Coventry and Warwickshire Partnership NHS Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same.

This meant some aspects of the service were not always safe, and there was limited assurance about safety. There was an increased risk that people could be harmed. The service did not consistently follow appropriate systems and processes to ensure the safe administration, recording, and storage of medicines. Not all teams were fully staffed. Patient waiting lists and staff workloads across the service were generally high, which often resulted in people experiencing lengthy delays for appointments. However, staff demonstrated good understanding of safeguarding responsibilities and worked effectively with partner agencies to protect people from abuse. The service also managed safety incidents appropriately, with processes in place to respond and learn when things went wrong.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew how to report incidents and recorded them on an electronic incident record. They were aware of the different types of reportable incident and reported all incidents that they should report.

Between March 2025 and February 2026, a total of 365 incidents were reported across all services. Of these, 90 related to patient deaths and 72 were related to patient care. Other commonly reported types included incidents relating to assault, medication, and self-harm.

We saw evidence that learning from incidents had led to changes in practice. A staff member described learning following a patient death in Coventry, where a review identified missed opportunities linked to incomplete and untimely recording, meaning staff did not always have a full picture of patients’ risks and needs when making decisions. The investigation highlighted the need for improvements to the duty system, handovers, and escalation processes. As a result, a duty‑focused quality improvement project was implemented to strengthen handovers between crisis and CMHT services and improve escalation from duty calls. Further actions included the introduction of a daily risk meeting to provide a more structured and risk‑focused approach than previous handovers, a recruitment drive to address vacancies, strengthened induction and support for newly qualified staff to aid retention, and work to enhance MDT working and increase clinical space.

Following a serious incident review in Nottingham, the report identified gaps in the identification, escalation, and continuity of care for people experiencing psychosis, including delays in accessing timely, coordinated support. In response, the Coventry and Warwickshire Partnership Trust used these learning points to strengthen their model of care through the development of an enhanced psychosis pathway, aimed at improving early intervention, risk management, and consistency of treatment across services. We heard that development of this pathway was in progress and that it was anticipated to become operational in June 2026.

The service discussed patient safety incidents through a range of forums, including daily risk meetings, weekly MDTs, monthly place‑based governance and learning forums, service development meetings, and Integrated Management Group (IMG) meetings. These forums were used to review incidents and individual patients in detail and to share learning with staff across teams.

Staff understood the duty of candour and demonstrated openness and transparency, providing patients and families with a full explanation when things went wrong. For example, staff described apologising to patients and their families following incidents, explaining what had happened, outlining the actions taken, and sharing learning to reduce the risk of reoccurrence.

The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

External referrals to the Community Mental Health Team (CMHT) were received from a range of sources, including GPs, NHS Talking Therapies, self‑referrals, substance misuse services, the police, and social care.

All referrals were triaged to determine the most appropriate care pathway. This included deciding whether an individual required assessment by the CMHT or whether their needs would be better met by third‑sector provision, such as support groups, housing support, wellbeing services, or mental health charities.

CMHTs described ongoing work to discharge people back to primary care once they were assessed as clinically stable. This was supported by a 12‑month rapid re‑referral pathway, enabling individuals to return to the service without re‑entering a waiting list if required.

Referrals to the Early Intervention Teams were received via the Mental Health Access Hub (NHS 111), GPs, self‑referrals, or hospital wards, with all referrals processed through a shared email inbox. A duty worker triaged referrals and people were usually offered the next available assessment appointment within a few days. The Early Intervention Teams aimed to complete assessment and allocation within two weeks, which was consistently achieved. Referrals relating to psychosis were triaged within 48 hours.

Assessment clinics were held twice weekly and staffed by two Band 6 clinicians. Assessments were undertaken using the Comprehensive Assessment of At‑Risk Mental States (CAARMS) framework and included screening for a range of mental health and neurodevelopmental needs, as well as exploration of personal goals and desired life changes.

Following assessment, cases were discussed at a weekly multidisciplinary team (MDT) meeting, with urgent cases reviewed sooner where necessary. The MDT agreed the most appropriate treatment pathway for each individual.

People typically remained on the Early intervention team’s caseload for up to 3 years, with discharge planning commencing around the two‑year point. Support was gradually stepped down to promote independence, with a focus on coping strategies, relapse prevention, identifying early warning signs, and strengthening protective factors. Most people were discharged back to their GP, with some stepping down to CMHT support where appropriate.

