Avon and Wiltshire Mental Health Partnership NHS Trust

Updated 16 October 2023

We carried out this unannounced comprehensive inspection of the specialist community mental health services for children and young people, and the wards for older people with mental health problems provided by this trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

Avon and Wiltshire Mental Health Partnership NHS Trust provides Mental Health services across a catchment area covering Bath and North-East Somerset, Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. It also provides services for people with mental health needs relating to drug and alcohol dependency and mental health services for people with learning disabilities. The trust also provides specialist forensic services for a wider catchment extending throughout the south west.

Avon and Wiltshire Mental Health Partnership NHS Trust serves four clinical commissioning groups and six local authorities, NHS England also commission specialist services. The trust employs over 4000 substantive staff. It operates from over 90 sites including eight main inpatient sites and services are delivered by 150 teams across a geographical region of 2,200 miles, for a population of approximately 1.8 million people. The trust has a total of 21 locations registered with CQC.

The trust sits within two Integrated Care Systems (ICS). These are:

• Bristol, South Gloucestershire and North Somerset (BNSSG)
• Bath and North-East Somerset, Swindon and Wiltshire (BSW).

At our last inspection we rated the trust overall as requires improvement. Overall, we rated safe, responsive and well led as ‘requires improvement’, and effective and caring as 'good'.

Services Inspected

The specialist community mental health services for children and young people provided by Avon and Wiltshire Partnership NHS Trust in Bristol, North Somerset and South Gloucestershire are part of the community children's health partnership (CCHP), which includes all community-based children's healthcare services across the area. CCHP is made up of Sirona Care and Health, University Hospital Bristol NHS Foundation Trust, Barnardo's, Off the Record and Avon and Wiltshire Partnership NHS Trust.

We previously inspected this service in 2020, when it was rated as good overall and in all key questions. In 2020 the service incorporated North Somerset child and adolescent mental health services (CAMHS) from another provider. CAMHS are provided by locality teams across Bristol, North Somerset and South Gloucestershire. Referrals for Bristol and South Gloucestershire came through the Community Children’s Health Partnership (CCHP), which serves as a single point of access to the CAMHS service. North Somerset referrals come direct to the CAMHS team. The locality teams are based in Kingswood (South Gloucestershire), Barton Hill Settlement (east and central Bristol), Brentry (north Bristol), Osprey Court, Knowle (south Bristol), Weston-Super-Mare and Clevedon (North Somerset). These teams deliver tier three (assessment and consultation services delivered by multidisciplinary CAMHS teams) and tier two (early intervention) services.

A warning notice (which requires the provider to take immediate action to make improvements) was served on the North Somerset service under the previous provider in 2019 due to concerns about staffing and waiting lists. We also found concerns around high caseloads, issues with care plans, incident recording, staff supervision and a lack of robust governance. The current inspection is the first time the North Somerset services have been inspected since Avon and Wiltshire Mental Health Partnership NHS Trust took responsibility for the services.

Avon and Wiltshire Mental Health Partnership NHS trust provide eight wards for older people with mental health problems across five sites; Aspen ward at Callington Road hospital, Cove and Dune wards at Long Fox Unit, Amblescroft North and South wards at Fountain Way hospital, Liddington and Hodson wards at Victoria Centre, and ward 4 at St Martin’s hospital.

All wards except Amblescroft South and Cove ward look after patients with functional or organic illnesses. In response to the ongoing coronavirus pandemic, Amblescroft North and Cove wards admitted patients with mixed illnesses and have been identified as admissions wards. During this time patients are encouraged to isolate and complete regular testing before transferring to an assessment and treatment ward, following a negative coronavirus test.

During this inspection we visited all five sites and seven wards; Amblescroft South and North, Aspen ward, Cove and Dune wards, ward 4 (St Martins Hospital) and Hodson ward. During our visit to Aspen ward we only looked at the ward environment and did not review care records, or interview staff. Dune ward was closed in December 2020 due to concerns regarding the quality of care and staffing of the ward. The ward reopened in February 2021 following implementation of a quality improvement plan.

The service was last inspected in October 2017 and was rated requires improvement for the safe domain, and good overall. Following that inspection, we told the trust it must make improvements to:

• ensure clear risk management and staff must ensure they clearly document and review risk management. Staff must ensure they transfer patients’ risks clearly to care plans.
• ensure blind spots on Aspen ward including the garden are observed safely and mitigated.
• ensure they prioritise removal of dormitory accommodation on ward 4 in order to ensure optimum safety of patients particularly at increased risk times such as at night.

During this inspection we found that, although the trust had taken some action in response to these requirement notices, they had not all been fully met. Ward 4 continued to consist of dormitory accommodation.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

We inspected the wards for older people with mental health problems because we had a number of concerns about this service. We had not inspected this core service since 2017. The service was previously rated as good overall, with a rating of requires improvement in safe, and good in effective, caring, responsive and well led.

We did not inspect acute wards for adults of working age and psychiatric intensive care units (PICUs) and the child and adolescent mental health ward because the services had not had time to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

Our rating of services stayed the same. We rated them as requires improvement because:

Overall, we rated safe, caring, responsive and well led as ‘requires improvement’, and effective as 'good'.

