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

Well Led: 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 this key question requires improvement. At this assessment the rating has remained requires improvement.

Staff across teams told us they were not routinely involved in decisions about service changes, which had affected morale and engagement. This was supported by the trust’s 2025 staff survey results.

Although staff were aware of the Freedom to Speak Up process and felt able to raise concerns, many were not confident that issues raised would lead to meaningful action. This had discouraged some staff from speaking up. Governance systems were in place but did not always provide robust oversight. For example, mandatory training compliance was inconsistent, staff sickness and vacancies continued to impact service delivery, and performance data, including targets for timely assessments and length of stay in the health-based place of safety, had not always been captured or used effectively to drive improvement.

The service valued equality, diversity and inclusion, with staff able to access a range of support networks and flexible working arrangements to support their wellbeing and personal circumstances.

The service had some focus on learning and improvement, with several quality improvement initiatives underway, including work to improve response times to urgent referrals and staff confidence in specialist assessments. Further work was needed to ensure staff were consistently involved, governance systems were effective, and leaders at all levels were visible and responsive to the pressures faced by frontline teams.

This service scored 57 (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 clear shared vision and strategy. However, not all staff felt involved of service changes.

Staff we spoke with were aware of the values of the trust and some staff had an awareness of the overarching trust strategy entitled “People at our heart.”. Staff regularly talked about providing the best care they could, with the resources they had, in a kind and compassionate way. All these aligned with the values of the trust. We saw staff show these values during observations across the sites during the inspection.

Most staff across the teams told us they were not involved in decisions about changes that had occurred within the service. Numerous staff said service changes had been shared with teams after decisions were made at a more senior level, rather than staff being involved or listened to. The trust’s 2025 staff survey results for the crisis service reflected what staff told us. They showed that fewer staff in the Coventry team felt involved in decisions about changes that affected their work (37.9%), compared with 47.2% across the trust overall.

Not all staff felt decisions made about clinical care had considered the additional strain on the staff, affecting morale. An issue that repeatedly came up was around the expectation of staff to work evenings and nights. The trust had explained to staff that the service needs to be a 24-hour service, in line with national expectations, and had been reflected within job descriptions. Staff spoke positively about colleagues within their immediate teams and described how they supported one another at a local level.

The service had local managers and directorate leaders who understood the context in which they delivered care, treatment and support. Leaders we spoke with were knowledgeable and passionate about the service.

Managers we spoke with placed emphasis on supporting staff to develop their skills and experience, supporting personal and professional development. This aligned with what staff told us, with some having attended external conferences or courses. Several staff told us making time for mandatory training being a challenge at times, due to workload and staffing situations.

Many staff we spoke with said the trust senior leadership team did not appreciate the workload, pressures, and the difficulty in meeting day to day expectations. Many staff told us they would welcome more senior staff work alongside them to get an idea of what they had to achieve on a day-to-day basis. Staff reported local leadership being visible, but service and trust leaders not as visible as they could be.

While some staff told us they did not always feel supported by senior management, we saw evidence that staff had opportunities to raise concerns with senior leaders and that feedback had resulted in service improvements. For example, additional administrative support was introduced for out-of-hours services, and plans for a new telephone system were amended following staff feedback. Senior leaders also provided forums where staff could raise questions and discuss concerns.

People did not always feel they could speak up and that their voice would be heard.

The trust had a Freedom to Speak Up Process in place, which staff were aware of. As well as the Freedom to Speak Up Process, staff were able to raise concerns through other avenues, including their line manager, clinical leads or professional leads. The trust had Freedom to Speak Up champions, who promoted the service. Staff told us they were not afraid to speak up. However, many staff said while they would raise concerns, they were not sure these would be acted upon. This had discouraged some staff to voice concerns.

This was reflected in the trust’s 2025 staff survey results for the question ‘I feel safe to speak up about anything that concerns me in this organisation’. This showed only 56.7% of respondents in the Coventry team reported positively, compared with 62.0% across the trust overall. The trust advised us that from April 2026, a new independent and confidential guardian service had been introduced, with the aim of strengthening their culture of openness, safety and support for staff.

