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Avon and Wiltshire Mental Health Partnership NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important:

Listen to an audio version of the report for Avon and Wiltshire Mental Health Partnership NHS Trust from our inspection on 04 September - 04 October 2018, which was published on 21 December 2018. Listen to the report

Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

4-5 and 12 July 2023

During an inspection of Forensic inpatient or secure wards

Fromeside is an 81 bed medium secure service caring for people with a mental illness and/or personality disorder who also have a criminal history or have risks and behaviours that mean they cannot be treated in mainstream mental health services. Our rating of this location went down.

We rated it as requires improvement because:

• Staff were not following procedures for when clinic room temperatures were above the recommended guidance.

• Substantive staff were not having regular line management supervision. Temporary staff were not fully engaging with patients.

• There were blanket restrictions. Patients had access to fresh air for 15 minutes every hour and when garden doors were open all other doors to communal areas were closed. Restrictions were then imposed on patients not having access to fresh air.

• Activities were not always meaningful, consistent or regular.

• While audits assessed and monitored systems to ensure patient safety, the findings had not been used to make improvements. Some audits had not fully assessed and monitored systems. For example, levels of noise from staff keys, use of mobile phones on wards and the conduct by temporary staff.

However:

• The trust was responsive to complaints raised by patients.

• Training was encouraged and there were opportunities for progression.

• The trust was taking steps to develop community relationships to support the smooth transition of patients into discharge.

• There was a patient representative on wards.

• Patients cared under MHA section were told about their rights and their S17 leave was rarely cancelled.

• The service provided safe care and wards were safe and clean.

• Staffing levels were maintained with regular bank and agency staff.

• Staff managed medicines safely and followed good practice with respect to safeguarding patients.

• Patients cared under MHA section were told about their rights and their S17 leave was rarely cancelled.

• The service provided safe care and wards were safe and clean.

• Staffing levels were maintained with regular bank and agency staff.

• Staff managed medicines safely and followed good practice with respect to safeguarding patients.

Background to inspection

The hospital is registered to carry out three regulated activities.

• Assessment or medical treatment for persons detained under the Mental Health Act 1983,

• Diagnostic and screening procedures and

• Treatment of disease, disorder, or injury

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?

What people who use the service say

Overall patients felt safe at the service and felt confident to approach staff and advocates with complaints.

Patients were knowledgeable about their care needs. They were aware of their legal status, conditions of their stay and were informed about their rights. They said their S17 leave was rarely cancelled.

However, some patients said temporary staff were not always respectful, took mobile phones on the ward and activities were inconsistent and lacked variety.

There was a patient representative on each ward who attended community meetings to represent patient views.

Patients that gave us feedback about the levels of noise from staff’s keys, door slamming and viewing windowpanes left open.

21, 22 and 23 February 2023

During an inspection of Community-based mental health services for adults of working age

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.

10, 11, 12, 19th January 2023

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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.

10-12 January 2023

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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.

27/07/2021 - 16/09/2021

During a routine inspection

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.

10, 11, 14 December 2020

During an inspection of Community-based mental health services for adults of working age

We carried out this unannounced focused inspection because we had received information which gave us some concerns about the safety and quality of the Wiltshire, Swindon and perinatal community services. This included information provided to CQC by patients, and details contained within serious incident reports submitted to us by the trust. This information identified potential safety concerns about the assessment and management of risk for patients accessing community mental health services within Wiltshire and Swindon localities. We also received information giving us concerns about the safety and safeguarding processes for patients under the care of the trust’s community perinatal teams.

The inspection focused on four community teams and the trust’s two specialised perinatal teams. During the inspection we interviewed staff and patients, and reviewed care records for Swindon recovery team, North Wiltshire community mental health team (CMHT), Swindon intensive service and North Wiltshire intensive service. We focussed our inspection on these four services due to serious incident reports received which led us to believe that there might be repeated issues with risk assessment and documentation, completion of crisis and contingency plans, involvement of family and carers, and multiagency working. We also spoke with staff and reviewed safeguarding processes for the Bristol, North Somerset and South Gloucestershire (BNSSG) and Bath, Swindon and Wiltshire (BSW) community perinatal services.

During this inspection we focused on specific aspects of the key question are services safe and inspected across three service types; community based mental health services for adults of working age, mental health crisis services, and specialised community perinatal services. We did not rate these services at this inspection.

We found that:

Staff in all teams worked well with internal and external teams involved in patients’ care. There was good multiagency working and multidisciplinary teams worked well together to consider and respond to risk and deterioration in patients’ mental health.

The services managed patient safety incidents well. Staff recognised and reported incidents. 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. We saw evidence of learning from incidents and associated action plans being implemented within teams.

Staff in the perinatal teams understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust had identified previous incidents where opportunities to safeguard patients had been missed, and had implemented an effective action plan to improve safeguarding processes.

The service provided mandatory training in key skills to all staff to ensure they could do their jobs and made sure everyone completed it.

Staff had established effective processes to assess patient risk and ensure effective infection prevention and control processes in response to the COVID19 pandemic. Despite the pandemic impacting negatively on staff availability, the number of face to face appointments, and patient wellbeing, patients told us that the level of support and input from teams had not changed and they were happy with their care. Patients who presented with high risk were seen face to face. There had initially been a reduction in the number of face to face visits offered at the start of the pandemic. However, staff had since increased face to face appointments, and where appropriate, appointments were also offered over video calls.

Staff supported patients during a crisis and ensured easy access to psychiatrists and specialists following deterioration of their mental health or in response to increased risks. Patients and their carers told us that staff took action to respond to their concerns and any deterioration in their mental health.

However:

Staff did not always update risk assessment tools and risk management plans in response to newly identified or changing risks. We reviewed 11 care records that did not include up to date risk assessment and management plan following reference to new risks to self within progress notes. Staff did not always update risk assessments and management plans following patients discharge from inpatient admissions.

There were increasing staff vacancies within the Swindon intensive service, and substantive staff worked extra hours to cover vacancies. Staff in this team did not always have available time to complete risk documentation in patient care records, although risk information was kept up to date in progress notes.

How we carried out the inspection

During this inspection, the inspection team:

  • spoke with 20 staff, including managers, psychiatrists, clinicians and allied health professionals
  • spoke with 12 patients and two carers
  • looked at 25 patient care records
  • looked at a range of policies, procedures and other documents relating to the running of the services.

What people who use the service say

Patients told us that staff were respectful and supportive. Patients had not noticed a significant change with the level of support and care they received during the COVID19 pandemic.

14 and 15 December 2020

During an inspection of Forensic inpatient or secure wards

Fromeside is an 81 bed medium secure service caring for people with a mental illness and/or personality disorder who also have a criminal history or have risks and behaviours that mean they cannot be treated in mainstream mental health services.

We carried out this unannounced, focused inspection because we received information that gave us some cause for concerns about the safety and quality of the services. We visited five medium secure wards to assess the concerns identified. These centred on how the rights of these patients were respected and the continuity of care provided by staff and whether the service was able to consistently deliver specialist care and treatment to patients on enhanced levels of supervision with sufficient experienced and qualified staff. We also had reports that the environment was not adequate for all patients whose care, at times, had to be delivered away from the wards in seclusion or long-term segregation due to a number of risks.

The service is registered to provide the following regulated activities:

• Assessment or medical treatment for persons detained under the 1983 Act.

• Treatment of disease, disorder or injury.

During the inspection we looked at relevant key lines of enquiry from the key questions, ‘are services safe and effective’.

We did not rate the service during this inspection. The previous rating of good remains.

We found:

  • The service provided safe care. The ward environments were safe and clean although we saw one seclusion suite that needed repair. Managers said staffing levels were maintained with regular bank and agency staff. Staff assessed and managed risk well. Steps were being taken to minimise the use of restrictive practices. Staff managed medicines safely and followed good practice with respect to safeguarding patients.
  • Staff developed care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards.
  • Staff planned and managed discharges and liaised with services that would provide aftercare.

However,

  • Multidisciplinary teams did not always work well together, and communication was poor between some medical staff and nursing staff.
  • Staffing levels were maintained by regular bank and agency staff due to vacancies, although recruitment was in progress
  • There were a few care plans that lacked guidance to staff on how patient’s needs were met in their preferred manner. Managers had recognised this, and action plans were in place to improve care planning procedures.
  • Some records including mental capacity assessments and details of whether patient’s rights had been explained to them on a regular basis when detained under the Mental Health Act were not always kept in care files.
  • A few reports of the debriefs undertaken with staff were not documented following incidents

How we carried out the inspection

We conducted an unannounced focused inspection looking at specific areas of two key questions:

  • Is it safe
  • Is it effective?

During this inspection, the inspection team visited Laden Brook, Wellow, Severn, Teign and Cary and spoke with

  • Clinical manager and clinical lead
  • Two modern matrons
  • The acting quality improvement manager
  • Three ward managers
  • Eight ward staff, including nurses and healthcare support workers.
  • Three patients during the site visit and three patients remotely
  • Three relatives
  • Nine care and treatment records and 11 medicine records
  • A range of policies, procedures and other documents relating to the running of the ward.

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.

Tuesday 25 February 2020 to Wednesday 25 March 2020

During an inspection of Specialist community mental health services for children and young people

  • The service was easy to access. Staff assessed and treated young people who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers.
  • Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They ensured that young people had good access to physical healthcare and supported young people to live healthier lives. The service had enough nursing and medical staff, who knew the young people and received basic training to keep young people safe from avoidable harm. Staff used recognised rating scales to assess and record severity and outcomes.
  • The teams included or had access to the full range of specialists required to meet the needs of young people. Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain young people’ rights to them. Staff supported young people to make decisions on their care for themselves proportionate to their competence. Staff assessed and recorded consent and capacity or competence clearly for young people who might have impaired mental capacity or competence.
  • The environments were safe, clean, well-furnished and well maintained.
  • Staff assessed and managed risks to young people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff understood how to protect young people from abuse and the service worked well with other agencies to do so. Managers ensured that where lessons were learnt in relation to incidents, these were shared with staff.
  • Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for young people and staff. Governance processes operated effectively at all levels and performance and risk were managed well.
  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.

However:

  • Not all young people found it easy to access advocacy services.
  • Not all premises were fit for purpose. Clinicians did not all have enough space in their premises to treat young people or to hold team meetings.

 

Tuesday 25 February 2020 to Wednesday 25 March 2020

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

Our rating of this service stayed the same. We rated it as requires improvement because:
  • Staff did not always manage risk in a way that ensured the safety of patients and staff. The service had not reduced the use of prone restraint (face down position) as identified as an improvement the trust must make following our last inspection in September 2018. The number of prone restraint incidents had increased and the percentage of all restraint incident types that involved prone position had increased from 24% to 26%. Patients had been admitted to wards out of hours despite ward staff identifying that their risks or needs could not be managed on the ward. These patients had required more restrictive interventions to manage their risks and, in two cases, had been transferred to psychiatric intensive care units, soon after admission.
  • Managers had not ensured that staff received mandatory physical health response training (PERT). Staff told us it was difficult to reserve a place on PERT courses and these were often cancelled or held outside of their locality. Training compliance with this course was below 75% across the service and 50% on Juniper ward.
  • There was not always a bed available within the trust wards for a person who would benefit from admission. Bed occupancy was generally between 95% and 100% for the previous 12 months. There had been 382 patients admitted to out of area beds due to capacity issues in the previous 12 months. The trust had identified three urgent transfer beds on Oakwood and Poppy ward which were used for patients who had been at the place of safety longer than 24 hours. Managers told us that these beds were not always used in line with the standard operating procedures and were not always reserved primarily for people from the place of safety. Staff told us they experienced increased pressure due to the quick transfer of patients into and out of the urgent transfer beds and the extra work this created from admission, assessment and risk management processes. The manager on Oakwood ward had raised these concerns with the trust and the use of these beds and impact had been added to the wards risk register.
  • Six of the nine wards we visited required environmental works to ensure they were safe and therapeutic spaces. Environmental changes were required to the layout of seclusion rooms on Elizabeth Casson House, Oakwood and Juniper ward, to ensure that patients who were high risk could safely access en-suite facilities. Some seclusion rooms also had blind spots despite the presence of CCTV. The trust had undertaken a seclusion room review and had identified these issues and particular safety risks within Juniper seclusion room. The review had concluded that work on Juniper ward should be prioritised and a further full review of seclusion rooms should be completed. The doors on Oakwood and Silverbirch ward were identified on the ward risk registers following an increase in detained patients going absent without leave (AWOL) from these wards. Silverbirch ward did not secure shut automatically and Oakwood ward’s main door opened out to the hospital grounds, and was controlled from the nursing office, therefore patients had been able to leave these wards as staff entered. Elizabeth Casson House and Oakwood ward layouts did now allow for space for female patients to access quiet and private space other than their bedrooms.

