Avon and Wiltshire Mental Health Partnership NHS Trust

Updated 29 May 2025

Date of assessment: 16 July to 8 August 2024. Avon and Wiltshire Mental Health Partnership NHS Trust provides Mental Health services across a catchment area covering Bath and North East Somerset, Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. Avon and Wiltshire Mental Health Partnership NHS Trust serves 2 Integrated Care Boards and 6 local authorities; NHS England also commission specialist services. The trust employs over 5,000 substantive staff. It operates from over 90 sites including 8 main inpatient sites and services are delivered by 150 teams across a geographical region of 2,200 square miles, to a population of approximately 1.8 million people. The trust has a total of 21 locations registered with CQC.

The trust sits within two Integrated Care Systems (ICS). These are:

• Bristol, South Gloucestershire and North Somerset (BNSSG)

• Bath and North East Somerset, Swindon and Wiltshire (BSW).

We carried out a well led assessment of the trust which commenced with a 3-day site visit on 15, 16 and 17 July 2024. This assessment was due to concerns over the previous 12 months about the quality of care across various services. Before carrying out this well led assessment, we carried out assessments of Acute and Psychiatric Intensive Care Unit services and Community Mental Health services for people of working age to check how well the overall trust strategy and risk management aligns with local services.

During the Well led assessment, we identified breaches of the legal regulations relating to safeguarding and good governance. This was because the trust had not ensured leaders consistently and fully engaged with system partners on strategic issues. They had not ensured, Freedom to Speak Up processes were effective, that racism and discrimination were addressed across all services and safeguarding systems and processes were effective.

Updated 2 May 2024

We carried out a responsive on-site assessment to determine if the service had made improvements since the last inspection. Following the last inspection, the trust was issued a Warning Notice under Section 29A of the Health and Social Care Act 2008 due to our concerns that patients on the acute mental health inpatient wards were not receiving safe care and treatment under regulations 12 and 17 of the Health and Social Care Act 2008 (regulated activities).

At this inspection we reviewed three key questions: Safe, Responsive and Well-led. During our last inspection Safe was rated inadequate. Responsive and Well-led rated were rated as requires improvement.

On this inspection we found that the service had made significant improvements and had met most of the requirements of the previously issued breaches of regulation 12 and 17. However, there continued to be concerns regarding some of the ward environments and timeliness of responding to environmental risk.

The overall rating for this service is Good. We rated the Safe and Responsive and key questions as Good. We rated Well-led as requires improvement. The previous ratings of Good for Caring and Effective remain.

Updated 2 May 2024

We carried out a responsive on-site assessment to determine if the service had made improvements since the last inspection on 5 May 2023. At the previous inspection we found breaches of regulation for:

• Medication management and associated documentation. Regulation 12 (safe care and treatment).

• Lack of governance processes to highlight area for improvement, risk and errors in relation clinic rooms and medication management, including issues with staff competency when errors are made in relation to medication. Regulation 17 (Good governance)

• Lack of clear oversight and responsibility for the management of the clinic room and medication stored on site. Regulation 17 (Good governance).



We reviewed 2 full key questions: Safe and Well-led, as well as 2 quality statements in Effective and Responsive. Safe and Well-led were previously rated requires improvement, with Effective and Responsive rated good.

We found that the service had made significant improvements. However, we identified concerns in the trust’s safeguarding processes. The safeguarding policy was not clear regarding staff responsibilities and was open to interpretation on safeguarding processes. Staff gave us mixed feedback on their understanding of the policy instructions. However, this did not impact the standard of safeguarding practices across the teams as staff we spoke to explained they escalated and referred safeguarding concerns as a priority regardless of the mixed understandings some staff had of the policy.

The overall rating for this service is Good. We rated the Safe and Well-led key questions as Good. The previous ratings of Good for Effective and Responsive remain.

Updated 1 May 2024

Date of Assessment 23 January 2024

We completed an unannounced inspection due to concerns we had about some areas of service quality. We assessed a small number of quality statements from the safe and responsive key questions and found areas of concern. The scores for these areas have been combined with scores based on the key question ratings from the last inspection.

