Coventry and Warwickshire Partnership NHS Trust

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the service management and leadership was inconsistent. The culture and leadership approach did not always support the delivery of high-quality, person-centred care. However, there was a clear commitment to continuous learning and service improvement. The service worked in partnership with a range of internal and external teams to support joined-up care.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed significant shortfalls. The service did not always ensure effective staff engagement and communication during organisational change. However, leaders understood the challenges facing the service and had begun implementing measures to improve culture, engagement and support for staff.

The service underwent a transformation in 2024 as part of the wider NHS England programme to redesign Community Mental Health Services. This aimed to move away from a diagnosis-led model, where patients were referred to specific teams based on their condition, towards a more holistic, needs-led approach. The intention of this transformation was to improve integration between primary and secondary care, strengthen links with voluntary and community sector organisations, and ultimately provide more flexible, person-centred care. As part of this change, previously separate teams with different ways of working were merged, requiring significant adjustments to roles, processes, and team dynamics.

However, staff described the transformation as a particularly stressful period that had negatively impacted morale. Many reported feeling dissatisfied and frustrated with how the changes had been managed, highlighting a lack of clear direction, communication, and visible senior-level support throughout the process. Staff felt that more work was needed to effectively bring teams together and align ways of working following the transformation.

The provider highlighted a range of measures that had been implemented to support staff during the transformation, including regular communications through newsletters and a dedicated intranet page, virtual engagement events, and development days designed to support staff through the transition and refresh their skills.

Operational staff and their managers described concerns about the quality of relationships between frontline teams and senior leadership. These concerns were commonly linked to a perceived cultural shift within the organisation, which some felt coincided with changes in personnel at senior level. This shift was described in terms of less effective communication, diminished professional autonomy, and a perception among staff that their views and feedback were not being fully heard or acted upon. This was felt to have negatively affected trust, engagement and confidence in senior leadership.

However, the trust board was aware of these concerns and was in the early stages of taking action to addressing this.Following the inspection, the trust highlighted a number of steps that had been taken to address concerns relating to culture and engagement within community mental health services. These included listening clinics and cultural barometer sessions to gather staff feedback, with identified actions being regularly monitored through assurance meetings. The trust also told us it had strengthened leadership capacity within the service through the introduction of additional clinical leadership roles and a new General Manager post, with the aim of improving communication, engagement and support for frontline teams.

The evidence showed some shortfalls. Leaders did not always understand or respond effectively to the experiences and concerns of operational staff. Staff reported variable levels of support, communication and engagement from senior leaders, which contributed to reduced trust and confidence.

Many staff reported feeling well supported by their line managers, however others did not share this experience, often attributing this to periods of management sickness. Staff frequently described a strong sense of teamwork at a local level. However, we also heard about a perceived disconnect between CMHTs and the senior management team, with some staff feeling that they were not effectively listened to, consulted, or kept informed by organisational leaders.

A small number of examples highlighted concerns about the consistency of managerial support. These included reports of agreed adjustments following sickness absence not being implemented or followed up, leaving staff feeling under supported. There were also instances where staff felt support following difficult situations, such as the death of a patient, was limited.

A recurring theme was a sense of disconnection between operational teams, including first‑line and middle managers, and the senior management team (SMT). Many reported feeling that their views and experiences were not consistently heard or taken into account.

Managers reported uncertainty regarding their level of autonomy and decision‑making authority. Some staff described a feeling of being micromanaged. They said that procedural changes had been introduced by senior leadership with limited consultation or engagement with operational teams. This was felt to reduce local ownership and flexibility and contributed to frustration at an operational management level.

Communication from senior leadership was also identified as an area for improvement. Operational staff and managers described senior leaders as sometimes being out of touch with day-to-day operational pressures. Information from director level was reported to be inconsistently cascaded, and opportunities for meaningful two-way communication were perceived as limited.

The trust highlighted actions taken to improve leadership visibility and engagement, including senior leadership presence across community sites, listening clinics to gather and respond to staff feedback, and visits by the Chief Executive to better understand concerns raised within the Coventry CMHT.

