Avesbury House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating was requires improvement. This meant improvements were needed to keep people safe and protected from avoidable harm.

There was a breach of regulation 12(1)(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a number of safety issues during the inspection. These were addressed during or shortly after the inspection, but it was of concerns that the service’s own systems had not identified these issues independently. Issues we found included recording action taken if physical health scores were outside of the normal parameters; some patient records lacking clinical detail; storage of medication keys, out of date medicine stock items, and some environment security issues.

Staff completed comprehensive risk assessments using a structured judgment tool to assess the risks for each patient on admission and reviewed these regularly as needed. However, they did not always record what action was taken when patients’ physical health scores were outside of the normal parameters, and some patient records lacked clinical detail.

Staff reported incidents and were aware of the learning from recent incidents. Staff were trained in safeguarding and knew how to make safeguarding alerts. Appropriate safeguarding concerns were raised by staff relating to patients, with protection plans put in place when needed.

Staff completed targeted searches if there were specific risks identified. Staff applied blanket restrictions on patients’ freedom only when justified, such as items that they were not allowed to bring into the hospital. Patient lockers containing restricted or higher‑risk items were checked 2-weekly at the time of the inspection.

There were systems in place for staff to follow before patients went out on unescorted leave. Staff recorded what patients were wearing and checked on how they were feeling and presenting before going out. However, the folder in use for patients who were absent without leave was not up to date. This was corrected shortly after the inspection visit.

Patients were positive about the environment within the unit. The hospital environments were visibly clean and well maintained. Staff were supported by CCTV to observe patients and ensure their safety. The hospital was for male patients only, and some patients shared bathroom facilities. All members of staff carried a personal alarm, and there were wall-based alarms throughout the hospital as well as in patient bedrooms. Work had been undertaken to reduce the risk of ligature anchor points in the unit by 35%. However, there were some security issues with the hospital environment including the car park gates, and the stable doors on the clinic and security rooms. These were addressed shortly after the inspection.

There were few vacant posts and little use of agency staff. Safe staffing levels (for registered and non-registered nurses) had been assessed. Extra staff were provided when enhanced observations were needed. When temporary nursing staff were used, those staff received an induction to familiarise them with the hospital and policies. Staff told us that there was adequate medical cover to meet the needs of patients. A duty doctor and an on-call consultant were available out of hours.

Most staff had received and were up to date with their mandatory and statutory training courses as at the time of the inspection. Overall compliance with mandatory training was 91%.

Relevant health and safety environmental checks were in place. Staff and patients said that the level of cleanliness on the was good.

The clinic room was clean and tidy. Prescribed medication stock was all in date and medication fridge/cupboards all tidy and in order. Medicines administration records were completed appropriately. Staff signed when they administered medicines or recorded why not, in accordance with provider policy. Staff understood how to use sedative medicines safely as a last resort. However, we found that storage of medication keys was not secure at the time of the inspection. These issues were addressed during or immediately after the inspection.

Medicines cupboards and drawers were cluttered, making items harder to find quickly. Five stock items were out of date, suggesting that monthly stock checks were not always completed or thorough. Several medication charts were missing patient photographs. The provider advised us that these issues were addressed after the inspection.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We saw appropriate examples of learning from incidents, and actions being put in place to prevent their recurrence. All staff we spoke with, were aware of incidents that had taken place in the last year and learning put in place as a result. Incidents recorded primarily related to behavioural issues, alcohol/drugs, violence/aggression, and clinical care.

They gave examples of learning from incidents including systems put in place following a patient going absent without leave. All staff were notified of a ‘5 point risk assessment’ to be completed in full before being passed to reception staff. There was updated guidance on pre and post leave checks and agreeing a grace period allowable. Staff also noted improved handover information and recording of physical health checks. They had scenario training at regular intervals to ensure that they were ready for a range of different health emergencies.

Staff knew what incidents to report and how to report them. Managers reviewed incident reports and completed a fact finder report where required to ensure that rapid learning could be put in place. Where needed a more detailed incident investigation was put into place. Incidents were discussed at handover meetings, brief sessions, team meetings and supervision sessions. Learning was captured in physical and electronic lessons learnt folder for staff not in attendance at meetings.

All incidents were discussed in monthly Clinical Governance Meetings and lessons learned were shared with the wider provider group. Serious Incidents required Team Incident Reviews. Security incidents and incidents relating to alcohol and drugs were drivers to changes in the secure environment and referral processes. For example, the building of Safer Rooms within the service, purchase of safety pods, installation of wire mesh on top of a secure wall and installation of wall mounted electric water boilers in all the flats.