We rated both of the core services inspected as requires improvement.

In rating the trust, we took into account the current ratings of the ten core services not inspected this time.

The rating for the trust overall remains requires improvement.

With overall ratings of requires improvement for the key questions, are services safe and responsive and good for the key questions, are services effective, caring and well-led

We rated it as requires improvement overall because:

Since the last inspection, the trust had revised the governance structure and trust leadership demonstrated a high level of awareness of the priorities and challenges facing the trust. However, despite action plans being in place to address these, actions had not and did not always happen at pace. It must be recognised though that the trust leadership had responded quickly in taking action to keep staff and patients safe during the COVID-19 pandemic.

During the inspection we heard that there had been variability in the visibility, openness and transparency of senior and services leaders during the pandemic. This had impacted on the experience of staff in some areas where visibility, openness and transparency was seen to be poor. We heard about a disconnect in some areas between front line staff, service managers and executives.

Most staff we spoke with during the core service inspections told us that team or ward managers and matrons were visible and supportive. However, staff did not always feel that senior leaders outside of the locality were approachable or had a good understanding of the services and staff experiences. Staff did not always feel able to raise concerns without fear of retribution.

The trust strategy was not supported by a long-term financial plan and indications were that this was some way off in the context of significant changes to the national financial architecture. The trust were unable to credibly evidence that the trust strategy was affordable or financially sustainable.

The trust did not have a clear, strategic, structured and systematic approach to engaging people who use services, those close to them and their representatives despite some examples of positive engagement.

Not all staff we spoke with, as part of the core services inspection, felt involved in developing the trust strategy and did not understand how this might impact on them or what might be required of them. Some staff felt the strategy was something that had been “done to” them, rather than with them.

The trust had not responded to all previous inspection findings where we had told the trust improvements must be made. The trust had not made the required improvements identified to ensure the dormitory accommodation on ward 4 had been changed to single room accommodation (although the ward moved to an alternative location the month after the inspection).The trust did not have a well-developed estates strategy, despite estates being identified as a key issue. However, the trust was recruiting a director of estates to join the executive team. The trust acknowledged that the issues with the trust estates had not been resolved, despite being a high priority.

Environmental risk management plans to reduce or mitigate identified risks, including known ligature points on the older adults wards had not been fully implemented. Staff did not consider environmental risks when developing risk management plans for patients. Clinical premises where patients were seen in the North Somerset and North Bristol specialist community mental health services for children and young people service were not all safe and clean. The North Somerset team did not have environmental risk assessments in place.

Staff did not complete and regularly update risk assessments in the North Somerset specialist community mental health services for children and young people service. The team did not have enough staff. The number of patients on the caseload of the team, and individual members of staff, was too high to enable staff to give each patient the time they needed. Staff did not always assess and treat young people promptly. The service did not meet target times and an increase in complex referrals meant that staff were finding it difficult to cope with the demand. The trust were aware of this and had action plans in place to address the concerns.

On ward 4 (St Martins Hospital) it was not always clear whether staff had considered the least restrictive interventions when managing patient risk, such as self neglect. The staff team on ward 4 were unclear on the key principles of the Mental Capacity Act. Staff on this ward were unable to describe the principles of the Mental Capacity Act and did not always consider capacity on a time and decision specific basis.

Staff on the older adults wards did not always treat patients with respect and dignity when entering their rooms or interacting with them during an activity.

Our findings from the safe, and effective key questions on the older adults wards highlighted concerns with the governance processes at team level and the management of performance and risk. Ward managers’ understanding and implementation of governance processes differed across the wards and ward managers did not monitor performance and quality consistently.

However:

Since our last inspection a number of new appointments had been made to the board; both non-executives and non executives and a number of new appointments were planned. The trust were in the process of recruiting a full time dedicated deputy chief executive, a director of transformation and a director of estates to join the executive team. The changes were being made to ensure a more diverse board with a wider range of skills and experience and the proposed new appointments would increase the executive team capability and capacity meaning that the board could provide high quality, effective leadership. All board members demonstrated dedication and commitment to improving the care delivered to patients. The chair provided clear leadership and the non executives provided appropriate input and challenge to the various sub-committees that they chaired or had input to and challenged executive members appropriately at board meetings.

Board members demonstrated a real understanding of the issues that faced the trust and were clear that the trust faced many challenges including a difficult financial position, challenges with the estate, a low bed base per population and a number of infrastructure and system issues. They were all clear that where investment was needed to improve the quality of services, this was supported.

The governance framework was now aligned with the Care Quality Commission domains of safe, effective, caring, responsive and well led. There were clear lines of accountability and governance arrangements in place to provide ward to board assurance. The five domain subgroups fed into the executive team and clinical directors. Executive leads took a lead on the domains, within the new structure designed to strengthen reporting arrangements and provide assurance to the trust board.

