Coventry and Warwickshire Partnership NHS Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Staff assessed the physical and mental health of all patients on admission, ensuring relevant information was collected to inform the development of individualised care plans. Care plans were developed for each patient and reviewed regularly through multidisciplinary discussions, with updates made as required to reflect changes in patient needs, risks, or treatment goals. Staff provided a range of treatment and care based on national guidance and recognised best practice, ensuring interventions were evidence-based, safe, and responsive to the diverse needs of patients. Staff from multiple disciplines worked collaboratively, combining their expertise and coordinating effectively to ensure that care and treatment decisions were comprehensive, consistent, and promoted safe, positive, and person-centred outcomes for patients. However, there was variation in the quality and completeness of record‑keeping across teams and the assessment and recording of patients’ mental capacity were inconsistent across the care records we reviewed.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 13 patients’ care records and found variation in the quality and completeness of record‑keeping across teams. While some records were detailed, up to date, and demonstrated good oversight of physical health needs, others lacked key information, particularly in relation to physical health monitoring.

The teams had recently transitioned to a new electronic patient record system and it was evident during our assessment and review of patient records that a significant amount of information had not yet been transferred across. As a result, locating relevant information was more time consuming and challenging, as it was often necessary to review both the new system and the legacy system to obtain a complete and accurate picture of the information recorded for individual patients. This was a challenge identified by the assessment team and echoed by many staff members working within the teams.

Within the Coventry team, we found that some patient records were not fully up to date, particularly in relation to physical health monitoring. For example, we saw instances where patients were reported to be receiving regular physical health checks as part of medication monitoring; however, these checks were not consistently reflected within care records. In one case, the most recent physical health assessment recorded had taken place in April 2025, with no further physical health monitoring documented beyond that date. Similar gaps in the recording of recent physical health monitoring were identified in other records reviewed within the Coventry team.

In contrast, patient care records reviewed within the North Warwickshire and South Warwickshire teams were generally found to be comprehensive and of a good quality. These records demonstrated thorough annual physical health reviews and clear evidence of ongoing physical health‑related support and monitoring where required. The patient’s voice was consistently well reflected, and action plans were detailed, personalised, and comprehensive.

The service planned and delivered people’s care in line with legislation and current evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence.

Community Mental Health Teams (CMHTs) supported adults with a broad range of mental health needs, including severe and enduring conditions such as psychosis, bipolar disorder, and complex depression and anxiety. Referrals were received through a variety of routes, including the Mental Health Access Hub (111), GPs, self-referral, and hospital wards.

The teams delivered ongoing, person-centred care, working in partnership with individuals and, where appropriate, their carers. Support focused on comprehensive assessment, care planning, and the coordination of treatment, including medication management, the administration of medication such as intramuscular depot injections, and relapse prevention. CMHTs also operated clozapine clinics to support patients prescribed clozapine, which required regular monitoring. These clinics facilitated routine blood testing to monitor for potential side effects, ongoing physical health checks, review of mental state, and oversight of medication adherence, in line with national safety requirements. Staff also supported individuals with daily living needs and facilitated access to wider services to promote wellbeing, such as housing, employment, and substance misuse support. Each patient had an identified care coordinator who acted as the central point of contact and ensured care was responsive to their changing needs.

CMHTs worked closely with inpatient and crisis services, as well as primary care and voluntary sector organisations, to provide continuity of care and support recovery within the community. The teams were multidisciplinary, comprising of nurses, psychiatrists, occupational therapists, support workers, social workers, psychologists, and other allied health professionals.

Patients were allocated a care coordinator and offered a range of interventions, including medication management under a consultant psychiatrist, psychological therapies such as cognitive behavioural therapy for psychosis and behavioural family therapy, and individual placement support for employment. Additional support included peer support, support workers, occupational therapy, physical health checks, smoking cessation support, and carer and family work. The team also included a pharmacist who ran medication clinics and maintained close links with a local substance misuse service, which attended MDT meetings. Social support was further promoted through group activities such as walking groups and community‑based programmes.

Early Intervention in Psychosis (EIP) teams provided a time-limited, specialist service for individuals experiencing a first episode of psychosis or those at risk of developing psychosis. Referrals were typically made via GPs or other mental health services. The EIP service offered intensive support for up to three years, with a strong emphasis on early intervention and recovery. Care was delivered collaboratively with individuals and their carers and included a range of therapeutic and practical interventions, such as psychoeducation, family work, cognitive behavioural therapy, physical health monitoring, and support with education, employment, and finances. As with CMHTs, patients were supported by a care coordinator who worked alongside them to plan and review their care.

