The Care Quality Commission
  • Mental Health
  • Independent mental health service

Avesbury House

Overall: Requires improvement read more about inspection ratings

85 Tanners End Lane, London, N18 1PQ (020) 8803 7316

Provided and run by:
Partnerships in Care 1 Limited

Important: The provider of this service changed. See old profile

All Inspections

During an assessment of Forensic inpatient or secure wards

Avesbury House is provided by Partnerships in Care 1 Limited under the Priory group. The service provides a 24-hour low secure service to male patients with severe and enduring mental health needs, often with a forensic history. The service has 24 beds across five units including bedrooms, ensuite/communal bathrooms, communal areas and kitchen facilities. The service was last inspected in December 2021 and received an overall rating of Good. The service provides a step down for patients coming from a medium and high secure unit at a local forensic hospital. NHS England contracts the beds at Avesbury House and commissioned the North London Forensic Service at North London NHS Foundation Trust to provide the forensic multi-disciplinary team. The North London Forensic Service subcontracts to Avesbury House to provide the building, nursing, security, and domestic staff and support workers.

The current inspection took place on 10-11 February 2026 at 30 minutes notice. We spoke with 5 patients and one relative at the service and conducted a tour of the environment. We spoke with 20 staff members including the hospital director, director of clinical services, managing director, director of therapies, registered and non-registered nurses (including the safeguarding lead and physical health lead), a consultant psychiatrist, speciality registrar, clinical psychologist, occupational therapist and assistant, dietitian, ward clerk, student nurse and Mental Health Act administrator.

We had the opportunity to attend a ward round, and a flash meeting. We reviewed 5 care records of patients on the wards. We reviewed the medicines administration and care records for 5 people. Following the inspection we spoke with 5 carers/relatives of patients at the service.

Prior to the inspection we received anonymous whistleblowing concerns about the hospital with concerns about patient care, medicines administration, restraint, racial bias towards staff, and recruitment practices. We did not find evidence of these concerns, and these were not substantiated by the provider's investigation. A closed culture review had been arranged by the provider, and the provider was still reviewing its recruitment practices and allegations of racial bias. . However, we did note that there were gaps in senior oversight of safety measures across the hospital.

The ward felt welcoming, and staff–patient interactions were consistently warm and respectful. Patients rarely approached the nursing station directly, as staff were visible and available in communal areas.

There were breaches of regulation 12(1)(2) and regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a number of safety issues during the inspection, which had not been picked up by management checks and audits. These were addressed during or shortly after the inspection, but it was of concerns that the service’s own quality assurance systems had not identified these issues independently. Issues we found included recording action taken to address physical health scores; patient records lacking clinical detail; and some medication storage and environment security issues.

Care plans stated that patients were involved in planning their care, but their voice was not clearly reflected in 2 of the 5 care plans we reviewed.

Staff supported patients with activities within and outside of the service, such as education and employment.

Patients appeared to enjoy and actively take part in occupational therapy activities. However, some patients thought there should be more activities available at weekends.

We saw evidence that patients views and requests as raised in community meetings and patient council meetings, led to changes within the hospital such as activities provided, and new equipment for the hospital.

Discharge planning was clear for patients nearing transition. External professionals were involved where needed, helping maintain continuity of care.

There was a clear framework for the discussion of important information such as learning from incidents, complaints, audits and alerts and staff met regularly at business team meeting to discuss this. Leadership development opportunities were available, including opportunities for staff below ward manager level. Some staff raised concerns about staffing numbers, discrimination, and a divide between the medical and nursing teams.

Most staff were up to date with their mandatory training courses as at the time of the inspection with compliance of 91%.

During an assessment of the hospital overall

Avesbury House is provided by Partnerships in Care 1 Limited under the Priory group. The service provides a 24-hour low secure service to male patients with severe and enduring mental health needs, often with a forensic history. The service has 24 beds across five units including bedrooms, ensuite/communal bathrooms, communal areas and kitchen facilities. The service was last inspected in December 2021 and received an overall rating of Good. The service provides a step down for patients coming from a medium and high secure unit at a local forensic hospital. NHS England contracts the beds at Avesbury House and commissioned the North London Forensic Service at North London NHS Foundation Trust to provide the forensic multi-disciplinary team. The North London Forensic Service subcontracts to Avesbury House to provide the building, nursing, security, and domestic staff and support workers.

