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CQC finds improvements by Avon and Wiltshire Mental Health Partnership – but concerns remain about places of safety

8 September 2016
  • Media,
  • Hospitals

The Chief Inspector of Hospitals has told Avon and Wiltshire Mental Health Partnership NHS Trust that it must continue to make improvements following its latest comprehensive inspection by the Care Quality Commission.

Inspectors found there had been major improvements in community mental health services in Bristol. But, there were significant failings in the delivery of health based places of safety. Overall the trust has been rated Requires Improvement. Full reports on all core services are available at

Avon and Wiltshire Mental Health Partnership provides mental health services across Bath and North East Somerset, Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. The trust also provides specialist mental health services for a wider catchment extending throughout the south west.

Following the inspection, in May 2016, CQC issued a Warning Notice requiring the trust to make urgent improvements to the health based places of safety services.

Inspectors found that in some cases, vulnerable patients were detained in police cells because there were no beds available in the trust’s designated places of safety. Patients were regularly waiting over twelve hours for a Mental Health Act assessment and then had to wait again for admission to a suitable ward. Inspectors had further concerns about the safety of the environments of some places of safety.

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (and lead for mental health), said:

“When a person in a crisis who requires mental health care is detained by the police, they should be taken immediately to a properly staffed place of safety where they can be assessed by a mental healthcare professional. They should be taken to a police cell only in exceptional circumstances. We found that too often the designated places of safety managed by AWP were not available when needed. This must be addressed as a priority and I know the trust is already working closely with the police to tackle this problem.

“Despite these specific concerns, we found that Avon and Wiltshire Mental Health Partnership NHS Trust has a committed and caring workforce that is trying to meet the needs of all people who use the services safely and effectively. Almost without exception, patients and carers spoke positively about the care they received and patients. They described staff as being caring, enthusiastic and committed to delivering high quality care and treating patients and carers with dignity and respect.

“The trust has responded well to make the improvements that we required following previous inspections. However, there is still a significant amount of work to be done to improve quality and consistency of services and effectiveness of working practices across the trust.”

After the trust’s last inspection in December 2015, CQC served a Warning Notice because of significant concerns about the Bristol crisis, assessment and recovery services for adults of working age. People needing urgent community-based mental health services were waiting several months for assessment. At the time, inspectors found that the trust did not have effective governance arrangements in place to enable it to assess, monitor and improve the quality of services. When we inspected again in May 2016, we found that the trust had made major improvements to the community mental health services in Bristol. However, there is still more work to be done; particularly to the north Bristol community mental health services.

Inspectors also found there had been considerable improvements since the trust’s last comprehensive inspection in 2014. A service manager had been appointed to cover all three Bristol teams and there had been an increase in staffing.

The report highlights areas of good practice including:

  • Staff throughout the trust were committed to continuous improvement with many involved in a wide variety of local initiatives. On Alder ward (rehabilitation)staff and patients worked together to raise funding to buy musical instruments and bikes for the patients.
  • The trust had participated in a number of quality improvement programmes or accreditation schemes covering ECT, inpatient wards, home treatment, memory services, forensic mental health services, eating disorder services and perinatal services.
  • The trust was committed to participation in research and viewed it as a core activity. It had developed good collaborations with three universities of Bristol, West of England and Bath.
  • Staff were actively encouraged to publish papers describing their achievements or innovations. For example, a consultant at the Victoria Centre in Swindon had recently published a paper on the management of aggression in patients with dementia.


For further information please contact CQC Regional Engagement Manager, John Scott on 07789 875809 or, for media enquiries, call the press office on 020 7448 9401 during office hours. Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. (Please note: the duty press officer is unable to advise members of the public on health or social care matters).

For general enquiries, please call 03000 61 61 61.

Last updated:
29 May 2017

Notes to editors


This report follows a focussed inspection on the quality of services provided at Avon and Wiltshire Mental Health Partnership NHS Trust. Inspection teams include a range of clinical and other experts including experts by experience. 


Whenever CQC inspects it will always ask the following five questions of every service: Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led? You can find out more about CQC’s approach to inspection on our website at


Registered providers of health and social care services are required to display their ratings on their premises and on their websites so that the public can see their rating quickly and easily. For further information on the requirement for providers to prominently display their CQC ratings, please visit:


About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.