There were a range of mechanisms in place for identifying, recording and managing risks, issues and mitigating actions. Individual services maintained their risk registers which were submitted to the trust’s electronic risk management system. All staff had access to the risk register and were able to escalate concerns when required. Staff concerns matched those on the risk register. The trust had introduced an early warning dashboard as part of their improvement work on one of the older adults wards. This enabled them to identify areas of concern using a series of data measures.

An external review into physical healthcare commissioned by the trust earlier this year and recently completed identified a number of areas for concern and made recommendations for improvement. This was on the trust risk register, an action plan in place, and the trust was drafting an updated strategy to address these issues.

There was a focus on aligning the strategy with both local and national priorities. The trust were engaged with the wider health economy and system locally. The trust was working with other providers in the strategic development of mental health services within the Integrated Care System (ICS). The trust board regularly discussed this, and acknowledged the challenges associated with working with two different Integrated Care Systems.

The trust had a clear set of visions and values which staff understood. Staff we spoke with during the core service inspections felt increasingly supported, valued and respected. We saw significant improvements in the culture, although there was still work to be done. Staff demonstrated a passion for delivering high quality patient care and put patients at the centre, despite morale being low amongst some staff groups.

Leadership of medicines optimisation within the trust had improved. Recruitment of deputy chief pharmacists had allowed the chief pharmacist to work more strategically. Chief Pharmacist was accountable to the Medical Director and medicines optimisation issues remained visible to the trust board. Governance processes meant there was oversight of risks, performance and processes. However, the risk around medicines safety remained whilst the medicines safety officer role was vacant.

The trust Infection, Prevention and Control (IPC) lead was given a nursing award for their work within the trust. The Daisy Unit (inpatient ward) received a highly commended in the category of Learning Disability Initiative of the Year at the Health Service Journal Patient Safety Awards, in recognition of the work carried out to reduce restrictive practices on the unit. The trust was also a finalist in the category of Patient Safety Collaborative Mental Health Initiative of the Year for its work to reduce restrictive practice on Bradley Brook, a medium secure ward at Fromeside.

The specialist community teams for children and young people, where staff understood the principles underpinning capacity, Gillick competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.

Within the specialist community services for children and young people, we saw staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

Before the inspection visit, we reviewed information that we held about the services and asked a number of other organisations for information.

During the specialist community mental health services for children and young people inspection, the inspection team:

• visited the South Gloucestershire, Bristol North and North Somerset specialist community mental health services for children and young people and looked at the quality of the environment
• ran four focus groups with 35 staff members including, team leaders, child and adolescent mental health safeguarding lead, nurses, primary mental health specialists, administrative staff, clinical psychologists, a doctor, psychotherapists, family therapist and consultant psychiatrists
• spoke with a further seven staff which included three nurse leads, an administrator and three managers
• conducted a review of three clinic rooms
• spoke to nine parents/carers and five young people
• reviewed 22 care records.
• reviewed three supervision records, three team meeting minutes and two appraisals.

During the wards for older people with mental health problems inspection, the inspection team:

• visited seven wards across all five sites, looked at the quality of the ward environment and observed how staff were caring for patients
• spoke with seven patients who were using the service
• spoke with ten carers of patients who were using the service
• spoke with the managers or acting managers for each of the wards
• interviewed 34 staff including, consultant psychiatrists, nurses, healthcare assistants, psychologists, occupational therapists, activity coordinators, physiotherapists, and speech and language therapists
• reviewed 38 care records for patients on six of the seven wards visited
• reviewed 58 patient medication charts
• attended three ward activities including handover meetings, and patient activity groups, and completed a short observational framework for inspection (SOFI2) tool
• carried out a specific check of medication management and clinic rooms on all the wards.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Children and young people said staff treated them well and behaved kindly.

In all the specialist community mental health services for children and young people teams we saw examples of positive feedback from young people who had received a service. Feedback from the participation groups was overall positive but two young people said they had to wait for a long time to get a service.

Carers we spoke with told us staff listened to them.

Carers and families from the wards for older people with mental health problems told us that they felt involved and informed by staff. Carers and families had been given opportunities to join care meetings virtually or in person and received regular updates from staff. Carers told us that staff were considerate of their specific needs during discharge planning and when organising family visits.

Updated 1 May 2024

Date of Assessment 23 January 2024 We completed an unannounced inspection due to concerns we had about some areas of service quality. We assessed a small number of quality statements from the safe and responsive key questions and found areas of concern. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. Staff were not always aware of who the designated unit nurse in charge was, who had authority to deploy staff to other wards in an emergency. Shifts were cancelled at short notice which meant some shifts were short staffed or covered by agency staff who did not know the patients well. Staff told us they were anxious about reporting incidents and using the Freedom to Speak Up Guardian process due to concerns of job security. Although some blanket restrictions had been removed around patients access to fresh air and refreshments, staff told us some night time restrictions remained in place because staffing levels were not changed to reflect a 24 hour service. Relatives told us they were concerned about the standards of care and the services over reliance on, and the quality of agency staff. Patients told us food choice and quality was poor. We found evidence that the service was slow to respond to concerns raised by patients. We reviewed learning from the service but found this was not applied in practice. For example, ward welcome packs were introduced but some staff did not know they existed. Staff did not follow ward rules such as no mobile phones on wards, and activity boards were introduced but we saw evidence of patient requests for activities that were not provided. We found regulation breaches concerning safety. However, senior leaders had responded to a number of patient care concerns and suspended staff from duties whilst investigations took place. The service are addressing staff culture concerns by providing more training and staff told us there were improvements in culture due to this.

