Coventry and Warwickshire Partnership NHS Trust

On this page

• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated well-led as requires improvement. At this assessment the rating stayed the same. Leaders did not always have the skills, knowledge and experience to perform their roles. Governance processes did not always operate effectively to enable safe and good quality care. Performance and risk were not always managed well.

However, staff knew and understood the Trust’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Teams had access to the information they needed to provide safe and effective care.

The service was in breach of regulation 17 for governance at the service.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders ensured there was a shared vision and strategy and that staff in all areas knew, understood and supported the vision, values and strategic goals. Staff spoke to us about the values of the Trust, describing them as being focused on providing compassionate care and involving patients. The Trust shared their strategic vision which was focused on fundamentals of care, embedding MDT working, timely access, treatment and discharge from inpatient services, improving the experience, safety and culture of inpatient care, staff feeling valued, safe and supported and having a voice that counts.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding. Staff described leaders as role modelling Trust values. The chief executive facilitated a series of ‘collaborative executive conversations’ and gathered feedback from 100s of staff across the Trust. From this feedback leaders identified 7 areas to improve on, including patient experience and voicing concerns. An immediate action was to increase the provision of Freedom to Speak Up Guardians (FTSU).

Equality and diversity were actively promoted, and the causes of any workforce inequality were identified and action was taken to address these. We reviewed the Trust’s ‘Work Force Race Equality Standard (WRES) 2023-24’ report. The actions within the report indicated that the Trust was effectively monitoring WRES indicators to improve the working environment for staff from ethnic minority groups. The Trust increased the number of BAME staff employed and there was a decrease in the ratio of staff from ethnic minority groups subjected to disciplinary processes. However, staff from ethnic minority groups reported an increase in bullying and harassment from other colleagues since the last report in 2022. Staff from ethnic minority groups did not believe they had access to equal opportunities for progression. The Trust also reported that racial abuse of staff by patients and the public increased since 2022. The Trust advised they were working with the staff from ethnic minority groups network and wider staff group to create an action plan to improve this and were supporting staff to report incidents of racial abuse.

We scored the service as 2. The evidence showed some shortfalls. Leaders did not always lead effectively.

Leaders did not always ensure risks were well managed. We were concerned about how well risks were managed after identifying breaches of regulations in relation to low rates of staff completing ILS and resuscitation training, safety of the environment and medicines management. We also identified concerns, that did not amount to a breach of regulations, relating to involvement of patients in managing risk, infection prevention and control, assessing needs, delivering evidence based care and treatment, treating people as individuals, responding to people’s immediate needs, person centred care and planning for the future.

Leaders at every level were usually visible and led by example, modelling inclusive behaviours. We asked 9 frontline staff about visibility and approachability of senior leaders, 7 answered positively and told us about visits from the Trust chair and chief nurse. Two staff raised concerns that they were not supported by senior leaders following incidents, including after being physically assaulted and racially abused. We reviewed evidence of senior leaders and members of the board visits to the Caludon Centre between 24 October 2024 and 11 February 2025. There were 12 visits including presentations, change NHS workshops, meetings with matrons, Christmas celebrations with the teams and involvement with interview panels. Senior Leaders included the CEO, acting Chair, Chief Medical Officer, Chief Nurse, and Chief People Officer.

High-quality leadership was sustained through safe, effective and inclusive recruitment and succession planning. We spoke with senior leaders who worked at the Trust for several years and developed their career. One leader started with the Trust in an administrative role, was supported to complete their nurse training and now held a senior leadership position. Another leader started as a HCA and was supported to develop and take opportunities, which led to them being in their senior leadership role. We spoke with the ‘Professional lead for Psychological Professions and Services’ who told us there were 2 new development roles for psychologists and teams could choose their own staff to develop into these roles. We spoke with the Recovery Lead who said the AHP workforce now had a clear leadership associate director, who supported the lived experience and recovery work. This also helped with recognising achievements and rewarding AHP staff for the work they did.