Across the crisis service, 7 Freedom to Speak Up concerns had been raised in the last 12 months. These related to themes including unprofessional conduct, bullying, team culture, concerns about processes, and dissatisfaction with consultation arrangements for staff changes. In 2025- 2026, 71 concerns were raised across the organisation through the Freedom to Speak Up route. Although the inspected services represented around 3% of the organisation’s staff, they accounted for 10% of the concerns raised. This indicates that staff were aware of and had used the Freedom to Speak Up process

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

The trust had support networks available for staff, which enabled colleagues to learn from and support each other. Some examples include the black, Asian and minority ethnic network (BAME); disability and wellbeing network (DAWN) and LGBTQIA+ and allies’ network, supporting staff of diverse sexual orientations and gender identities.

Managers confirmed they used the trusts flexible working policy to action any requests for flexible working. The policy informed staff of their rights to request flexible working and the process to follow to do so. Several staff told us of some flexible working arrangements in place, which supported personal circumstances and or health issues.

The service had governance arrangements in place, but they were not working robustly. They did not always deliver appropriate levels of oversight to drive improvement for people accessing urgent care services.

Urgent care held regular mental health quality forum meetings. These had a standard agenda which included reporting on performance and finance; as well as individual team updates around staffing, caseloads, pressures and challenges faced. Minutes of meetings between January and March 2026 highlighted a need for improved staff training for completing RIDDOR (Reporting of injuries, diseases and dangerous occurrences regulations) reports, which staff had not been submitting in a timely way. Further training was being looked into, to improve this.

The meeting minutes included discussion about the transfer of the electronic records system, initial challenges and identification of improvements needed. The electronic system caused significant difficulties for us to locate documents during this assessment. Staff could not navigate these effectively, despite training and preparation rolled out before launch.

Ongoing staff sickness and vacancies was an ongoing challenge across the service. Efforts continued with managers escalating urgent posts which required filling, in line with the recruitment pause process. Regular bank staff were being used to cover gaps. Long term sickness had contributed to shifts needing to be covered.

Compliance with some mandatory training had been highlighted during monthly meetings. Staff reported difficulties with booking training, sessions being cancelled and staff shortages. All of which had contributed to the trust target compliance not having been met in some areas. Regular clinical supervision had been difficult to achieve across some teams.

The organisational risk register had 2 risks associated with urgent care services. These were around telephone systems and calls, and access to psychological interventions. The trust had plans in place to replace the telephone system to support improved functionality. Call handling support had been reviewed and continued to be monitored. There had been an increase in abandoned calls in the 111 service since January 2026. The trust continued to work on staff being available to answer calls.

In the months leading up to our assessment, there had been a failure to consistently capture data around the length of stay in the health-based place of safety (HBPoS). The trust assured us that a new process had recently been put in place to enable monitoring of this.

As indicated within this report, staff were not consistently meeting targets for seeing people referred to the urgent care service. This had been ongoing for some time and needed improvements to ensure people accessing urgent care services were being seen and assessed in line with national guidance.

The service understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement.

Staff at all levels we spoke with told us about the importance of partnership working with organisations and the wider community to deliver care and treatment. For example, some staff told us about the need to work closely with local acute hospitals to support patient flow through emergency departments. Staff working within the health-based place of safety (HBPoS) talked to us about maintaining effective working relationships with the Police and other appropriately trained professionals to ensure people were safe and offered assessment at the earliest opportunity.

Staff worked with primary care partners to support people who used services. Staff across the crisis and home treatment teams provided advice, consultation, triage and assessment to people in primary care with mental health needs.

Managers held regular meetings with partners and agencies who were working with the trust to provide and support people who required urgent care in Coventry and Warwickshire.

The service had some focus on continuous learning and development across the trust and within the urgent care service.

The urgent care service had not been accredited by the Royal College of Psychiatrists for meeting the standards of the Quality Network for Crisis Resolution and Home Treatment Teams at the time of our assessment. The trust informed us that 4 staff members within the trust quality improvement team had completed training and had achieved the AWuA QSIR associate accreditation training, which meant they had been prepared to lead and sustain improvement projects within the organisation.

We were told of 3 ongoing quality improvement initiatives at the time of our assessment. One related to urgent referrals being seen within 24 hours of referral (Coventry crisis team). One was in relation to improving the crisis team’s confidence in assessing mental illness and risk in the perinatal period. We observed a presentation given by the perinatal team as part of this initiative. The third quality improvement initiative was about reducing time spent with medical correspondence across the crisis teams.