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
• Environmental sustainability – sustainable development

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Find out about when we will not publish a key question score and what we look at when we assess Well-led.

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. There was a strong culture of care and compassion towards patients. Most staff, leaders and stakeholders spoke positively about the future of the trust. However, the trust was struggling to develop a consistent response to changing strategic demands. Some proposals for significant organisational developments lacked detail and did not include the views of staff or patients. Staff and leaders had different perspectives on operational risk. Many staff had a negative experience of an organisational restructure in the last two years. This continued to have an impact on staff morale and engagement. For some staff, constant change was leading to staff burnout and declining morale.

Leaders ensured there was a shared vision and strategy. The trust’s current strategy, entitled “People at our heart” began in 2022/23 and was scheduled to be completed at the end of 2027/28. This document sets out the trusts’ values as being compassion, respect, excellence, collaboration and integrity. The board monitored the implementation of “People at our heart” through quarterly updates of its Strategic Delivery Plan. The report for Q4 2025/26 highlighted achievements across all directorates. For example, in mental health services, all assessment and treatment wards now had a maximum of 18 beds, there were no inappropriate out-of-area placements and there was a reduced reliance on locked rehabilitation facilities. In learning disability services, there had been an expansion of individual placement support. Within the children’s services, the trust was expanding its ‘Mental Health in Schools’ programme. However, there were some areas where improvements were still needed to achieve the strategy’s stated objective. For example, despite setting an objective to reduce sickness absence, this figure remained consistently above the sector average. In October to December 2025, the sickness rate was 7%.

The overall strategy was underpinned by accompanying strategic plans for specific areas of work. A further 13 strategies and plans had been developed to cover specific areas of work. For example, the Medicines Optimisation Strategy (2025 to 2030) was aligned to the trust strategy and priorities as well as the NHS 10-year plan. The strategy was developed through consultation with directorates, people who use the service, carers, ward staff, integrated care system colleagues and pharmacy staff. There was regular reporting of progress through the Strategic Drug and Therapeutic Group and the Safety and Quality forum.

Whilst the current strategy remained relevant, most strategic changes took place outside the published strategic plans. The primary external drivers for change since 2022 fell into four categories. These were unexpected adverse events, changes to national policy, financial pressures and opportunities to provide new services. A ransomware attack on the trust’s electronic patient record in 2022 was a significant adverse event. The trust had spent four years resolving this, culminating in the introduction of a new patient record system in January 2026. The biggest development in national policy was the publication 10-Year Plan for England in July 2025. The three priorities in the plan were moving care from hospital to the community, moving from analogue to digital and moving from sickness to prevention. Financial pressures had led the trust to develop its cost reduction programme, comprising of 24 initiatives with the aims of reducing expenditure in 2026/27 by £10.9mn. Finally, new opportunities included the trust successfully winning a tender following the recommissioning of inpatient child and adolescent mental health services across a large part of the West Midlands, which will come under the remit of the Children’s Directorate.

Significant internal strategic changes that were not mentioned in the strategy had also occurred. In 2022, the trust began a transformation of its community mental health services. This involved the amalgamation of services that had previously been divided into services for people with psychosis and people with other mental illness. This led to a management of change process in 2023 for senior staff working in these services. This involved changes to the role of some senior staff and some staff having to reapply for their jobs. In 2024, the trust ceased to provide community health and well-being services for adults. The provision of these services transferred to other NHS trusts in the local area. This change caused the trust to restructure its directorates and create the Children’s Integrated Health Directorate. The trust’s strategy had not been updated following these significant changes.

In its response to changing demands on the organisation, the trust lacked a consistent approach to proposing, researching and recommending organisational developments to the Board. Proposals were presented to the Board in different formats that, in some cases, lacked sufficient detailed analysis. For example, a proposal to close a ward included modelling different scenarios in relation to length of stay on the wards for that patient group. However, there was no analysis of how the trust would manage its duty to provide appropriate and sufficient inpatient facilities for people detained under the Mental Health Act 1983 with fewer beds. Also, a proposal to submit a bid to provide a new service, included only very brief details of the possible clinical risks associated with the service. Of the four proposals for development we reviewed, the trust had not completed Equality Impact Assessments. None of the proposals included the views of staff, patients or carers.

There was a consistent disparity between the ambition of the board and caution of staff working directly with patients. During interviews, leaders were keen to emphasise the positive aspects of developments, whilst staff were more focused on the potential risk to patients and potential for things to go wrong. For example, in relation to setting up a new inpatient child and adolescent mental health service, leaders highlighted that it was a positive development that would enhance the reputation of the trust. Staff spoke about how it was a very high-risk service, with deeply embedded cultural challenges and repeated episodes of enhanced oversight from the provider collaborative. Similarly, in relation to a ward closure, leaders spoke very positively about the benefits of treating patients at home. However, staff working in the service felt that reducing inpatient provision would make it far more difficult to admit patients to hospital. The trust had been unable to resolve these differences in professional opinion. This had led to the change being implemented with strong opposition from senior clinicians who were working directly with the patients.

There was a strong culture of care and compassion towards patients. Staff described positive cultures within their teams in which colleagues supported each other and took pride in the care they delivered. Staff also talked about a strong professional pride and commitment to delivering compassionate care despite ongoing pressures. However, staff gave very mixed feedback about their experience of working at the trust. The internal restructure in 2024 had been a difficult time for many staff. Staff said that communication at that time had been very poor and that it had been difficult to understand the reasons for the changes. Staff told us that during that time, many experienced colleagues left the service. Other staff talked about negative experiences of having to apply for their jobs during that time and feeling very insecure about the future. Within focus groups, staff told us about the cumulative impact of constant overlapping change including service reconfiguration, workforce shortages, electronic patient record implementation and repeated transformation initiatives. Some participants described staff burnout, declining morale and difficulty sustaining psychological safety.