The current inspection took place on 10-11 February 2026 at 30 minutes notice. We spoke with 5 patients and one relative at the service and conducted a tour of the environment. We spoke with 20 staff members including the hospital director, director of clinical services, managing director, director of therapies, registered and non-registered nurses (including the safeguarding lead and physical health lead), a consultant psychiatrist, speciality registrar, clinical psychologist, occupational therapist and assistant, dietitian, ward clerk, student nurse and Mental Health Act administrator.

We had the opportunity to attend a ward round, and a flash meeting. We reviewed 5 care records of patients on the wards. We reviewed the medicines administration and care records for 5 people. Following the inspection we spoke with 5 carers/relatives of patients at the service.

Prior to the inspection we received anonymous whistleblowing concerns about the hospital with concerns about patient care, medicines administration, restraint, racial bias towards staff, and recruitment practices. We did not find evidence of these concerns, and these were not substantiated by the provider's investigation. The provider had arranged for a closed culture review of the service to take place. The provider was still reviewing its recruitment practices and allegations of racial bias. However, we did note that there were gaps in senior oversight of safety measures across the hospital.

The ward felt welcoming, and staff–patient interactions were consistently warm and respectful. Patients rarely approached the nursing station directly, as staff were visible and available in communal areas.

There were breaches of regulation 12(1)(2) and regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a number of safety issues during the inspection, which had not been picked up by management checks and audits. These were addressed during or shortly after the inspection, but it was of concern that the service’s own quality assurance systems had not identified these issues independently. Issues we found included recording action taken to address physical health scores; patient records lacking clinical detail; medication security, and some environmental security issues.

Care plans stated that patients were involved in planning their care, but their voice was not clearly reflected in 2 of the 5 care plans we reviewed.

Staff supported patients with activities within and outside of the service, such as education and employment.

Patients appeared to enjoy and actively take part in occupational therapy activities. However, some patients thought there should be more activities available at weekends.

We saw evidence that patients views and requests as raised in community meetings and patient council meetings, led to changes within the hospital such as activities provided, and new equipment for the hospital.

Discharge planning was clear for patients nearing transition. External professionals were involved where needed, helping maintain continuity of care.

There was a clear framework for the discussion of important information such as learning from incidents, complaints, audits and alerts and staff met regularly at business team meeting to discuss this. Leadership development opportunities were available, including opportunities for staff below ward manager level. Some staff raised concerns about staffing numbers, discrimination, and a divide between the medical and nursing teams.

30 November and 1st December 2021

During a routine inspection

Our rating of this location stayed the same. We rated it as good because:

  • At the last inspection, we found the ligature risk assessment did not identify all ligature anchor points which meant staff were unaware of the risks and how to mitigate them. On this inspection we found that this had improved. The service had a detailed ligature risk assessment which included information on ligature points within each ward. Staff were mitigating the risks through observations and CCTV cameras.
  • At the last inspection, we found staff did not have a good understand of the Mental Capacity Act 1983. During this inspection we found this had improved. All staff we spoke with understood the Mental Capacity Act and its principles. Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • The service had improved compliance with safeguarding vulnerable adults training to 94%. Staff were aware and understood their roles and responsibilities around safeguarding.
  • At the last inspection we found staff supervision notes were not always recorded appropriately. On this inspection we found appropriate supervision records which were stored securely.
  • At the last inspection, staff did not provide all patients with copies of their care plans. On this inspection, all patients we spoke with told us they had access to a copy of their care plans. Patient records we looked at reflected if patients had been given a copy of their care plan.
  • Managers did not use agency staff at the service. The service used bank staff who worked regularly on the unit to fill vacancies. This meant the service always had regular staff on the wards.
  • Staff did not restrain patients at the service. Staff used de-escalation techniques and completed training for this. Staff told us they felt able to manage aggression without using restraint. The service did not have a seclusion room and patients were not secluded at the service.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • 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.

However:

  • Although we saw evidence of patients receiving good support with their physical health needs, care plans did not always detail enough information about how staff were meeting each patient’s specific physical health needs. We also found that records of physical health checks were not always complete.
  • We found some gaps in the monitoring and oversight of staff completion of safety checks. For example medical equipment was not always checked daily. There were audits completed to check on staff practices, but they did not always specify actions to be taken for improvement.
  • Managers did not have oversight of all aspects of bed management within the service. There was no data about the delayed discharges. This information would be helpful in bringing about improvements in patients’ experience. However, no patients had discharge delayed without clinical reasoning.
  • The service had a blanket restriction on energy drinks for all patients. This was not individually assessed or reviewed to ensure that this was not overly restrictive. This was not inline with the organisations policy.
  • Some patients were not aware of having access to a multi-faith room, although this was available at the service.
  • Managers did not have a strategy for the service.