However:

  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. This included, psychologists, nursing staff, medical staff and occupational therapists. Managers ensured that these staff received regular supervision and appraisal. Ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff completed comprehensive assessments of the physical and mental health of all patients and reviewed patient needs, and progress, regularly through multidisciplinary discussion. On Beechlydene, Sycamore, Oakwood, and Poppy wards staff developed individual care plans, which reflected the assessed needs, were personalised, holistic and recovery-oriented.
  • 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 through one to one sessions, ward reviews and care programme approach meetings,
  • Staff told us that there had been a recent improvement in engagement with staff by senior managers on design of the service and management of ongoing local risks. Staff praised their ward managers and multidisciplinary team relationships and said that morale had improved on all wards.

Tuesday 25 February 2020 to Wednesday 25 March 2020

During an inspection of Wards for people with a learning disability or autism

  • 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.

Tuesday 25 February 2020 to Wednesday 25 March 2020

During a routine inspection

This report includes the findings from the completed service level inspections, but the well-led inspection was not completed. CQC is only able to update findings on well-led at the overall trust level or update the other trust-level ratings when we have inspected the well-led component. As a result, the ratings for the overall trust and five key questions included in this report are from a previous inspection.

4th Sept 2018 – 4th Oct 2018

During a routine inspection

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

  • We rated safe, responsive and well led as requires improvement and rated effective and caring as good. Our rating for the trust considered the previous ratings of services not inspected this time.
  • We rated well led for the trust overall as requires improvement. The rating for well led is based on what we found during our well-led inspection but also takes into account the aggregated ratings from each of the core services. Ratings for other key questions are derived from aggregating the ratings from each of the core services.
  • Whilst the chief executive provided positive and passionate leadership working with two strategic transformation plans (STPs) took up a considerable amount of time. The trust had not progressed a number of required improvements as quickly as it should have done. We were concerned that the trust did not have the leadership capacity it needed to deliver its vision and strategy, as well as focus on day to day delivery.

  • Although the trust had a vision for what it wanted to achieve staff were not fully aware of the trust plans to turn this into action. The relatively new trust strategy had not really been embedded across the trust and staff were unclear as to the direction of travel and how they played a part in achieving the strategy. The measures or milestones to demonstrate progress with the strategy were not clear and were not well understood. However, the trust had structures, systems and processes in place to support the delivery of its strategy including committees, sub-committees and team meetings

  • The trust did not use a systematic approach to continually improve the quality of its services or safeguard standards of care. There was a lack of quality governance systems in place. However, there were some good local initiatives to improve services being progressed in different services across the trust. It was unclear how some of the assurance frameworks used by the trust related to one another. For example, there was no clear alignment between the board assurance framework and corporate risk register although the trust was subsequently reviewing this. However, the trust had structures, systems and processes in place to support the delivery of its strategy including committees, sub-committees and team meetings. In 2018, the trust underwent an external review of its committees and their terms of reference. The review identified the need for more robust quality governance reporting systems.

  • Prior to undertaking an inspection CQC asks trusts to submit a range of up to date information about it how managers and delivers its services. The trust was unable to provide us with the full range of information requested. The trust appeared to hold information at service level but we were told it was difficult to pull this together to give a trust wide picture. This led us to question whether the trust board had all the information it needed to assure itself of the quality of care delivered across the trust.

  • Across the acute wards and psychiatric intensive care units the trust had not made the improvements that we told it must be made at the two previous inspections in 2016 and 2017. At this inspection we found that there were still improvements required to ensure that environmental risks related to ligatures and seclusion practices were effectively managed.
  • Within the child and adolescent inpatient unit, we found that some of the environmental risk issues that we identified at the last inspection remained. During a period of building works, the ward was unable to admit young people with a high level of risk because it could not care for them safely. Although the trust planned to relocate the ward to complete the next phase of building works it was unclear when this would take place.
  • Community child and adolescent mental health teams were understaffed and there was a high turnover of staff. We found staff had increased levels of stress caused by a combination of complex caseloads and the pressures of long waiting lists.
  • We rated the Daisy unit, an inpatient service for people with a learning disability, as inadequate overall. We found that there were a high number of physical interventions used to manage the behaviour of patients but that the unit did not have a plan to reduce the use of these practices. The model of care was not clear. The unit did not have a focus on enabling people to leave hospital and integrate back into the community in line with national guidance and best practice.
  • Staff, including managers, did not know about the Freedom to Speak Up Guardian and some staff were not aware of the whistleblowing procedure.
  • Many staff we spoke with were concerned about a current review of the administration staff roles and were concerned this would lead to a reduced number of administration staff.
  • The roles and purpose of infection prevention and control (IPC) within the trust needed further development. IPC was not a high priority throughout the trust. However, the new Director of Nursing and Quality had taken on the director of infection prevention and control role and was planning to ensure this was given a higher priority to ensure patients were not put at risk of infection whilst receiving care at the trust.

However:

  • The trust board and senior leadership team had a wide range of skills and experiences and were passionate about wanting to deliver safe, high quality services for the patients that used the trust services. The non-executive directors brought a range of expertise from their professional backgrounds, such as organisational change and financial performance. The board was building a new leadership team; there had recently been a number of new directors appointed. Following the appointment of the director of finance there was now assurance that, while there was still more to do, there was movement towards a more robust and transparent financial position. The new director of human resources had made good progress to address recruitment issues and the newly appointed Director of Nursing and Quality had a good grasp of what needed to be done to address the quality governance issues.
  • The culture of the organisation had improved since our last inspection. The majority of staff said they felt respected, supported and valued by the trust. Staff felt that the senior leadership team had supported a number of significant improvements in services and as such staff now had more confidence in senior leaders.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs. We observed staff responding well to individual patient need. Staff usually involved patients and those close to them in decisions about their care and treatment.
  • The trust had a structured approach to engaging with people who used services, those close to them and organisation representing them. The wards, teams and divisions had access to feedback from patients, carers and staff and were using this to make improvements.
  • Within the core services staff, analysed, managed and used information well to support all its activities, using secure systems with security safeguards. The wards and community teams had good systems and processes in place to assess and monitor quality and safety. Staff participation in audits was good and there were regular audits conducted including infection control and medication audits.
  • Acute wards had moved towards a trust wide approach of bed management with the aim of ensuring a bed could be found as near as possible to where they lived for anyone who needed to be admitted. The trust had introduced a daily bed management call for all ward managers and matrons to manage the effective discharge of patients, and any potential barriers to discharge.
  • Staff assessed the mental health and physical health of patients on admission. Staff supported patients with their physical health and encouraged them to live healthier lives.

4th Sept 2018 – 4th Oct 2018

During an inspection of Specialist community mental health services for children and young people

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

  • Teams were understaffed. We found staff had increased levels of stress caused by a combination of complex caseloads and the pressures of the long waiting lists. Vacancies increased pressure on the remaining staff and further increased workload and the length of waiting lists. For example, autism spectrum assessments could take up to a year.
  • Staff did not record risk assessments consistently across the teams. Numerous young people did not have risk assessments.
  • Clinical records for children and young people did not always contain care plans.
  • Staff did not have access to facilities to allow them to do their jobs properly. There were not enough therapy rooms and there were not enough desks for staff to use, some staff in the South Gloucestershire service reported working on the floor due to a lack of desk space.
  • Policies and procedures had yet to fully embed within the teams, for example staff did not know about the Speak Up Guardian and few knew about the whistle blowing process.

However:

  • The culture in the teams had improved since the last inspection and there was now a clearer management structure. Staff were confident to approach managers without fear of discrimination and there was a positive and optimistic staff culture, despite all the pressures currently faced.
  • The Thinking Allowed and Be Safe programs were well constructed and operated well. They allowed very vulnerable groups of young people to access mental health, primary medical and other services.
  • Care plans and assessments that were in place, were of good quality and showed involvement and input from the young people and if appropriate, their families or carers.
  • Staff had caring and compassionate attitudes towards young people, and treated with dignity and respect.

4th Sept 2018 – 4th Oct 2018

During an inspection of Wards for people with a learning disability or autism

Our rating of this service went down. We rated it as inadequate because:

  • There were a high number of physical interventions used to manage the behaviour of patients at the Daisy Unit and the staff did not have a plan in place to reduce the use of physical interventions. Because of poor recording the unit could not provide the inspection team with accurate information about whether there had been an increase in physical interventions during the period that it had been open (less than two years).
  • The model of care was not clear. The trust believed that unit was implementing a positive behavioural support model. However, staff were not trained appropriately to use this model and mangers confirmed it was not being used. Staff were unable to explain how they used National Institute for Health and Care Excellence best practice guidance in delivering care to ensure a focus on enabling people to leave hospital and integrate back into the community.
  • There was little evidence of discharge planning undertaken and staff had not considered how patient activities would prepare them for potential discharge.
  • The unit did not use a recognised tool to measure patients’ progress. The patients did not have access to a range of professional to fully meet their needs. For example, there were no dedicated occupational therapists or speech and language therapists at the unit. A number of staff had not received specific training required to help them meet the needs of the patients.
  • Care plans did not explain what care should be provided to individual patients. Patients were not consistently involved in developing their care plan and staff did not record when a patient did not want to be involved. Staff did not regularly give care plans to patients or provide these or other information in an easy read format.
  • Staff at the unit used four separate patient records. Due to the number of records, staff found it difficult to find information quickly and could not be certain that they always had the most up to date information.

  • The assessment of and recording of patients’ capacity was inconsistent. Most capacity assessments contained a very limited amount of information and what was there did not make it clear how patients’ right were being protected. Patients did not get easy read menus and had to choose meals a week in advance.
  • The regular community meeting had been cancelled because staff believed that these caused patients to become agitated. These had not been replaced with an alternative means by which patients could contribute their thoughts or views on how the unit was run or what activities should take place each day.
  • The ward manager was not able to explain the unit’s governance processes. The local risk register did not list all of the risks at the unit and risks had not be escalated as needed. Audits had not been used to support improvements. Whilst staff did review every incident that occurred there was little evidence analysis of trends and learning from incidents. The unit nor the trust had any way of monitoring the quality of the service provided at the Daisy unit.

However:

  • The trust had designed the building to meet patients’ needs. Nurse and healthcare assistant staffing levels had been planned to allow them to respond to challenging behaviour and allow patients to access the community daily.
  • 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.
  • All assessments undertaken at admissions were person-centred and took place at a time that suited patients. Staff met the physical health needs of patients.

  • Staff felt the local management team was approachable and acted on their concerns.

