Avesbury House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating was requires improvement. This meant the service was not always consistently managed and well-led. Leaders and the culture they created did not consistently promote high-quality, safe, person-centred care.

Prior to the inspection we received anonymous whistleblowing concerns relating to racial bias and favouritism towards staff, and retaliatory treatment to those raising concerns. The provider had arranged for a closed culture review of the service to take place. Recruitment practices and racial bias within the service remained under review by the provider. Overall, we did not find evidence of these concerns during the inspection. However, we did note some gaps in senior oversight across the hospital. 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.

There was a breach of regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a range 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. 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scores were outside of the normal parameters; some patient records lacking clinical detail; storage of medication keys, out of date medicine stock items, and some environment security issues.

Leadership development opportunities were available, including opportunities for staff below ward manager level. Staff spoken with during the inspection felt supported by their colleagues and managers. They knew how to use the whistleblowing process and how to contact the freedom to speak up guardian. Staff appraisals included conversations about career progression where relevant and how they could support staff development. However, some staff raised concerns about insufficient staffing numbers, discrimination towards staff and patients, a divide from the medical and nursing teams, and not being made aware of the results of audits.

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.

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. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. The service had plans for emergencies. This included contingency arrangements for adverse events.

We have not awarded this service a score for Well-led.

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

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

Most staff told us they felt comfortable to raise concerns with their line managers and that they would be listened to. Prior to the inspection we received whistleblowing concerns regarding senior management and staff culture. Concerns included racial bias and favouritism towards staff, insufficient action to address staff misconduct, and fraudulent recruitment practices. There were also concerns raised regarding a senior manager. The provider had arranged two listening exercises with staff and commissioned a formal closed culture review.

The Staff Survey for 2026 demonstrated a score of 89% in diversity and inclusion and that the site leadership was rated as 89% effective in 2026. Staff spoke positively about opportunities for professional development. There were development opportunities available for both qualified and unqualified staff. Staff appraisals included conversations about career progression where relevant and how they could support staff development.

Staff were aware that they could access support for their own physical and emotional health needs through the provider’s occupational health service.

We met with the hospital director and the managing director for the service. They demonstrated the skills, knowledge and experience to perform their roles. There was no ward manager position for the hospital, but there was an interim director of clinical services newly started at the service. Despite being new they were aware of the performance of the service, and quality outcomes for patients as well as the condition of the environment.

The managing director noted that there had been some concerns about cliques amongst the staff team, and some staff raising their voices with patients, and sponsorship processes for new staff. Prior to the inspection, the provider had arranged 2 listening exercises with staff and a closed culture review for the service. The Staff Survey for 2026 demonstrated a score of 89% in effective leadership in 2026. Staff spoke positively about opportunities for professional development.

Although leaders understood what the local risks were and had quality assurance measures in place, at the time of the inspection, oversight was not sufficient to identify the concerns we found with staff recording physical and mental health observations, and some environmental security, and medicines management issues.

Leadership development opportunities were available for staff. Senior managers said that there was a plan to adopt a rehabilitation model at the hospital.

Staff spoken with during the inspection did not report any cases of bullying or harassment on the wards and told us that they felt supported by their colleagues. Staff knew how to use the whistle blowing process and how to contact the freedom to speak up guardian.

However, prior to the inspection we received anonymous concerns raised by staff regarding patient care, discrimination towards staff, medicines errors, improper recruitment practices, and a lack of consequences for staff misconduct. We did not find evidence of these concerns during the inspection but discrimination and favouritism towards staff, and recruitment practices remained under review by the provider.

At the time of the inspection staff did not express any concerns about workforce equality, diversity and inclusion. However, whistleblowing concerns received by CQC indicated that some staff felt that staff members from a particular ethnic group were being favoured in recruitment.

The most recent staff survey results from April 2025 (with a response of 84% staff) indicated improved scores for communication, appreciation, leadership, empowerment and teamwork. Lower scores were returned for line manager support, contact with senior managers, discrimination and purpose.

Some staff members expressed concerns due to the price of staff meals at the hospital having increased significantly. Staff and patients eating together was seen as helpful to the therapeutic relationship.

There was a hospital director, interim director of clinical services, and 2 lead nurses for the hospital. There was no ward manager position in place, and some staff felt that this meant that there was some blurring of job roles in managing clinical care. The MDT and nursing staff also used 2 different electronic record systems. Whilst MDT members had access to both systems, the nursing staff could not access the local NHS mental health records. Some nursing staff felt that there were sometimes gaps in information passed down to frontline staff from the MDT.

We were advised that in the last year there had been some incidents of patients bringing illicit substances into the hospital, and several patients being recalled to the mental health trust inpatient ward. At the time of the inspection the hospital had intentionally admitted an older contingent of patients to change the culture of the service. There had been an increase in the physical health needs of patients at the service, and staff were being upskilled to meet these needs. There was also a focus on greater police liaison.

However, 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 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.

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 team meetings to discuss this. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts within the provider organisation. The service had plans for emergencies. This included contingency arrangements for adverse events.

We reviewed the minutes of clinical governance meetings, head of department meetings and team meetings at the service. Topic discussed included the hospital environment, patients ready for discharge, the hospital’s search policy, nursing staff issues, incidents, clinical governance, outcome measures, physical health and security. The provider was in the process of introducing the Patient and Carer Race Equality Framework within the service.

The risk register for the service included damage to an external wall, the different electronic records systems used by nursing staff and the MDT, the nurse call system, use of toughened windows and portable heaters, and airlock doors. There were actions in place to mitigate each risk.

Patients were able to raise their views in community meetings and at patient council meetings. Actions taken in response to patient feedback included replacing the kitchens within the flats, providing new washing machines and tumble driers to each flat, provision of portable heaters, more organised trips out to places of interest, more snacks, and new activities. Blanket restrictions were discussed with patients at community meetings, and a new register of blanket restrictions was completed in February 2026.

There were also regular relatives’ forum meetings, and an annual carers survey. The most recent carers survey had 10 responses, and 98% positive feedback. Staff were able to attend Your Say forum meetings, and there was an annual staff survey.

At the time of the inspection some management issues remained under investigation following staff whistleblowing concerns.

Staff kept patients up-to date by displaying information on notice boards as well as discussion of any relevant matters during community meetings and one-to-one sessions. There were monthly team meetings where staff had the opportunity to raise any concerns.

Patients and carers had the opportunity to give feedback on the service through surveys and direct contact with staff. A patient representation attended clinical governance meetings to represent patient views in this forum.

Staff used feedback from patients and carers to bring about improvements on the wards.

Quality improvement projects that staff at the hospital were involved in included processing of clozapine bloods and making ward rounds more effective.

At the time of the inspection, the service was undergoing self-assessment for the Quality Network for Forensic Mental Health Services accreditation programme.