Updated 21 December 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

• Staff were unable to observe all parts of the ward due to the current layout. Staff did not routinely undertake observations of all of the ward, nor did they record when observations were carried out. Plans to mitigate ligature risks on the ward were reliant on staff being in communal areas at all times. The bannister and stair lift leading to the communal area posed a significant ligature risk and staff did not carry out observations sufficiently to ensure the safety of young people.
• The service had not completed environmental risk assessments. During the summer, staff placed a chain across the doors leading to the garden. This did not allow enough airflow into the dining room to cool it down. Staff had not completed individual risk assessments for use of the garden area therefore there was a blanket restriction on young people having access to the garden. Risks identified in the risk assessment were not always addressed within a care plan. Not all young people had a crisis plan.
• Although staff provided care and a range of treatments that met the young people needs, these were not reflected in the written care plans. Care plans were generic and used standard statements that did not show personalised care. Young people told us they were not involved in their care planning and that their feedback was not incorporated or listened to. Care plans were not holistic. Young people had a nursing treatment care plan however there was no evidence of input from the wider multi-disciplinary team for example occupational therapist, social worker and psychologist. Some care plans had not been updated in a timely manner in line with trust policy.
• Staff did not receive specialist training to ensure they could meet the needs of all young people. For example, working with someone diagnosed with eating disorder or an autistic spectrum disorder.
• Young people did not always have a discharge plan in place. In the year prior to the inspection, seven young people’s discharge had been delayed. The manager had not completed an analysis to determine causes of the delayed discharges.

However:

• The trust had taken action the action we had required it to make at the last inspection and had ensured the fence that led from the garden directly onto the car park was now secure.
• Staff were trained in safeguarding, knew how to make a safeguarding alert and knew how to identify young people at risk of significant harm.
• Young people had a wide range of treatment and therapies available to them. This included a structured therapeutic programme consisting of psychological therapies, family therapy and numerous activities on and off the ward.
• Staff interacted and engaged well with the young people. Most young people were very complimentary of the staff and the level of care available to them. For example, during the recent building work the staff organised additional activities off the ward so they could escape the disruption.
• The service ensured that young people continued with their education when admitted and provided young people with the educational materials required for continuing with their education.
• There was a consistent management team in place. This had improved since the last inspection. The service had implemented a management structure that included a ward manager and a service manager.

Updated 10 November 2021

Updated 8 September 2016

We gave an overall rating for community mental health services for people with learning disabilities or autism of good because:

• The services conducted assessments, including specialised risk assessments, at the appropriate time. Teams considered physical health needs and monitored them. Care plans were patient focused and staff were respectful of people using the service. Information was available in an accessible format and there was a patients forum that inputted in to the service that people could attend.

• There were good staffing levels and caseloads were appropriate. There was clear eligibility criteria and a referral pathways.

• The services regularly reviewed their practice; we saw evidence of learning from incidents, including changes in working practices. The intensive support team was reviewing their operating policy and referral procedure to ensure it met the needs of the people accessing the service. The forensic team had developed interventions from an evidence base, which met the identified needs of the people accessing the service.

However:

• The intensive support teams electronic record system did not have active risk assessments or contain all the required risk information. There was no effective procedure in place to mitigate this. Not all intensive support team care plans were uploaded on the electronic record system. Some people using the forensic service had not received their care plan in a timely fashion.

• Services did not have a full range of mental health professions in their teams.

• There were no recognised outcome measures in place and staff did not routinely give people information on how to make a complaint.

Updated 8 September 2016

We rated community-based mental health services for older people as good because:

• Staff demonstrated an awareness of risk. The majority of care records contained an appropriate and up to date risk assessment. Staff had safe lone working arrangements. Staff had an understanding about how to report incidents. Staff felt confident in raising concerns and knew how to escalate them if necessary.

• The teams included a full range of specialist allied health professionals to provide effective assessment and treatment. The staff in the teams worked well with other local services and with the other older adult services provided by the trust in their locality.

• Patients and carers that we spoke with reported that the staff were kind and caring. They said they felt included in their care and we saw that this was clearly documented in almost all of the care records we reviewed.

• Staff reported that management within the locality were approachable. They said that morale was generally good and that things had improved in recent years.

However:

• Some teams (North Somerset later life therapies and Swindon memory service) were not meeting the trust’s targets for assessment.

• In the North Somerset teams, although there were alarms available for staff to use, there was no record to show these had been routinely checked.
• While local management was approachable and involved, staff reported that the senior management team based at trust headquarters were not as visible.