The Staff Survey in 2025 showed the trust’s scores were slightly below the average for its benchmark group. The survey had been completed by 49.6% of staff. The trust scored 6.01/10 for staff morale, just below the benchmark average of 6.12/10. It scored 6.78/10 for staff engagement, again just below the benchmark average of 7.02/10. The trust’s highest score, of 7.54/10, was for compassion and inclusivity.

Leaders were aware of the challenges faced by staff working on the wards, although the impact of efforts to address these challenges was mixed. For example, the trust had introduced a violence reduction strategy, based on analysis of incident data. The strategy was being introduced in the context of wider developments on the wards to reduce restrictive practices, reduced levels of enhanced observations and introduce more trauma informed practice. However, whilst some staff spoke positively about changes, some staff told us there was no support from the leadership in response to repeated physical assaults and spending many hours on back-to-back enhanced observations of patients in order to mitigate risks.

There was very mixed feedback from staff on whether strategic change was being delivered in a collaborative manner. Some staff described uncertainty around changes due to unclear timelines, reduced autonomy and repeated restructuring. Staff frequently talked about concerns surrounding the implementation of the new electronic patient record. Whilst there had been 20 regular clinical staff working on the design of the system, most staff were not aware of this. Staff frequently talked about a lack of involvement at the initial stages of the implementation and how initial training sessions did not feel relevant to their roles. However, staff also said that once the new system was operational, they valued the support provided by 400 colleagues working as ‘digital champions’.

Most people, across the leadership, the staff and key stakeholders, were positive about the future. There was a consensus that the trust was taking positive steps to improve its strategy and culture. For example, some staff reported that they had begun to feel more empowered to lead change in services through quality improvement programmes. Other staff said they viewed change positively, highlighting resilience, adaptability and effective local leadership. The improvement team had a strong focus on enabling staff to develop new initiatives. Over the last year the team had engaged with over 1000 staff to develop their understanding of quality improvement. However, collaboration with patients was still at its early stages. Whilst some services had introduced roles specifically for people with lived experience, leaders recognised that collaboration with people using services needed further development.

Leaders had the experience, capacity, capability and integrity to ensure that the organisational vision can be delivered and risks are well managed. Senior staff all had extensive relevant experience. Leaders were engaged in operational matters and had a good understanding of challenges within their services. Stakeholders spoke positively about the leadership team. The trust had appropriate arrangements to ensure compliance with the Fit and Proper Person test.

Members of the board all had extensive experience, relevant to their role. The Chair had substantial experience of working at a strategic level, having held senior level roles with the NHS. Within those roles they had led on changes and organisational development. The Chief Executive was appointed shortly before this assessment, having previously been in the roles the interim chief executive and chief nurse. They were a registered mental health nurse with extensive experience of senior nursing and quality governance roles. The Interim Chief Nursing Officer had been in post since August 2025. They had a professional background in both mental health and learning disability nursing and had previously held senior roles within other NHS trusts and NHS England.

During their first six months in the role, the Chair had conducted a review of the performance of the trust Board. This included attending the sub-committees. They identified areas for improvement. Following this review, they reduced the number of non-executive directors (NEDs) from 10 to 8. Three new NEDs were appointed after other NEDS had reached the end of their terms. The new NEDs had been appointed to bring in specific skills to strengthen the board. NEDs skills and experience included NHS leadership, executive nursing roles, accountancy, clinical leadership, general practice, leadership in the voluntary and community sector and digital healthcare technology.

Staff, stakeholders and other leaders all gave consistently positive feedback about the Chief Executive, highlighting their energy, visibility and vision.

Non-executive directors said there was good teamwork across the board. They described their relationship with the executive leaders as open and respectful. Non-executive directors had a clear understanding of the key risks within the trust, they facilitated sub-committee meetings well and spoke positively about the value of hearing directly from patients about their experiences at the start of each board meeting.

All Board members talked about frequent visits to services and their engagement with staff and patients. For example, the Chair had recently visited a ward after a serious incident involving assaults on staff. They had also visited a service that was due to close to understand the views of staff effected by the closure.

Each directorate was led by a director of operations, a deputy chief medical officer and an associate director of nursing. Members of these leadership teams spoke positively about their collaborative leadership. Key areas of risk and challenges in performance were prominent in our discussions. For example, leaders in the mental health directorate talked in detail about the background and context of challenges at a community team. Leaders within the children’s directorate had a good understanding of details surrounding the long waiting times for neurodevelopal assessments.

Most staff had a positive view of the involvement of the trust’s leadership. They described leaders as visible, approachable and clinically experienced. Most staff felt confident that leaders understood frontline pressures and promoted trust values. Some staff commented that there had recently been significant improvement in the visibility and approachability of senior staff, and they valued this.

The Chief Medical Officer provided monthly supervision for the Chief Pharmacist. Discussions covered all aspects of medicines management which allowed the opportunity to discuss any challenges or gaps in the service. This was described as a good working relationship which helped as a sounding board for the direction for the service.

Senior staff in NHS agencies and local authorities spoke very positively about leadership within the trust. They described senior leaders as being accessible and having a positive approach to resolving any problems collaboratively. They also described a culture of openness and honesty within the trust’s leadership.