EIP teams also maintained close links with inpatient and crisis services, as well as community and voluntary organisations, to ensure a coordinated approach to care and to support individuals in achieving sustained recovery and independence. The teams operated within a multidisciplinary model, including nurses, psychiatrists, occupational therapists, support workers, social workers, psychologists, and students in training.

Doctors prescribed medicines in accordance with trust policies and national guidance. Psychologists provided cognitive behavioural therapy and a range of trauma focused therapies. Occupational therapists conducted functional assessments. Nurses, support workers and other allied professionals provided therapeutic support, ongoing physical and mental health monitoring, medication support and psychoeducation. They also offered crisis intervention, care coordination, and practical social support such as housing, benefits and daily living skills.

Staff ensured patients had access to physical healthcare through the trust’s physical health team and GP referrals when needed.

The service worked well across teams and services to support people. Staff worked collaboratively within multidisciplinary teams to review needs, share information and agree coordinated care plans. Teams maintained strong partnership working with external agencies to promote continuity of care and holistic support.

The service worked in partnership across teams and with external agencies to support people with complex and changing needs. Daily clinical risk meetings and weekly multidisciplinary team (MDT) meetings provided regular opportunities for staff from multiple disciplines to come together, share information, and coordinate care. This included input from CMHT clinicians, Early Intervention teams, family specialists, clinical leads for autism and representatives from substance misuse services, who routinely attended MDTs.

The service also worked collaboratively with social care under a formal partnership agreement, supporting joint working for people requiring both health and social care input. Links were maintained with children’s services, learning disability services, and the crisis team, with ongoing work to strengthen coordination as CMHTs increasingly supported people with higher levels of complexity. Staff described efforts to further improve joined‑up working with voluntary sector organisations, to enhance community‑based support for patients and families.

We also heard that the teams held shared care meetings on Mondays, Wednesdays, and Fridays to discuss patients who were disengaging from services, where there were specific concerns, or who were on enhanced psychosis pathways, including those with schizophrenia or bipolar disorder. These meetings provided an opportunity to identify early warning signs and patients at increased risk of relapse. Attendees included a range of multidisciplinary roles, such as support workers, nurses, and social workers.

The service supported people to manage their health and wellbeing. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff across the teams told us that the service had a dedicated physical health team responsible for annual physical health checks, which many staff described as responsive and accessible. However, within the Coventry team, some staff reported difficulties accessing this service. As a result, patients were often referred back to their GP to complete physical health checks.

We heard how teams signposted people to a range of services to promote wellbeing, including Mind support groups, women’s groups, substance misuse services, and yoga or other community‑based activities, and supported referrals to these services where required. Staff also described routinely discussing healthy living with people during contacts, including the importance of a balanced diet and lifestyle choices. In addition, we observed that smoking cessation was discussed during patient contacts, with appropriate signposting to GPs and community pharmacies for further support where indicated.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes. The service used the Dialogue tool, a system that enabled patients to rate their satisfaction with key aspects of their lives and treatment. Staff established patients’ baselines by completing this questionnaire during the early stages of their care and treatment. The questionnaire was repeated at later stages of treatment to measure patients’ progress over time.

The service gathered patient feedback through the I Want Great Care (IWGC) platform, and we reviewed feedback collected during 2025. Feedback highlighted compassionate and supportive care across teams, alongside recurring themes for improvement relating to communication, access, staffing pressures, and waiting times.

The evidence showed some shortfalls. The service did not always ensure that mental capacity assessments and consent arrangements were completed and documented consistently.

The assessment and recording of patients’ mental capacity were inconsistent across the care records reviewed. While some records included clear, decision‑specific mental capacity assessments, others recorded conclusions about capacity without supporting assessments, lacked clarity about the decisions assessed, or made no reference to mental capacity at all.

Patient consent was sometimes documented within care records; however, this was inconsistent, often making it unclear what consent arrangements were in place, including around information sharing with family members.

Staff explained that care plans and risk assessments were carried out and reviewed with service users where possible, involving patient’s friends and family where appropriate and consent was gained.

The provider informed us that record-keeping audits were undertaken within the CMHT. As part of these audits, there was a review of whether mental capacity had been appropriately documented. The most recent results for this element of the audit showed compliance of 70%, against the provider's target of 90%. The provider also highlighted a range of resources available to support staff in relation to mental capacity and mental health legislation, including guidance materials available on the trust's intranet, regular bulletins from the Head of Mental Health Legislation, and externally commissioned training.