Updated 21 December 2018

Our rating of this service improved. We rated it as good because:

• The service had taken steps to address environmental and safety concerns raised at our last inspection in June 2017. We saw that there were now safe lone working policies and staff could access personal alarms when seeing patients on site. Patient environments were assessed for risks and staff undertook checks and assessments to ensure that patients were kept safe.
• On this inspection we found that that staff assessed patients’ mental health and risk well, updating these assessments appropriately and regularly in patient records. Staff discussed patient risk frequently in handovers, complex case review meetings and had access to supervision to help them provide high quality care.
• Patients had access to experienced staff from a variety of mental health professional backgrounds. From observing care, speaking with patients and reviewing records, we saw that staff worked collaboratively with patients to develop care plans and meet the patient’s needs. Staff were able to offer a range of nationally recommended interventions (such as psychological therapies recommended by the National Institute for Health and Care Excellence) and had good links with local services to help meet patient’s needs.
• Staff routinely met their targets for assessing patients in a timely way. In the health-based places of safety this ranged from 95-97% of patients being seen in 24 hours. In the intensive teams, staff saw patients within 4 hours, or within 72 hours depending on the risks of the patient. While they were with the teams, patients had access to appropriate care environments that protected their dignity and privacy appropriately. After they had left the care of the teams, staff collected patient feedback and used this to learn and improve their services.
• Patient representatives were included in recruitment panels for new starters and managers held meetings with patient representatives to gather feedback for service developments. Staff would also meet with carers and help them receive carers assessments to meet their needs.
• Staff teams had strong bonds and reported respecting and valuing their local leadership. They felt their managers were approachable and supportive. Staff felt able to raise concerns without reprisals.

However:

• The North Bristol Intensive team reported that there were a number of shift were staffing levels had fallen below the minimum agreed staffing levels and had not been able to access bank or agency staff to cover these. This problem was made worse when they covered the out of hours cover for the Bristol intensive teams and meant they had to postpone visits.
• Medicines were not managed consistently across the intensive teams. Where we found issues with how medicines were managed, staff addressed these promptly.
• Trust policies on completing physical health checks for patients had not yet been implemented by the intensive support teams.
• The North Bristol Intensive team did not have good access to therapy rooms on site. Staff prioritised meeting patients the patients home. Some patients would have preferred meeting staff away from their homes due for privacy reasons.

Updated 22 May 2020

• There was a strong, visible person-centred culture. Staff treated patients with respect and built open relationships so that patients felt able to discuss their needs and raise concerns. The unit would invite families and advocates to be involved in meetings about the patients.
• The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Managers ensured that staffing levels were adjusted to reflect the fluctuating needs of patients and the risk levels present at that time. Any potential impact of staffing vacancies was mitigated by the use of bank and agency staff familiar with the ward and its patients.
• Staff assessed and managed risk well, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and autism and engaged in clinical audits to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• There were high levels of satisfaction within the staff groups. There was strong collaboration and team-working and a common focus on improving the quality and sustainability of care and people’s experiences. Quality improvement methodology was embedded on the ward. Staff were empowered to lead and deliver change.
• The service participated in the trust’s restrictive interventions reduction programme, which met best practice standards. The service had appointed a reducing restrictive practice lead and had embedded a Positive Behaviour Support model of care, this had been effective in significantly reducing the number of restrictive interventions.
• Governance arrangements were robust, and incidents and risks were reported, analysed and shared. Leaders had high quality management information, which showed trends and risks in the service. They were able to use this information to manage risks and improve the service.

However,

• Medication records had a number of missing signatures and review dates. We raised this at the time of inspection and the manager agreed to follow up.

Updated 7 March 2023

Avon and Wiltshire Mental Health Partnership NHS Trust have four long stay and rehabilitation mental health wards for working age adults. During this inspection, we visited 3 wards; Alder ward (10 beds), Windswept ward (14 beds) and Whittucks road (15 beds) which are based in Bristol, Swindon and South Gloucestershire respectively. We did not visit Elmham Way in North Somerset.

During this focused inspection we inspected the safe and well led domains due to having concerns around the safety on the wards.

We rated this service as good because:

• Staff assessed and managed risks to patients and themselves well. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff assessed the physical and mental health of patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. They involved patients and gave them access to their care planning.
• Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the service they managed and were visible and approachable for patients and staff.
• Staff felt respected, supported and valued. They said the service promoted equality and diversity and provided opportunities for development and career progression. They could raise any concerns without fear of retribution.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, not all of the matrons or managers had received level 3 safeguarding training in line with the safeguarding intercollegiate document.
• While staff had received basic training to keep patients safe, none were aware of the Oliver McGowan training for patients who may require support with learning disability or autism.
• Bedrooms on Alder ward and Whittucks Road were located on the 1st floor. While there were evacuation chairs in situ none of the staff had received up to date training to use the equipment. Staff informed us individual evacuation plans would be implemented when needed. It was noted during the inspection, that none of the patients required a personal emergency evacuation plan.
• Not all staff had received prevention management of violence and aggression (PMVA) training and felt vulnerable when requested to support patients on the acute wards.
• While the service had enough nursing staff and consultants on Alder ward and Whittucks Road, Windswept ward did not have a substantive medical cover and were dependent on medical cover from an acute ward. The service had limited access to junior doctors. Staff told us the availability of a doctor attending the ward quickly in an emergency was on occasions difficult. However, there had been no adverse incidents identified within the records seen.While there were systems and processes to safely prescribe, administer, record and store medicines, we found that prescriptions charts were not always updated to provide accurate information to staff. There were gaps in the calibration of blood monitoring machines on Alder ward and Whittucks Road.
• While monthly quality assurance data was completed and analysed, we saw these were not always accurate. We found no cleaning records available on Alder ward and those on Whittucks Road had gaps in recording. Blood monitoring machines had also not been calibrated which may result in patients receiving inaccurate readings. This meant that audits were not picking up issues on compliance.
• Outcomes data and quality improvement opportunities and evidence-based policies and procedures were reviewed within the clinical governance framework. However, we were not assured how this information was shared with staff. Most staff spoken with said they did not know how well the service was performing.