The trust had appropriate arrangements to ensure that members of the board were of good character and had the qualifications, competence, skills and experience necessary to carry out their duties. When staff were appointed to the organisation, they were required to provide a curriculum vitae, proof of identity, proof of qualifications and proof of professional registration. Background checks on non-executive directors were conducted by NHS England. The trust conducted checks of police records for all board members through the Disclosure and Barring Service (DBS). The Associate Director of Corporate Affairs conducted annual checks of publicly available information for all members. This included checks of data held by Companies House, the Financial Conduct Authority and Professional bodies. They also conducted a review of social media accounts. Secondments to the trust were governed by a secondment agreement.

Most staff were aware of the Freedom To Speak Up (FTSU) Guardian service and felt confident in raising concerns although some staff described a loss of trust in the process. The trust had struggled to maintain a consistent FTSU service. This meant that the amount of contact with the FTSU office was low. The trust had commissioned a new service to address this. When incidents occurred due to shortfalls in services, the trust provided a sincere and timely apology and told the people concerned about any actions being taken to prevent similar incidents happening again.

The trust had struggled to maintain a consistent Freedom to Speak Up (FTSU) Guardian officer, since the previous post-holder retired in 2024. At the time of the inspection, there were two FTSU posts within the trust, although these posts were unoccupied due to vacancies and sickness. The trust had appointed an independent organisation to provide the FTSU Guardian service. This included a telephone service that staff could use to raise concerns. This service was open 24-hours each day. The independent service will replace the in-house service when all ongoing casework has been concluded. There were 14 Freedom to Speak Up champions across the organisation, although these staff were not spread evenly across the different services.

Over the 4 quarters from Q3 2024/25 to Q2 2025/26, there had been a total of 24 cases brought to the FTSU guardians, 3 of which were raised anonymously. Of the 24 cases, 22 (92%) contained an element of ‘worker safety or wellbeing’, 14 (58%) contained an element of ‘bullying or harassment’ and 8 (33%) contained an element of ‘other inappropriate attitudes or behaviours’. The trust recognised that contact with the FTSU office was low. Leaders hoped that the new provider would lead to an increase in this.

Most staff felt that Freedom to Speak Up arrangements were well-understood and trusted by staff. Staff consistently said they felt confident in raising concerns without fear of reprisal. Trade Union representatives said that the trust was improving in its efforts to ensure that staff feel safe to speak out about concerns. However, some staff, particularly at middle management grades described a loss of trust, a lack of feedback when they raised concerns and inconsistent handling of concerns.

Reports on FTSU activity were provided to the quality committee and the people committee every six months. The Freedom to Speak Up Guardians had given a presentation to the trust Board in May 2025.

A Guardian of Safe Working Hours (GOSWH) was appointed to ensure that resident doctors work safely, within their agreed number of hours. Quarterly GOSWH reports were presented to the trust board by the Chief Medical Officer. The report in January 2026, stated that resident doctors were, on the whole, satisfied with their rotas, although there had been instances of high levels of fatigue. Resident doctors spoke highly of the Guardian for Safe Working. They said they were attentive to resident doctors concerns and keen to advocate for resident doctors at senior level meetings. Between August 2025 and January 2026, there had been 9 contractual breaches that should lead to a fine. Typically, contractual breaches occur through doctors working long hours, such as shifts exceeding 13 hours. All breaches related to the middle grade rota. During that period there was one exception report, highlighting an unfilled twilight shift at St Michael’s Hospital. A resident doctor forum was held every three months.

Staff in front line services were aware of the trust’s duty of candour. They apologised to patients and families when things went wrong. The trust provided guidance for staff on their statutory duty of candour and how this should be reported. The Incident Review Group reviewed data on the duty of candour and monitored incidents where this duty applied. In the event an incident has been reported as a Patient Safety Incident Investigation, senior managers met patients’ families to agree the terms of reference for the patient safety incident investigation. Between November 2025 and April 2026, the Interim Chief Nursing Officer had met with four families of patients who had died whilst under the care of the trust. These meetings provided an opportunity to explain to families how the trust would be implementing the learning from these incidents. The Board received reports of significant events, including Patient Safety Incident Investigations, at confidential trust Board meetings. These reports included details of how the duty of candour had been carried out. However, data and other information about the duty of candour was not reported directly to the Board.

Leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. The trust had introduced initiatives to address inequalities in recruitment and collaborated with the voluntary sector to establish innovation programmes to address mental health inequalities. Equality groups were well attended. Discrepancies between the experience of disabled and non-disabled staff were small. However, staff from minority ethnic groups reported more adverse experiences at work such as harassment and discrimination. Staff from minority ethnic groups, especially African staff, were more likely to be the victims of violence or aggression.

The celebration of diversity and appreciating the views of other people was central to the trust’s value of respect. This was reflected in the commitment senior leaders showed in supporting equality, diversity and inclusion initiatives. For example, the Chair and Chief Executive chaired a forum where diversity champions could talk to them directly about staff experiences of equality and diversity. Information was displayed across the trust’s premises, highlighting the breadth of national and cultural backgrounds of staff. In 2025, 29% of staff employed by the trust were from black and minority ethnic backgrounds. There had been a steady increase in this number form 22.8% in 2022. On the trust Board, 31% of members were from black and minority ethnic backgrounds, compared to a national average of 16%. This broadly reflected the local population.