4th Sept 2018 – 4th Oct 2018

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

Our rating of this service went down. We rated it as requires improvement because:

  • The trust had not acted to address some of the required improvements that we had told it that it must make in this services at two previous inspections to ensure that environmental risks to patients and seclusion practices were effectively managed.
  • During our inspections in May 2016 and June 2017 we told the trust it must ensure it maintained safe environments. On this inspection we found that staff on the wards across the trust were not managing ligature risks effectively. There were areas of wards that staff had identified as posing a high ligature risk but observation of these areas relied on casual observation as opposed regular observation that was recorded. The risk mitigation plan stated that doors to these areas should be locked, although on inspection we found that staff had left these doors open exposing patients to risk. Staff had not updated the environmental risk assessments to include new risks from potential ligature points.
  • During our inspections in May 2016 and June 2017, we found that male patients were being secluded on a female psychiatric intensive care unit (PICU). This caused distress for the female patients as male patients had to be brought through the ward plus it did not preserve the dignity of the male patients. We told the trust it must revisit this arrangement to ensure it met the safety, privacy and dignity needs of patients. On this inspection we found that male patients from Silver birch ward were still being secluded on the female PICU (Elizabeth Casson ward).
  • Staff were not recognising or recording seclusion in line with trust policy or the Mental Health Act (1983) Code of Practice. Staff on some wards only reported that seclusion was taking place if they had locked the seclusion room door. They were not recording episodes where they confined patients to an unlocked room from which they would have prevented the patient leaving had they attempted to do so.

  • There was a high level of prone restraint used across all the acute wards. Prone restraint had been used in 41% of all episodes of physical intervention.
  • The level of cleanliness on Beechlydene ward was of a poor standard. Patients reported that rooms were not being cleaned adequately. We found that rooms that we were told had been cleaned were still dirty.

However:

  • Staff were caring and compassionate. Staff communicated well with patients and introduced new initiatives such as the safe wards.
  • The physical health of patients was well cared for on all the wards. Patients were regularly assessed in weekly physical health checks.
  • There was good multi-disciplinary work among nurses and other professionals on all the wards. All staff, including healthcare support workers, peer support workers, advocates and social workers felt involved in patient care and were invited to the patient review meetings.
  • Care records on all the wards were comprehensive, holistic and personalised. Patients told us that that they were involved in their care and that staff listened to their wishes.
  • Staff were very passionate about ensuring that carers felt involved in their loved ones’ care and had introduced support groups and sessions for carers.
  • Staff felt that they had good opportunities for personal and professional development and that the trust encouraged career progression.
  • Most staff spoke highly of their managers and management teams, and felt supported and listened to. Supervision and appraisal was being carried out in most cases.

4th Sept 2018 – 4th Oct 2018

During an inspection of Mental health crisis services and health-based places of safety

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.

4th Sept 2018 – 4th Oct 2018

During an inspection of Child and adolescent mental health wards

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.

26-30 June 2017

During an inspection looking at part of the service

Following the inspection in June 2017, we have not changed the overall rating for the trust from requires improvement because:

  • During the comprehensive inspection of the trust in 2016 we told the trust it must make improvements in a number of areas. The two main areas of concern were the health based places of safety which we rated as inadequate, and wards for older people which was rated as requires improvement. Whilst we found on this inspection improvements had been made across all the areas we inspected, not all of the planned improvements had been made.
  • In May 2016 at the previous inspection we rated six out of 10 core services as requires improvement. At this inspection the number requiring improvement is now seven out of 13 core services.
  • Within the wards for older people core service, ward 4 at St Martins hospital in Bath still had dormitory style shared accommodation. The trust was continuing to work with commissioners to try and address the issues. However, this will require significant capital investment. Aspen ward at Callington Road hospital, had blind spots and there were no convex mirrors in place, which meant that staff could not fully observe patients. Laurel ward, at the same site, had been closed suddenly by the trust two weeks prior to this inspection and was the subject of an ongoing safeguarding inquiry by Bristol City council.
  • Within acute wards and psychiatric intensive care units, we found that the work to minimise ligature risks was ongoing. A ligature point is anything that could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. Although progressing, works to address all ligature risks across the service remained outstanding. Arrangements for the safe administration of rapid tranquilisation had improved, and work to address the privacy and dignity issues around the use of seclusion was ongoing. However, access to seclusion from Silverbirch ward at Callington Road hospital remained a concern. Although the trust was holding a consultation about the future use and provision of its seclusion arrangements, during the inspection. Alarm systems on Beechyldene and Ashdown unit were inadequate. The checking of medical equipment and emergency drugs was not always being done in line with organisational policy.
  • In the Devizes health based place of safety, staff had not identified some potential ligature points as part of the risk assessment, and there was a lack of clear plans in place to mitigate the risks. There were significant problems accessing beds for people requiring admission to hospital. We saw examples of patients waiting 32 to 50 hours after being assessed in the place of safety before admission to hospital. This also put pressure on the crisis teams who had to deal with patients requiring a high level of care in the community.
  • From 1 April 2016 the trust had taken on responsibility for children and adolescents mental health services (CAMHS) in the wider Bristol area. This included community teams and an inpatient unit (the Riverside unit). This service had lost its service managers during the transfer and many management tasks now fell to senior clinicians. In addition, there were shortfalls in staffing in young peoples’ community mental health team, which had led to increased waiting times. Staff morale was variable in the service and the lack of a consistent contract with NHS England was having a negative impact. We found the current level of risk on the Riverside unit to be manageable, given the current level of challenges staff face with the children currently admitted to the ward.

However:

  • The majority of the issues we previously identified with the environment at the places of safety had been addressed .There had been a reduction in the number of people exceeding the maximum 72 hours in the place of safety. This had occurred on two occasions in the previous year. This was in comparison to eight occasions in the year before our last inspection. The trust had introduced systems to alert managers to delays in the place of safety. There regularly remained significant delays in assessments commencing at the places of safety.
  • At the time of this inspection, the trust was going through a significant period of change. The trust had a relatively new senior leadership team, with a range of appointments made over the last 12 months. This included a new chair, medical director, finance director, operations director and two non-executive directors. A new appointment to the director of human resources role was due to commence in post shortly after the inspection.The trust chair was implementing a considerable change programme. This included a new focus on the governance and reporting arrangements for the board, in order to improve its overall effectiveness. The trust was implementing a new divisional structure aligned to the two Sustainability and Transformation Plan footprints which maintained oversight of the six locality and three specialist delivery units. The Trust has embarked on a significant cost improvement programme which had been caused by an overspend the previous year. The details of this cost reduction plan were still to be agreed by the trust board and commissioners; however the scale of the savings over the next 12 months will have a significant impact on the future operating model of the trust.
  • In May 2016, the trust did not ensure staff adhered to Mental Health Act (MHA) legislation and the standards described in the MHA code of practice. When we visited in June 2017, we found managers had made improvements, so staff worked appropriately within the legislation.

The full report of the inspection carried out in May 2016 can be found here http://www.cqc.org.uk/provider/RVN

20th June 2017

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long-stay rehabilitation services for adults of working age as good overall because:

  • Following our inspection in May 2016, we rated the services as good for effective, caring, responsive and well led. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.

  • During this most recent inspection, we found that the trust had addressed most of the issues at Windswept ward and some of the issues at Whittucks Road that had caused us to rate safe as requires improvement following the May 2016 inspection.

  • Windswept ward and Whittucks Road had installed frosted glass between male and female wards and staff had lifted the blanket restrictions at Whittucks Road.

However:

  • Patients at Whittucks Road still had to used a shared bathroom to have a bath and had to enter into or move through a ward for the opposite sex in order to access the lift.

20 June 2017

During an inspection of Wards for people with a learning disability or autism

We rated The Daisy as good because:

  • The Daisy was designed to meet the needs of the residents. Each resident had self-contained independent living areas with private outdoor space. There was a large amount of communal indoor and outdoor space.
  • The Daisy agreed staffing levels based on the individual needs of each resident and additional staff were always available.
  • A registered adult nurse led on physical health needs and liaised with the local GP. They also developed hospital passports and health action plans.
  • Residents and their families had been involved in developing the service. The residents could invite their family to visit and attend clinical appointments whenever they wanted.
  • Residents could decorate and furnish their pods to meet their own tastes, including the garden.
  • The service was involving residents in developing the mission statement based on their experiences of care.
  • The service had a local recruitment strategy that included developing service specific job descriptions and developing the role of the health care support worker with an apprenticeship programme.

However:

  • Ligature assessments had not identified all risks.
  • There were no facilities to allow children to visit the unit.
  • Staff had not provided care plans to residents and they were not in an accessible format.
  • There were no outcome measures used within The Daisy.
  • There was no occupational therapist at the service and activities lacked a therapeutic focus.
  • There was no local induction to the service.
  • Capacity was not assessed on a decision specific basis.

20-29 June 2017

During an inspection of Wards for older people with mental health problems

We re-rated wards for older people with mental health problems as good overall because:

  • Following our inspection in May 2016, we rated the services as good for caring but requires improvement for safe, effective, responsive and well-led. During the most recent inspection, we found that the service had addressed the majority of the issues and had made sufficient improvements.
  • The wards for older people with mental health problems were now meeting Regulations 10, 17 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • In May 2016 the trust did not have effective alarm systems for the use of patients and staff in all wards. When we visited in June 2017, we found this had been addressed and a replacement system due to be installed on one site.
  • In May 2016 the trust were not ensuring staff received the necessary training to respond to a physical emergency. When we visited in June 2017, the majority of staff had received this training and those who had not received it had a date booked within the next two weeks.
  • In May 2016, the trust did not transfer patients to seclusion using safe or dignified methods. When we visited in June 2017, the trust had implemented a new seclusion policy to ensure the safe and dignified transfer of patients.
  • During our May 2016 inspection, there was no psychology cover for Hodson and Liddington wards. When we visited in June 2017, the wards had recruited to this post.
  • In May 2016, the trust did not ensure staff adhered to Mental Health Act (MHA) legislation and the standards described in the MHA code of practice. When we visited in June 2017, we found managers had made improvements so staff worked appropriately within the legislation.
  • In May 2016, the trust was not ensuring privacy and dignity on all the wards. Windows that looked out onto public areas did not have privacy film. When we visited in June 2017, the trust had applied opaque style window film. Also in May 2016, most of the wards for patients with dementia were not dementia friendly (where the environment is changed to help patients with dementia cope with their surroundings). When we visited in June 2017, we saw the trust had made significant improvements to ward environments and this work was ongoing.
  • During the 2016 inspection, the wards did not have good governance systems around the application and monitoring of the MHA. When we visited in June 2017, we saw improvements in this area with staff monitoring paperwork and storage and dedicated MHA administration staff.
  • All wards had access to physical health equipment and staff assessed patients on admission. Staff completed initial risk assessments on admission and ensured emergency equipment was stored safely and checked regularly. Medicines management was good across all wards.
  • Care records overall contained some detailed admission information although on some wards documentation was more thorough than on others. Staff demonstrated good examples of providing holistic ongoing care on most wards. Staff made efforts to involve patients in care planning where possible.
  • Staff prescribed medicines in line with National Institute for Health and Care Excellence (NICE) guidelines. They followed best practice to avoid using antipsychotic medicine where possible.
  • All wards held multidisciplinary meetings to discuss complex patient needs, discharge planning, Care Programme Approach reviews and risk management. We observed some robust and good quality discussions between the wards and partner agencies.
  • We observed kind, discreet and respectful interactions by staff towards patients. Feedback from patients and carers was highly positive across the wards.
  • The trust monitored admissions and readmissions carefully. Managers escalated delayed discharges to senior trust staff that monitored inpatient capacity through the corporate risk register.
  • Ward managers were visible on the wards and had made improvements to their areas of responsibility since the 2016 inspection. Staff described them as approachable and hands-on and staff reported good morale on the majority of the wards.

