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CQC acts to protect the safety and welfare of people onthe Lansdowne Unit at Blackberry Hill Hospital, Bristol

24 October 2012
Blackberry Hill Hospital
Avon and Wiltshire Mental Health Partnership NHS Trust
  • Media,
  • Hospitals

24 October 2012

The Care Quality Commission has warned Avon and Wiltshire Mental Health NHS Partnership Trust that it is facing enforcement action unless it makes immediate improvements at Blackberry Hill Hospital in Bristol.

CQC has issued two formal warning notices to the trust following an unannounced inspection of the Lansdowne Assessment and Treatment Unit in September. The unit is a 12-bedded unit for adults with learning difficulties who are experiencing mental health problems. Some patients are detained under the Mental Health Act.

Inspectors found that the trust was in breach of national regulations covering the care and welfare of patients, and the safety and suitability of the premises.

The unit was also failing to meet four other standards including respecting and involving people using the service, safeguarding arrangements, staffing, and the monitoring of the quality of service provided. By law, providers of care services must ensure that they are meeting all standards.

CQC has told the trust that it must make improvements required by the warning notices by this week, and that it must provide a report within seven days setting out how it will comply with the other standards.  

Avon and Wiltshire Mental Health NHS Partnership Trust has decided to close the unit temporarily. The trust had already stopped all new admissions, while Bristol City Council and NHS Bristol have been reviewing the care of the nine patients who were at the unit. CQC has continued to monitor the service to ensure that the people being treated there were protected.

A report which is published on the CQC website today gives full details of the inspectors’ findings. The two warning notices were issues in relation to the following two standards:

Care and welfare of people who use services

The trust had failed to ensure that patients experienced care, treatment and support that met their needs and protected their rights. Individual care plans were incomplete and there were few activities for patients.  On the day of the inspection, the activities programme was listed as breakfast and board games in the morning, and relaxation in the afternoon.

Inspectors were concerned that there was nowhere on the ward that could be used when patients became distressed or agitated because the intensive care suite had been permanently occupied for several months by one person.

Safety, availability and suitability of premises

The premises were not fit for purpose. Layout was cramped, furnishings inadequate and the building was in a poor decorative order. Communal areas for socialising, and undertaking activities were limited. Inspectors found the environment to be cold and hostile, with poor acoustics causing distress for patients and visitors.

Ian Biggs, deputy director of CQC in the South said:

“It is quite clear that there are fundamental problems with the cramped layout of the Lansdowne Unit affecting the basic standards of care and inevitably restricting people’s activities.

“We have previously raised concerns about the building, which we said was not well furnished or properly equipped to ensure people's wellbeing and safety, let alone promote their independence and comfort.

“People’s families told us they felt safe, and the staff were patient and understanding, but it is disappointing that issues which we highlighted when we inspected a year ago had still not been resolved. The trust had acknowledged that the size and layout of the building were unsuitable for the care of people with complex and challenging mental health needs, when they needed a calm therapeutic atmosphere.

“Avon and Wiltshire Mental Health NHS Partnership Trust has assured us they will now carry out substantial maintenance work on the building. In the longer term, they will set out to determine the most effective ways of meeting the mental health needs of people with learning disabilities.

“We will continue to monitor the trust’s progress and when the Lansdowne Unit reopens, we will return to satisfy ourselves that the improvements we required have been made. If not we will consider further action to support the people who depend on this service.”


For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

The warning notices find that Avon and Wiltshire Mental Health NHS Partnership Trust is in breach of:

  • Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 - Care and welfare of service users.
  • Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 - Safety and suitability of the premises.

If the required improvements are not made within a set timescale, CQC has a range of enforcement powers which include restricting the services that a provider can offer, or, in the most serious cases, suspending or cancelling a service. CQC can also issue financial penalty notices and cautions or prosecute the provider for failing to meet essential standards. Any regulatory decision that CQC takes is open to challenge by a registered person through a variety of internal and external appeal processes.