Coventry and Warwickshire Partnership NHS Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant people’s needs were not always met. Patients often experienced extended waiting times for assessment and treatment. There was limited evidence of actions taken to address inequalities, such as engaging with communities that were typically harder to reach or ensuring equitable access for patients with hearing impairments. However, the service provided care that was personalised, compassionate, and respectful. There was a positive culture of reviewing and learning from complaints and feedback received.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service delivered care that was personalised, compassionate and respectful. Patients told us that staff worked collaboratively with them, and where appropriate with families and carers, to plan and deliver care that reflected their individual needs, preferences and circumstances.

Many patients reported positive experiences of continuity of care and strong therapeutic relationships. Some patients told us they were supported by the same member of staff over time, which helped them feel known and understood. Others described reliable and flexible support, including appointments being on time and arranged to take place in their home. Patients spoke positively about being involved in decisions about their treatment, including choice around medication changes.

Patients also told us that staff communicated clearly and helped them to understand their care and condition. Therapeutic interventions were described as supportive, interactive and inclusive, with some patients highlighted that staff respected their beliefs and helped them feel comfortable during therapy. Several patients said that support from care co‑ordinators and support workers had helped improve their stability, confidence and quality of life. However, some patients reported inconsistency in the staff delivering their care. This included changes in psychiatrists, care co‑ordinators and healthcare assistants, as well as seeing different staff members for depot administration, which some patients found frustrating and disruptive to continuity of care.

Feedback about access to the service was mixed. Some patients reported being able to contact the service easily and speak to someone promptly when needed. Others described difficulties getting through by telephone, including lengthy waits on hold or calls not being answered. Several patients told us that having direct contact details for their care co‑ordinator or key worker improved their experience of accessing support.

Leaders described work that was underway to develop an enhanced psychosis pathway within the service, in response to national guidance from NHS England and recommendations arising from the Nottinghamshire Inquiry. The pathway was intended to improve outcomes for people with psychosis who were assessed as being at higher risk, non‑engaging, or experiencing repeated crisis and use of urgent care.

The enhanced psychosis pathway was expected to provide a more intensive model of care for a defined cohort of patients already open to services. Patients were identified through caseload reviews and a centralised database, using agreed criteria including presence of psychosis, high non‑attendance, frequent crisis or urgent care use, police and AE contact, prolonged admissions, community treatment orders, substance misuse and homelessness. Leaders estimated that around 350 patients would be supported through the pathway, based on benchmarking and population need, with numbers expected to fluctuate.

The service implemented the pathway through caseload reviews across community mental health teams, early intervention services and older adults services, and by providing education to staff on the identification of eligible patients. The model included reduced caseloads for clinicians and a minimum expectation of weekly contact, enabling a more assertive and intensive approach than standard community mental health provision. Patients who met the criteria were able to move from outpatient‑based care to this enhanced model.

At the time of the assessment, the pathway remained in development, with a business case progressing through governance. Development groups, including experts by experience, had been established to support implementation and workforce planning, and a training programme was in development. Leaders reported that the enhanced psychosis pathway was planned to become fully operational from June 2026.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Care and treatment delivered by the service reflected a flexible approach to meeting patients’ mental health needs across the care pathway. The service offered a range of psychologically informed interventions, including graded exposure and anxiety management through psychoeducation, behavioural activation, and support to address patterns of avoidance. Emotional regulation and distress tolerance were embedded within support approaches, including through a dialectical behaviour therapy (DBT) informed Managing Emotional Skills (MES) group. Additional group‑based interventions included programmes such as Mood on Track for people living with bipolar disorder.

We heard how support workers played a key role in promoting engagement and continuity, supporting patients to attend appointments, access group interventions and build confidence in managing their mental health.

The service described using psychologically informed practice across teams to support consistent approaches to care delivery. Physical health monitoring was also integrated into care provision, alongside depot clinics and outreach activity, which supported continuity for patients who required ongoing medication management or found it difficult to attend clinic‑based appointments.

The service worked across multiple pathways, including Early Intervention Services and a dedicated personality and trauma pathway (PACT), supporting joined‑up working and continuity across different stages of a patient’s journey. Depot clinics and outreach activity further supported continuity of care for patients with more complex needs.

The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies where required, including safeguarding referrals to the Local Authority and statutory notifications to the Care Quality Commission (CQC).