However:

  • Although they had partially addressed the risk issues identified in May 2016 around ligatures, The service still did not fully meet regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014 in this and some other areas.
  • Staff did not always clearly document how they were managing initial or ongoing risks. There was not always a clear path from the initial risk assessment to the planning of care. Documentation of risk was disjointed and not well communicated in places, such as handover or the daily records, which meant risks could be overlooked.
  • Ward 4 in Bath had dormitory style shared accommodation. This increased risks to patients particularly at night. This was a dementia ward with some complex, confused and sometimes aggressive individuals and the staff could not guarantee optimum levels of safety as compared to individual bedrooms.
  • Aspen ward had blind spots that staff could not mitigate well particularly at night and had no convex mirrors in place to aid this. This area of the corridor had handrails that the trust had not adapted or boxed in to reduce risk. Patients were in the garden area unsupervised during our inspection when we were told they should be monitored.
  • The trust had addressed the issue of privacy and dignity on wards with bedroom windows looking out on public areas.
  • There were too many generic care plans that lacked individualisation across all the wards. Occupational therapy (OT) and psychology cover was sparse on Cove and Dune wards. Staff did not consistently use health of the nation outcome scales in order to effectively measure outcomes.
  • Dune ward was still awaiting improvements to the environment. The flooring was problematic for the patient group, as it was multi-tonal and shiny, potentially increasing visual perception problems and confusion in this client group. Ward clocks were too high for patients to see clearly.
  • Not all managers had completed root cause analysis (RCA) training in order to investigate incidents.

19 June 2017 – 29 June

During an inspection of Mental health crisis services and health-based places of safety

We rated mental health crisis services and health-based places of safety as inadequate because:

  • During this most recent inspection, we found that the service had taken steps towards addressing the issues that had caused us to rate it as inadequate following the May 2016 inspection and had more work planned. However, at this most recent inspection, we also identified some new issues of concern. We judged that the trust had taken sufficient action to lift the warning notice from the 2016 inspection and we have issued requirement notices regarding issues where the trust must improve, these are detailed at the end of the report.
  • The trust had addressed some ligature risks at the places of safety however in Devizes and Mason unit, we saw examples of ligature points that either did not appear to be mitigated or had not been identified by a local assessment. There were problems with damp in a kitchen at the Devizes place of safety and the effectiveness of the alarm system in Salisbury.
  • There were significant problems accessing beds for people requiring admission to hospital. Some patients waited 32 to 50 hours after being assessed in the place of safety before admission to hospital. This put pressure on the capacity in the places of safety and could be a factor in levels of restrictive interventions. This also put pressure on the crisis teams who had to deal with a high level of acuity of risk in the community. A patient under the care of community mental health services had waited five weeks for admission to hospital as an informal patient. We identified this information as a complaint was made but the trust did not monitor this.
  • There had been a reduction in the number of people exceeding the maximum 72 hours in the place of safety. This had occurred on two occasions in the previous year. This was in comparison to eight occasions at our last inspection. The trust had introduced systems to alert managers to delays in the place of safety. There regularly remained significant delays in assessments commencing at the places of safety. There were significant problems with the availability of section 12 approved doctors. There were times when the AMHP services were delayed in attending due to the need to attend when the doctor was available or due to problems with their own capacity to respond. Overall 61% of people waited more than 12 hours to be seen for assessment. This was an increase on the level of people waiting 12 hours or more than at our inspection in May 2016.
  • The trust was not routinely monitoring how often people were taken to the emergency department due to a lack of capacity at the place of safety. The impact and frequency of people being diverted long distances across the trust when the local place of safety was full and then being returned to their local place of safety in order to be assessed was not routinely being monitored.
  • There had been a significant increase in the level of prone restraint at the Mason unit, when compared to data provided by the trust at our inspection in 2016. The trust did not provide specific restraint, rapid tranquilisation or seclusion data for the Wiltshire and Swindon places of safety.
  • The level of suspected suicide and unexpected death for this core service had increased since our inspection last year.
  • Staff recorded assessments of physical health on all patient notes that we looked at in South Gloucestershire. In the remaining crisis teams, staff did not consistently record this information.
  • There were some gaps and deficiencies with the quality of crisis plans and care plans in the crisis teams and some examples of limited discharge summaries.

However:

  • We observed the staff in all of the teams to be caring, compassionate and kind.
  • The trust had put governance systems in place to monitor and address the complex issues affecting the use of the places of safety more effectively.
  • The trust had been involved in extensive inter-agency work to try and address some of the problems affecting the use of section 136. The trust had supported street triage and control-room triage initiatives.

27 & 28 June and 7th July 2017

During an inspection of Specialist community mental health services for children and young people

We rated specialist community mental health services for children and young

people as requires improvement because:

  • Teams did not currently have the right numbers of staff or skill mix to deliver a safe service to all who needed it. There were staffing issues at each of the teams, including high vacancy rates and difficulties in recruiting staff. As a consequence, there were high case loads and a number of staff experienced work related stress. There were plans in place to address the staffing shortfalls but these had not been progressed at the time of the inspection.
  • Care records were not sufficiently holistic or recovery focused. They contained limited evidence that staff responded to children and young people’s physical health care needs, and did not show that the views of children and young people were taken into account in planning care. Records contained limited evidence of specific outcomes, treatment goals or strengths. Similarly, the majority of the care records we viewed contained no evidence of the patient’s consent to treatment.
  • Care records were stored on different systems and in different formats which caused confusion, disruption and an increased workload for staff who had to search both systems to find information out about children and young people.
  • A large number of staff were not up to date with essential mandatory training and over a third of staff had not had a valid and up-to-date disclosure and barring check.
  • There were long waiting lists in each of the locality team which translated into corresponding delays and long waits from referral to assessment, and from assessment to treatment for a large number of children and young people. The trust was aware of the situation and had some plans in place to address the waiting lists.
  • The service had been through a prolonged period of uncertainty and considerable change. High caseloads, staff vacancies and disconnect from the senior management had impacted on staff morale. There had been a change of provider, and some staff were still unsure of which organisation they actually worked for and which organisation was responsible for them.
  • Although the service had transferred from North Bristol NHS Trust to Avon and Wiltshire Mental Health Partnership NHS Trust as part of a consortium, it had still not been completely formalised as to which organisation/s were responsible for overseeing the contract or for how long they would deliver that service.
  • Some staff we spoke to were unable to tell us about the organisation’s values and were uncertain as to its vision and the governance systems were not yet fully embedded.

However:

  • Staff were taking appropriate steps to monitor and respond to the risks to those children and young people on a waiting list. Teams were able to see and assess urgent and crisis referrals quickly and effort was being made to respond to less urgent referrals according to identified risks.
  • Risk assessments were in place in care records and were generally up to date. We found staff responded well to identified risks, such as changes in a child or young person’s personal circumstances which increased their risk level.
  • The community bases at which care and treatment were provided were safe and clean and supported comfort, dignity and confidentiality. Staff alarm systems were in use and staff followed clear lone working and personal safety protocols.
  • Despite key staff vacancies, there was effective multidisciplinary working and a good range of different professional disciplines provided input at each team. Teams provided a range of psychological therapies as recommended by the National Institute for Health and Care Excellence.
  • Young people and their carers told us they were treated with kindness, dignity and respect. Without exception, the staff we met were conscientious, professional and committed to doing the best they could for the children and young people in their care.
  • Young people and carers told us they were kept up to date and involved in assessments and decision making processes. They were given opportunity to provide feedback on the service they received and were able to be involved in decisions about the service, including helping to recruit staff.
  • Staff in different roles told us they felt valued and appreciated by their colleagues, and all staff spoke positively of their immediate peers and line managers. Most staff were positive about the potential for improvement under a new provider, one which had greater mental health focus and specialist experience.

To Be Confirmed

During an inspection of Child and adolescent mental health wards

We rated Riverside child and adolescent mental health ward as requires improvement because :

  • The environment was not suitable to safely accommodate more than young people who were a risk to themselves or those that needed a higher level of care.There were multiple ligature points throughout the ward. These were in public areas, bedrooms and in the extra care areas. There was no plan to remove or minimise the risks. Staff did not always take the action necessary to mitigate the risks posed by potential ligature anchor points. For example, on the day of inspection, the extra care bedroom, with multiple ligature risks, was left open all day. The ligature risk assessment stated the room must be locked to ensure the young people did not have unsupervised access.
  • The perimeter fence was also not secure with large gaps leading directly onto the car park.
  • There were no risk assessments about the locking of the external doors in relation to the new current group of young people. Staff members did not apply the locked door policy consistently.
  • At the last Mental Health Act (MHA) visit on 06 July 2017 staff used the extra care area to seclude young people but had not recognised it as seclusion. Whilst they had a new policy in place to ensure this would not happen again, the staff team remained unclear about what constituted seclusion under the Code of Practice and would benefit from additional training.
  • There was no social worker on the team so other staff had to undertake takes usually associated with a social worker, like finding placements for the young people, taking them away from their own duties and responsibilities.

However:

  • Care plans, risk assessments and crisis plans were comprehensive and helped staff to deliver safe care and treatment to young people.
  • The service delivered all the psychological therapies recommended by National Institute for Health and Care Excellence.
  • Young people and carers were positive about the staff team. We observed interactions between staff and young people and their families that were warm, good humoured, and professional. Young people we spoke with said the staff they worked with were respectful, supportive and caring.

19 June 2017 – 29 June 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

  • Following our inspection in May 2016, we rated the acute and PICU service as good for effective, caring and responsive. Since that inspection we have received no information that would cause us to re-inspect these areas or change the ratings.
  • Although we had rated well led as good during the May 2016, we revisited this domain to ensure that the management and leadership arrangements for the acute and PICU service remained good. We found this to be the case during our inspection.
  • During our inspection in May 2016, we rated safe as requires improvement. We had concerns relating to seclusion arrangements, rapid tranquilisation and ligature risks. During this inspection, we found that the work surrounding ligature risks was ongoing. Arrangements for the safe administration of rapid tranquilisation had improved. Work to address the privacy and dignity issues around the use of seclusion was ongoing. However, access to seclusion from Silverbirch remained a concern.
  • In addition, we found areas of concern relating to how the recording of patient observations was being done on Elizabeth Casson unit. Alarm systems on Beechyldene and Ashdown unit were inadequate. Staff were not aware of the risks related to neuroleptic malignant syndrome (NMS). The checking of medical equipment and emergency drugs was not always being done in line with organisational policy and although progressing, works to address all ligature risks across the service remained outstanding.

16 – 19 may 2016

During an inspection of Community mental health services with learning disabilities or autism

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.

16 - 27 May 2016

During an inspection of Wards for older people with mental health problems

We rated Wards for older people with mental health problems as requires improvement because:

  • There were not sufficient staff numbers to meet the needs of people using the services. There was a high level of qualified nurse vacancies on some wards with no psychology input.
  • Levels of emergency response training and practical patient handling training were low.

  • Staff did not consistently adhere to Mental Health Act legislation and standards described in the Mental Health Act (MHA) 1983 code of practice.
  • Staff completed mental capacity assessments but did not document decision specific assessments.

  • Staff were inconsistent when reporting of incidents.
  • Staff did not always follow agreed actions or involve patients in care plans.
  • Staff did not all use the health of the nation outcome scales for over 65s. They were not consistently monitoring patient’s outcomes.
  • Multidisciplinary team meetings did not all have a full range of professions.
  • The standard of the environments was variable. They were not all “dementia friendly”. Safety alarms were of variable quality or were not available. Some bedroom windows did not protect patient’s privacy and some patients slept in dormitories.

However:

  • There was a recruitment plan in place to address shortages of qualified nurse vacancies.

  • Staff met the mandatory training targets set by the trust in most subjects.
  • Medicines management was effective throughout the services. Where medicines were kept on site, they were stored, monitored and audited safely.

  • All patient files contained holistic, patient centred care plans.

  • All wards had access to physical health care for patients. Staff assessed physical health on admission and monitored it frequently.
  • Staff were very caring and demonstrated a high level of positive regard and respect to people accessing the services.

  • Staff confirmed that they felt comfortable raising concerns with managers and were able to use the trusts whistle blowing process.