Overall, while operational staff frequently described strong local teamwork and peer support, the relationship between operational services and senior leadership was characterised by reduced trust, limited confidence in speaking‑up processes, and a perception that engagement and communication from senior leaders could be strengthened.

The evidence showed some shortfalls. Staff were not always confident in using formal speaking-up processes or that concerns raised beyond their immediate team would be managed confidentially and acted upon.

Several staff members reported feeling able to raise concerns, particularly with their direct line managers, who were often described as approachable and supportive. Many felt comfortable raising issues or complaints at a team level. However, difficulties were more commonly reported when concerns were escalated beyond the immediate team, including to senior management and the executive team. At this level, operational staff and managers described a reduced sense of psychological safety, with apprehension about potential negative consequences, which affected confidence in raising issues related to service delivery and staff wellbeing.

Staff and managers reported limited confidence in the Freedom to Speak Up process, particularly in relation to confidentiality. We were told that 1 of the Freedom to Speak Up Guardians had left to take up another role, while the other was absent on sick leave. The Interim Chief Nursing Officer was providing temporary cover for the role. Staff described uncertainty about who may have access to information shared through the Freedom to Speak Up process. This was said to increase anxiety and deter use of the process. We also heard an example where concerns raised through the Freedom to Speak Up process were perceived to have been shared more widely than expected, rather than being kept confidential, which further reduced trust in the process.

The trust highlighted a range of measures to raise staff awareness of the Freedom to Speak Up process and the support available for raising concerns, including discussion of Freedom to Speak Up during CMHT induction, Freedom to Speak Up Champions within teams, and information displayed across services.

The trust also told us that an independent Freedom to Speak Up Guardian service had been commissioned and went live shortly after the inspection.

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

The service supported equity and equality in the workplace by recognising individual staff health needs and implementing appropriate reasonable adjustments. Staff experiencing mental and physical health difficulties described being supported through occupational health involvement and completion of stress risk assessments. Where required, flexible working arrangements were agreed, including later start times and earlier finish times, to support attendance, reduce stress and help staff manage their wellbeing effectively.

Staff with longer-term physical health conditions were also supported through practical adjustments tailored to their circumstances. These included amended shift patterns to better meet individual needs and the provision of specialist equipment, such as sit–stand desks, to support ongoing conditions were used to help staff remain well at work.

The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not consistently demonstrate strong governance, clear leadership or well‑defined accountability arrangements. Staff frequently described a lack of clarity about roles and responsibilities, which they attributed to management instability and the need to undertake duties outside their usual roles due to staffing shortages.

The Coventry CMHT had been recorded on the Trust’s risk register since April 2025, with the risk rated at a score of 20, indicating a high level of risk.

The risk related primarily to leadership stability, workforce morale, waiting lists, MDT working and caseload management. Leaders acknowledged that if these issues were not effectively addressed, there was an increased risk of patient harm, including delays in allocation and review, deterioration or relapse for people awaiting care, and challenges in managing unknown or emerging risks.

The risk register identified potential consequences for patient and public safety, including delays in patients being seen, reduced capacity to review patients discharged from acute and urgent care services, and increased risk where patients with unknown levels of risk were not promptly assessed.

Leaders also recognised pressures on care co‑ordinators, who were managing large caseloads alongside multiple administrative and clinical responsibilities, which further increased the risk of the delaying of care. The Trust noted that these pressures could also contribute to a rise in complaints and reduced capacity to complete audit actions and quality checks during periods of sustained pressure.

Leaders identified high sickness levels, low staff morale and difficulties with recruitment and retention as compounding factors. There were concerns that the service was becoming less attractive to potential applicants, which further affected staffing capacity and skill mix. These workforce challenges were recognised as having a direct impact on service quality, continuity and patient experience.

Staff reported dissatisfaction with the implementation, training and rollout of the electronic patient record system. Many staff felt this negatively affected their ability to carry out their roles effectively and added to existing pressures.

