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

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. 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 breaches in Regulations 12 and 18. We have asked the trust for an action plan in response to the breaches of regulations found during this assessment.

There were areas where the service did not consistently meet the required standard of safety. Risk assessments and management plans were not always easy to find, consistently recorded, or clearly developed with people and their carers. Environmental limitations within the psychiatric clinical decisions unit affected privacy, dignity and the ability to safely manage people during busy periods, although improvement works were underway. Staffing pressures, including vacancies, reliance on bank staff and gaps in mandatory training, meant the service did not always ensure care was as safe as it could be.

However, the service demonstrated a positive learning culture and effective safeguarding arrangements. Staff were open and transparent about safety, understood the trust’s patient safety incident response framework, and routinely reported and discussed incidents. There was an emphasis on learning from previous serious incidents, even though no serious incidents had occurred within the crisis service in the last 12 months. Staff felt supported following incidents through supervision, reflective practice and access to occupational health. Staff understood their responsibilities under the duty of candour. Systems and pathways supported access to crisis care, continuity between services, and effective multi‑agency working.

This service scored 56 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events.

Staff we spoke with across the crisis service were aware of the trust’s patient safety incident response framework and knew how to apply this. Staff completed incident forms as and when necessary, which they discussed during handover meetings. Risks were appropriately escalated and reviewed by senior staff to ensure oversight and effective management. There was an emphasis upon learning from incidents that had put people or staff at risk of harm, or that had caused harm.

Staff in the Health-based place of safety (HBPoS) reported and escalated extended stays and any concerns about potential unlawful detentions.

There had been no reported incidents which warranted a patient safety incident investigation relating directly to the service over the past 12 months. However, the trust was issued with a Report to Prevent Future Deaths from a Coroner in January 2026, from an incident which had occurred in June 2024. Reports are issued if, following investigation, there is a risk that future deaths could occur unless action is taken. Two concerns were raised. One related to staff on an inpatient ward not completing comprehensive risk documents upon referral to the home treatment team. A second concern highlighted shortfalls in policy relating to a conflict of interest and how staff should manage this. The trust responded to the letter and had taken relevant actions.

Staff we spoke with across the teams talked about learning from previous serious incidents and were able to relay some findings and lessons learnt.

Staff we spoke with confirmed there was support for staff following serious incidents. Examples of support included supervision, reflective practice, referral to occupational health, and counselling.

Staff were encouraged to be open, honest and transparent, and understood the duty of candour. Staff we spoke with understood the importance of engaging and involving people, families and staff following incidents which had resulted in further investigations.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. There was continuity of care, including when people moved between different services.

The trust had systems in place to ensure people could access crisis services. The trust worked with healthcare partners and emergency services to promote continuity of care as people progressed through their care journey.

People who had used the service told us they could access the crisis service when they needed too. Staff triaged calls received through the 111-telephone service, with relevant referrals made for support, including to the crisis and home treatment teams. Staff discussed referrals and risk during handover meetings.

Between April 2025 and March 2026, the crisis team held patients on their caseload between 6 and 28 days. Staff told us this depended on levels of need. Staff did not report patients remained on the caseloads unnecessarily.

The health-based place of safety (HBPoS) had an effective protocol in place for the handover of patient care from the Police to the care team, which they consistently achieved within a 1-hour period.

Right Care Right Person (RCRP) is a national initiative to ensure people receive the correct treatment from emergency services during a mental health crisis. Staff held monthly multi-agency meetings with relevant partners, including the Police and ambulance services.

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

Staff were aware of and followed the trust’s safeguarding policy and procedures to maximise the safety of people. Staff showed awareness of safeguarding concerns and were supported by trust safeguarding leads. Staffed referred concerns to the Local Authority and put actions in place to minimise the risk of harm.

Staff were trained in safeguarding of adults and children. The trusts compliance target was 90%. Data reviewed during our assessment showed some teams had not met this target, with staff in the health-based place of safety, Coventry home treatment team and the northwest treatment team, falling just below at 89%. However, staff we spoke with were confident with what safeguarding was and described measures they took to protect people. Staff escalated and acted upon concerns appropriately

Staff were guided by up-to-date policies on safeguarding adults and children and Prevent. Prevent is the UK’s counter terrorism strategy to safeguard people and communities from the threat of terrorism.

Staff recorded safeguarding concerns within individual care records, with a narrative of how to minimise any risks. We reviewed 10 records across the crisis and home treatment teams, and 3 in the HBPoS. Staff had recorded if there were any active or previous safeguarding concerns. Staff routinely recorded if children were living with patients, and if a safeguarding referral was needed. Staff discussed any safeguarding concerns during routine handover and multi-disciplinary meetings. Where applicable, staff communicated with other agencies, such as substance misuse teams, to ensure consistent monitoring and a shared understanding of risks.