Duty of candour is a legal requirement, which means providers must be open and transparent with patients about their care and treatment. This includes a duty to be honest with patients when something goes wrong. Staff were aware of the need to always be open and transparent, including after an incident.

There was a risk register for the hospital to manage the chief risks to patients and staff. This included damage to an external wall, the different electronic record systems used by hospital staff and the multi-disciplinary team (MDT) from a nearby NHS trust, the patient call system, and various issues within the hospital environment

The average length of stay across the service was 604 days in December 2025. This had reduced from 872 days the month before, which was more in keeping with the average over the previous year.

The hospital held regular meetings to discuss referrals, transfers and discharges. Transfers from the hospital could occur when patients were ready to move on to less restrictive settings, or if a patient required a higher level of supervision. Staff ensured that when they transferred or discharged patients that this was always at an appropriate time of day, except in the event of an emergency.

Staff and management noted that the profile of patient acuity within the service had increased in recent years. Management were working to upskill staff to meet these higher needs and ensure close liaison with the police when needed.

Staff carried out daily safety checks and appointed a security lead on each shift. Managers conducted a monthly safety audit. Staff were trained in searching patients for banned items, and dog searches were conducted at the hospital periodically for banned substances.

Appropriate safeguarding concerns were raised relating to patients and led to protection plans being put into place when needed. Staff gave examples of safeguarding alerts that they had made relating to patients at the hospital.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of safeguarding alerts they had made. The allocated social worker kept a safeguarding tracker and noted that all staff were up to date with their safeguarding training. All staff received an appropriate level of safeguarding training for their role. Safeguarding adults and children training at levels 1 & 2 was at 100% and at level 3 was at 91%.

Children visiting the service were not permitted in patient areas. Instead, patients could see children in a visitor’s room, if this was identified in their risk assessment as being appropriate.

There was a breach of regulation 12(1)(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a number of 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 if physical health scores were outside of the normal parameters; some patient records lacking clinical detail; storage of medication keys, out of date medicine stock items, and some environment security issues.

Staff assessed and managed risks to patients and themselves well. Staff had the skills required to develop and implement positive behaviour and followed best practice in anticipating, de-escalating and managing challenging behaviour. As a result, staff did not restrain patients at the service.

Staff followed policies and procedures for the use of observation. Staff completed targeted searches if there were specific risks identified. Staff applied blanket restrictions on patients’ freedom only when justified, such as items that they were not allowed to bring into the service. Staff participated in reducing restraint intervention training, and there had not been any physical restraints of patients within the last year.

Staff completed a comprehensive risk assessment using a structured judgment tool to assess the risks for each patient. This was completed on admission and then reviewed regularly as needed. We saw detailed risk assessments in place for patients on the wards and care plans in place to address the risks identified.

There were systems in place for staff to follow before patients went out on unescorted leave. Staff recorded what patients were wearing and checked on how they were feeling and presenting before going out, and had clear guidelines on action to take if they did not return by the agreed time. There was a folder available for when patients were absent without leave but this contained information that was not up to date. Following the inspection, the provider advised that this folder had been removed as its use was not in line with their policy.

As recommended at the last inspection, the provider had maintained oversight of restrictive interventions, and regularly reviewed restrictions to ensure patients were treated with the least restrictive intervention being applied to them as possible.

Physical health vital signs for patients were recorded on NEWS2 charts as appropriate. However, it was not always clear what happened when a score was raised outside of the normal parameters. There was no consistent documentation showing whether the score was escalated, or the patient was reviewed to determine that escalation was not required at that time.

Patient lockers containing restricted or higher‑risk items were checked 2-weekly. We suggested that the service should keep this frequency under review, to ensure sufficient monitoring for this secure setting.

The ward environment was safe and clean. Staff undertook regular risk assessments of the care environment and recorded and reported on any areas that required attention, for example broken items of equipment.

Staff were supported by CCTV within the unit to observe patients and ensure their safety. Staff knew about potential ligature anchor points and told us how they mitigated the risks to keep patients safe. They were clear about where to access ligature cutters if needed and a current ligature assessment of the environment was available. The most recent ligature risk assessment for the service was completed in January 2026. The service had reduced ligature anchor points by 35% since the previous inspection.

All members of staff carried a personal alarm, and there were wall-based alarms throughout the unit. The provider undertook weekly fire alarm tests and regular fire drills. Three safer rooms had been created within the service, for patients identified to be at higher risk to themselves, and two safety pods were provided for use in the event of physical restraint being necessary.