Staff across teams described the working relationship between the CMHTs and the crisis team as strained at times and not as joined‑up or effective as they would wish. While patients were referred between services according to changes in need and assessed risk, staff reported ongoing challenges around communication and agreement on case categorisation, particularly what constituted an urgent or crisis‑level presentation. This led to some referrals not being accepted and perceptions of barriers to access, with some staff expressing concern that patients were occasionally stepped back to CMHT care before they were ready, increasing the risk of relapse. However, weekly management‑level meetings between the CMHTs and crisis team were described as beneficial, and work was underway to improve joint working, including developing clearer parameters for urgent referrals and a quality improvement initiative focused on strengthening collaboration between services.

The CMHTs worked alongside an on‑site social work team operating under a Section 75 agreement. A Section 75 agreement is a formal partnership arrangement that allows the NHS and local authorities to integrate services and pool responsibilities, with the aim of improving coordination and outcomes for people who require both health and social care support.

Under this arrangement, social workers remained involved in CMHT activity, including key working some patients, attending MDT and risk meetings, providing advice, and supporting the duty system, with a visible presence within team bases. However, staff reported that since service transformation, social care had become more separate, with social workers now managed by local authority services across different councils and focusing predominantly on Care Act assessments. This was described as creating a clearer divide between social work and CMHTs than had previously existed, resulting in less joined‑up working.

A Section 75 working group had been established to address these challenges and improve communication and collaborative working between CMHT and social care services.We also heard that an organisational development away day had been organised, bringing together community mental health teams and local authority colleagues. This reflected efforts to strengthen collaborative working and improve integration between services.

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

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. All staff were required to complete mandatory training in safeguarding. 83.33% of staff had completed Level 1 safeguarding for both adults and children. Completion rates for Level 2 safeguarding were 96.21% for adults and 95.85% for children, while Level 3 was 89.14% for adults and 89.05% for children.

Staff understood how to make safeguarding referrals, supported by a training programme covering both adults and children. During the 12 months prior to our assessment, across the community mental health teams a total of 502 safeguarding concerns were raised collectively, with an additional 28 safeguarding concerns raised by the early intervention teams.

Safeguarding referrals were tracked through weekly quality summits and regular corporate reports. Open safeguarding concerns were reviewed in multidisciplinary safeguarding meetings, with Section 42 enquiries, which are local authority investigations into concerns about possible abuse or neglect, allocated for investigation, with progress updates discussed at weekly multidisciplinary team (MDT) meetings.

Details of open safeguarding concerns and enquiries were provided to managers on a weekly basis to support effective oversight. The Safeguarding team produced quarterly data and analysis reports, which were presented to the Safeguarding Operational Group, Section 75 Safeguarding Group, and Section 75 Board. The safeguarding team also met monthly with Local Authority colleagues to review data, identify trends, and address recurring safeguarding issues.

Staff were given guidance and support on safeguarding patients by the Trust’s safeguarding team, and safeguarding concerns were regularly reviewed and discussed. We heard that the service previously managed a higher volume of safeguarding referrals. However, changes had been made to referral management, including work with staff to clarify what constitutes a safeguarding referral, to help ensure that referrals raised were appropriate.

We heard an example of safeguarding concerns being appropriately raised and acted upon. In one case, a vulnerable patient was subjected to exploitation, resulting in their property being taken over by drug dealers and the subsequent loss of their home. The service was working with social care and housing teams to address the situation.

The service did not always work well with people to understand and manage risks. The service did not consistently seek or record patient involvement, including their views and wishes.

Teams actively monitored and managed risk through regular discussion at daily clinical risk meetings and weekly multidisciplinary team (MDT) meetings. Patients’ written risk assessments were generally reviewed and updated when changes in presentation or risk were identified. Staff told us that where risk increased, responses included undertaking urgent clinical reviews, liaising with and referring to the crisis team, increasing the frequency of contact, allocating a named keyworker where one was not already in place, providing short‑term intervention from wellbeing practitioners, and signposting to additional support where appropriate.

We heard that waiting lists were actively managed and regularly reviewed to try to ensure that emerging risks were identified and acted upon in a timely manner.