In the staff survey in 2025, the trust achieved a score of 6.78/10 for Staff Engagement. This was slightly below the NHS average of 7.02/10. The trust achieved a score of 6.67/10 in response to the statement: “We each have a voice that counts.” Again, this is slightly lower than the NHS average of 6.89.

In the 2024 NHS Staff Survey Benchmark Report, the Workforce Race Equality Standard (WRES) indicators demonstrated differential experience between white staff and staff from all other ethnic groups combined. In relation to harassment, bullying or abuse from patients, relatives or the public, 20.23% of White staff reported experiencing this behaviour compared with 36.31% of staff from other ethnic groups. For harassment from staff, 17.35% of White staff and 19.88% of staff from other ethnic groups reported such experiences. Perceptions of equal opportunities for career progression also differed, with 60.96% of White staff reporting positive perceptions compared with 50.20% of staff from other ethnic groups. Reports of discrimination from managers or colleagues were 6.16% for White staff and 12.35% for staff from other ethnic groups. Overall, these scores are broadly aligned with benchmark medians. However, internal disparities remain evident across harassment, discrimination and career progression indicators.

The 2024 NHS Staff Survey Workforce Disability Equality Standard (WDES) indicators compare staff with a long-term condition to those without. Overall, WDES findings indicate consistent differentials between staff with and without long-term conditions across harassment, reporting behaviour, career progression perceptions, pressure to work when unwell, feeling valued and engagement. However, these differences were small at less than 5% across all the themes.

The trust had introduced initiatives to address disparities, focusing on recruitment, progression and inclusion. For example, the trust had developed action plans to ensure recruitment and selection processes were inclusive, including coaching and interview support for candidates from black and minority ethnic backgrounds and feedback for unsuccessful candidates. Leaders were proactive in promoting equality groups. These groups were well attended, with 80 staff attending the most recent black and ethnic minority network meeting, 60 staff attending the disability network and 50 staff attending the neurodiversity network. The trust also facilitated a dedicated lesbian, gay, bi-sexual, transgender, queer, and intersex (LGBTQIA+) network. The trust had introduced a Multi-Cultural Handbook with accompanying training to encourage safe spaces in which people can talk about race and language. The trust had also attracted £1million of addition funding from the Integrated Care Board to address mental health inequalities. The trust had used this money to fund eight scalable and innovative projects in the voluntary sector. These projects aimed to improve access and provide services in ways to support groups of people who had poor experiences of health services. Following its success, the trust was seeking to expand this programme of work.

Equality, diversity and inclusion (EDI) initiatives were viewed positively by staff. Staff described an open culture, opportunities for learning, and proactive support around protected characteristics. Most staff felt they were treated fairly and supported with training, reasonable adjustments, and wellbeing initiatives such as health and carers’ passports. However, ward-based staff said it was more difficult for them to become involved in EDI initiatives because of the pressure of their workloads. Part-time staff also highlighted difficulties in accessing training, and they felt that opportunities were more limited.

The trust promoted it’s “No Excuse for Abuse” anti-violence campaign. A specialist security officer and an anti-violence strategy had been introduced in an attempt to reduce incident of harassment from patient and public. Managers and psychologists facilitated support and debriefing session after incidents. However, the trust recognised that instances of assault and aggression towards staff remained high. Staff at lower grades were most likely to be the subject of this abuse. Staff from minority ethnic groups were over-represented in these roles. In March 2026, there were 222 incidents in which a member of staff was recorded as the victim, and the ethnic background of that member of staff was recorded. This data showed that 34% of these staff were white and 64% were from other ethnic groups. Forty-four percent of these staff were African.

The trust had governance, management and accountability arrangements in place. Roles and responsibilities were defined through a scheme of delegation. Financial governance was overseen by committees chaired by suitable qualified and experienced board members. Managers could account for the actions, behaviours and performance of staff. The Board had appropriate arrangements for reporting and managing risks. The Board has good oversight of statutory duties under the Mental Health Act 1983. However, the trust was in the lowest segment of the NHS National Oversight Framework. In part, this was due to significant challenges in accessing good quality data which made it difficult for the trust to accurately monitor performance in some areas of service delivery.

The Board met in public bi-monthly, with private board meetings and board development sessions in the interim. There were nine sub-committees that reported to the board. The trust had a comprehensive Scheme of Delegation setting out roles, responsibilities and the scope of decision making for leaders and managers across the trust. We attended the trust Board, Finance Performance and Investment Committee and the Quality Committee. The trust Board was held at the trust Headquarters. Sub-committee meetings were held using electronic conferencing facilities. Both the Board and Committee meetings followed a clear, standard agenda that aligned to key risks, performance indicators and the board assurance framework. Sub-committees were all chaired by a non-executive director. Each sub-committee provided a written report to each board meeting. The executive lead for the sub-committee took questions about the report. Papers were well written and sent out in advance of meetings, indicating whether they were being presented for assurance, approval or information. They were presented in a consistent format including the author, details of committees at which the paper had been discussed, details of how information aligned to strategic priorities, a summary of key points, and recommendations.

The trust’s financial governance was overseen by the Audit Committee, and the Finance, Performance and Investment Committee (FPIC). The audit committee was chaired by an accountant of seniority and experience; the chair of FPIC had significant experience in operational performance and delivery. The improvements in productivity and efficiency were overseen by the cost reduction board (CRB) supported by detailed committee scrutiny through the monthly meeting of FPIC. The committee also provided oversight of the capital programme and approved business cases above a threshold of £500k. Assurance of benefits realisation including post-implementation review of business cases was not yet embedded.

