. We spoke with 6 patients about their involvement in managing risks and 4 said staff involved them in managing their risks. Staff did not always record patient involvement in managing their risks in their care records. We reviewed 15 care records across all wards. Staff did not evidence patient involvement in managing their risks in 6 of these records. Staff did not record this on Beechwood (2 records), Spencer (2 records), Edgwick (1 record) and Swanswell (1 record) wards. The Trust advised they audited care records for all patients between March 2025 and April 2025 and noted an improvement in patient involvement to 91% compliance. We asked 3 carers of patients at the service if they were aware of their relative’s risk assessment and if risks were managed safely, 2 said no and 1 said yes.

Staff did not always assess patients’ risks. Staff were not completing full risk assessments and risk management plans for all patients using the service on Edgwick, Beechwood, Spencer and Sherbourne wards. We reviewed 15 care records across all wards. Staff had not fully completed risk assessments or risk management plans in 5 records. Staff had used global risk stratification to predict self harm risk in 2 records reviewed. This was not in line with National Institute for Health and Care Excellence (NICE) guidance for assessing risks of suicide and self harm. However, the Trust advised they were in the process of implementing a new risk framework in line with NICE guidance, but not all staff had completed the training. We observed an MDT risk formulation meeting for a patient on Swanswell ward, the team discussed protective factors, precipitative factors and perpetuating factors. The Trust advised they audited care records for all patients between March and April 2025 and noted a compliance rate of 96% in relation to staff completing up to date risk assessments and risk management plans for patients. Staff told us they understood patients’ risks, and these were discussed in handovers and daily safety huddles. Staff told us they would also check patients care records for information on their risks and how to manage these.

There was a balanced and proportionate approach to risk management that supported patients. The Trust improved their approach to the management of Section 17 leave and developed an updated policy. Section 17 of the Mental Health Act allows a patient’s responsible clinician (RC) to authorise a leave of absence from the ward for a specific occasion or occasions and/or specific period. The patient’s RC may also place other conditions on a patient’s leave of absence, including whether they need to be accompanied by staff. Nurses described the process for enabling patients to access their Section 17 leave. They told us they would assess the patient to ensure they were safe to go on leave, check the leave form for any conditions put in place by the RC and record what the patient was wearing before they left. Nurses were responsible for assessing patients for leave and recording correctly, they received training from the Trust’s MHA team to do this. On Swanswell ward, staff gave patients cards with contact numbers, so patients were always able to make contact when on leave. The Trust implemented improved processes for the management of risk items on the wards. Managers described the new process that included a contraband signing in/out log on each ward and improved storage facilities for patient contraband items. Staff followed the Trust search policy when searching patients, including on return from leave. Staff conducted searches off the ward and had access to an electronic ‘wand’ to help locate contraband items.

Most staff followed the Trust policy on therapeutic observation and engagement when allocated to observe patients who may be at risk of harming themselves or others. We checked observation records on Swanswell and Beechwood wards. On Beechwood ward we reviewed observation records for 1 patient on level 3 observations completed for April 2025. Although staff completed most records in full, we found staff occasionally did not complete risk information and the Nurse in Charge did not sign off all records. Following the inspection the Trust advised they had already identified through their clinical audit programme concerns about the Nurse in Charge (NIC) signing records on Beechwood ward with there being 91.7% compliance for the NIC checking the document at the time of the inspection., they advised this had since increased to100%. Managers mostly followed NICE guidance in relation to the time staff spent allocated to patients’ observations being no more than 2 hours. We found most staff were allocated to observations for 1 hour but found 3 instances of staff being allocated to observe people for 3 consecutive hours. We also found 12 entries indicated only 1 staff member was observing the patient, when their prescribed observations were for 2 staff. However, these times were when the person was sleeping and had no impact on their care. We reviewed observation records for 1 patient on intermittent observations (4 random checks per hour). Whilst staff mostly carried out the checks at random times throughout each hour, we found 2 examples of staff completing the checks at exact 15 minute intervals for that hour. This was not in line with Trust policy or best practice guidance which directed staff to complete 4 random checks within an hour. On Swanswell ward we checked observation records for 1 patient on level 3 (eyesight) observations from 3 February 2025- 28 April 2025. Staff completed correctly and clearly recorded changes in observation levels.