For patients awaiting allocation or intervention, proactive contact was undertaken at a minimum of four-weekly intervals. During these contacts, structured questions were asked to assess wellbeing, level of risk, and the presence of any safeguarding concerns.

Patients open to the service had access to the Community Mental Health Team (CMHT) duty line between 09:00 and 17:00, and to NHS 111 or the Home Treatment Team (HTT) outside of these hours. Established processes were in place to ensure that relevant contacts with NHS 111 or HTT were shared with the team.

The majority of care records we reviewed were comprehensive and person-centred, with robust and up-to-date risk assessment and risk management plans in place. However, this was not consistent across all records; some lacked sufficient detail, did not include information on physical health monitoring, and did not clearly evidence crisis or safety plans.

Most of the care records we reviewed clearly evidenced patient involvement in care planning and risk management. Patients were actively engaged in discussions, consulted throughout decision-making processes, and supported to collaboratively develop their risk management plans. This included identifying factors that help maintain their safety and completing the Mental Health Dialogue Tool, which supports open, person-centred discussions about mental health needs and risks. The tool covers key areas such as risk factors, protective factors, coping strategies, as well as the individual’s goals, needs, and preferences. Agreed actions were discussed and mutually established between patients and professionals, reflecting a person-centred and collaborative approach to care. However, a small number of care records reviewed lacked patient voice and did not effectively capture patients’ views and wishes.

Care records relating to Ministry of Justice (MOJ) and Community Treatment Order (CTO) conditions demonstrated that relevant and required information was appropriately documented, included in care plans, and accessible. Conditions associated with these orders were discussed with patients, and in some cases, patients’ goals and aspirations were shaped in alignment with these requirements, including goals focused on working towards the removal of the order where appropriate. The conditions within CTO and MOJ orders were primarily aimed at maintaining patient safety and wellbeing, and staff’s easy access to this information supported effective risk management.

Staff were still adapting to the recent introduction of a new Electronic Patient Record (EPR) system, which had gone live throughout CMHT services around 8 weeks prior to the inspection. Several staff reported not feeling confident in navigating the system, while others expressed frustration with certain aspects or limitations. It was felt that some staff would benefit from additional time and training to become sufficiently competent, and that the system itself required further development, taking into account staff feedback, to ensure it effectively meets the needs of the service.

Staff reported they felt the training provided for the new system was inadequate and that the rollout was too rapid, resulting in the system going live before staff had sufficient knowledge and confidence to operate it effectively. In particular, they highlighted a lack of training on how to record risk within the new system, which they identified as a significant concern with potential implications for safety. However, staff noted that additional support has since been introduced, with specialists now visiting services to help staff better understand and effectively navigate the system.

Teams reported that they were required to use the old EPR system alongside the new system, as a significant proportion of patient information and documentation, including caseload and triage forms, had not yet been transferred. The arrangement was described by staff as time-consuming and overly burdensome, and there were concerns that it may have presented a potential patient safety risk due to key information remaining on the old system and not being fully accessible within the new system.

The evidence showed some shortfalls. The service did not always make sure equipment, facilities and technology supported the delivery of safe care.

A range of measures were in place to keep staff safe, including the use of portable lone worker devices for community work and panic alarms attached to consultation room keys, linked to a central control panel in reception areas.

A buddy system was also in place, with staff routinely checking in with one another.

For higher-risk situations, such as visits to patients in challenging environments, risks were mitigated by requiring 2 staff members to attend, each supported by an additional buddy.

Risks associated with patients were regularly discussed, including how they should be managed, during MDT meetings. Staff also reported routinely reviewing patient care records, including risk assessments, prior to each contact to ensure they were up to date on risks and any control measures in place, and stated that they felt safe while carrying out their work.

The majority of physical health monitoring and emergency equipment across the teams was well maintained; however, a set of scales used for weighing patients at Avenue House, North Warwickshire, was overdue for calibration. Following the inspection, the provider informed us that the scales had been recalibrated and that strengthened oversight arrangements for weighing equipment had been introduced.

Staff reported, and leaders recognised, that there was insufficient clinical space at the Coventry service, including a lack of appropriate rooms for patient meetings, which was affecting the delivery of safe, effective, and timely support.The provider told us about plans to split the Coventry team into 3 separate teams, with some teams operating from new locations. It was anticipated that these changes would support wider service improvements, including improving access to appropriate clinical space.