The trust had had a strong track record of delivery of its financial plans. It had approved its financial plans for 2026-27 at the March 2026 meeting of the Board: expecting to receive £283million in income in 2026-27, and to spend £294.5million. In order to break even, it had formally approved schemes to increase its productivity and efficiency by £10.9million but recognised that not all the initiatives would deliver the full cost reductions in that year. It planned to cover £3million from its internal resources.

The Audit Committee oversaw the work of the internal audit service. Internal auditing systems had identified weaknesses in 2025-26 including delays in implementing agreed improvements. The committee expected to give an opinion of moderate assurance about the effectiveness of the trust’s internal control arrangements.

NHS England had assessed the trust as being in segment 4 (low performing) of its National Oversight Framework, meaning that it received a greater level of scrutiny from regulators. There were four domains in which the trust received a low score. These were:

• The percentage of patients with a length of stay greater than 60 days was 30.23%, compared to a national average of 23.24%.
• The percentage of patients in mental health crisis to receive face-to-face contact within 24 hours was 38.59%, compared to a national average of 65.99%.
• Total sickness absence was 6.6%, compared to an average 5.62%.
• The relative difference in costs was running at 118.72%. This figure indicates higher than average spending, suggesting lower financial productivity.

The trust recognised that improvements were required in data quality. Managers explained that the quality of data being reported to NHSE was poor, and this was a significant contributory factor in them being placed in segment 4. For example, data submitted to the NHS for Q3 2025/26 was generated through the electronic patient record. This showed that only 38.6% of patients in a mental health crisis received a face-to-face contact within 24 hours, placing the trusts’ performance at 46 out of 48 similar providers. However, data presented to the Board, based on operational data, showed this figure to be 95%. Also, the data the trust used on inpatient stays focused on an average length of stay, rather than looking at inpatient stays beyond 60 days, as reported by the NHS. Data on average length of stay could be misleading when there is a mixture of very long and very short admissions. It does not lend itself exploration into the reasons for extended stays. Similarly, staff talked about 9000 children being on a waiting list for neurodevelopmental assessments. Some staff said they were under considerable pressure to reduce this waiting list, whilst other staff said that this number was a result of very poor data quality. This confusion was causing distress among some of the staff. The trust was confident that the new electronic patient record would address these discrepancies.

Performance in relation to the national oversight framework was reported at each board meeting, primarily through the Integrated Performance Report (IPR). The IPR showed variations in performance in relation to key areas over two years. This was presented in statistical control charts that showed the target, along with upper and lower controls. Data outside the upper and lower control limits were described as ‘special cause variation’ which prompted further investigation. These charts covered 34 performance indicators, including staffing, use of restrictive interventions on patients and waiting times. The report indicated strong performance in compliance with mandatory training, out-of-area placements and agency use. However, there were continuing challenges in sickness levels, especially relating to stress and anxiety, and waiting times for autism services. Senior leaders demonstrated an awareness and understanding of these matters throughout our interviews.

The trust used the Mental Health Optimal Staffing Tool to calculate the number of staff required on each ward. This calculation was regularly refreshed. The Board monitored staffing levels through the Staffing Exception Report. This report highlighted instances of staffing being above 130%, or below 80%, of the establishment. In May 2026, the report included 5 instances of staffing below 80%. In each instance, the Board was assured that staff had assessed the level of risk and provided assurance that the ward was safe. Across the trust, over 80% of staff had received an appraisal in the last 12 months. Around 70% of staff received clinical and management supervision each month. The staff turnover rate was 9%. Agency use was 3%. Since August 2024, sickness rates remained consistently between 6-7%.

The governance framework for monitoring the Mental Health and the Mental Capacity Act was well-established. The Head of Mental Health Legislation led a specialist team responsible for ensuring legal compliance, safeguarding patient rights, and embedding a human rights-based approach across services. Their remit included scrutiny of documentation, ward visits, trend analysis, and reporting into structured governance routes. This activity was monitored quarterly through the Mental Health Operational Group, the Mental Health Legislation Committee and the trust board. The Mental Health Legislation committee was chaired by a non-executive director. Two further non-executive directors attended, along with two members of the executive. Regular reports to these committees covered assurance metrics, including consent to treatment, referrals to independent mental health advocacy services, tribunal activity, use of legal sections, incidents, and patient rights delivery. Data was drawn from audits, site visits, and national benchmarks such as CQC reports. However, there was a reliance on manual data processes.

The Board monitored risks through the organisation’s risk register and Board Assurance Framework. In March 2026, there were 32 risks on the Board level risk register. Key themes of risks were waiting times to access services, quality of care and cyber security risks. The Quality Committee, People Committee and Finance Committees reviewed risk reports at each meeting. The Board Assurance Framework provided a structured process through which the board identified and monitored key risks to achieving strategic objectives relating to finance, performance and quality. The framework was updated for each board meeting. The report for the board meeting in May 2026 shows that the risk profile was broadly stable, with minor changes in some areas. Risk scores were calculated by multiplying the impact of something happening by its likelihood. Three risk categories were scored at 4/4 for both impact and likelihood, giving a risk score of 16. These were access to appropriate and timely services, sustainable and modern workforce and organisation culture. The report included details of controls, mitigations and actions in place to ensure that objectives are achieved.

The trust has established an extensive cycle of annual audits that were reviewed by the audit committee. This included financial audits, audits of quality and patient safety and audits of the estate and ward environments. The Audit Committee reported their findings to every board meeting.