The service had processes in place to identify and record patients’ communication needs, supporting compliance with the Accessible Information Standard.

Staff told us that communication needs were routinely considered and documented; however, we saw limited evidence of these needs being consistently met through the proactive provision of accessible information, such as large print or easy‑read materials.

Information was not routinely displayed in alternative languages within service environments, including waiting areas. Staff explained that accessible formats and translated materials could be arranged through the Trust’s communications team when required, and staff reported that information could be provided in different formats or languages on request. However, Interpreting services were available when required to support patients’ communication needs, and staff told us they could arrange interpreters as needed.

Staff acknowledged challenges in meeting the needs of some deaf patients, particularly in relation to the availability of sign language interpreters, which had resulted in appointment cancellations.

We also heard feedback that some autistic patients felt the service could be better adapted to meet their needs in terms of greater flexibility in communication methods, such as increased use of text or email for patients who preferred non‑verbal communication.

Patients were provided with information about their care and treatment options, local support services and how to raise concerns or make a complaint. The service also promoted opportunities for patients to share feedback, with staff routinely encouraging engagement through patient experience surveys, including the distribution of I Want Great Care feedback forms.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We reviewed data relating to complaints received by the service between March 2025 and February 2026. During this period, a total of 75 complaints were recorded across the service. Of these, 32 related to Coventry CMHT, 21 to South Warwickshire, and 18 to North Warwickshire. A small number of complaints were received by Early Intervention Services, with 3 relating to Coventry Early Intervention team and one to the South Warwickshire team.

The main themes of complaints received by the service were unmet care needs, delays in treatment and insufficient support. Patients reported long waits, limited follow-up and feeling unsupported during periods of increased need. Communication difficulties were also common, including delays in responses, inconsistent information and poor information sharing between professionals. Concerns were raised about the accuracy of clinical records and the impact this had on care. Some complaints related to staff conduct and professionalism, particularly where interactions were perceived as lacking empathy. Appointment-related issues were also highlighted, including delays, cancellations and a lack of clear follow-up. A small number of complaints raised concerns about consent, confidentiality and discharge arrangements.

Complaints were initially managed through local resolution wherever possible. Team managers engaged directly with patients, either in person or by telephone, to discuss their concerns. Where appropriate, medical issues were escalated to medical colleagues. Formal complaints were progressed via the Patient Advice and Liaison Service (PALS) and were independently investigated. Learning from complaints was reviewed through the Community Complaints Action Meeting.

We saw evidence of learning and service improvement following the receipt and investigation of complaints. For example, a patient raised concerns regarding a consultant’s manner and the structure of appointments. In response, the service facilitated a change of consultant and arranged a transfer to a different team. Concerns regarding the consultant’s behaviour were escalated to medical leadership for further review. In another example, complaints had been received regarding difficulties in accessing the duty team. This led to the development of specific staff responses, including the introduction of tailored care planning for a patient who frequently contacted the service while under the influence of alcohol.

Information was available in waiting areas and staff spaces to guide patients and staff on how to share feedback or raise concerns. This included contact details for the Trust’s Customer Relations Team, the Freedom to Speak Up Guardian and the Care Quality Commission, as well as access to patient and staff surveys. Patients were also directed to advocacy services to help them voice concerns where needed.

The evidence showed significant shortfalls. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

The data provided by the Trust in relation to waiting times was only available up to December 2025. This was due to the implementation of a new electronic system around that time, along with issues affecting the system, which meant that accurate waiting time data was not available following its rollout. We heard that the Trust had a dedicated team working to resolve identified issues with the Electronic Patient Record (EPR) system.

The Trust set a 4-week target for the commencement of treatment within CMHT services. However, this target was consistently not achieved, with waiting times regularly exceeding this target by a considerable margin.

Between April and December 2025, average waiting times from referral to treatment within CMHT services were 14.5 weeks in North Warwickshire, 16.2 weeks in South Warwickshire, and 31.7 weeks in Coventry.

Between April and December 2025, average referral-to-initial assessment waiting times varied across the 3 CMHTs. In comparison to the trust’s target of 4 weeks, North Warwickshire averaged approximately 6.7 weeks, South Warwickshire averaged 7.4 weeks, and Coventry averaged 16.8 weeks. During the same time period, in the South Warwickshire team an average of 53.2% of patients were seen within the 4 week target for referral to initial assessment, compared with 35.1% in the North Warwickshire team and 18.7% in Coventry.