Staff told us restraint was only ever used as a last resort after de-escalation attempts had failed. The Trust reported 313 incidents involving the use of physical restraint between 1 October 2024 and 31 March 2025. Sherbourne PICU recorded the highest use at 101, Beechwood acute ward reported the lowest with 2. The Trust reported 38 incidents involving the use of prone restraint between 1 October 2024 and 31 March 2025. Sherbourne PICU recorded the highest use at 25, Beechwood acute ward reported the lowest with 0. Of the 38 prone restraints reported, the Trust advised staff held patients in the prone position for less than a minute in 6 instances and for between 1-5 minutes in 32 instances. Sherbourne PICU reported the most with staff holding patients in the prone position for between 1-5 minutes 22 times. CQC expects providers to ensure prone restraint is only used in exceptional circumstances. The Trust advised that the prone restraint data included incidents where staff used prone restraint more than once within the same restraint episode. The Trust advised there was a reducing restrictive practice lead working with ward teams to reduce the use of restraint and prone restraint. The Trust board recently approved a new strategic delivery plan focused on reducing violent incidents and use of restrictive practices. The Trust advised the higher numbers reported for Sherbourne ward were reflective of a PICU and there were 2 patients waiting for medium secure beds that required frequent restrictive interventions to keep them and others safe. The service took a proportionate approach to imposing restrictions on patients. The Trust reported 36 incidents involving the use of seclusion between 1 October 2024 and 31 March 2025. Sherbourne PICU recorded the highest use at 35, Hearsall acute ward reported 1 and the other wards reported 0. The Trust reported no use of long term segregation between 1 October 2024 and 31 March 2025. We reviewed 2 seclusion records, which evidenced staff followed the Mental Health Act Code of Practice in relation to seclusion practices.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Patients were not always cared for in safe environments that were designed to meet their needs. Facilities, equipment and technology were not always well-maintained. Although managers completed ligature risk assessments that identified and mitigated against potential ligature risks, not all staff spoken with were aware of these risks on Sherbourne and Spencer wards. Staff on Edgwick PICU raised concerns that the environment was not suitable for a PICU as the ceiling was too low and the walls too flimsy (plasterboard). Leaders advised the ward would be renovated as part of the estates project across the Caludon centre. This work was scheduled to take place over the next two years following a lengthy process to change contractual processes outside of the Trust's control.This work was scheduled to take place over the next two years. Staff on Sherbourne PICU raised concerns about the noise levels in the ward environment and the impact this could have on distressed patients, resulting in incidents. Staff on Sherbourne ward were not always completing the safety checklist for gym equipment before and after use. Staff recorded the last check on 15 April 2025; however, the ward manager said the gym had been used since then. We found a games console with an out-of-date PAT (Portable Appliance Test) sticker. We asked staff to remove it and request for it to be tested as soon as possible. Staff raised concerns that the PIT alarm system did not always work, and they did not always receive required support from colleagues when dealing with incidents. However, leaders advised the system was being replaced as part of the renovation works across the Caludon centre. Staff were provided with radios as a back-up. On Beechwood ward, during the tour of the ward, a PIT alarm went off (it turned out to be a false alarm) and we observed a speedy response from allocated response staff on Beechwood and other wards. We reviewed the ligature risk folder on Beechwood ward. Managers identified all ligature risks and mitigated these through individual patient risk assessments, allocation of staff to observe high risk areas and daily environmental checks. The folder contained photographs and detailed descriptions of ligature points. There was guidance for staff including challenges with line of sight and details of items that could be used to tie a ligature. We asked 3 carers of patients at the service if they thought their relative was cared for in safe environments, all answered yes.