23 – 27 May 2016

During an inspection of Specialist psychological therapy services

We rated specialist services as good because:

  • The specialist services of Avon and Wiltshire Mental Health NHS Trust provided care and support for adults at a range of locations across the trust catchment area. Specialty services included: New Horizons, mother and baby unit and SpecialistEating DisorderService (STEPS), both based at Southmead Hospital.
  • We found areas of good practice in both teams we inspected. In particular, we found that the inpatient eating disorder unit and the community teams were delivering specialist intervention work, and working together to ensure a smooth transition from referral through to aftercare in the community.
  • The specialist mother and baby unit, New Horizons, had identified, through learning, that there was a need for a community team to support them with referral, access, discharge and aftercare. They were in the process of setting up this service within Bristol.
  • Staff undertook research and accreditation programmes which resulted in service improvements. Learning also took place through incidents.
  • The staff teams were consultant psychiatrist led and came from a range of appropriate disciplines. Each environment was appropriate for the specialism and was suitably adapted. However, the time given by some of the multi-disciplinary team was limited. For example, at STEPS, all staff and patients we spoke with told us that they could use more time with a dietician. At New Horizons there was no psychologist, however, the team worked closely with individual patient’s psychologist in the community and continued to support the relationship while the patient was on the unit.
  • The activities on offer were varied and rehabilitative in approach. New Horizons had an occupational therapist who worked with every patient in a therapeutic way and used evidence based approaches. The building been purpose built as a mother and baby unit to meet the specific needs of the patient group and their babies.
  • Each unit offered a comfortable, homely, and non-clinical environment with a focus on stepping back in to the community and involved family members.
  • Staff appraisal, mandatory training and supervision rates were high. There was a commitment from the trust in continuing professional development, career progression, specialist training for their staff but it was limited due to budget.
  • Staff used evidence-based tools to assess, monitor, and manage individual patient needs and risks. Assessment and planning was thorough and considered the patient’s physical and mental health. Family, carers and other professionals were involved in the patients’ treatment.

Are services safe?

We rated safe as good because:

  • Both units were clean, homely and well maintained.
  • There were risks, for example, ligature risks; however, these were managed through risk assessment, and action planning. There had been no recorded incidents relating to ligatures on either unit.
  • There were two vacancies at the time of inspection and a recruitment process in place. All shifts were managed in advance, which allowed managers to ensure staffing levels were sufficient. There was an approval system in place and bank and agency staff were only used when necessary.
  • There was an out of hours system in place, which was accessible to patients.
  • Staff used de-escalation techniques to reduce the need for restraint.
  • Risk assessments were completed for every patient on admission then regularly reviewed.
  • Staff could identify what would constitute a safeguarding concern and knew how to alert the local authority or trust safeguarding team.
  • Pharmacists and technicians regularly visited the wards to audit patient records and identify errors in line with the trust medication policy.
  • Staff reported incidents. Managers ensured learning was shared following incidents.

Are services effective?

We rated effective as good because:

  • Patients had a comprehensive assessment on admission, which included mental and physical health. On-going assessment was evident.
  • Patient records were on a shared electronic record system that staff from other directorates could access at any time.
  • Care plans were personalised, holistic and recovery orientated.
  • Each ward was consultant led with junior and specialist doctors.
  • Both units had received Quality Network Accreditation.
  • Each unit carried out a number of audits, which involved clinical staff to help improve quality and make improvements when needed.
  • Services were involved in research projects to help improve services and provide an evidenced approach.
  • Mandatory and specialist training was supported and delivered to encourage professional growth for the benefit of patient recovery. There was scope for career progression.
  • All staff received mandatory management and clinical supervision and staff appraisals were completed within timescales.
  • Each ward had access to a multi-disciplinary team. A pharmacist attended wards weekly.

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  • Both units had good connections with the general hospital.
  • Staff knew, understood and observed the principles of the Mental Health Act and Mental Capacity Act.

Are services caring?

We rated caring as good because:

  • All patients and carers we spoke with told us that staff were caring, kind and compassionate.
  • Relatives and carers were welcomed and supported in continuing support to their loved ones while on the unit.
  • Patients and carers were given welcome packs on admission. Visits on to the ward took place before admission and all patients and their carers were orientated on to the ward.
  • Patients were offered treatment choices and they were fully involved in care decisions and given a copy of their care plan.
  • Patients were involved in community meetings and had the opportunity to give feedback on the service they received and make suggestions for improvements.
  • Patients who were discharged could give feedback and comment on their stay on the units.

Are services responsive to people’s needs?

We rated responsive as good because:

  • Patients were assessed for appropriateness for access and discharge. This was considered as a multi-disciplinary team and could involve commissioners. There was an introductory period before admission and a local orientation for patients upon admission.
  • Patients were prioritised within area and staff had relationships with other units to work together to find the right placement if an out of area was a consideration.
  • Following discharge, patients received aftercare and follow up by the community team.
  • Each unit had good links with local hospitals to support physical health needs of patients. They also had scope to increase staffing numbers if a patient required more intensive care.
  • STEPS had communal and gender specific rooms. This enabled patients to mix with each other, partake in different activities, or spend time in quiet areas.
  • Each unit had an activity room equipped with various activities such as crafts, games, jigsaws and activities of daily living kitchen.
  • Patients were encouraged to spend time with their relatives, including children and we saw this happen on each unit.
  • Patients were made aware of their rights on assessment, during their stay, and there was information on display on notice boards on each unit.
  • There were activities at the weekend. Patients used community meetings to decide on activities and groups. Patients on each unit were supported in having home leave at weekends to spend with their families.
  • There was a ‘you said, we did’ board and patients were encouraged to contribute to service developments at community meetings. There was scope to contribute outside the meetings, with anonymity, in the form of a comments box.

Are services well-led?

We rated well led as good because:

  • Staff on each unit demonstrated the trust’s values and were proud of the job they did.
  • There was an open culture of discussing issues arising within the units. Staff told us that they had respect for each other, that they worked well together and had the support of their managers.
  • The trust, managers, and staff were committed to regular supervision and there was performance management in operation. Staff were appraised and supervised regularly and reflection groups facilitated by psychology were available to help staff reflect, learn and develop.
  • Managers made use of part time staff who increased their hours to cover shifts to avoid using agency staff.
  • There were governance meetings every fortnight led by the modern matron.
  • There were care planning quality forums to improve quality; encourage patient led care plans, and discuss what makes care plans meaningful.
  • The units worked closely with the local services, including hospitals to share resources and good practice.
  • Working rotas were planned at least six weeks in advance but were not always as flexible as staff would have liked.
  • Staff had access to some specialism training but this was limited. Staff told us they would benefit from wider range of options to gain the skills needed to work with their speciality.

24 -27 May 2016

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long stay/rehabilitation mental health wards for working age adults as good

because:

  • Staff maintained the environment across all wards. We saw clinic rooms that were clean and arranged in a way that protected privacy. Information was freely available specific to independent living. For example, activity programs, educational opportunities and advocacy.
  • The wards were staffed by a full multi-disciplinary team. This was reflected in the care plans and the majority of staff received regular supervision, appraisals and training.
  • 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.
  • Medicines management was effective throughout the services. Where staff kept medicines on site, they were stored, monitored and audited safely. Three out of four wards had emergency drugs and resuscitation equipment present and documentation showed staff checked these regularly.
  • Each ward had up-to-date, robust ligature risk assessments (environmental features that could support a noose or other method of strangulation), and management plans. Each ward had up-to-date environmental checks and clinical audits, including learning from incidents and improving standards, and reliable systems and practices to keep people safe.

However:

  • The doors on Alder ward and Whittucks Road that separated male and female corridors did not have privacy glass. This meant male patients could clearly see into the female corridor.
  • Staff on Elmham Way could not tell us where the ligature cutters were. This meant there might be a delay in responding to an incident.
  • At Whittucks Road and Windswept, risk assessments did not link in with the appropriate care plan, and there was limited information about patient and carer involvement.
  • Whittucks Road had some blanket restrictions in place that were not appropriate. These included, a notice asking patients not to watch the television after midnight, staff asked patients not to leave the premises after 10pm and staff kept the main kitchen locked at all times.
  • Staff at Whittucks Road also managed the intensive service at night. This made staff feel vulnerable and meant that patient safety on Whittucks Road could be at risk because staff had to answer crisis calls when then should be working with patients on the ward.

23 - 27 May 2016

During an inspection of Forensic inpatient or secure wards

We rated forensic inpatient/secure wards as good because:

  • We noted significant improvements across both the medium and low secure units at this inspection. On entering the units, particularly Fromeside, there was a different atmosphere. Staff were visibly more relaxed and confident. We found issues we had raised previously had been comprehensively addressed and a considerable amount of quality improvement had taken place, with more planned.
  • There were safe systems of work in place with good environmental security and good individual patient risk assessments. The introduction of ‘Safer’ staffing levels had reduced the usage of agency staff and improved relational security by using staff who knew patients. All wards had a very low use of restraint and seclusion and the majority of staff and patients told us they felt safe.
  • Secure services management, ward staff and patients were working together to reduce blanket restrictions.
  • The multi-professional staff team provided a good standard of care. Doctors followed best practice in prescribing and had an excellent system for monitoring physical health in relation to anti-psychotic medication. Occupational therapists ran the shift with registered nurses on rehabilitation wards and this had been a positive innovation. The service had piloted collaborative risk assessments which had improved patient care. Psychological therapies were available and there was a comprehensive range of activities, therapies and life-skills work available at the Malago centre.
  • Patients were treated with dignity and respect and supported to be involved in the running and development of the service. The service was working towards developing greater friends and family input.
  • Patients could feedback through their community meetings and issues were taken to the service user steering group which was attended by senior managers. The log of the meetings showed that issues were taken seriously and actions developed and followed up. Patients had complained about food quality and a large piece of work had been undertaken to try to improve the quality of the food.
  • Senior management and the modern matron were visible to, and accessible to staff. Staff told us they felt listened to and could raise any concerns. Staff had a positive attitude to management. We found that there were measures in place to improve the leadership of new ward managers with coaching. The trust had put in place practice development nurses to provide additional development for nursing staff.
  • Governance within secure services was effective. We noted that where we found areas needing improvement, management had identified these and already had a plan in place.

However:

  • There were not enough qualified nursing staff on Siston ward and the service was finding it difficult to retain nurses on this ward.
  • Although changes had been made to the search policy, there was no system in place to monitor the consistency and effectiveness of the new policy across both units.

24-26 May 2016

During an inspection of Substance misuse services

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.

16 - 27 May 2016

During a routine inspection

We rated one of the core services inspected as ‘inadequate’ and one as ‘requires improvement’. We rated five of the core services ‘good’ overall. We rated the specialist services as ‘good’ overall

We rated the trust as requires improvement overall because;

  • We have served two warning notices in the past six months which imposed a legal duty on the trust to make significant improvements. We served one warning notice in December 2015 because we had significant concerns about the Bristol crisis, assessment and recovery services delivered to adults of working age and one during this inspection (May 2016) because of serious concerns about the quality of care in the health based places of safety across the trust. On both occasions we found that the trust did not have effective governance arrangements in place to enable it to assess, monitor and improve the quality of services (including the quality of the experience of service users in receiving those services). The trust had little knowledge of either of the issues until we raised these at the respective inspections and as such, we were not assured that governance arrangements and board oversight were robust enough to identify, address and learn from key risks in a timely manner.

We had serious concerns about the trusts ability to deliver safe, effective and responsive health based place of safety services. Patients were regularly taken to police cells (used as health based places of safety) because of the lack of availability of beds in the trust’s health based places of safety (police cells should only be used in exceptional circumstances). In addition, if the Mason unit at Bristol was full patients would be taken to the emergency departments at the local general hospitals. Emergency department staff raised concerns as this was felt to potentially put patients and staff at risk. Patients waited too long for a Mental Health Act assessment in the health based places of safety. Patients regularly waited over twelve hours for assessment and then waited many more hours for admission to a suitable ward if they needed inpatient care. In addition we had concerns about the safety of the environments of some of places of safety. at The new health based place of safety at Devizes had only been opened the week prior to our inspection despite us telling the trust that the old health based place of safety was not suitable for use during our inspection in 2014. It was not fit for purpose and did not have an appropriate emergency response system.There were on-going environmental issues with legionella at the Mason unit in Bristol as well as multiple known ligature points (environmental features that could support a noose or other method of strangulation).