Leaders were alert to any examples of poor culture that may affect the quality of patient care and have a detrimental impact on staff. Leaders spoke about implementing ‘quality summits’ and ‘culture reviews’ on wards where there were concerns about quality of patient care or staff morale. Staff on the wards where these processes were implemented told us that improvements were made as a result, including better visibility of senior leaders.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. Most staff were confident that their voices would be heard. We spoke with 10 staff across all wards and asked them if they felt able to raise concerns and were confident they would be listened to. Nine staff answered positively, 1 staff said they tried to raise concerns, but senior leaders did not listen. The Trust expanded the provision of Freedom to Speak Up Guardians (FTSUG) from 1 to 2 plus a network of 10 FTSU champions and promoted this through posters, videos and in the virtual staff room. FTSU champions acted as points of contact for staff who may be unsure about raising a concern, offered informal advice and signposting, and helped reduce barriers to speaking up by being visible, approachable, and informed about the FTSU process. Hearsall ward manager invited the FTSUG to speak to staff at their practice development day. However, 2 staff spoken with were not aware of the FTSUGs and their role. There was a whistle blowing policy in place, that most staff were aware of. Staff told us the executive team were more visible, and the chief nurse held informal drop-in sessions for staff. Staff fed back that leadership and visibility improved following the staff survey 2 years ago when they raised concerns about this. The Trust advised no concerns were reported to the FTSUGs between 1 October 2024 and 31 March 2025.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Staff across the service told us diversity was celebrated and they were able to bring their whole selves to work. Staff described teams as welcoming and inclusive and said everyone was treated as equals. We spoke with the Trust Recovery Lead who told us about campaigns and support networks for LGBT+ colleagues and staff from ethnic minority groups. The Trust promoted the ‘no excuse for abuse’ campaign. The senior leadership were committed to this and made it clear that any form of discrimination would not be tolerated.

Leaders took action to improve where there are any disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups. Any interventions were monitored to evaluate their impact. The operations director told us they took a zero tolerance approach to racism and would tackle this directly. During the anti-immigration protests that occurred in 2024, the Trust paid for taxis to take staff to and from work who were living in affected areas. Hearsall ward manager told us about the work done to improve culture. This included learning about each other, for example, people's beliefs and values, understanding that everyone is different and learning from each other. They described different cultural events and celebrations, including easter egg and spoon races, world cup, Victory in Europe day and international men's day.

We reviewed a report produced by the ‘Local Security Management Specialist’ reviewing patient assaults on staff. One aspect focused on racially aggravated assaults and work with managers and staff to ensure they accurately recorded all assaults where race had been an aggravating factor. The author was continuing to work on ensuring racial abuse was both accurately reported and subsequently prosecuted. They met with senior officers at both police forces that covered the Trust area to discuss improved ways of joint working.

We reviewed the Trust’s Workforce Race Equality Standard report dated 2023/2024 which aimed to ensure that staff from ethnic minority groups had equal access to career opportunities and receive fair treatment in the workplace. The Trust’s total workforce was 4,405 people of which 3,223 were White and 1,183 were from staff from ethnic minority groups. The number of staff from ethnic minority groups had been increasing from 2022 to 2024, nearly reaching the national average. In 2023-2024, White staff were 27.3% more likely to be hired, with staff from ethnic minority groups staff were10.2% likely. Staff from ethnic minority groups staff were now more likely to be hired than in previous years, and this was better than the national average. The Trust board was less diverse in 2024 compared to 2023 but was still more diverse than the national average.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There were not always clear and effective governance, management and accountability arrangements. Staff did not always understand their role and responsibilities. The Trust did not always operate effective systems and processes to make sure they assessed and monitored their service against regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended).We were concerned that the Trust governance processes were not robust enough and staff were not provided with the right tools to provide safe care and treatment. The Trust’s audit and governance systems were not effective in identifying and acting on risks. Although the Trust provided evidence that regular audits took place within an extensive audit programme, this process had not identified all concerns found by the inspection team. Whilst wards were generally clean, we found isolated areas that were dirty and dusty, including in clinic rooms. Staff on Sherbourne ward were not always completing the safety checklist for gym equipment before and after use. Westwood ward patient fridge was not clean and contained unlabelled left over takeaway and other opened, unlabelled perishable food items. There was no process in place for monitoring the fridge temperature, the age, usability or safety of food stored there or for cleaning and defrosting. Not all clinic rooms were equipped with a full range of medical equipment. Staff did not always follow best practice in their approach to medicines. Staff were not completing full risk assessments and risk management plans for all patients. Assessments did not always consider the patient’s physical health needs. Doctors were not always completing the initial assessment process, including a physical health check, when patients were admitted out of hours or at weekends. Staff did not always monitor and take action to ensure patients’ good physical health. Some staff and managers raised concerns that the audits were often meaningless and took them away from more important tasks. Staff gave an example of the care plan audit highlighting whether a care plan was there or not but not capturing the quality of the care plan. Following our assessment and inspection the Trust reported that required improvements had been identified by the audit programme, an example was of care plan audits on the 4 wards that CQC identified concerns reporting a compliance of 70.3% in April 2025, this increased, after the inspection, to 81.8% in August 2025. The Trust shared the audit programme in place at the time of the inspection which included a requirement to check on the quality of care plans, however, we still identified concerns in relation to the quality of care plans.