Information about the service

We inspected 3 long-stay and rehabilitation mental health wards for adults of working age under Avon and Wiltshire Mental Health Partnership NHS Trust. These were; Alder ward (10 beds), Windswept ward (14 beds) and Whittucks Road (15 beds) which were based in Bristol, Swindon and South Gloucestershire respectively. All wards provided support to both male and female patients.

Windswept ward was currently running as an 8-bed mixed sex rehabilitation ward for adults of working age. The ward was closed during the pandemic and reopened towards the end of 2021. There were no plans to extend the number of patients due to not having substantive medical cover.

Whittucks Road was a standalone unit which provided accommodation for 5 female and 4 male patients. The remaining 6 beds provided independent step-down accommodation for 3 male and 3 female patients. The step-down beds were for patients who were able to live a more independent life and aimed to help them prepare for a return to the community.

The trust described these locations as community rehabilitation units as they provided care to patients who were at a point where they might be discharged into supported accommodation, or into the community.

The rehabilitation services worked with a client group who experienced long-term complex mental health problems, offering an extended period of engagement.

The service was registered for the following regulated activities:

• Assessment and/or medical treatment based for persons detained under the Mental Health Act 1983.
• Diagnostic and screening procedures.
• Treatment of disease, disorder or injury.

The service was last inspected in 2017 where it was rated as good overall. We rated safe as requires improvement while effective, caring, responsive and well-led were rated good. During this inspection we reviewed the rating for safe and well-led only.

During the last inspection which was carried out on 20 June 2017 the Care Quality Commission (CQC) imposed a breach of Regulation 10, (Dignity and Respect) at Whittucks Road. During this inspection we found this breach had been met.

Updated 10 November 2021

Updated 29 March 2023

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services. We last inspected the service in February 2020 and rated it requires improvement overall.

We inspected the acute wards for adults of working age and psychiatric intensive care units, focusing on key lines of enquiry to review whether the service was safe and well-led. Avon and Wiltshire Mental Health Partnership NHS Trust provides 9 acute wards and 3 psychiatric intensive care units (PICU) for adults of working age. The wards are based across seven locations throughout Avon and Wiltshire.

• Callington Road in Bristol has 3 acute wards; Lime unit with 22 beds, which is male only, Silverbirch ward with 19 beds, which is female only and Cherry Ward with 18 beds, which is mixed sex. There are also 2 PICUs; Hazel with 12 beds, which is male only and Elizabeth Casson House with 8 beds, which is female only.

• Fountain Way, in Salisbury, has an acute ward; Beechlydene with 21 beds, which is mixed sex and a PICU; Ashdown, which is male only.

• Green Lane Hospital, in Devizes has a 20 bed acute ward; Poppy, which is mixed sex.

• Sandalwood Court, in Swindon, has a 15 bed acute ward; Applewood, which is mixed sex.

• Hillview Lodge, in Bath, has a 15 bed acute ward; Sycamore, which is mixed sex

• Southmead Hospital, in Bristol, has a 20 bed acute ward; Oakwood, which is mixed sex.

• Long Fox unit, in Weston-Super-Mare has a 18 bed acute ward; Juniper, which is mixed sex.

We visited eight of the 12 wards across four dates. We did not visit Ashdown, Poppy, Lime or Silver Birch wards but viewed a range of data, policies and documents relating to the running of these wards.

Following the inspection we issued a Warning Notice under Section 29A of the Health and Social Care Act 2008 due to our concerns that patients on the acute inpatient wards were not receiving safe care and treatment under regulations 12 and 17 of the Health and Social Care Act 2008 (regulated activities).The trust responded to the warning notice with an action plan and timeframes to address the issues and improve the safety of care.