Across all sites, the general environments, including waiting rooms, consultation, meeting, and clinic rooms, were basic and functional and appeared clean. However, at St Mary’s Lodge, where the South Warwickshire team was based, the environment was notably aged and in a generally poor state of repair, indicating a need for refurbishment and modernisation.

The evidence showed significant shortfalls. The service did not ensure there were enough staff to consistently meet patients' needs or to maintain manageable workloads for staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Multidisciplinary teams were comprised of registered nurses, support workers, consultant psychiatrists, specialty doctors, occupational therapists, psychologists, and administrative staff. They worked alongside local authority-managed social workers as part of a Section 75 agreement, whereby the NHS and local authorities pool resources and share responsibility for delivering integrated care.

We heard from staff and leaders that ongoing staffing challenges affected all teams, primarily due to high vacancy rates, staff turnover, sickness levels, and low morale. These issues were particularly acute at the Coventry Community Mental Health Team service, where staff overwhelmingly reported low morale, feeling under-supported by managers, and experiencing burnout, largely as a result of high workloads linked to low staffing levels. Staff also reported resignations being driven by unmanageable workloads, poor integration between health and social care teams, and a lack of support from managers and the wider organisation.

Staff and managers at the Coventry service reported that high levels of sickness and unfilled vacancies had significantly affected the team’s capacity to carry out the work required to meet patient needs. Sustaining initiatives such as quality improvement projects had been challenging, with frequent absences disrupting continuity and leaving morale low. Team members described the environment as reactive, reporting that they often felt they were ‘fire-fighting.’

According to staff, these pressures had left them feeling overwhelmed and under supported, which in turn had negatively impacted upon patient care. Non urgent work, such as routine follow-ups and care plan updates, had been deprioritised, with staff redirected to more urgent duties. One member of staff said that patient care suffered due to prioritising urgent cases which meant support for less urgent cases was delayed. Another staff member reported that, due to limited capacity, support workers sometimes had to handle tasks that would normally be carried out by qualified staff.We heard how the Trust had implemented a Quality Improvement project to address support worker workload and capacity issues. This included reviewing roles, responsibilities and supervision arrangements, and introducing a referral process with clear criteria to help ensure workloads were managed more effectively and support worker time was used appropriately to support safe and effective care.

These issues were observed to a significantly lesser extent within the Early Intervention Teams. These teams had lower vacancy, turnover, and sickness rates. In addition, staff within these teams reported comparatively higher morale than generally described by staff working within the CMHTs.

Leaders were aware of the particular challenges at the Coventry service, as reflected by its inclusion on the trust’s risk register. The register specifically highlighted concerns related to leadership, morale, waiting lists, MDT working, and caseload management, along with the associated risks and control measures. An improvement plan for Coventry was in place, which the trust was actively progressing.

Sickness rates across the teams were generally high. Data from February 2026 showed that the North Warwickshire Early Intervention Team had a sickness rate of over 15%, while Coventry and South Warwickshire CMHTs reported rates exceeding 14%, and North Warwickshire CMHT was over 10%. However, Coventry and South Warwickshire Early Intervention Teams reported significantly lower sickness rates of 0.68% and 0% respectively. Staff sickness data for March 2026 indicated an overall reduction in sickness rates compared with the previous month.

We reviewed staff turnover data from February 2026, which covered the preceding 12 months. Coventry CMHT had the highest average turnover rate at 16.7%, followed by South Warwickshire CMHT at 15.4% and North Warwickshire CMHT at 13.3%. Among the Early Intervention Teams, North Warwickshire recorded the highest turnover rate at 18.3%, with South Warwickshire and Coventry reporting lower rates of 8.3% and 8.1% respectively. Staff turnover data for March 2026 indicated an overall increase in turnover rates over the preceding 12 months compared with the February data.

Managers reported that the Vacancy Control Panel (VCP) process was frustrating and caused significant delays, mainly due to the length of time it took executive-level staff to authorise requests, sometimes several months after submission. This exacerbated existing staffing pressures. Senior leaders told us that the VCP process was soon to be changing, which would allow sign-off for the filling of existing posts to be made at a more local level, while newly created posts would still require executive-level approval. Following our assessment, the Trust provided additional context regarding the VCP process. Outlining that from 1 April 2026, a revised approach was implemented to promote greater ownership and accountability within directorates, while maintaining appropriate Executive oversight during the initial implementation period.