However, a senior leader told us matron assurance checklists were completed fortnightly, to make sure there were no gaps in the delivery of care, for example, checking staff completed Section 17 leave processes correctly. Matrons highlighted any gaps to ensure improvements were made. One leader described how the performance improvement process impacted positively on a ward in terms of improvements to patient care, documentation and staff management. We spoke with the leader for safer staffing at the Trust. They developed a safer staffing dashboard that was being trialled with a report to board later that month. The dashboard included data on complaints, PALS (Patient Advice and Liaison Service), incidents, sickness, bank/agency use, turnover and provided a triangulation and a full picture of what was happening on the ward. For example, when there was high staff sickness or lack of a manager and how this impacted on the number of incidents and complaints. The trial included meeting with leaders for the service to review each ward and get to the detail of what was going on. We spoke with another senior leader who said they made changes to the governance and oversight of their wards by changing the matron role to be more visible on the wards and introducing a matron quality assurance process, including an assurance matron walk around with the ward manager. They changed the focus of their role and the matron’s role from operations to safety and quality.

We reviewed entries on the Trust’s risk register relating to inpatient mental health services. All risks were managed in line with the risk management strategy where oversight was provided by board subcommittees and the board. The Trust transferred their risk registers to a risk management platform which allowed for greater oversight and management of the risks within the Trust. Red rated risks included ligature points, fire compartment lines, wiring integrity of PIT (Personal Infrared Transmitter) alarms (personal alarms used by staff to call for immediate assistance) and demand and capacity challenges of psychological services. However, the risk management processes did not always ensure all risks were well managed as reflected in our inspection findings.

We reviewed the Trust ward to board flow chart. The Safety and Quality framework allocated group/committee attendance for mental health services. There were clear processes for each group including for serious incidents, ligature reductions, physical health, violence and restrictive interventions, food, hydration, ventilation and water safety.

We reviewed minutes from clinical governance meetings. These meetings were attended by ward managers, consultants, deputy ward managers, occupational therapists, student nurses, activity coordinators, work experience staff, pharmacy technicians and pharmacists. Staff discussed a range of topics including debriefs, feedback and learning from incidents, complaints and compliments, safeguarding issues, MHA/MCA/Dols, restrictive practices, local risk registers, medicines management, delayed discharges, audits, action plans, ward budgets, training and compliance, and use of development days to keep all staff updated.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. We spoke with the operations director, who told us there had been lots of work with Healthwatch, who visited the wards and held listening groups. They told us about linking with local employment and training organisations to support patients. They described relationships with their counterparts in other local NHS Trusts and with the local authority and Integrated Care Board (ICB).

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. The director of operations told us about working with colleagues in other local NHS Trusts to ensure patients were able to access the right care in the right place, they described an example of working with a local accident and emergency department to find a bed for a patient. Another leader told us about engagement with community teams and homelessness teams to support patients’ transition from hospital. They were starting to engage with the prison service as they identified a trend of patients being admitted to PICU a few days before their release date. The Trust was awarded the Veterans Covenant Healthcare Alliance (VHCA) which meant they met the standards for being veteran aware.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff and leaders did not always have a good understanding of how to make improvement happen. We identified multiple breaches of regulations and additional concerns as described in this report, which indicated improvements were required, which had not been acted on by staff and leaders.

Since our last inspection, the trust improved the support and education provided for resident doctors. We spoke with a resident doctor on their first mental health placement, they said they felt really supported. They had access to 3 hours training every week plus an open forum for discussions.

Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation. Staff on Edwick ward told us about their participation in a project to reduce restrictive practice and reduce the use of rapid tranquillisation. A nurse on Swanswell ward was part of the reducing restrictive practice group. Staff on Sherbourne ward told us they were able to contribute ideas for improvements and were part of the safer wards project. We spoke with a senior leader who told us about the professional development agenda including work around our Professional Nurse Advocates (PNAs). There were 8 trained PNAs across the Trust (2 in inpatient mental health). The Trust was looking to expand and had a further 9 in training (3 in inpatient mental health), and 10 more planned for October. The Trust made links with a local university who offered a PNA course which was open to other professions, so the Trust were able to offer the opportunity to AHPs and had 4 in training. The Trust reported Carers awareness training had been coproduced with people using services and their families. The Trust introduced peer support worker roles across inpatient wards. The Trust reported that they contracted ImROC to facilitate MDT development sessions as part of improving the recovery focused, trauma informed, culture of inpatient care and embedding person centred principles. The Trust recently recruited to three ‘lived experience engagement facilitator’ (Leef) posts to hear the voice of inpatients and feed this into co-creation steering groups. On Swanswell ward, staff created a ‘Pets corner’ to help patients keep in touch with their much-loved animals. On Quinton (Westwood) ward, staff implemented patient feedback forms to ensure patients felt listened to and to build better relationships. Collaborative note writing was introduced between staff and patients on Hearsall ward, with positive feedback reported by the Trust.