There were effective arrangements to monitor the safety and upkeep of the premises. Leaders told us matrons completed “walk arounds” and there were processes in place to ensure oversight of the environment. These included cleaning audits, and separate audits carried out by the estates team. Staff completed daily environmental checks on electronic handheld devices, which were accessed by managers and senior leaders. Ward managers checked these for their wards at least once a week before the weekly QIP (Quality Improvement Plan) meeting. We reviewed reports generated from daily checks completed by staff for the 4 weeks preceding the inspection. The report indicated that out of 196 days, 66 were coded red. Edgwick recorded the highest number of red days with 23. Quinton (Westwood), which was a newly refurbished ward reported the lowest number of red days at 1. The Trust advised that if a ward was coded red that meant that an action was required to address an issue which had been identified. These actions could range from removing a trip hazard, which would be addressed instantly, to logging a job with estates for them to complete some work. If an action was identified for estates via the app, this would automatically log a job for them to be completed. The ward would remain as requiring an action (red) until all outstanding actions were completed. We found there were 8 days when staff did not submit an environmental check and 4 days when staff checks were incomplete.

Equipment used to deliver care and treatment was not always available and was not always stored securely. Clinic rooms on Westwood, Hearsall and Spencer wards were not equipped with a full range of medical equipment. Not all equipment required for physical health checks was present, including waist measuring tapes, alcometers, neurological testing pins, ophthalmoscopes/auroscopes, tendon hammers and tuning forks. The Trust advised that whilst it did not have all the equipment which is on the CQC's list of recommended healthcare equipment, their standardised equipment list was based on the input from clinicians across the trust for the needs of their patients. They said they believed their equipment list met the needs of patients and if there were any changes to this, they would request the required equipment. Staff had not secured spare oxygen cylinders on Beechwood, Edgwick and Westwood wards. On Beechwood ward one of the spare oxygen cylinders did not have an expiry date and we were unable to assess the status of the battery on the defibrillator. Expiry dates on some equipment had rubbed off. On Hearsall ward the oxygen mask on the emergency bag expired on the date of inspection and staff had not flagged this on the checklist record. Staff recorded the wrong expiry date for the tourniquet. On Spencer ward the spare oxygen cylinder expired a few days before our inspection, staff completed checks of equipment but had not identified the expired oxygen cylinder or that the expiry date on the Automated External Defibrillator (AED) pads was wrong. We shared these concerns with the Trust, and they reported (after the inspection) that they had taken the following immediate actions; all spare oxygen cylinders have been secured in all clinic rooms across the inpatient wards and a new medical devices daily checklist has been introduced for all areas.

We scored the service as 2. The evidence showed some shortfalls. They did not always make sure staff received effective support, supervision and development.

The Trust provided vacancy rates as of the 31 March 2025. The Trust reported 12% nursing vacancies across the service. Sherbourne PICU reported the highest vacancy rate for nurses at 24%. The Trust reported a vacancy rate of 4% for HCAs across the service. Sherbourne PICU reported the highest vacancy rate for HCAs at 21%. The Trust advised the high vacancy rates on Sherbourne were impacted by the dismissal of 3 staff and they were actively recruiting. The Trust reported a vacancy rate of 20% for allied health professionals (AHPs) across the service. AHP staff included occupational therapists (OTs), physiotherapists, dietitians and speech and language therapists (SaLT). The Trust reported an average sickness rate of 11% between 1 October 2024- 31 March 2025. Sherbourne PICU reported the highest rate at 20%. The Trust were aware of the sickness levels and held regular review meetings with staff to support them back to their roles or to consider redeployment. The Trust reported a turnover rate of 5% across the service. Sherbourne PICU reported the highest rate at 19%, impacted by recent retirements and dismissals. The Trust brought in a new ward manager for Sherbourne to support a positive culture change. The Trust reported 29% qualified shifts were filled by bank staff and 3% by agency staff between 1 October 2024- 31 March 2025. The Trust reported 43% HCA shifts were filled by bank staff and 3% by agency staff between 1 October 2024- 31 March 2025. The Trust advised that substantive staff covering shifts as additional hours were included in the bank figures. The Trust reported 0.2% qualified and 0.2% unqualified shifts were unfilled between 1 October 2024- 31 March 2025.