Under this revised approach, Executive oversight was retained through the Executive VCP; however, escalation to this forum was expected to occur on an exception basis rather than as standard practice. This change reflected the Trust’s intention to embed accountability and decision-making responsibility within directorates, supported by clear and robust governance arrangements.

Some staff at both the North and South Warwickshire services reported being short staffed and feeling under pressure. However, the majority described feeling well supported by colleagues and managers, and staff morale did not appear as low as at the Coventry service.

Several staff at the Coventry hub reported concerns that internal promotions had often occurred before individuals had attained the necessary experience and expertise for their roles. Staff told us this was frequently driven by the need to fill vacancies arising from high staff turnover. This was perceived to have resulted in gaps in competence at both staff and management levels and led to doubts about whether teams consistently the appropriate skills, knowledge, and experience had to meet the needs of the patient group.The Trust was aware of previous staff concerns regarding internal promotion opportunities and the impact these had on staff. Leaders had engaged with staff and taken steps to address the concerns raised.

We heard that the trust was seeking to address issues related to staff retention and turnover was by strengthening the induction programme for new starters. This included the development of a community mental health–specific induction, providing protected time and covering areas such as outcome measures, physical health, and psychology services, to support staff understanding of the wider multidisciplinary team.

An Advanced Clinical Practitioner (ACP) Trainee had recently started within the service, with key areas of focus for them including the development of an improved face-to-face assessment clinic to increase access, reduce waiting times, and achieve better outcomes, while also providing learning opportunities for junior staff. In addition, we heard that the ACP would lead the development of a caseload management forum, providing a space for staff to discuss cases and offer peer-to-peer support. We also heard that a Matron had been successfully recruited and was awaiting a start date. This role was intended to drive quality improvement, strengthen the learning environment, embed best practice, and support multidisciplinary working.

We were also informed that the Coventry service was managing the impact of its current vacancies through the use of agency and bank staff, primarily to cover Community Psychiatric Nurse (CPN) posts.

The trust provided a comprehensive programme of statutory and mandatory training programmes, covering approximately 44 subjects. These included safeguarding, basic life support, intermediate life support, infection prevention and control, equality and diversity, Mental Health Act, Mental Capacity Act and Oliver McGowan training on learning disability and autism.

Managers were able to monitor staff compliance with mandatory training through a dashboard and a dedicated training IT platform. This data was used in supervision sessions and appraisals and was sometimes looked at following incidents and within clinical governance sessions.

The majority of staff mandatory training subjects had completion rates above 85%, however, some areas fell significantly below this level, either overall or within specific teams. For example, the overall compliance rate for Resus level 2 training across the service was of significant concern, averaging only 55.37%, with North Warwickshire CMHT at 68.18%, South Warwickshire at 51.06%, and Coventry at 46.88%. This meant that, across the teams, 27 staff were non‑compliant in this area. We were informed that 11 of these staff were either on long‑term sick leave or had recently returned from sick leave. The trust provided assurance that community staff were clear about procedures for responding to medical incidents, by contacting emergency services where required.

Overall compliance for Safety Intervention and Disengagement Training across the service was low, averaging 40.85%, with North Warwickshire CMHT at 77.27%, South Warwickshire at 23.40%, and Coventry at 21.88%. The trust assured us that, while some staff were not up to date with this training, community workers used lone‑working devices and risk was mitigated by seeing higher‑risk or unknown patients at the team base or through joint visits.

For Oliver McGowan training, 88.9% of staff had completed Tier 1 overall, with North Warwickshire and Coventry CMHT at 100.0% and South Warwickshire at 66.7%. Tier 2 completion was 75.2% overall, with North Warwickshire at 90.9%, South Warwickshire at 75.0%, and Coventry at 59.6%.

Supervision meetings for staff were generally not conducted as frequently as required to meet trust’s target of staff receiving individual supervision every 6 weeks, with some staff going several months without supervision. However, staff generally reported that supervision was beneficial when it took place. Data reviewed from February 2026 indicated an overall clinical supervision compliance rate of 62.5% across the teams, with 100 out of 160 staff having received supervision in line with the policy. This increased to 74.1% according to March 2026 data. Managerial supervision compliance across the teams was 54% in February 2026, with 120 out of 210 staff receiving supervision within the Trust’s 6 week target. This rose to 66% in March 2026. In relation to appraisals, 87.8% of staff across all teams had received an appraisal within the previous 12 months, based on February 2026 data. This figure decreased slightly to 85.4% in March 2026.