Despite these challenges, we saw evidence that incidents were reviewed to identify themes and trends. Learning from audits, complaints, incidents and safeguarding alerts was reflected on in team meetings, supporting continuous improvement in processes and patient care.

The service held monthly Safety and Quality Forum meetings where key information was shared and reviewed. This included risks and the risk register, safeguarding matters, learning and actions arising from incident reviews, quality improvement, and themes from complaints and compliments. Performance updates were also shared, such as referral volumes, waiting times, staff supervision and training compliance figures. Managers also met regularly through management meetings. We reviewed meeting minutes and saw evidence that key risks were routinely reviewed, monitored and discussed.

Multidisciplinary and team meetings were held on a regular basis and followed a clear agenda, supporting consistent sharing of essential information. These meetings included discussion of incidents, complaints and safeguarding concerns, which supported shared learning and contributed to service improvement.

We heard how the Trust had focused on stabilising the workforce and strengthening leadership and operational oversight. Active recruitment and retention activity was undertaken, alongside the introduction of staff listening clinics to improve engagement and address morale. An improved, more CMHT specific, induction programme was developed to better support new staff joining the service.

Operational changes were introduced to try to improve patient safety and access. This included work to improve the duty system, enabling patients to be put directly through to a member of staff rather than relying on call‑backs, reducing delays and the risk of unmet need. A duty‑focused quality improvement programme was initiated, including to support closer joint working between the CMHT and crisis services. The Trust also began reviewing its transitions policy to strengthen systems supporting patients moving between services and reduce risk at point of transfer.

Additional leadership capacity was introduced to support quality and safety. A head of nursing role within urgent care was planned to strengthen clinical governance, and a matron role was introduced within the Coventry hub to provide greater clinical oversight and leadership presence.

Leaders recognised that the size, complexity and demand within the Coventry service presented ongoing challenges in sustaining improvement. While some progress had been made, particularly in stabilising elements of the workforce and improving duty arrangements, staffing numbers, sickness rates and workload pressures continued to limit the pace of change.

A key recommendation within the trust’s improvement plan was to decentralise the Coventry CMHT from a single site into three geographically distinct teams aligned to the communities they served. Leaders believed this would support improved teamwork, accountability and ownership of performance, while aligning with the Integrated Neighbourhood Teams model and bringing care closer to local populations. However, leaders and staff also acknowledged the risks associated with this change, including anxiety related to further organisational change at a time of low morale, and recognised that relocation alone would not resolve underlying workforce and demand pressures.

Overall, leaders demonstrated awareness of the significant risks facing Coventry CMHT and had implemented a range of actions to mitigate these and protect patient safety. While the service was in the early stages of improvement, some progress had been made, leaders recognised that sustained effort and further development were required to embed improvements, stabilise the workforce and reduce clinical risk over time.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners.

The service worked in partnership with a range of internal and external teams to support joined‑up care, effective information sharing and shared learning. As part of service transformation, a GP advice line had been introduced to enable consultant psychiatrists to provide timely advice and guidance to general practitioners. Clinicians described increasingly positive working relationships with GPs, including shared discussions about patient care, medication adjustments and follow‑up arrangements, which supported continuity and helped reduce unnecessary referrals into secondary care.

A range of forums had been established to support integrated working across health and social care. Weekly multidisciplinary team (MDT) meetings enabled staff to share information, review risk and coordinate care. Substance misuse services attended MDT meetings, supporting joined‑up working for patients with co‑existing mental health and substance misuse needs. Social workers also attended weekly meetings alongside clinicians and managers to discuss complex cases, care packages and funding‑related issues. While staff reported that these meetings supported shared decision‑making, many told us this had not consistently translated into effective joined‑up working at an operational level between CMHTs and social care teams.

Shared care meetings were held several times each week, with a particular focus on patients with psychosis who were disengaging from services, showing early warning signs of relapse or requiring enhanced support. These meetings involved nurses, support workers and social workers, supporting a multidisciplinary approach to care planning and risk management. Medical staff did not routinely attend but were kept informed of patients discussed and any agreed changes to care arrangements.