  • All crisis and health based place of safety staff we spoke with told us of the lack of bed availability across the trust which caused significant delays in getting patients into a bed following admission and had a serious impact on the capacity of staff (for example, taking clinician’s a whole shift to find a bed) and on the care of patients.
  • The trust board was going through a period of significant change. The chief executive had only been in post three months during our inspection. The trust was recruiting to a number of director posts, including the medical director and finance director and was waiting for a new director of operations to commence in post. In addition, the chair was coming to the end of his term of office. Once the chair left post an interim chair would cover until a perminant appointment could be made. A number of non-executive director posts were also in the process of being appointed to. Alongside this, there had been a whole scale review of senior roles and strengthening of nursing leadership with the director of nursing and quality taking the lead for quality governance. This had caused significant instability, a lack of clear leadership and accountability for some initiatives and delivery of functions and some lack of engagement between senior leaders and staff. Staff reported that senior management based at trust headquarters were not as visible as they would like them to be.
  • The triumvirates (locality and speciality management arrangements), whilst generally working well locally, often worked independently of each other and staff felt that they sometimes worked in silos, resulting in a lack of sharing and learning across the trust.
  • We found that seclusion practices at Callington Road Hospital were not safe and that Silver Birch ward did not have adequate resources or facilities to care for people requiring seclusion. On some wards when seclusion was required patients were escorted, under restraint, out of the ward and across the hospital grounds to an available seclusion room. We felt that this placed patients in significant danger and did not preserve their dignity. The trust had advised that Silver Birch used secure transport to transfer patients to wards with seclusion facilities. However, the secure transport often took in excess of five hours to respond causing further delays in ensuring patients received the appropriate care at the right time.
  • Older people’s wards across the trust, with the exception of ward four at Bath, did not provide appropriate environments to care for people with dementia. Laurel, Amblescroft North and Dune wards had made minimal adjustments to ensure they were ‘dementia friendly’. Laurel and Amblescroft were bleak and sparse with little in the way of decoration and no dementia friendly signage. Staff had made some changes on Dune, with some tactile artwork, appropriate signage and brightly coloured furniture. In some older peoples wards staff did not always report all incidents that occurred as there was a culture of acceptance about aggression exhibited by elderly patients with mental health problems, including dementia.

In the rehabilitations wards the trust was not meeting guidance on same sex accomadation. For example, Whittucks Road only had bathrooms

in female areas, which meant staff had to supervise if male patients requested a bath.

  • In the acute wards and psychiatric intensive care units bed availability caused significant issues. Patients were regularly cared for in an ‘out of area’ bed, sometimes a long way from home. When patients went on leave there was often not a bed in the same ward that they left to come back to.
  • The trust faced major challenges with maintaining safe staffing levels. In some services, particularly in crisis services the trust had difficulty providing data outlining the staffing establishments and when it did provide this it provided different information prior to inspection, during inspection and directly from the teams. This made it difficult to understand the staffing arrangements of the teams but all the data reflected that there were significant numbers of vacancies in some teams. The trust had undertaken a review of staffing levels on inpatient wards and for most staffing levels increased. This had resulted in a number of vacancies but the trust was proactively recruiting to fill these. In community and crisis teams, the trust had commissioned a review of working practices and caseloads and as a result staffing numbers had been reduced in some teams, for example the Wiltshire crisis team. Staff were not happy about this and reported that they felt there were not always enough staff to safely meet the needs of the service. There were high vacancy, turnover and sickness rates in a number of services including, forensic, acute inpatient and psychiatric intensive care, older people’s wards and substance misuse services. All areas used bank and agency staff but all areas tried to use the same staff to ensure continuity of care. Ward managers and team leaders were able to adjust staffing levels when bank staff were required. If bank staff were not available, ward managers and team leaders had to seek authority to use agency from service managers.
  • In community based mental health services for older people targets for waiting times for memory service assessment were not always being met and in services for people with learning disabilities there was no information kept about waiting times.

However:

  • Generally, the trust were aware of areas that required improvement. When we raised issues that the senior team wasn’t as sighted on as they thought they were the response was immediate, really positive and they put in mechanisms to ensure they would be sighted in the future. Throughout the inspection the trust were very receptive to any comments that we made and took immediate action when we raised a concern. For example, the trust undertook an immediate review of seclusion practice at Callington Road Hospital, it put in a senior nurse to support staff and immediately changed transport arrangements so patients could be transported to seclusion facilities in around 10 minutes. It made changes to the health based place of safety environment at Devizes and ensured appropriate emergency equipment and an emergency response system was available.
  • We found that the trust had made some significant improvements to the safety and quality of services, staffing levels and governance arrangements across the Bristol community teams. During this inspection we were able to lift the warning notice that we had served during an unannounced, focussed inspection in December 2015. However, we identified that some further improvements were still required in the Bristol north team and asked the trust to provide written assurance by 13 June 2016 of action it would take to ensure the required improvements were made.
  • Without exception patients and carers spoke positively about the care they received and patients said they felt safe. Staff were caring, enthusiastic and committed to delivering high quality care and treating patients and carers with dignity and respect. We observed therapeutic, compassionate and relaxed relationships between staff and patients. Across the majority of services patients had good access to emotional support and there was clear evidence that staff considered patient’s diverse and cultural needs.
  • There were some impressive services with staff going the extra mile to deliver innovative service in challenging circumstances. For example, substance misuse services where there was a real evidence base to the service delivery with, creative, strong pathways, comprehensive assessments, positive working relationships with commissioners, good partnership working across services. In addition, forensic services had transformed service delivery since our last inspection with a good environment, good risk assessments, some excellent practice around the minimal use of restraint and seclusion. The triumvirate were working well together and had developed a positive culture which staff bought into.
  • It is our view that the provider had made significant progress in developing services and bringing about improvements since our last comprehensive inspection in 2014. The new chief executive and director of nursing and quality had brought a real focus on quality and a proactive style of leadership. The ‘can do’ attitude of the senior leaders was having a positive effect on changing culure and there was a real commitment to actively engage with staff, patients, the public and partner organisation. Given time, we believe, that with a continued focus on quality and the establishment of a stable trust board to lead and drive through changes the provider will realise its vision. However, some significant work is still required to improve quality and consistency of services and effectiveness of working practices across the trust.
  • We will be working with the trust to agree an action plan to assist them in making the improvements the standards of care and treatment.

23 - 27 May 2016

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We rated acute wards for adults of working age and psychiatric intensive care units good overall because:

  • Statutory and mandatory training was good. Staff were receiving regular supervision and appraisal rates were good. Staff morale and team spirit was high on most wards and staff meetings were occurring regularly.
  • Medication management was good. The storage and disposal of medicines was well managed and recording errors were addressed.
  • Overall, safeguarding procedures were being adhered to and incidents that should be reported were reported and there were lessons learnt from incidents.
  • Overall care plans were good, up to date and recovery orientated. Risk assessments were completed and aligned with plans of care. We found that physical health care monitoring was good and occurred routinely and regularly.
  • Handovers were structured, comprehensive and informative. Information that was shared amongst staff was risk based and comprehensive.
  • Overall, adherence to the Mental Health Act and Mental Capacity Act was good.
  • Patients were treated with kindness and respect with regular community meetings held on wards. In addition, wards held drop in sessions for family members. Patients told us that they felt safe and patient complaints were investigated. Patients had access to advocacy services who visited the wards regularly. There was a range of psychological, educational and recreational activities to meet patient’s needs.
  • Two electroconvulsive therapy (ECT) suites within the trust were well managed and organised with good governance arrangements in place

16th May 2016

During an inspection of Community-based mental health services for older people

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.

17 – 26 May 2016

During an inspection of Mental health crisis services and health-based places of safety

We rated mental health crisis services and health-based places of safety as inadequate because:

  • Within the health-based places of safety, the wait for a Mental Health Act assessment was too long. We found evidence that people regularly waited over twelve hours for assessment. People also waited for many hours while found suitable placements for people following an assessment. There were significant challenges in relation to the capacity of places of safety that the trust. We have served a warning notice that requires the trust to take significant action. This will need a multi-agency response. There were many reasons for lack of access to the places of safety, delays in beginning and completing assessments and finding suitable placements for people following an assessment.
  • Police regularly took people subject to section 136 to a police station because there was no available space at the places of safety. Police stations can be a place of safety, but should not be seen as an appropriate location for people experiencing a mental health crisis. The Mental Health Act Code of Practice 2015 (paragraph 16.38) states that a police station should be used as a place of safety only on an exceptional basis.
  • The trust did not have effective systems in place to monitor the health-based places of safety across the trust and to assess the impact of gaps in service provision. We were concerned that the trust was not able to identify incidents that occurred in the health-based places of safety in Wiltshire as these were recorded as part of the ward incident data. The trust could not provide data for incidents that had occurred within these places of safety. There had been no reviews undertaken into the use of restrictive interventions across any of the places of safety. We found significant problems with the availability and robustness of the data collected to monitor the operation of places of safety in Wiltshire and Swindon. This meant that the trust could not monitor quality and safety effectively. We found issues with the safety and suitability of some of the environments of the places of safety, including ligature points and lack of appropriate furnishing.
  • All the teams we met with told us that bed availability caused significant issues and that the delays had a serious impact on staff capacity (taking a clinician a whole shift to locate a bed) and on care for some patients. Staff told us about increased length of time waiting in places of safety, deterioration in mental health in the community and patients being transferred multiple times between hospitals or to locations great distances from their homes.
  • The trust intensive teams operated a gate-keeping function for inpatient beds, and all staff spoken with told us that lack of bed availability caused significant issues. We heard from staff that finding a bed took a substantial amount of time. All teams had bed management caseloads, detailing people who needed repatriation to a local bed, which could take up a significant amount of staff time.
  • Arrangements for night-time crisis calls varied between the localities. With the exception of Bristol, where there was a dedicated crisis line, calls to most of the intensive teams were taken by a call centre from 5pm until 8am weekdays and at weekends. The call centre was a messaging service and took basic information from the caller but was not staffed by trained mental health clinicians. Teams could not clarify how long it took them to return a call. The South Gloucestershire team operated an on-call system at night, with crisis calls being put through to a ward in the first instance.

However:

  • It was to the credit of the local team at the Mason unit that despite significant challenges in relation to managing the health-based place of safety, and a lack of clear planning and direction from the commissioners and trust, morale was good and the team were positive and proud of their work. The team felt valued and well supported by their team manager. The team had developed and maintained excellent working relationships with the police. The ward staff that supported the Wiltshire and Swindon places of safety also demonstrated good understanding of the processes and meeting people`s needs. The police were positive partners in working with the trust to meet more effectively the needs of people presenting in mental health crisis.
  • The trust intensive teams that formed a core part of the crisis service provision across the whole trust had clear clinical pathways to support effective assessment, management and treatment of clinical needs. The intensive teams and Bristol access and triage team worked effectively and collaboratively with other services to ensure continuity and safety of care across teams, including involvement of external agencies. The teams worked hard to meet the varied demands on the service despite challenges they faced at times with limited resources; for example, lack of in-patient beds.
  • We observed that staff in all of the intensive teams were caring, compassionate and kind. People we spoke with were positive about the care and support they received. Staff demonstrated that they knew the needs of the people on their caseloads, and discussions in handovers were patient focussed and respectful.
  • The intensive teams had systems and capacity to respond to referrals in a timely manner. The teams were confident that they all worked within the assessment targets agreed by the trust, and data collected by the trust reflected this. We found that there were variations between the localities we visited, in relation to receiving and responding to crisis calls and ‘out of hours’ contacts. However, from trust data only one person had complained about response times out of hours if they had called any of the teams. People we spoke with told us they could access the teams by telephone easily and got a timely response.
  • The intensive teams had meeting structures in place that supported effective local management oversight and development across the whole service; for example, the trust-wide crisis good practice network and locality multi-agency meetings with police, acute hospital and local authority colleagues, mental health liaison and in-patient services. However, crisis concordat meeting minutes from the past 12 months showed that concerns were consistently raised about the capacity of places of safety and the use of police cells and emergency department, with little evidence of a senior management plan to monitor and respond to these concerns.
  • We saw good examples of local leadership from the team managers, modern matrons and service managers of the intensive teams. Staff told us that they felt well supported by their team managers and were able to raise concerns and contribute to service development. The service managers and modern matron showed a good understanding of the current challenges for this service and staff.