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

Compliance with Infection Control Training across the teams averaged 96.15% for Level 1 and 86.03% for Level 2 training.

The various spaces used by teams, including consultation rooms, clinic areas and office environments, appeared clean and well maintained, with no concerns noted, aside from at St Mary’s Lodge where the environment appeared, in general, in need of modernisation.

We observed evidence of regular infection prevention and control audits being conducted, including audits specifically focused on hand hygiene and sharps safety practices. Identified issues were reviewed, and appropriate actions were taken to improve compliance and working practices.

For example, work had been undertaken to improve access to glow boxes used during hand hygiene training for staff. In addition, steps were being taken to transition to the use of safety needles across all procedures within the service, following the identification that some teams were still using non-safety needles for intramuscular injections.

The evidence showed some shortfalls. The service did not always make sure that medicines were managed safely and securely.

The clinic room at Avenue House in North Warwickshire was well organised, with medication appropriately stored and individual medication records and prescription charts well maintained. Medication ordering and temperature monitoring records were consistently recorded.

However, in the clinic room at Swanswell Point within the Coventry service, we noted some concerns in relation to the system for recording the receipt and administration of depot medication. Entries in the log often lacked signatures, dates, and records of who received or administered the medication. Entries recorded only incremental additions (+1) or deductions (-1) each time medication was received or administered, rather than maintaining an accurate record of stock balances. This increased the risk of medication errors, inhibited accountability, and compromised patient safety, as stock levels, usage, and discrepancies could not be reliably tracked or verified.

In the same clinic room, we noted several discrepancies between the quantities of medicines in stock and the amounts recorded. These discrepancies indicated missing medication and demonstrated that stock levels were not being accurately monitored or documented. We also observed inconsistencies on the prescription (Kardex) charts, including instances where patients’ legal status had not been recorded.

Staff highlighted some concerns regarding the management of medicines within the Coventry service at Swanswell Point. There were reports of Kardexes going missing and situations where patients arrived for depot injections but their Kardex could not be located, causing delays and increasing clinical risk. We also heard about outdated prescription charts being mixed with current ones, which had led to medication errors. These included instances of patients being administered incorrect medications and, on occasion, medication intended for another patient. Staff also described occasions where depot medications were administered but not subsequently reordered, resulting in medication being unavailable at the patient’s next scheduled appointment.

Further concerns were raised regarding medicines safety and oversight at the Coventry service, including within the depot clinic. Significant responsibility appeared to have been placed on relatively inexperienced staff who had not had adequate support or opportunity to learn from more experienced colleagues. We heard an example of a medication incident whereby a patient had accessed and ingested the contents of a depot vial, highlighting risks in storage and supervision. Staff also raised concerns about sharps boxes not being stored appropriately and, at times, being overfilled.

At St Mary's Lodge within the South Warwickshire service, there was no system in place to monitor the clinic room temperature. The provider advised us that medicines were delivered on the day of administration and were not routinely stored on site. Given the limited time medicines were present before administration, the risk of temperature-related effects on medicine quality was considered low. However, following the inspection, the trust informed us that it had commenced monitoring clinic room temperatures at St Mary's Lodge.

Once these issues had been highlighted with the trust, we were promptly provided with written assurances and an action plan addressing the medicines management concerns identified at the Coventry service. Additionally, following the inspection, the provider updated us on actions implemented to strengthen medicines management within the Coventry CMHT. These included completing a review of depot clinic management arrangements, improving Kardex management processes, introducing weekly stock audits, increasing clinical oversight, and implementing regular clinic room audits to monitor compliance and identify any concerns.

We heard from staff that the Clinical Team Lead responsible for overseeing medicines management had left in August 2025 and that a replacement had recently been appointed, which it was hoped would improve oversight of medicines management and safety at the Coventry service.

We were informed that Medicines Management training was not mandatory for all staff. However, a medicines course was available for qualified nurses, with 23 out of 105 nurses across the teams having completed it, equating to a compliance rate of 22%. However, following our visit, we were advised that the service’s Community Matron was liaising with the medicines management team to arrange bespoke training to be delivered to all Community Mental Health Teams.