The Trust reported an appraisal compliance rate of 90% across the service as of 31 March 2025. The Trust reported a clinical supervision compliance rate of 89% and a managerial supervision rate of 87% across the service as of 31 March 2025.

There were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care that met their needs. We reviewed staffing levels and skill mix on the wards for the days we were on site. This included checking whether staff were permanent, bank or agency. We also checked that there were enough staff trained in safety interventions and enough staff to observe patients as per their care plans. We found actual staffing numbers were as planned on all wards and were sufficient and of the right skill mix to meet patients’ needs. The majority of staff on duty were permanent, with some bank staff. Managers told us they tried to use regular bank staff. There were no agency staff on duty during the inspection and managers advised the Trust were trying to phase out use of agency staff. We asked 12 patients, across all wards, if there were enough staff to support them. Eight patients told us there were enough staff, although 6 said staff were busy, and 4 patients told us there were not always staff available to take them on leave. We asked 3 carers of patients at the service if they thought their relative was looked after by staff who were knowledgeable and skilled, 2 answered yes and 1 said it varied. Staff on Spencer ward raised concerns that the staffing establishment had reduced by 1 HCA per shift. We discussed with leaders who advised this reduction was in line with MHOST Mental Health Optimal Staffing Tool (MHOST) as the number of patients on the ward had reduced. MHOST is a standardised and nationally recognised NHS staffing tool. The 4 patients spoken to on Spencer ward did not express any concerns about staffing levels.

Staff did not always receive training appropriate and relevant to their role. The Trust reported a compliance rate of 93% for staff mandatory training. Mandatory training included infection control, information governance, health and safety, equality and diversity, manual handling, fire safety, safeguarding, prevent and resuscitation. There was one mandatory training with a compliance rate below 75% and that was resuscitation at 53%. The Trust provided compliance data for the following training courses they classified as ‘specialist’; safety intervention foundation at 83%, safety intervention refresher at 48%, intermediate life support at 61%, national early warning scores 2 at 96%. Leaders advised their training data included staff on long term absences which impacted on the compliance rate. The Trust reported a loss of internal trainers impacted on the delivery of specialist training. This issue was included on the risk register to ensure executive oversight. Leaders told us the Trust purchased additional resuscitation equipment with plans for an external specialist organisation to deliver the training. They did not provide timescales for this training to be completed.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

There was not always an effective approach to assessing and managing the risk of infection. Hearsall, Beechwood, Spencer, Swanswell and Sherbourne clinic rooms had no clear cleaning schedules, records or audits. Staff completed cleaning tasks ad hoc throughout the week then a checklist was completed and signed by weekend staff. Staff were not aware of any process in place to escalate any concerns or actions required.However, following our on-site visit, the Trust provided cleaning schedules which included the clinic rooms.

Patients were not always protected from the risk of infection because premises and equipment were not always clean and hygienic. Whilst wards were generally clean, we found isolated areas that were dirty and dusty, including in clinic rooms. On Swanswell ward the clinic room floor was not clean and had black marks. On Westwood ward there was dust behind the spare oxygen cylinders in the clinic room. Sherbourne ward décor was tired and needed refurbishing. We checked an empty bedroom and saw paintwork was scratched and flaking off the walls. Staff advised most bedrooms were like this. The ward area was generally clean. However, we found some areas were dusty and there was debris underneath the seat cushions in the games room. The Trust were part way through a full rebuild and refurbishment of the Caludon centre. This involved decanting wards as the works were being completed. Westwood ward was now located in the newly refurbished Quinton ward. The ward was generally clean, and furniture and décor was in good, well maintained condition.