17/05/16-26/05/16

During an inspection of Community-based mental health services for adults of working age

We rated community-based mental health services for adults of working age as good because:

  • We found very caring, compassionate and motivated staff, and, saw good, professional and respectful interactions between staff and patients during our inspection visit. Patients were extremely complimentary about staff and commented positively about how kind the staff were towards them. We found that staff promoted relationships with patients based on respect and showed empathy consistently. We saw evidence of initiatives implemented to involve patients in their care and treatment. Comprehensive assessments were completed in a timely manner. Most care records showed personalised care which was recovery oriented.
  • Following on from the concerns we raised at our December 2015 inspection visit, the Trust had reviewed the skill mix in the Bristol teams and increased the number of registered staff. Staffing levels were safe and recruitment was in progress to fill vacancies. Caseloads were managed and informed by a comprehensive case management tool and re-assessed regularly and were discussed in supervision. Waiting times from referral to assessment and through to start of treatment were now kept to an absolute minimum. The Trust set targets were being met, with very few exceptions.
  • Governance structures had been reviewed and systems put in place, since our inspection visit in December 2015, which meant that managers were now aware of how effectively their teams were performing. Where performance was below the standard expected, managers were alerted in a timely way so that they could plan and take act to correct any poor performance.

However:

  • Across all 11 teams, there was no system in place for monitoring uncollected medication from the community team bases, and at the Swindon team base, there was no effective system for monitoring repeat prescriptions.
  • Brookland Hall and the Greenway Centre still required full implementation of the premises improvement plans, developed following our concerns raised in December 2015. There were also ongoing concerns about the size and complexities of the recovery navigator caseloads in North Bristol.

08 and 09 December 2015

During an inspection of Community-based mental health services for adults of working age

On 8 and 9 December 2015 we inspected the crisis, assessment and recovery services that the trust delivered to adults of working age in response to a number of concerns.

The local commissioning group and local safeguarding adults team told us they were also concerned about the poor performance of services and that patients may be at risk.

Assessments were not always carried out in a timely way, there were over 500 patients waiting for assessment at the time of our inspection. A small number of these patients had been waiting several months. Some patients did not have risk assessments or risk assessments were not linked to patients' care plans. We found that patients' care needs were not always met in a timely way, that some patients did not have care plans whilst others had plans of poor quality. In some cases care plans were out of date.

There were not enough qualified nursing staff to provide care for complex patients, the current model underestimated number of qualified staff needed. Qualified staff needed to devote large amounts of time to supporting recovery navigators (support workers not qualified in mental health nursing) in addition to carrying a caseload which was larger than that planned in the new model.

Recovery Navigators were supporting complex people. Recovery navigators often had no experience of working within the NHS and didn’t understand how to work with such complex patients. There was a 30% turnover of recovery navigators which meant some people had not had a consistent worker. The majority of recovery navigators were new in post.

There were inadequate governance systems in place. Not all the assessment and recovery teams had a system in place to ensure all referrals were tracked and there was no effective system in place to identify, track and follow up safeguarding concerns. The trust were aware of the difficulties within the service. No effective measures had been put in place to address the issues. The lack of a service manager for the assessment and recovery teams meant there was nobody with overall responsibility for the systems and processes within these teams. Senior managers were aware of the problems but there was no effective strategy in place to tackle them.

Systems in place to audit electronic care records had not identified the poor quality of these records.

We returned to the trust on 17 February 2016 to check that the actions specified in the section 29a warning notice had been completed. We only checked the trust had completed the specific actions required by 1 February 2016.

We found that there was now an effective system in place to monitor referrals. The provider had established a tracking tool and escalation process to monitor the waiting lists and times for referral to assessment and referral to treatment. Individual teams now had information about all patients on the waiting list, how long they had been waiting, and reasons for any wait over four weeks. Staff updated the tracking system daily.

The trust had provided extra staff resources to address the waiting lists and manage the service. The trust had reached agreement with the Clinical Commissioning Group (CCG) to undertake a skill mix review to ensure there were enough qualified staff to assess and care manage patients.

The service had revised its governance structure within Bristol to focus on gaining detailed assurance that all teams were delivering safe and effective care in a timely manner. The trust had introduced new governance groups across Bristol.

The service had established a safeguarding tracking system and was in the process of rolling out additional training to all staff over the next two months.

10-13 June 2014, 11 december 2015 and 17-18 December 2015

During an inspection of Forensic inpatient or secure wards

The forensic and secure services are based in Blackberry Hill Hospital. They are purpose built facilities and provide inpatient mental health services for adults aged between 18 and 65.

At our inspection of 10 -13 June 2014 we found staff shortages on wards were widespread and were covered by taking staff from other wards. We were told bank staff did not want to work at Fromeside. Staff felt unsupported and concerned about the lack of experienced senior nurses on the wards. Senior managers, when asked, did not demonstrate a clear plan of how to support staff until a service redesign was implemented.

We found that this service did not focus enough on safety. Staff on the wards were not told about learning from serious incidents, and in general staff did not receive feedback about incidents they had reported. We found potential ligature points throughout the medium and low secure units and, despite these having been reported, these risks to people’s safety had not been removed.

The provider had not checked that all medicines were stored at the correct temperature.

On Bradley Brook ward a compliance action had not been met regarding a corridor carpet that smelt of urine. There was no system in place to check this had been addressed.

While there were systems in place to record and report incidents and to assess risk, learning from incidents was not always implemented well at ward level. We found a number of risks to the service and the people who used it, such as ligature points, low staffing numbers, and a lack of experienced staff.

We found a lack of governance at ward level, which meant that the provider could not continually check the quality of services.

The care delivered by frontline staff was good. We saw that staff were caring, respectful and polite and patients confirmed this.

At our inspection of 17 and 18 December 2014 we found that the trust had made significant improvements. Although there continued to be staff shortages, particularly in respect of qualified nurses, the trust had taken steps to mitigate this. One ward had been closed and processes had been put in place to enable easier access to agency staff. Whilst staff still had to move to cover skill mix shortages this was having less impact on wards.

Ligature risks across the medium and low secure units had been identified, and where possible removed, with some work still in progress. There was an effective audit system in place to manage and mitigate other ligature risks.

Where needed carpets had been replaced.

10-13 June 2014, 11 December 2015 and 17-18 December 2015

During an inspection of Acute admission wards

The acute admission wards are based in seven hospitals sites across Bristol, Weston Super Mare, Bath, Swindon, Devizes and Salisbury. All provide inpatient mental health services for adults.

Overall, we found that adult acute services required improvement and we are concerned about the safety of the care that patients receive within some acute adult wards at this trust.

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

Overall, we saw good multidisciplinary working and found staff who were compassionate and caring. However a number of units had significant staff shortages and environmental challenges which may have impacted on patients’ care and safety.

People we spoke with were mainly positive about the staff and felt they made a positive impact on their experience on the ward. However, some people were concerned at the lack of time staff had to spend with them.

The availability of beds appeared to be a trust-wide issue, with acute care beds always in demand. This meant that occasionally people may have been discharged early or managed within an inappropriate service. People were not always being treated within their local area and sometimes had been moved during their care, which would have an impact on their recovery.

We found that both staff and patients knew how to make a complaint and many were positive regarding the response they received.

The trust’s board and senior management had a clear vision with strategic objectives, though staff knowledge of this varied. Staff generally felt supported by the managers at ward level, however leadership from above ward level was not visible to all staff.

There is a trust-wide governance and information system called IQ and governance processes are in place; however these had not always led to positive changes in practice.

We returned to inspect Hillview Lodge on 17 December 2014 and found the required improvements had been made.

10-13 June 2014, 11 December 2015 and 17-18 December 2015

During an inspection looking at part of the service

We found that there are some areas of improvement needed to ensure the delivery of a safe, effective and responsive service.

While the board and senior management had a clear vision with strategic objectives, and a clearer management structure had been put in place, staff did not feel fully engaged in the improvement agenda of the trust.

The trust told us that executives and board members had been involved in a number of initiatives to engage with staff and give staff the opportunity to talk directly about issues that affect them. However, staff told us that leadership from above ward level was not visible or accessible to all staff.

We found that while performance improvement tools and governance structures had been put in place, these had not always facilitated effective learning or brought about improvement to practices.

We found that both staff and patients knew how to make a complaint and most were positive about the response they received. There had been a number of positive initiatives to engage service users, carers, and wider stakeholders in the development of the trust. However throughout this inspection we heard from service users, carers and local user groups who felt that they had not been effectively engaged by the trust in planning and improvement processes.

We had a number of concerns about the safety of this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patient’s needs; inadequate arrangements for medication management; and safety and fire equipment that was not fit for purpose. 

We were also concerned that while the trust had systems in place to report incidents, improvement was needed to ensure that all incidents were reported, investigated and learnt from, and that changes to practice were made as a result. We found a number of concerning incidents across the trust that had not resulted in learning or action.

Some staff had not received their mandatory training and many staff had not received regular supervision and appraisal. However overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.

Most teams were using evidence based models of treatment and made reference to National Institute for Health and Care Excellence (NICE) or other relevant national guidelines. However, we found incidents of restraint and seclusion that had not been safeguarded in line with the guidance of the Mental Health Act Code of Practice.

A lack of availability of beds was a trust-wide issue, with intensive, acute and older people’s beds always in demand. This meant that people did not always receive the right care at the right time and sometimes people may have been moved, discharged early or managed within an inappropriate service.

We found that generally there was evidence of different groups working together effectively to ensure that patients’ needs continued to be met when they moved between services. Overall, we saw that staff were kind, caring and responsive to people and were skilled in the delivery of care. We observed some very positive examples of staff providing emotional support to people, despite the challenges of staffing levels and some poor ward environments.

It is our view that the trust needs to take significant steps to improve the quality of their services and we find that they are currently in breach of regulations. 

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they had taken to address our concerns.

We gave the trust some Enforcement Actions which gives a strict timescale for them to improve. We will be working with them to agree an action plan to assist them in improving the standards of care and treatment.

We returned to the trust on 11 December, where we interviewed senior manager and members of the board. We also carried out unannounced focussed inspections on the 17 and 18 December 2014. We carried out focussed inspections at Hillview Lodge, Fromeside, Juniper Ward, Elizabeth Casson, Range Ward at Callington Road, crisis team Swindon, community team South Gloucester and North Somerset. The inspections focussed on the trust's compliance with he requirements of the enforcement actions, the four warning notices. 

The trust had taken all reasonably practicable steps to comply with the warning notices within the timeframe provided. The Enforcement Actions, namely the four warning notices have been removed. These focussed inspection did not review the existing compliance actions, these remain in place. Please see the safe domain of the report for further details of our findings.

10-13 June 2014

During an inspection of esb.services_rated.na

The specialist services of Avon and Wiltshire Mental Health NHS Trust provide care and support for adults at a range of locations across the trust catchment area. Services include: New Horizons mother and baby unit; STEPS eating disorder unit; a drug and alcohol detoxification unit and  community services for the deaf, and those with ADHD and autistic spectrum disorders.

We found areas of good practice and many positive interventions in all the teams we inspected. In particular, we found that the inpatient eating disorder unit and the community teams were delivering very good specialist intervention work.

10-13 June 2014

During an inspection of Mental health crisis services and health-based places of safety

Avon and Wiltshire Mental Health Partnership NHS Trust has seven intensive support teams, which provide rapid assessments and treatment to people aged 18 or over, who are experiencing an acute breakdown in their mental health. The service was available 24 hours a day, 365 days of the year.

