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

This means 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 requires improvement. This meant some aspects of the service were not always safe. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment (Regulation 12).

This service scored 62 (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 a good standard. 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 what incidents should be reported and how to report them. For example, in March 2026 there had been 17 instances of self-harm or aggression on Ferndale Ward, 9 on Woodloes Ward, 3 on Stanley Ward and 1 on Pembleton Ward. Healthcare assistants reported incidents to nurses, who then completed incident reports on their behalf. Other staff told us that everyone reported incidents. The Patient Safety Team was in the process of reviewing the incident reporting policy to strengthen incident reporting governance.

Staff received debriefs after incidents. Staff said they felt there was a no blame culture. The psychology team supported debriefing sessions and reflective practice. They also provided support to staff around specific patients, including how best to support them and providing context surrounding their histories and admission. We observed one of these meetings on Ferndale ward. Staff completed reviews when patients died to identify potential learning. For example, staff conducted an investigation after a patient took their life whilst on home leave. Following this investigation, Stanley ward introduced a system where patients on leave are called every day, and a risk assessment is completed and concerns escalated to community crisis teams if required.

Staff received feedback from incidents. One senior staff member said they felt there was little cascading of learning from events. Another staff member said that learning from incidents is disseminated during staff away days.

Incidents were discussed in a weekly incident management group meeting, a monthly inpatient quality forum meeting and in ward level governance meetings.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Patients were admitted into services from their homes, other mental health units, care homes, or the general hospital. This meant liaison with different professionals at times such as adult social care, community mental health teams and other hospitals.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

The majority of patients on the wards had been admitted within the last 6 months. However, there was greater variation in the length of stay on Woodloes Ward, where patients had generally been admitted for longer periods. The longest admission was 2 years; this patient had been admitted voluntarily, and staff told us they were working to find a stable placement to support their discharge.

Woodloes Ward was due to close in June 2026. The trust planned to replace the ward with a service providing enhanced support to patients in their home. This approach, delivered as part of the community crisis teams, aimed to provide and maintain care for patients within the community and reduce the restrictions associated with hospital admissions. However, staff were concerned about how the closure of Woodloes Ward, which would result in a reduction in bed numbers for older people with mental health problems across the trust from 60 to 45 beds, would impact on patients.The trust was seeking to address this by setting up a 'Hospital at Home' as an alternative to inpatient admissions.

The evidence showed a good standard. 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.

Over 90% of staff had completed mandatory training on safeguarding.

Woodloes ward was 87.5% compliant for safeguarding children and adults level 3 and Ferndale and Pembleton wards were above 90% compliant for these modules.

Staff were able to identify different types of abuse and knew how to make a safeguarding alert and did that when appropriate. Staff on Woodloes ward were able to recount a safeguarding concern for a patient where they liaised with internal and external safeguarding teams and ensured the patient had access to an advocate. Ward managers had oversight of safeguarding concerns, and overall oversight was maintained by a designated safeguarding lead within the trust.

The evidence showed significant shortfalls. The service worked well with people to understand and manage risks and produce clear guidance on how staff should manage them. However, patients’ records did not always include a clear statement, agreed by a multidisciplinary, team on how to manage patients’ physical health conditions.

Staff took appropriate steps to steps to mitigate risks. Based on the risk assessment, the multidisciplinary team set the level of observation the patient. This varied from Level 1, involving staffing checking the patient every hour, to Level 4, involving a member of staff being within arms-length of the patient at all times. Most patients were nursed on Level 2, involving checks on the patient every 15 minutes. The service used a digital patient monitoring system on 2 of the 4 wards we visited. The system was installed in patients’ bedrooms and used cameras and infrared technology to help keep patients safe by alerting staff to unusual activity in bedrooms, such as falls.

Some records demonstrated clear, multidisciplinary care planning. For example, one patient admitted to Ferndale ward had a pre-existing diagnosis of dysphagia on admission. We saw that a speech and language therapist had been involved in creating the care plan in accordance with the patient’s identified communication and swallowing needs. However, some patient records lacked clear, agreed statements, agreed by a multidisciplinary team about how a patient’s condition must be managed in a safe way. Thismeant staff didn’t always have all of the information they needed to safely and effectively support them. For example, the care plan for a diabetic patient on Ferndale ward lacked information about foot and wound care risks associated with diabetes. A patient on Stanley ward had a care plan for seizures, but this also lacked detail. This care plan heavily relied on staff knowing the patient well. This meant that if unregular staff were to attend the ward, there would not be clear guidance to support this patient if they were to have seizure activity.

Staff conducted checks and observations for patients with physical health conditions. For example, staff on Pembleton recorded the blood glucose levels four times each day for a patient with diabetes.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment. Wards had convex safety mirrors to cover blind spots. There was a secure, well maintained outdoor space between Stanley and Pembleton wards. We were told that a staff member from each ward observed the area when in use, to maintain safety.

Staff took appropriate steps to mitigate risks presented by the environment. Doors had been replaced on Stanley and Pembleton wards that included anti-barricade hinges to make them safer, as patients could lock their bedrooms from inside. There was still some exposed plaster around the door frames at the of the assessment. All wards had a fire risk assessment that was in date. Ligature risk assessments were reviewed on each ward.