Our rating of services stayed the same. We rated them as requires improvement because:

• The trust had not ensured that requirement notices served following our last inspection of acute inpatient services had been met and improvements maintained across the wards. Learning from recent significant incidents’ initial reviews and root cause analysis had not been implemented across all wards.
• Staff did not update risk assessments as necessary for all patients and risk management plans were not consistently developed in response to identified risks and safety incidents. Staff did not always report or respond to patient safety incidents. Staff did not consistently take action to respond to identified abuse.
• The ward environments were not maintained and monitored in a way to mitigate risks. Not all wards appeared clean and some were poorly furnished and in need of repair. The trust had not ensured that mixed sex wards were designed, utilised and monitored to mitigate associated risks and prevent sexual safety incidents. There were risks within the ward environments that had been identified on the risk registers up to 4 years ago. These risks had not been regularly reviewed and there was insufficient details and updates to evidence progress and plans to resolve these.
• We were concerned that prescribers did not safely prescribe and review pro re nata (as and when needed) medicines. Staff did not ensure clinic and physical health rooms were maintained and cleaned to ensure out of date medicines and dirty equipment were not used.
• There were high vacancy rates across the service, and these were above 30% on 6 wards. Staff felt they could not provide the level of care they wanted to due to these vacancies. When agency staff were used it was not always possible to allocate staff who were familiar with the ward. Agency staff did not have access to electronic care records to input observations and incidents, and support robust handover of information.
• We previously served a requirement notice for the trust to improve compliance with physical emergency response training. The training compliance on 6 of the wards was below 75% and as low as 45% on 1 ward.
• Staff did not consistently follow processes related to leave for patients detained under the Mental Health Act.
• Staff did not always feel respected, supported and valued in their roles. Staff from Juniper, Oakwood, and Beechlydene wards told us they had limited engagement with leaders from across the wider trust and felt their challenges and concerns were not fully recognised and understood by directors.
• Our findings from other key questions demonstrated that governance processes did not always operate effectively at team level to ensure that performance and risk were well managed. The identification, management, and review of risk, issues and performance was not always sufficiently implemented to provide assurance of a safe and quality service.

However:

• On Elizabeth Casson House, Hazel and Sycamore wards, although the risk management was variable, we saw evidence of some high standard risk assessment and care planning that had led to robust and individualised risk management for patients with complex needs.
• The overall compliance with mandatory training across the wards was good.
• The trust had completed environmental works to improve Elizabeth Casson House. Staff were positive about the refurbishment and the impact this had, and felt it was a safer and more therapeutic environment.
• All staff knew about the freedom to speak up guardian. Staff provided examples of concerns they had raised with the freedom to speak up guardian and how these were resolved. Teams generally worked well together and when there were difficulties managers dealt with them appropriately.

Updated 8 September 2016

We rated Avon and Wiltshire Mental Health Partnership Trust’s substance misuse services as Good because:

• Staff were following ‘Drug misuse and dependence: UK guidelines of clinical management (2007) and National Institute for Health and Care Excellence (NICE)’ guidelines for substitute prescribing and psychological therapy, which also informed trust policies and procedures.

• Staff monitored clients in the community safely and regularly throughout the treatment period. Medical cover was available over a 24 hour period and there were emergency procedures in place.

• Staff completed and updated risk assessments. They had a clear understanding of individual risks and were highly skilled and experienced. Risks were managed well both in community and inpatient settings. Recovery care plans involved the client and were clear and holistic and contained detailed information regarding client’s care and treatment..

• Environments, including clinic rooms, were clean and well maintained and laid out in a way which protected privacy. Information was freely available specific to substance misuse problems. For example other agencies, social services and advocacy.

• Medicines management was effective throughout the services. Where medicines were kept on site they were stored, monitored and audited safely.

• There were sufficient staff numbers to meet the needs of people using the services. The community specialist substance misuse services (SDAS) had reduced their staffing numbers when they redesigned their service models. Managers had worked creatively to ensure client safety through the redesign of the service.

• Community SDAS and inpatient services provided support for all healthcare needs associated with substance misuse. Staff supported people with blood-borne virus testing. Electrocardiograms were taken for people receiving high doses of methadone to monitor the effects on the heart. Some services provided specialist input into general practitioner (GP) surgeries, which was considered by GP’s as a highly effective service.

• Staff were very caring and demonstrated a high level of positive regard and respect to people accessing the services. Staff attitudes towards people were warm, kind, non-judgemental and thoughtful.

• The services were managed by highly committed and inspirational leaders. They demonstrated a clear determination to ensure that needs and safety were not affected by the redesigns and upcoming retendering processes. For example, Avon and Wiltshire Mental Health Partnership Trust provided the South Gloucestershire service. However in the near future other health organisations would have to opportunity to bid to manage this service instead. Staff told us they felt supported, supervised and positive about their place within the teams.

• The trust gave staff opportunities to develop leadership and specialist skills across the different roles within the service. Poor performance issues were managed well.

However:

• Although we saw that risks were discussed, reviewed and updated on Acer Unit, locating where updated risk assessments was difficult in patient records. There was no clear system in place.

• The redesign of the Bristol recovery orientated alcohol and drugs service specialist drug and alcohol service (Stokes Croft) had resulted in pressure and a backlog within the rapid prescribing service. This team was holding high caseloads as they waited to transfer clients to their Colston Fort specialist drug and alcohol service.