The services provided by the intensive teams required some improvement. We saw that staff shared information well at a local level and that learning from incidents was shared at both trust and local level. However, some staff told us that learning was not always shared effectively. Also, there were not always appropriate arrangements in place for managing and disposing medicines.

Overall, the intensive teams had enough staff, with the right mix of skills to provide effective services. However, two teams, South Gloucestershire and BaNES, told us that there were staffing vacancies that sometimes had an impact on the team’s capacity. Improvements should be made to the out-of-hours medical cover in the North Somerset and Bristol intensive support teams, to make sure that it is adequate to meet people’s needs.

Most of the people who used the service received effective care and treatment by competent staff. We also saw that staff received regular clinical and management supervision, but some staff were concerned that the opportunities for training and professional development had decreased. There was also little on offer in addition to core mandatory training.

There were some good examples of people being involved in decisions about their care and contributing to their care plans. However, we also found occasions where staff found this hard to achieve or where this was not happening consistently. Most people were treated with dignity and respect, although some people told us that the received inconsistent and uncaring responses.

People could not always speak to someone when they needed to. Calls to six of the intensive support teams were taken by a call centre outside of office hours and messages passed on to the appropriate team. A large number of service users, carers and staff were concerned that people could not speak with someone quickly enough in a crisis. The teams did not have any clear guidance to tell them how quickly to respond to messages they received. In addition, this system was not monitored and evaluated for effectiveness.

We saw good examples of local leadership in all of the services we visited. The staff we spoke with felt well supported by their immediate line manager and were aware of the senior leaders in their local areas. There were mixed views from staff, working in different locations, about how effective they felt communication from board was.

10-12 June 2014

During an inspection of Adult community-based services

Avon and Wiltshire Mental Health Partnership NHS Trust provides community-based mental health care, treatment and support to people, their friend’s families and carers. It offers people a range of treatments (psychological and medication, support and advice.

Although, we found that services generally managed risks well, we found that two of the teams did not monitor or store medicines, or dispose of unwanted medicines, in a safe manner.

We concluded that people received effective care and treatment by hard working, caring and competent staff who received regular clinical supervision. Most patients that we talked to told us that staff treated them with dignity and respect and whenever possible, staff supported people who used services to manage their own health and care needs to maintain their independence.

The care plans that we reviewed suggested that care was planned and delivered in a way that took into account the wishes of the person. However, some of the care plans reviewed lacked detail and there was no evidence that people’s rights were explained to them under their ‘community treatment order’ (CTO). There was also limited evidence that, where needed, people’s care plans were linked to their community treatment orders. We brought this to the attention of senior staff during the inspection.

The work of the community mental health teams was affected by the unavailability of admission beds.  This meant that some people were being accommodated in hospital beds that were a long distance away from their home. It also meant that there were, on occasion, delays in accessing a bed. Throughout the services we visited, however, we did find good working arrangements with primary care and third sector providers.

We saw good examples of local leadership in all of the services we visited. Most staff were aware of the trust’s vision, values and strategies, and of its local management structure. However, other staff felt undervalued by the trust. There was an ‘Information Quality’ (IQ) system in place, which enabled senior managers to regularly review the service’s quality and records management, with findings disseminated to the teams. We saw that this was being effectively used by senior managers.

10-13 June 2014

During an inspection of Services for older people

Avon and Wiltshire Mental Health Partnership NHS Trust’s older people’s services provide support for people aged 65 and over with mental health needs or functional mental illnesses (such as depression). The service also provides both community and inpatient support for people of any age with a diagnosis of dementia. We also inspected the Bristol and South Gloucestershire later life liaison team.

Overall, we found that older people’s community services were generally effective however older people’s inpatient services required improvement. We were particularly concerned about how safe the care was for patients in some of the inpatient wards.

Staff understood their responsibilities about safeguarding, but we found that incidents at the inpatient units had not always been recognised, reported, investigated or learnt from. Although risks were usually assessed, it did not always lead to changes in practice.

There were ligature and environmental risks on some of the wards that had not been addressed. In addition, some wards were described as cold and institutional. There were also issues about mixed sex accommodation and protecting people’s dignity.

Multidisciplinary staff worked well together and we found staff were compassionate and caring. However, on a number of units there were not enough staff, and there were issues with the environment, which may have had an impact on patient care and safety.

On the whole, people we spoke with were positive about the staff and felt they made a positive impact on their experience on the ward. However, some people were concerned that staff did not have enough time to spend with them.

The availability of beds appeared to be a trust-wide issue, with beds for older people always in demand. People were not always treated in their local area and were sometimes moved during their care, which had an impact on their recovery.

Staff knowledge about the trust’s vision and values varied across services. In general, staff felt supported by their managers at a local level, but not all staff felt supported by senior trust management.

There are governance processes in place, as well as a trust-wide governance and information system called IQ, but this had not always led to positive changes in practice.

10-13 June 2014

During an inspection of Forensic inpatient or secure wards

The forensic and secure services are based in Blackberry Hill Hospital. They are purpose built facilities and provide inpatient mental health services for adults aged between 18 and 65.

Staff shortages on wards were widespread and were covered by taking staff from other wards. We were told bank staff did not want to work at Fromeside. Staff felt unsupported and concerned about the lack of experienced senior nurses on the wards. Senior managers, when asked, did not demonstrate a clear plan of how to support staff until a service redesign was implemented.

We found that this service did not focus enough on safety. Staff on the wards were not told about learning from serious incidents, and in general staff did not receive feedback about incidents they had reported. We found potential ligature points throughout the medium and low secure units and, despite these having been reported, these risks to people’s safety had not been removed.

The provider had not checked that all medicines were stored at the correct temperature.

On Bradley Brook ward a compliance action had not been met regarding a corridor carpet that smelt of urine. There was no system in place to check this had been addressed.

While there were systems in place to record and report incidents and to assess risk, learning from incidents was not always implemented well at ward level. We found a number of risks to the service and the people who used it, such as ligature points, low staffing numbers, and a lack of experienced staff.

We found a lack of governance at ward level, which meant that the provider could not continually check the quality of services.

The care delivered by frontline staff was good. We saw that staff were caring, respectful and polite and patients confirmed this.

10-13 June 2014

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

The psychiatric intensive care units (PICUs) are based in two hospital sites, one in Bristol and one in Salisbury. All provide inpatient mental health services for adults.

We were concerned to see potential ligature points and had concerns about the monitoring of temperatures in rooms where medicines were stored and medicines refrigerators.

Staff we spoke with were passionate about providing high quality care in a challenging environment. However, we were concerned that staffing levels were not sufficient on Elizabeth Casson House or Ashdown, particularly at night, to provide safe and therapeutic care for patients.

Overall, arrangements for reporting incidents and allegations of, or actual abuse, were in place, but were not completely effective in all units. Some learning had taken place from incidents.

People’s needs, including their physical health needs, were assessed and care and treatment was planned to meet them. Overall we saw good multi-disciplinary working.

People’s knowledge and involvement in their care plans varied across the sites as did the range of activities available. Staff had mostly received their mandatory training but had been unable to access more specialist training. Overall, most staff had received regular supervision but there were some gaps.

Systems were in place to ensure compliance with the Mental Health Act (MHA). However Mental Health Act assessments following a section 136 were often delayed out of hours and we noted that two different section 136 protocols were being used in the different places of safety. We also found occasions where seclusion was not recognised and managed within the safeguards set out in the Mental Health Act Code of Practice.

Staff appeared kind and compassionate. We observed them treating patients with respect and communicating effectively with them. People were positive about staff, although some were concerned at the lack of time staff had to spend with them. Patients’ cultural needs were generally being met.

The lack of available beds meant that some patients were waiting too long to be transferred between services, and others were being transferred from PICUs to acute beds too early. We also saw some significant delays in people moving on to the appropriate service once their assessment had been completed.

Staff members’ knowledge of the vision and values of the trust varied, and they told us they did not feel they had had any input into them. Staff generally felt supported by the managers at ward level but felt isolated within the trust and did not feel that their views were encouraged. Staff, including some consultant psychiatrists, did not feel their concerns had been listened to or that appropriate action had been taken. Several meetings were held by the trust focusing on current provision and identifying concerns, but little if any action was taken to address some concerns.

10-13 June 2014

During an inspection of Acute admission wards

The acute admission wards are based in seven hospitals sites across Bristol, Weston Super Mare, Bath, Swindon, Devizes and Salisbury. All provide inpatient mental health services for adults.

Overall, we found that adult acute services required improvement and we are concerned about the safety of the care that patients receive within some acute adult wards at this trust.

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

Overall, we saw good multidisciplinary working and found staff who were compassionate and caring. However a number of units had significant staff shortages and environmental challenges which may have impacted on patients’ care and safety.

People we spoke with were mainly positive about the staff and felt they made a positive impact on their experience on the ward. However, some people were concerned at the lack of time staff had to spend with them.

The availability of beds appeared to be a trust-wide issue, with acute care beds always in demand. This meant that occasionally people may have been discharged early or managed within an inappropriate service. People were not always being treated within their local area and sometimes had been moved during their care, which would have an impact on their recovery.

We found that both staff and patients knew how to make a complaint and many were positive regarding the response they received.

The trust’s board and senior management had a clear vision with strategic objectives, though staff knowledge of this varied. Staff generally felt supported by the managers at ward level, however leadership from above ward level was not visible to all staff.

There is a trust-wide governance and information system called IQ and governance processes are in place; however these had not always led to positive changes in practice.

10-13 June 2014

During a routine inspection

We found that there are some areas of improvement needed to ensure the delivery of a safe, effective and responsive service.

While the board and senior management had a clear vision with strategic objectives, and a clearer management structure had been put in place, staff did not feel fully engaged in the improvement agenda of the trust.

The trust told us that executives and board members had been involved in a number of initiatives to engage with staff and give staff the opportunity to talk directly about issues that affect them. However, staff told us that leadership from above ward level was not visible or accessible to all staff.

We found that while performance improvement tools and governance structures had been put in place, these had not always facilitated effective learning or brought about improvement to practices.

We found that both staff and patients knew how to make a complaint and most were positive about the response they received. There had been a number of positive initiatives to engage service users, carers, and wider stakeholders in the development of the trust. However throughout this inspection we heard from service users, carers and local user groups who felt that they had not been effectively engaged by the trust in planning and improvement processes.

We had a number of concerns about the safety of this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patient’s needs; inadequate arrangements for medication management; and safety and fire equipment that was not fit for purpose. 

We were also concerned that while the trust had systems in place to report incidents, improvement was needed to ensure that all incidents were reported, investigated and learnt from, and that changes to practice were made as a result. We found a number of concerning incidents across the trust that had not resulted in learning or action.

Some staff had not received their mandatory training and many staff had not received regular supervision and appraisal. However overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.

Most teams were using evidence based models of treatment and made reference to National Institute for Health and Care Excellence (NICE) or other relevant national guidelines. However, we found incidents of restraint and seclusion that had not been safeguarded in line with the guidance of the Mental Health Act Code of Practice.

A lack of availability of beds was a trust-wide issue, with intensive, acute and older people’s beds always in demand. This meant that people did not always receive the right care at the right time and sometimes people may have been moved, discharged early or managed within an inappropriate service.

We found that generally there was evidence of different groups working together effectively to ensure that patients’ needs continued to be met when they moved between services. Overall, we saw that staff were kind, caring and responsive to people and were skilled in the delivery of care. We observed some very positive examples of staff providing emotional support to people, despite the challenges of staffing levels and some poor ward environments.

It is our view that the trust needs to take significant steps to improve the quality of their services and we find that they are currently in breach of regulations. 

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they had taken to address our concerns.

We have given the trust some Enforcement Actions which gives a strict timescale for them to improve. We will be working with them to agree an action plan to assist them in improving the standards of care and treatment.

14 June 2014

During an inspection of Rehabilitation services

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.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.