There were shortfalls in how the service involved people in managing risks and how risks were recorded. Staff were able to describe the people on their caseload and discuss current and emerging risks during handovers and multidisciplinary meetings. However, staff knowledge was not consistently supported by clear, accurate and easily accessible documentation.

Of the 10 care records reviewed across these teams, 9 included a risk assessment. However, the quality and location of risk information varied and was not easy to locate. We found three standalone risk management plans, with a further plan documented within a medical assessment. In other records, risk management information was recorded across different sections, such as mental health assessments or daily notes. Only 2 of the 10 records contained a clear crisis or safety plan. A further 2 records included some information about how the person could remain safe, but this was dispersed across the record rather than clearly documented in a single, accessible plan. Staff told us they were still becoming familiar with the new electronic recording system that had been introduced in January 2026. We were concerned that important risk information could be missed or overlooked due to inconsistent recording practices across teams.

Risk assessments and risk management information did not consistently demonstrate involvement of patients or carers. Only 2 of the 10 records reviewed included evidence that the person and or their family member had been involved in discussions about risks or the development of risk management plans.

In the health-based place of safety, staff recorded current risks on admission and implemented measures to manage these, such as enhanced observations or restricting access to items that could pose a risk. Restrictive interventions were used as a last resort.

The service identified and managed potential environmental risks in the care environment. However, not all facilities supported the delivery of therapeutic care. The environment in the health-based place of safety (HBPoS) was adequate. It provided people with the basic amenities they required for a short stay, providing somewhere to sit, sleep, shower and had access to food and drink. People had access to outside space and fresh air. This was consistent with the requirements of the Mental Health Code of Practice.

The adjoining psychiatric clinical decisions unit (PCDU) was very limited in space. We had concerns around safety, privacy and dignity of people using this area. The unit could accommodate up to 6 people. People were assigned to small, individual areas with a reclining armchair and a curtain for privacy. There were no separate, designated areas for male and female patients. There was one bathroom. Staff told us that they allocated people to chairs, taking consideration of gender, informed by clinical risk.

The trust operated separate staffing establishments for the Health-Based Place of Safety (HBPoS) and the Psychiatric Clinical Decision Unit (PCDU). Staff told us they provided mutual support across both areas during periods of increased demand. We were not assured that staffing arrangements were always sufficient to safely observe and meet the needs of all people using the service during particularly busy periods. This was of concern given the complexity and acuity of some people accessing the units, alongside environmental restrictions and the layout of the service.

We reviewed data from the previous six months and found that of the 196 people who used the Psychiatric Clinical Decision Unit, 51 (26%) had remained on the unit for more than 48 hours. These extended stays were not consistent with the intended purpose of the unit and were inappropriate given the facilities available.

Staff had regular contact with bed managers and worked with them to identify an inpatient bed where this was necessary. The service employed numerous administration, who supported discharge to ensure effective transfer of care between services.

The unit did occasionally care for young people aged 16-18 but staff told us that if this happened the unit was closed to other admissions to ensure safety.

The trust were aware of some of the challenges posed by the environment and had measures in place to ensure patients using the service were safe. Patients were able to pull curtains around their space for privacy. Staff checked routinely on all patients, maintained presence and engaged regularly with patients. Risks were assessed and reviewed throughout a patients stay.

At the time of our assessment, there were ongoing building works to enhance the facilities. The trust planned to open a clinical assessment service by the autumn of 2026, which will have 4 additional assessment rooms as well as additional communal areas, providing further space for patients and staff.

Rooms used for assessments and appointments across the crisis and home treatment teams allowed privacy. Staff were able to call for assistance from colleagues if required.

Staff were aware of ligature risks in all clinical areas and there were mitigations in place to reduce risk. Staff across the home treatment teams explained any individuals who were a high risk would not be left in an assessment room alone. In the HBPoS and the PCDU, managers ensured an annual ligature risk assessment was undertaken, reviewed and updated. Ligature cutters were easily available and disposed of after each use.

The service did not always make sure there were enough qualified, skilled and experienced staff who had received all required training to meet the needs of people in their care.

The service had vacant posts across all teams. Managers across the service monitored staffing levels daily to ensure there was sufficient staff. The service had not needed to use agency staff to cover registered nurse or support worker shifts. Substantive staff / bank staff had been used to cover any gaps. The trust had used some long-term, regular agency medical staff to compliment the permanent doctors in post over the 12-month period, to ensure adequate cover.