22 & 23 February 2017

During a routine inspection

We rated Avesbury House Good overall because:

  • Following our inspection in August 2015, we rated the service as good for effective and caring. We rated the service as requires improvement for safe, responsive and well led.
  • During this inspection, we found the service had made considerable progress since the previous inspection in August 2015 but in some cases the improvements were not yet fully completed or embedded. There were some areas where we have asked the service to do some further work and some new areas for improvement have been identified.
  • At the last inspection, in August 2015, there were no systems in place to handle complaints at the service. During this inspection we found there had been improvements. Patients knew how to complain. The service had a formal complaints system in place and staff were investigating complaints appropriately.
  • At the last inspection, in August 2015, there were no systems in place to ensure records were complete, accurate and up to date. At the inspection this had improved. The manager could access key performance monitoring information easily in order to understand the performance of the team and make improvements in the service
  • At the last inspection, in August 2015, we found that he service had not submitted all required statutory notifications to the CQC. At this inspection, we found that the service was regularly submitting notifications to the CQC when appropriate.
  • Patients’ risk assessments were regularly updated, comprehensive and personalised. Staff completed physical health assessments of patients on admission and on-going monitoring was robust. Staff had a good understanding of patient’s individual needs.
  • Staff used de-escalation techniques to calm any aggressive behaviour. Staff knew how to report safeguarding concerns and what to report. The service had introduced a new incident reporting tool which staff used with ease.
  • Staff operated an effective and well-maintained medicines management system.
  • The service had a full range of multi-disciplinary staff available due to the joint working with an NHS trust.

However,

  • At the last inspection in August 2015 we found that the service did not have a ligature risk assessment in place and that staff were not aware of ligature risks and how to manage them. During the inspection, although this had improved, we found that ligature risk assessments did not identify all ligature points in the service, which meant that staff were unaware of the risks and how to mitigate them.
  • At the last inspection, in August 2015, staff did not have a good understanding of the Mental Capacity Act. During the inspection, we found that this had not improved. Staff had little understanding of the Mental Capacity Act and its principles.
  • Safeguarding vulnerable adults training for staff was low at 61%. Staff supervision notes were not always recorded appropriately.
  • Staff did not provide all patients with copies of their care plans. 

18 - 19 August 2015

During a routine inspection

We rated Avesbury House as requires improvement because:

  • The provider did not have an up-to-date ligature risk assessment.
  • All staff did not have access to a personal alarm.
  • There were some staffing shortages on the weekends.
  • The provider had not submitted all required statutory notifications to the CQC.
  • There were no systems in place to identify, receive, record, handle, respond to and learn from complaints. All complaints were resolved informally and not centrally recorded. The provider had no record of any formal complaints made in the past year. Some patients wanted to make a complaint, but did not know how or did not feel comfortable to make a complaint.
  • The provider had not put systems in place to ensure records were complete, accurate and up-to-date, including patients’ care records, staffing rotas, staff supervision, staff training and community meeting minutes.
  • Patients’ care records were stored on two separate electronic systems in addition to the paper files. This was time consuming for staff and duplicated work. Staff did not always transfer information between the various systems. Risk assessments were not available for all patients on the electronic system that nurses accessed.
  • Staffing numbers were recorded on the staffing rota, daily planning rotas and staff time sheets. The daily planning rotas did not account for any absences such as sick leave. It was unclear from these records what the staffing numbers were on any given day.
  • Not all staff received regular monthly supervision. Records of staff supervision and training were not accurate.
  • A community meeting took place every fortnight where patients could express their views on the daily routines of the ward. Patients whose first language was not English said they were not involved with these meetings. Issues recorded in the meeting minutes were often carried over with no recorded outcome or person responsible for addressing that action.
  • There was no formal service level agreement in place between Care UK and BEH trust regarding joint policies and clinical governance.

However:

  • Patients said they felt safe at Avesbury house.
  • There was good multidisciplinary input.
  • Care records were of a good standard.
  • Patients said staff were caring and treated them with respect.
  • Staff had a good understanding of individual patient’s histories and care needs and patients said they felt involved in decisions about their care and treatment.