The trust was mindful of commercial and confidentiality factors underpinning decisions relating to the building used for many of its inpatient services. It had therefore established a separate sub-committee of the Board to review these matters. The committee’s transactions were reported to the private board.

Medicines optimisation and pharmacy related risks were included in a risk register. Sodium valproate was the main identified patient safety risk. This was a system wide and national safety priority. An action plan was in place which included monitoring prescribing, ensuring safeguards and working with system partners to mitigate risks across all care settings. Key performance metrics were reported to the board including medicines safety indicators such as errors and missed doses, audit compliance, medicines reconciliation and discharge turnaround times. These metrics were supplemented by the Chief Pharmacist’s annual report and other reports such as antimicrobial stewardship. These ensured there was board level visibility of compliance and any emerging medicine safety risks.

The trust employed a safeguarding team, comprising of 6.2 whole-time equivalent staff to oversee operational safeguarding. The team also included a co-ordinator to oversee child death reviews. This team ensured engagement with multi-agency reviews, including reviews of children’s deaths, deaths relating to domestic abuse and homicide reviews. The Safeguarding team also had the oversight of Section 75 Safeguarding compliance through to shared duties with the Local Authority. It produced quarterly reports, shared with the Section 75 Board. Data was from these reports was used to populate the Safeguarding Adult Collection. As well as mandatory safeguarding training, the team provided specific training and resources on subjects such as child neglect. Staff reported safeguarding concerns on a standard form through the electronic patient record. An annual report on safeguarding was presented to the Quality Committee. All staff were required to complete level 1 Oliver McGowan Training. Staff identified as having face-to-face contact with patients were required to completed level 2. Compliance with this requirement was 95%.

The trust had a clear framework for governance relating to patient mortality. The Board received a quarterly mortality report, presented by the Chief Medical Officer. The trust investigated deaths of people with learning disabilities and autism in accordance with NHS Guidance. The trust responded to matters of concerns matter of concern raised by Coroners in Prevention of Future Death (Regulation 28) Reports.

The trust expected that the implementation of its new electronic patient record, together with greater consistency and accuracy of data submissions, would improve its standing in 2026-27. However, the new electronic patient record was being introduced at a relatively basic level with a view to develop its reporting capabilities over time. This meant it was not clear how long it would take the trust to resolve its challenges with specific data.

The trust had policies and procedures to investigate complaints. Complaints were monitored through the Quality Committee. In March 2026, 30 formal complaints had been recorded. The trust had well-established policies and procedures for investigating complaints. This work was led by the Patient Experience Team. This team met with each directorate to review the progress of complaints and provided a weekly report to the Chief Nursing Officer. Reports of investigations into complaints included a list of actions to be taken to address any shortfalls identified. For example, the trust upheld a complaint from a parent who was unhappy with the care support their child was receiving. The investigation report recommended changes to the way in which the duty desk recorded calls, changes to care plans for psychological therapies and a review of monitoring of patients on waiting lists. These actions were discussed at the team meeting. However, complainants did not always receive a full response to their complaint within required timeframes. For example, information presented to the Quality Committee in May 2026 shows that 14 out of 44 recent complaints had been closed outside the expected timeframe due to delays in final response letters being agreed. This was, in part, due to the timescale in the policy being relative short at 35 working days. Information published by the NHS shows that complaints investigations typically take 25 to 60 days. When responses to complaint went beyond the agreed timescales, the trust contacted the complainant to explain the reasons for this.

Data and notifications were consistently submitted to external organisations as required. For example, the trust submitted notifications to the Care Quality Commission without delay, in accordance with registration regulations. Commissioners said that they received all the information they needed in a timely manner.

The trust had implemented some quality frameworks and recognised standards of best practice. For example, the trust had submitted evidence to the Carers’ trust for Triangle of Care level 1 accreditation. The initiative promoted the active involvement of carers in patients’ care and treatment. As part of the programme, 342 staff had completed Carer Awareness Training and some staff had been assigned the role of ‘Carer Champions’. The trust also submitted data to the Model Hospital System to enable benchmarking against other providers. The trust had also achieved accreditation from the Quality Network for Eating Disorders. However, the trust had struggled with the implementation of the Patient Carer Race Equality Framework (PCREF). The trust PCREF plan set out three priorities around data recording, training and education and engaging with communities. However, in March 2026, progress against all these objectives was rated as ‘red’ or ‘amber’, indicating the programme was behind in its implementation schedule. The Quality Committee had endorsed a proposal to re-launch of this programme to improve the progress of its implementation.

Staff and leaders were pro-active in developing effective, collaborative relationships with external stakeholders and agencies. Stakeholders described the trust’s leadership as positive and constructive. The trust had well-established formal agreements with both local authorities in the area. The trust worked collaboratively on specific initiatives with other NHS and voluntary sector providers. The trust also led the arrangements for multi-agency collaboration in the use of the Mental Health Act.

The trust recognised the importance of building and sustaining effective partnerships with the health, care and voluntary sectors. The potential failure to build these relationships was highlighted as a strategic risk on the board assurance framework and had been addressed.

Leaders from NHS organisations, local authorities and the voluntary sector described the trust as an active partner in local health and care networks. They described relations with the trust as positive, constructive and increasingly embedded in the wider system. A voluntary sector provider in Coventry and Warwickshire described a longstanding and generally strong partnership with the trust, built on mutual trust and increasing collaboration. At an operational level, there were regular meetings between the Integrated Care Board (ICB) and senior nurses that focused on quality, safety and incident management. A representative from the ICB was embedded within the trust’s Quality Committee to strengthen ICB oversight and facilitate timely information sharing. However, one stakeholder group felt that, in the past, the trust had been quite defensive in responses to concerns they had raised, but there were signs of a more constructive approach under the new leadership.