In contrast to the positive relationships reported with primary care, several staff described ongoing issues in joint working between the CMHTs and crisis team. Staff reported barriers to effective collaboration, including challenges with communication, role clarity and shared responsibility, which affected continuity at points of escalation and transition. Leaders acknowledged these challenges and told us that work was ongoing to improve collaboration, clarify pathways and strengthen information sharing between services.

The service worked in partnership with primary care, acute services, social care, and safeguarding partners to share information and coordinate care for patients assessed as being at higher risk. Any new information received while a patient was waiting triggered re-triage and escalation where necessary.

The service was also seeking to strengthen partnership working with voluntary sector organisations, including plans to improve links with local mental health charities, to better support patients’ wider social, emotional and wellbeing needs.

The service focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

We heard about several quality improvement projects that had been undertaken within the service, including one in Coventry to strengthen the team duty function. Previously, all incoming calls were logged onto the duty list, resulting in 40 to 50 calls requiring follow‑up each day by a duty desk of 4 or 5 staff, which was overwhelming and demoralising. The project involved reviewing call types and introducing clearer triage processes, with administrative and routine calls, such as appointment changes or discharge meeting invitations, redirected away from the duty system where appropriate. As a result, the number of calls carried forward reduced to single figures, supported by ongoing metrics to monitor inappropriate referrals. This led to improvements in efficiency, safety and quality of care, with staff reporting that they felt less overwhelmed when working on duty.

We also heard about another quality improvement project in Coventry, which related to improving patient safety and audit outcomes for the Depot Clinic. Leaders acknowledged that the project had lost momentum but noted that it had highlighted several important areas for improvement. At the time, there were 317 patients open to the Depot Clinic, prompting consideration of whether some individuals could have been more appropriately supported through primary care. This included exploring models where GPs administered depot medication with an agreed rapid re‑entry pathway to the CMHT, enabling referral back without waiting list delays. Additional issues identified included the lack of scheduled appointment times and the need to strengthen governance and oversight, in order to reduce risks associated with working in a busy clinic environment. The continuation and progression of this project had been identified as a key focus for the Clinical Improvement Lead who was due to start within the team.

In addition, we heard about a quality improvement project focused on optimising the use of support workers within the team. This work clarified and redefined the support worker role, providing greater assurance for colleagues and improving team functioning. Clear roles, responsibilities and referral criteria for support worker intervention were introduced, reducing inappropriate referrals and having a positive impact on waiting lists. Previously, demand and capacity pressures had resulted in support workers covering work ordinarily undertaken by registered clinicians. The project addressed this by clearly distinguishing duties for Band 3 and Band 4 roles. Staff reported that role clarity had improved morale within the support worker cohort, many of whom had worked within the service for several years.

The implementation of a Clozapine Clinic within the South Warwickshire team was a further quality improvement project that had been completed and embedded into practice. Staff told us that prior to this, the team did not have a robust or effective system for clozapine monitoring. Dedicated clinic rooms were secured within NHS premises, enabling a coordinated service where clozapine blood tests, rapid receipt of results and physical health checks were carried out in one location. Through the introduction of structured physical health monitoring, some patients were identified as having previously unrecognised serious physical health conditions, which may not have been detected under previous arrangements. Staff reported feeling particularly proud of this development, noting improvements in safety and patient experience. Patients provided positive feedback about the convenience and continuity of receiving clozapine monitoring and related support through a single, coordinated clinic, reducing the need to attend multiple appointments at different locations.

Staff and managers reported that progress on quality improvement projects was often constrained by low staffing levels and the resulting high workloads. While there was clear recognition of the value and benefits of undertaking improvement work, this was tempered by a sense of frustration about limited capacity to see projects through. At times of heightened operational pressure, quality improvement activity was paused or progressed slowly, as teams prioritised managing patient care with the available workforce.