We observed positive staff practices in relation to hand washing. Staff were able to describe IPC processes they followed, including use of PPE (personal protective equipment) and staff completed IPC training. We spoke with 9 patients across all wards and asked them if the ward was kept clean, 6 said yes and 3 said no. We asked 3 carers of patients at the service if they thought the wards were clean and well-maintained, all answered yes. The Trust reported an average cleaning compliance rate of 98% across the service for monthly audits completed between 1 October 2024 and 31 March 2025. The trust target was 95%. The audits gave an overall score for each ward and the data was not broken down into different ward areas, for example, clinic rooms. Beechwood ward was rated ‘red’ for 2 months (October and March) and Hearsall ward was rated ‘red’ in March 2025. Leaders advised any areas rated red required actions to be implemented by ward managers, with matrons checking that these were completed. The Trust reported in its annual IPC report that they were compliant with 9 out of 10 criterion set within the Health and Social Care Act (2008) Code of Practice on the Prevention and Control of Infections.

Roles and responsibilities around infection prevention and control were not always clear. During our tour of Quinton (Westwood) ward we identified patients’ opened food items, including part eaten takeaways, stored in the fridge with no labels to indicate date opened and date to be used by. Managers had not implemented processes to monitor the fridge temperature, the age / usability / safety of food stored there or for cleaning and defrosting the fridge. The ward manager advised they would implement processes with cross MDT responsibility including clear documentation and roles assigned for cleaning, auditing and ongoing checks.Following the inspection the Trust advised that the fridge should not have been used to store patient food items and was therefore not checked in line with safe food storage processes.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Patients’ medicines were not always appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence. Staff did not always follow best practice in their approach to medicines. On Hearsall ward we found 5 items (eyedrops and topical creams) opened and not labelled with the date of opening. There was no accounting system for TTOs (To Take Out medicines) and the trolley used to store TTOs was very full and included bags of medication waiting to be destroyed with no record of the number of boxes. On Edgwick ward 1 patient item (wash cream) was not labelled with the patient details, and 1 opened foot cream was not labelled with date of opening or use by date. However, following the inspection the Trust advised they were aware of the need to increase staff awareness of adding dates to medicines that may need ‘expiries’ adjusted on opening. They told us this was a learning stream identified through statutory audits and had been integrated into standardised weekly audits. The Trust reported an improvement on previous years from 59% to 74%. The Trust shared examples of ‘Medicines Matters’ bulletins which detailed learning from audits and good practice examples for staff.

We reviewed 3 medication incidents on Beechwood ward. In one incident the patient went for 3 days without prescribed antibiotics resulting in a deterioration of their physical health requiring an urgent admission to hospital. Staff had not followed the process for accessing medication out of hours and had not escalated. The other 2 incidents were medication errors. In the first staff gave the patient the wrong medication, staff took appropriate action and there was no harm caused. In the second incident staff withheld clozapine medication for over 48 hours as the patient had a fast heart rate. Staff did not follow the re-titration process for clozapine and did not inform the pharmacist that staff had not administered clozapine. Although the patient did not come to any harm there was a risk of harm occurring. Clozapine is used to treat schizophrenia. Use of clozapine must be carefully monitored, due to potential adverse side effects. This includes following titration processes when clozapine is first prescribed or following 48 hours or more of a person not taking the medicine.

Patients were not always appropriately involved in decisions about their medicines. We spoke with 9 patients across the wards about their involvement with their medicines. Five patients said they were not involved and 3 said they were involved. One of the patients told us that staff did not listen to their concerns about their medication. However, we asked 3 carers of patients at the service if they knew about their relative’s medication and if staff discussed this with them and all 3 answered positively. The Trust advised that their “Consent to Treatment” Audit from March 2025, achieved 100% compliance for all patients detained within the Trust having had the ability to discuss and consent to their medication and been made aware of treatment benefits and side effects.