During the same April and December 2025 time period, the average wait from initial assessment to onset of treatment was 7.8 weeks in North Warwickshire, 8.8 weeks in South Warwickshire, and 14.9 weeks in Coventry. In the South Warwickshire team an average of 45.4% of patients were seen within the 4 week target for referral to onset of treatment, in the North Warwickshire team an average of 42.8%, and in Coventry an average of 27.3%.

During January to December 2025, the Coventry Early Intervention team recorded an average referral to treatment waiting time of approximately 1.8 weeks, with South Warwickshire at 1.9 weeks and North Warwickshire at 2.1 weeks. During the same reporting period, the percentage of patients seen within the trust’s 2-week target across Early Intervention teams was 90.6% in North Warwickshire, 73.8% in South Warwickshire, and 72.5% in Coventry.

A significant number of staff and managers we spoke to expressed concern about long waiting times within the service, particularly for psychological interventions. Staff attributed these extended waiting times to staffing shortages, as well as difficulties and delays in recruiting new staff.

There was a Quality summit held on a weekly basis where waiting lists were shared and discussed.

We heard that the service prioritised patients with psychosis, causing longer delays for people with other conditions.

The average waiting times for individual psychological therapy with a psychologist or psychological therapist varied across the 3 localities. South Warwickshire reported the longest average waiting time at 111 weeks, followed by Coventry at 55 weeks, and North Warwickshire at 46 weeks. All three areas therefore demonstrated prolonged waits for psychological interventions, with South Warwickshire experiencing the most significant delay.

The average waiting times for access to psychological group therapy also varied across the teams. North Warwickshire reported the longest average waiting time at 31 weeks, followed by South Warwickshire at 25 weeks, and Coventry at 18 weeks.

Patients awaiting psychological therapies were supported through a range of preparatory interventions designed to promote readiness for treatment and provide interim therapeutic input. These included trauma-focused webinars, stabilisation groups, and cognitive behavioural approaches delivered by Mental Health Wellbeing Practitioners (MHWPs) and Assistant Psychologists.

All patients on the psychology waiting list received regular contact, including four-weekly reviews incorporating risk assessment. Patients not engaged in other interventions were offered additional monthly support from an Assistant Psychologist or MHWP, which included wellbeing check-ins, brief solution-focused interventions, signposting to other services, and escalation to clinical supervisors, duty teams, or urgent care where risks or concerns were identified.

The average waiting times across all teams for interventions delivered by the Personality and Complex Trauma (PACT) Psychotherapy Service varied by treatment type. The average waiting time for 1:1 psychotherapy was approximately 79 weeks, for Mentalization-Based Therapy (MBT) 77 weeks, and for Dialectical Behavioural Therapy (DBT) 24 weeks.

The average waiting times from referral to first contact with a psychological professional within the Early Intervention in Psychosis pathway were approximately 39 weeks in South Warwickshire, 33 weeks in North Warwickshire, and 12 weeks in Coventry.

The evidence showed some shortfalls. Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Staff compliance with Equality and Diversity training was over 99%.

Some staff and managers we spoke to demonstrated awareness of population groups that had historically under‑accessed services and were therefore more likely to experience inequalities in access, experience or outcomes. This included specific communities within the local area who were known to be harder to engage and more likely to manage mental health needs within the family or home environment rather than seeking external support.

However, we saw limited evidence that this awareness had translated into proactive or sustained actions to address these inequalities. While the service had identified external organisations that offered culturally specific support and reported signposting patients to these services, there was limited evidence of wider outreach, relationship‑building or targeted engagement activity to improve awareness of mental health support, reduce barriers to access or better meet the needs of these underserved communities.

Staff also identified people with hearing impairments as among the most disadvantaged patient groups within the service. Staff reported that this group experienced a higher rate of appointment cancellations, largely linked to difficulties securing appropriate communication support, including the availability of sign language interpreters. At the time of our review, there were a small number of patients on the caseload who required signed or specialist communication support. Leaders told us they were working with partner organisations to address these challenges and improve access, though availability of interpreters continued to impact the reliability and timeliness of appointments for these patients.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

We saw evidence within care records that staff supported patients and their families to plan for significant life changes, including future care arrangements. Care records routinely documented patients’ wishes and expectations, and patient choice was promoted wherever possible.