The trust held formal partnerships with Coventry City Council and Warwickshire County Council under section 75 of the National Health Service Act 2006. As part of this agreement, over 285 social care staff were seconded into the trust from the local authorities. This arrangement was well-established and had been renewed several times. Partner agencies described the relationship as collaborative and integrated, with strong governance structures in place through the Mental Health Collaborative and Section 75 Board.

Senior leaders participated in partnerships and collaborations. For example, the Chief Executive was a member of the Integrated Care Board. The chair was a member of the Integrated Care Partnership. The Deputy Chair attended the Warwickshire Health and Well Being Board. Partners noted that discussion with the trust’s leadership often looked beyond the trust’s services, to focus on system integration, commissioning alignment and shared priorities.

As the largest provider of mental health services in the area, the trust took a lead in the Mental Health Collaborative. The purpose of the collaborative was to bring together key partner agencies to improve the mental health and well-being of people living in Coventry and Warwickshire. For example, collaboration was taking place with Warwickshire County Council to improve access to urgent care services. The council was aware that people with social care needs did not have consistent access to support and were re-referred between health and social care agencies. Work was underway to develop a clearer single point of access and ensure that social care needs are recognised within triage processes. Leaders from the voluntary and community sector said the trust recognised that third-sector organisations can deliver better outcomes in community-focused, recovery-oriented care. Joint working initiatives included NHS Talking Therapies and 24-hour mental health hubs. The work undertaken on the Patient Carer Race Equality Framework (PCREF), was overseen by a steering group including local Black leaders who were involved in the development, implementation and ongoing scrutiny of the trust’s PCREF action plan.

Cross-organisational work was taking place between the Interim Chief Nursing Officer and their counterparts in other NHS trust to address specific pressures, such as prolonged mental health waits in emergency departments. The Chief Pharmacist participated in Chief Pharmacists’ Networks and Area Prescribing Committee. Through these meetings there was system wide support to improve patient outcomes with access to shared formularies, medicines governance and shared care issues. It ensured there was consistency for medicine safety and improvements across the system.

The Head of Mental Health Legislation attended a multi-agency meetings with partners across Coventry and Warwickshire, including the police, the ambulance service, general hospitals and social care services. The purpose of these meeting was to ensure that arrangements were in place to ensure the people experiencing mental health crises receive the right mental health care from the most appropriate health agencies as soon as possible. The trust had also led the development of a Memorandum of Understanding for the use of the Mental Capacity Act between the trust, three local general hospitals, the Integrated Care Board and local authorities. Partner agencies commented that these arrangements worked well. They were assured that multi-agency protocols were in place and that concerns about the Mental Health Act were escalated appropriately.

The trust had a good relationship with primary care colleagues. It provided a Community Mental Health Clinical Pharmacist workforce, employing 5.4 whole time equivalent pharmacists to strengthen medicines optimisation across primary and community care. This team provided education and training to primary care professionals on mental health medications and ensured people working in primary care had access to expert medicines advice. Following discussions with GPs, a shared care agreement was established for the prescribing of a high risk and high-cost medicine with the local prescribing committee and the General Medical Committee. This led to further workstreams, and the trust provided information to GPs on missed doses for this high-risk medicine and how to support patients.

Partner agencies commented that strategic developments within the trust aligned to the wider policy direction of the NHS. For example, the trust’s involvement in establishing Integrated Neighbourhood Teams was viewed positively. This model aims to deliver more locally based, person-centred care by integrating services across health, social care, and the voluntary sector.

Staff and leaders had created well-established systems for reporting, investigating and learning from incidents. The Improvement Team had trained over 1000 staff in quality improvement methodology and built capacity in the trust for improvement to be implemented. Stakeholders were positive about improvement and innovation across the trust. The trust was pursuing its ambition to become a Teaching trust. However, some significant proposals for improvement had not involved staff or patients.

The trust had systems in place to record incidents and learn from the findings of investigations. All staff had access to training on how to record incidents on an electronic incident reporting system. The system could generate data on incidents, broken down by ward, service and directorate. In March 2026, 1,283 incidents were reported across the trust, showing an increase on the 1,020 incidents reported in February 2026. Between January and March 2026, the top five themes of the incidents were physical assaults by patients on staff (566 incidents), non-physical assaults on staff (212), non-physical threats to staff (191), shortage of staff (126) and self-harm by non-suspended ligature (115).

The trust had a well-established governance process for managing incidents, based on the NHS Patient Safety Incident Response Framework (PSIRF). Incidents with a severity level higher than ‘Low Harm’ were reviewed at a weekly incident review group, with all other incidents subject to a review by the Patient Safety Team. At this meeting, senior clinical staff moderated the severity scoring and, when appropriate, escalated the matter to an initial level of investigation, known as a rapid review. Once the rapid review was complete, the incident was reviewed at the Directorate Incident Management Group. At this meeting, a decision was made on whether further investigation was needed, either through an After-Action Review or a more detailed Patient Safety Incident Investigation (PSII). Further scrutiny is provided through the trust-wide Patient Safety Incident Group and the Patient Safety Group, which reports to the board through the Quality Committee. Patient safety reports were appropriate, detailed and in line with the trust’s policy. The Trust recognised that investigations often took longer than the target of three months. However, they felt the depth and quality of investigations was good, and they received positive feedback from families and coroners.