Staff had easy access to alarms in case of emergencies on the ward and patients had access to a nurse call system to ensure that they could call for support if they needed it.

The service complied with guidance on single-sex accommodation. Patients were cared for on single-sex wards.

Wards were usually maintained to a good standard, although there had been some delays in completing repairs. Signage work was being completed on Stanley ward at the time of the assessment so that patients with cognitive impairments could clearly identify where they were and navigate the ward. We saw that wards had maintenance logs. Jobs were allocated a target timeframe based on their risk and classification. However, jobs were not always completed within the set timeframes they should have been based on this allocation. A locked fire door on Pembleton ward was loose and rattled when locked. We received immediate assurances that this was reported to the services maintenance team after it had been raised so that it could be rectified.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The evidence showed significant shortfalls. The service ensured sure there were enough qualified, skilled and experienced staff. These staff received effective support, supervision and development. However, not all staff had completed mandatory training on immediate life support, meaning that some staff may not know how to respond to a life-threatening emergency.

The service used a recognised tool to calculate the number of staff required on each ward. This was reviewed every six months.When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. We reviewed the amount of bank and agency shifts for the last 3 months within the service. There were 3 agency nurse shifts on Pembleton within the last 3 months. Agency staff were not used on any of the other wards within the service. There were 731 bank staff shifts on Woodloes ward, 236 bank staff shifts on Ferndale ward, 242 bank staff shifts on Pembleton ward and 225 bank staff shifts on Stanley ward. The use of bank staff for Pembleton and Woodloes wards was due to long-term sickness and enhanced observations for patients, whereas Stanley and Ferndale wards were predominantly due to enhanced observations rather than sickness. Staffing pressures were discussed in a weekly meeting and there was a daily escalation process for if staffing levels fell below the agreed safe numbers.

Managers monitored the sickness rate each month. Between January and March 2026, sickness across the service was around 10%. This was particularly high on the Woodloes at 13%. The Trust target was 4.65%.

The overall vacancy rate across the service was 19%. Planned changes to Woodloes Ward meant that it had the highest vacancy rate of 35%. These vacancies were covered by bank staff. The Trust was recruiting to these posts.

Between January and March, the staff turnover rate on Ferndale and Pembleton wards was low at around 3%. Changes at Stanley ward and the Woodloes Unit meant that turnover rates were higher at around 10%.

Compliance with the requirement for all staff to have an annual appraisal was above 85% on all wards.

Staff received monthly clinical and managerial supervision. On average, supervision rates were above 85%. However, there were occasional shortfalls. For example, in January 2026, clinical supervision on Pembleton fell to 42% and managerial supervision fell to 45%. Also in January 2026, clinical supervision at the Woodloes Unit fell to 70% and managerial supervision fell to 73%.

Overall compliance with mandatory training was 90% on all wards.However, immediate life support training was inconsistent across the service with 58% compliance for Pembleton ward, 75% for Woodloes ward, 84% on Ferndale ward and highest on Stanley at 90%. This meant that some staff, particularly on Pembleton Ward, may not know how to respond to a life-threatening emergency. Compliance with physical restraint training on Pembleton ward was below the Trust’s target, at 69%. Compliance with physical restraint refresher training on Woodloes ward was 68%.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The Trust had an infection control policy and worked within national guidelines set out by NHS England.

Staff maintained equipment well and kept it clean. Clinic areas were clean and tidy, and managers maintained oversight of cleaning audits.

The overall compliance for infection prevention and control (IPC) audits across all wards was at 93%. The service achieved 100% for hand hygiene and sharps compliance.

Mandatory training included level 1 and 2 IPC training. Stanley ward was 100% compliant for both modules. Pembleton ward was 96.55% complaint across both modules. Ferndale ward was 100% for level 1 96.97 for level 2. Woodloes ward was 100% for level 1 and 84.21% for level 2.

Most ward areas were clean, were well-furnished and well-maintained. However, Pembleton ward had some unfinished work around the doorframes as they had been replaced; they required the exposed plaster to be covered and painted.

There were no concerns regarding storage of food on the wards.

The evidence showed some shortfalls. The service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning. However, patients’ records did not include a clear statement from the prescribing doctor about when PRN medication should be administered.

Staff followed good practice in medicines management.

Controlled drugs (CD) were stored in a separate locked cupboard compliant with CD standards. Staff understood controlled drug procedures and followed policy appropriately.

At the previous assessment, there were concerns regarding recording of medicines fridge temperatures. This had improved and fridge temperatures were now being recorded daily, and this was audited weekly by pharmacy staff.

We saw an example of a patient with a rapid tranquilisation care plan, which outlined that rapid tranquilisation should be used as a last resort and included requirements for post-administration monitoring and debriefing.

Medication administration was recorded electronically. However, medicines administration records did not always include clear instructions for the use of PRN medications (medicines prescribed to be taken as required, rather than at regular intervals, for example to manage symptoms such as pain, anxiety, or agitation). This meant there was not clear guidance about clinical indications for administering PRN medication and how to monitor for side effects. In addition, there were no photographs of patients on the administration system. This meant that bank, agency, and newly appointed staff may be at increased risk of incorrectly identifying patients when administering medication.