Updated 5 May 2023

Avon and Wiltshire Mental Health Partnership NHS Trust provides community-based mental health services for adults of working age across Bath and North East Somerset, Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. The trust has 2 mental health assessment and recovery teams and 9 recovery teams, which cover 6 localities. The service offers people with identified mental health needs a range of assessments, community-based treatments, psychological support and interventions, medication, and advice.

The last comprehensive inspection of the community-based mental health services for adults of working age was in May 2016. The service was rated good overall with a requires improvement rating in the safe domain. Following this inspection, the trust were issued with a breach of Regulation 12 (safe care and treatment) and were told it must put a system in place for monitoring uncollected medication from the community team bases.

In December 2020, there was a focussed inspection of the Wiltshire and Swindon teams. Following this inspection, the trust was told to improve people’s risk assessments and risk management plans by ensuring they are updated in response to new or changing risks, which was a breach of Regulation 12 (safe care and treatment).

We carried out this focused inspection because we had concerns about the quality and safety of services. There had been a significant increase in serious incidents with recurring themes including management of medication. There was a concern that teams were not learning from incidents, and we were concerned there was a risk that further serious incidents would occur.

We visited 6 teams:

• Bath and North East Somerset (BaNES) recovery team
• North Bristol assessment and recovery team
• South Bristol assessment and recovery team
• South Gloucestershire recovery team
• Swindon recovery team
• North Somerset recovery team.

The community mental health teams were previously rated good overall in May 2016.

Our rating of services went down. We rated them as requires improvement because:

• The service did not always use robust systems and processes to administer, record and store medications. Staff did not always complete medicines records accurately or keep them up to date, which could lead to people not receiving the right medication, at the right time. We found examples where staff had administered medication to people with an expired prescription. In North Bristol, there was an excessive amount of medication being stored that should have been collected or disposed of.
• The service did not have robust governance processes in relation to medicines management. There were no formal audit processes in place to ensure the trust had oversight that medication was being prescribed, administered, recorded and stored correctly.
• Managers and senior staff did not have oversight of the clinic rooms. There was no accountability or clear lines of responsibility for the management of medicines. There were no clear processes to check that staff were safely administering, recording and storing medication. Managers were unaware of staff’s competency in medication management as issues were not being identified.
• Teams did not share learning across the service, between or within their localities or trust wide. This meant that learning and actions taken following incidents and complaints were not being shared higher than local level, which could have prevented incidents or complaints occurring in other areas.

However:

• The issues identified at the previous two inspections had improved. All teams, except North Bristol, now had an effective process in place for monitoring medication that had not been collected by people. All teams had improved risk assessment and management plans; staff now updated them regularly and following new and changing risks.
• Staff treated people with compassion and kindness and understood the individual needs of people. They actively involved people and families and carers in care decisions. People spoke highly of their care co-ordinators. People described their care co-ordinators as kind, brilliant, friendly and caring.
• Staff developed recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers where appropriate. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the people.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

How we carried out the inspection

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

Before the inspection visit, we reviewed information that we held about the service.

During the inspection we:

• Toured the premises that each team was based and completed checks on the safety of the environment,
• Spoke with 6 people who were using the service,
• Spoke with 5 relatives of those using the service,
• Interviewed 7 team managers, 1 early intervention manager, 4 service managers and 1 associate director of operations,
• Interviewed 43 staff members including five consultant psychiatrists, one specialist registrar doctor, 12 senior practitioners, nine community mental health nurses, four recovery navigators, one non-medical prescribing nurse, one recovery outreach support and engagement nurse, one student nurse from the early intervention team, two mental health wellbeing practitioners, one assistant psychologist, one personality disorder specialist, one clinical psychologist, one head of therapy, one social worker, one principle social worker and one trainee multiple-professional approved clinician,
• Attended 8 meetings including 1 high needs meeting, 4 team meetings, 1 cluster meeting, 1 crisis meeting and 1 clinically ready for discharge meeting,
• Reviewed 42 records relating to the care and treatment of people
• Reviewed 560 prescription and medication charts
• Completed a check of each clinic room, including medication stock and
• Reviewed a range of policies, procedures and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Everyone who provided feedback spoke positively about the care and treatment they received from their community mental health team and care co-ordinators. People described their care co-ordinators as kind, brilliant, friendly and caring. However, many commented that due to staff shortages and high caseloads, co-ordinators move on from the service too quickly and that they are not as “hands-on” as they used to be.

Updated 28 August 2014

The six rehabilitation wards are based in five hospital sites across Bristol, Weston Super Mare and Swindon. All provide inpatient mental health services for adults.

Risks were usually assessed and staff understood their responsibilities regarding safeguarding. However we found that incidents had not always been reported, investigated or learnt from, though this did not always translate in to changes in practice.

Overall, we saw good multidisciplinary working and staff working well with external services to ensure a positive care pathway for people.  Staff were compassionate and caring. People we spoke with were mainly positive about the staff and felt they made a positive impact on their experience on the ward.

We found good evidence that patients were involved in the planning of the services. Both staff and patients knew how to make a complaint and many were positive regarding the response they received.

Staff generally felt supported by the managers at ward level however leadership from above ward level was not as visible to all staff.