In January 2025, the trust introduced an Incident Review Group to provide greater scrutiny of the classification of incidents. Each meeting was chaired by a senior manager. This led to a significant change in the number of incidents being classified as moderate, severe or fatal. In 2024, 499 incidents were classified at this level. In 2025, this figure fell to 26. The trust provided an assurance that this enabled investigations to focus on more serious incidents in great depth.

Progress on all PSIIs were reported to the Quality Committee. At the Quality Committee meeting on 5 May 2026, the progress on six investigations was reviewed. The committee meeting also noted that 19 Rapid Reviews and two After-Action Reviews had been completed in March 2026. Incidents concerning the deaths of patient subject to Coroner’s inquests were presented to the full trust board meeting, along with any reports to prevent future deaths (regulation 28 reports) that Coroners had sent to the trust.

Learning from incidents typically involved changes to policies, raising awareness of risks at team meetings or providing enhanced training. The trust shared the learning from incident investigations through debriefing sessions and team meetings. The implementation of changes was monitored through data, feedback and quality assurance measures. Improvements in practice were embedded through training and supervision.

The trust had set up an improvement team in 2023 with the aims of training staff in quality improvement methodology and building capacity for improvement. Over 1000 staff attended sessions to introduce quality improvement (QI). In April 2026, the trust had 96 QI projects underway. Most of these projects had been initiated by staff in a ‘bottom up’ approach to improvement. In June 2025, the Improvement Team was shortlisted in the Quality Improvement Initiative of the Year category at the Health Service Journal Patient Safety Awards for an initiative to improve waiting times.

Staff highlighted strong engagement with quality improvement and frontline‑led innovation. Many teams reported being empowered to lead improvements locally, supported by the trust’s improvement team.

Staff in local NHS agencies and local authorities spoke positively about improvement and innovation at the trust. They said that the trust had a good, well-established quality improvement team that was underpinned by strong values.

As part of the ‘People at our heart’ strategy, the trust was pursuing its ambition to become a Teaching trust. The purpose of this was to enable staff and patients to have greater opportunities to participate in research activities and clinical trials. Teaching trust status would also enable further opportunities for career development. As part of this programme, the trust had appointed an associate medical director for research in order to develop research across the three directorates.

The trust had a patient and carer engagement and involvement strategy. Through this strategy, the trust had increased the involvement of people with lived experience. Over 30 peer support workers were employed across the trust. The trust also employed lived experience engagement facilitators across seven wards. All the lived experience facilitators had completed quality improvement training. This meant they were able to seek the views and perspectives of patients and use this to contribute to improvement initiatives. However, there was no involvement of staff, service users or carers in the proposals for key strategic developments such as a ward closure and acquiring an inpatient service.

Staff were supported to prioritise time to develop their skills around improvement and innovation. For example, pharmacists were involved in an initiative to become embedded in psychiatric liaison services, crisis home teams and primary care liaison roles. This initiative had demonstrated measurable outcomes such as medication optimisation, deprescribing, relapse prevention and admission avoidance. Other innovations included development of non-medical prescribing (NMP) pathways, integration into shared care models and use of electronic prescribing systems to improve safety and efficiency. These initiatives supported both clinical outcomes and system productivity, aligning with national workforce and digital transformation agendas.

Leaders were aware of the trust’s impact on environmental sustainability. They were able to provide examples of where the trust had made changes to reduce the trust’s carbon footprint. The Board monitored progress on the objectives set out in the trust’s Green Plan.

The trust had adopted a phased approach to incorporating the Task Force on Climate- Related Financial Disclosures part of its annual sustainability reporting requirements for NHS bodies. The trust was aware of the consequences of climate change such as increased dehydration, heat exhaustion, increased complaints due to extreme weather temperatures and reductions in the quality of care due to the impact of weather conditions.

The trust’s Green Plan outlined the trust’s strategy to deliver environmentally sustainable healthcare while improving population health. Its core ambition is to achieve net-zero carbon emissions for direct emissions by 2040, aligning with national NHS targets. The plan integrates sustainability into all aspects of service delivery, recognising that climate change, pollution, and waste directly impact health outcomes. It promotes sustainable healthcare principles such as prevention, patient empowerment, efficient service delivery, and low‑carbon alternatives. Key focus areas include workforce leadership, clinical and digital transformation, travel and transport, estates, procurement, and medicines. The plan emphasises reducing carbon emissions, minimising environmental impact, and improving operational efficiency. It also highlights collaboration with system partners and staff engagement as essential to achieving change. Overall, the Green Plan aims to create a resilient, low‑carbon organisation that delivers high‑quality care while protecting the environment and supporting long‑term community wellbeing. The Green Plan was reviewed at least once a year. The plan and related list of actions were updated and reviewed with approval from the Board every three years. This was in line with timescales set by NHS England.

The trust provided opportunities for staff to engage in sustainability through the Green Steering Group (GSG), the Green Champions Network and engagement events such as training sessions on carbon literacy. The GSG was chaired by the Chief Finance Officer and comprised of representatives from different departments across the trust. The GSG provided the board with assurance and updates on the progress of the Green Plan and its environmental commitments. The Chief Pharmacist participated in the sustainability group within the trust. The team supported the green agenda with a focus on recycling medicines where possible and looking at data for the use of inhalers. Work was also ongoing with the subcontracted dispensary to ensure sustainability and medicines was also a priority.