The service was for male patients only, and patients shared bathroom facilities. The service consisted of five flats. Each of the flats had a kitchen, living room, laundry and shower/bathing facilities with en-suite facilities available in some rooms, and a conservatory in three of the flats. During the inspection, a programme of refurbishment of each of the flat’s kitchens was in progress.

The hospital’s, car park gates were part of the secure perimeter. Each gate operated by only one gate opening at a time, however, during the inspection, both gates opened together. Managers had raised this issue in a flash meeting and had informed all staff about this risk. This issue was known to management, but it was of concern that despite actions taken, the issue had been reoccurring sporadically since July 2025. They were in the process of addressing this issue. During the inspection they also addressed another concern with incorrect fitting of a push button exit in one of the conservatories as identified during a recent incident.

In the clinic room the emergency grab bag was hanging on a wall hook, which we found to be difficult to reach, and remove in an emergency. This was raised and fixed during the visit.

At the time of the inspection, the design of the stable doors on the clinic and security rooms was not sufficiently secure, creating a security concern. There had not been any incidents relating to this issue.

There were few vacant posts and little use of agency staff. There were 8.5% vacancies in January 2026, with the lowest vacancies in July at 2.4% and highest in November 2025 at 11.5%. As there was a small overall staff team, 5% vacancies related to 1 FTE staff post. At the time of the inspection the service had over-recruited nurses, with no current vacancies.

The hospital had a turnover of 15.4% in February 2026, this was lowest in June at 4.6%, and highest in March 2026 at 19.3%. Staff sickness in February was at 4.5%, lowest in January 2025 at 0.5%, and highest in October 2025 at 5.8%.

Safe staffing levels (for registered and non-registered nurses) had been assessed for each ward. Extra staff were provided when enhanced observations were needed on a ward.

Staff knew patients well and said that they were supported by their colleagues and managers. When temporary nursing staff were used, those staff received an induction to familiarise them with the unit and policies. The temporary staff completed a checklist to demonstrate they had been inducted to the service.

Staff told us that there was adequate medical cover to meet the needs of patients. A ward doctor and consultant psychiatrist were available on working days, and a duty doctor and an on-call consultant were available out of hours.

Most staff were up to date with their mandatory and statutory training courses as at the time of the inspection, with an overall compliance rate of 91%. There was 93% compliance in basic life support, and 92% in immediate life support. There was 100% training compliance in diversity and inclusion, and medicines administration, and 82% training in breakaway techniques.

Some staff raised concerns about staffing levels during unexpected absences, leading to extra tasks for remaining staff and some patients’ needs not being met, such as escorted leave delayed or cancelled.

The hospital environment was visibly clean and generally well maintained. Relevant health and safety environmental checks were in place across the unit. Staff and patients said that the level of cleanliness was generally good. Some patients said that bedrooms could become hot in the summer, and appreciated the air conditioning available to them in the conservatory. We observed domestic staff on site who ensured premises were clean and supported patients who required additional assistance with cleaning.

Staff adhered to infection control principles, including handwashing and wearing appropriate personal protective equipment such as disposable gloves.

There was a maintenance log in place for the ward, and we noted that issues reported were responded to swiftly.

There were 3-monthly cleanliness audits for the hospital, and 6-monthly for non-patient areas. Hand washing and mattress audits were carried out 6-monthly.

Staff ordered, stored, dispensed and disposed of medicines safely. However, cupboards and drawers were cluttered, with items stored in a way that made them hard to find quickly. Five stock items were out of date, suggesting that monthly stock checks were not always completed thoroughly. These were removed during the inspection visit.

Medicines were stored at the correct temperatures to remain effective. Staff monitored the fridge and room temperature where medicines were stored daily. Controlled drugs were stored and managed appropriately. No patients were prescribed or receiving drugs liable for misuse (DLM) at the time of inspection and DLM monitoring was being undertaken in line with the provider's local procedure.

During the inspection medication keys were kept loosely in a pouch rather than securely attached to a registered nurse’s belt. After we raised this with management, communication was sent to all nurses reminding them that the medication keys must always be attached to their key strap and communication was placed in the lessons learnt/communication folder to be shared in handovers.

We reviewed the medicine administration records. These were completed appropriately. Staff signed when they administered medicines or recorded why not, in accordance with provider policy. Staff noted allergies and potential adverse reactions on the patients’ records. Several medication charts were missing patient photographs. This was raised and resolved during the inspection visit.

Staff understood how to use sedative medicines safely. They used de-escalation techniques and oral medicines first and rapid tranquilisation had not been used in the last year. There were robust care plans in place for patients prescribed the anti-psychotic medicine clozapine. Staff completed checks before and after each dose to monitor for risks and side effects.