There were 137.5 whole time equivalent (WTE) staff, with 19.5 vacant positions. There were 6 vacancies within the South Warwickshire Home Treatment Team and 5 vacancies at the Coventry Team. Many staff told us they believed recruitment activity had slowed or been paused, as posts vacated through secondments had not always been backfilled. Staff reported that this had contributed to workforce gaps within teams. The trust told us there had been no pause in recruitment and explained that a vacancy control panel had been introduced to provide a robust framework for the scrutiny and approval of vacancies. However, some staff continued to perceive the arrangements as limiting the timely replacement of vacant posts.

The trust turnover data over the past 12 months showed this had varied between 0% and 15%. The South Warwickshire team had seen the highest turnover of staff at 15%, which is higher than the national average. This team was a smaller team, in comparison to the others (3 staff members were leaving during the reported time period). The 111 service had no staff turnover with the team remaining stable.

Staff we spoke with confirmed the trust provided adequate training to support them in their roles. The trust target for compliance with mandatory training was 90%. At the time of our assessment, this target had not been met in some areas. Not all staff had received basic life support (level 2). Compliance across the 111 service and the South Warwickshire service was over 82%. However, compliance across other areas ranged between 46% and 55%. The trust had plans in place to address this. Not all staff were up to date with their safety disengagement training.

The trust submitted data showing that staff across this core service had completed Mental Health Act (MHA) and Mental Capacity Act (MCA) training at compliance levels of 75% or above. This training is not mandatory for all staff and was assigned according to role requirements. The Royal College of Psychiatrists' Home Treatment Accreditation Scheme (HTAS) standards recommend that clinicians working within mental health services receive training in the Mental Health Act and Mental Capacity Act. In addition, the Mental Health Act Code of Practice states that clinicians undertaking relevant duties under the Act should receive appropriate training to ensure they can effectively fulfil their responsibilities.

Staff told us they received clinical supervision, although said that this had been difficult at times. Supervision compliance rates across the teams ranged between 22% and 92%. The three lower compliance was in the clinical coordination / HBPoS (22%); Coventry crisis / home treatment team (55%) and the 111 staff team (64%). This was below expectations. Clinical supervision is essential for all staff, particularly those working in a high-pressured environment. Following our assessment the trust had been working hard to increase supervision. However, compliance was still low in the HBPoS in July, at 55%.

Most staff we spoke with told us caseloads were manageable. Caseloads in the Warwickshire teams at time of assessment were between 16 and 20. The Coventry team held the higher caseloads, 70 at time of inspection. Coventry did cover a wide geographical area and was a larger team.

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

Staff had easy access to various infection prevention and control policies and could contact an infection prevention control lead for advice as and when needed. Clinical areas we visited were clean, tidy and organised.

Staff in the health-based place of safety and the psychiatric clinical decisions unit had access to protective personal equipment which were regularly replenished.

The service had appropriate policies and guidance for staff to follow in relation to preventing and controlling infections.Staff were up to date with their infection control training; all teams had met the trust target of 90% or above.

The service did not always make sure that medicines and treatments were safe and met people’s needs.

Staff across the service stored medicines safely and undertook regular checks to ensure they were safe to administer. Temperature checks of fridges and rooms where medicines were stored were checked daily, with concerns escalated appropriately. All services had appropriate sharps disposal facilities.

Staff across the crisis and home treatment teams had secure containers to transport medicines. Staff explained that it was best practice to take the patients medicines chart with them to sign upon administration. However, some staff within the Coventry team said this did not always happen. Staff signed the medicines chart upon return to the base. This could increase the risk of a medicines error.

Controlled medicines were not routinely stored across the service, although they could be securely held in exceptional circumstances.

Staff were supported with monthly audits of medicines by a pharmacist who visited all teams regularly and monitored stock. Each home treatment team had non-medical prescribers. Nurses had been trained in patient group directives, which enabled them to administer agreed, specific medicines to patients as needed without delay.

Staff told us doctors were easily accessible and were able to give verbal instructions for medicines over the telephone. Some staff within the Coventry team reported they have had to follow these instructions up with the doctors in the past, as they had failed to record the instructions given within the patient records in a timely way.

In one team, we noted a patient had been prescribed an initial test dose of an intramuscular medicine, which should have been administered 5 days previously. This was bought to the attention of nursing staff, who confirmed an oversight with ordering. The nurse ordered it immediately.

On another medicine chart, we saw a patient was prescribed two medicines. Upon examination of the patient record, we identified the patient had not taken one of the medicines for approximately 4 weeks. However, staff had not discontinued this on the medicines chart. This was bought to the attention of the nurse who rectified the matter.