Staff were not always aware of who the designated unit nurse in charge was, who had authority to deploy staff to other wards in an emergency. Shifts were cancelled at short notice which meant some shifts were short staffed or covered by agency staff who did not know the patients well. Staff told us they were anxious about reporting incidents and using the Freedom to Speak Up Guardian process due to concerns of job security. Although some blanket restrictions had been removed around patients access to fresh air and refreshments, staff told us some night time restrictions remained in place because staffing levels were not changed to reflect a 24 hour service. Relatives told us they were concerned about the standards of care and the services over reliance on, and the quality of agency staff. Patients told us food choice and quality was poor. We found evidence that the service was slow to respond to concerns raised by patients. We reviewed learning from the service but found this was not applied in practice. For example, ward welcome packs were introduced but some staff did not know they existed. Staff did not follow ward rules such as no mobile phones on wards, and activity boards were introduced but we saw evidence of patient requests for activities that were not provided. We found regulation breaches concerning safety.

However, senior leaders had responded to a number of patient care concerns and suspended staff from duties whilst investigations took place. The service are addressing staff culture concerns by providing more training and staff told us there were improvements in culture due to this.

Updated 21 December 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

• Staff were unable to observe all parts of the ward due to the current layout. Staff did not routinely undertake observations of all of the ward, nor did they record when observations were carried out. Plans to mitigate ligature risks on the ward were reliant on staff being in communal areas at all times. The bannister and stair lift leading to the communal area posed a significant ligature risk and staff did not carry out observations sufficiently to ensure the safety of young people.
• The service had not completed environmental risk assessments. During the summer, staff placed a chain across the doors leading to the garden. This did not allow enough airflow into the dining room to cool it down. Staff had not completed individual risk assessments for use of the garden area therefore there was a blanket restriction on young people having access to the garden. Risks identified in the risk assessment were not always addressed within a care plan. Not all young people had a crisis plan.
• Although staff provided care and a range of treatments that met the young people needs, these were not reflected in the written care plans. Care plans were generic and used standard statements that did not show personalised care. Young people told us they were not involved in their care planning and that their feedback was not incorporated or listened to. Care plans were not holistic. Young people had a nursing treatment care plan however there was no evidence of input from the wider multi-disciplinary team for example occupational therapist, social worker and psychologist. Some care plans had not been updated in a timely manner in line with trust policy.
• Staff did not receive specialist training to ensure they could meet the needs of all young people. For example, working with someone diagnosed with eating disorder or an autistic spectrum disorder.
• Young people did not always have a discharge plan in place. In the year prior to the inspection, seven young people’s discharge had been delayed. The manager had not completed an analysis to determine causes of the delayed discharges.

However:

• The trust had taken action the action we had required it to make at the last inspection and had ensured the fence that led from the garden directly onto the car park was now secure.
• Staff were trained in safeguarding, knew how to make a safeguarding alert and knew how to identify young people at risk of significant harm.
• Young people had a wide range of treatment and therapies available to them. This included a structured therapeutic programme consisting of psychological therapies, family therapy and numerous activities on and off the ward.
• Staff interacted and engaged well with the young people. Most young people were very complimentary of the staff and the level of care available to them. For example, during the recent building work the staff organised additional activities off the ward so they could escape the disruption.
• The service ensured that young people continued with their education when admitted and provided young people with the educational materials required for continuing with their education.
• There was a consistent management team in place. This had improved since the last inspection. The service had implemented a management structure that included a ward manager and a service manager.

Updated 10 November 2021

Updated 8 September 2016

We gave an overall rating for community mental health services for people with learning disabilities or autism of good because:

• The services conducted assessments, including specialised risk assessments, at the appropriate time. Teams considered physical health needs and monitored them. Care plans were patient focused and staff were respectful of people using the service. Information was available in an accessible format and there was a patients forum that inputted in to the service that people could attend.

• There were good staffing levels and caseloads were appropriate. There was clear eligibility criteria and a referral pathways.

• The services regularly reviewed their practice; we saw evidence of learning from incidents, including changes in working practices. The intensive support team was reviewing their operating policy and referral procedure to ensure it met the needs of the people accessing the service. The forensic team had developed interventions from an evidence base, which met the identified needs of the people accessing the service.

However:

• The intensive support teams electronic record system did not have active risk assessments or contain all the required risk information. There was no effective procedure in place to mitigate this. Not all intensive support team care plans were uploaded on the electronic record system. Some people using the forensic service had not received their care plan in a timely fashion.

• Services did not have a full range of mental health professions in their teams.

• There were no recognised outcome measures in place and staff did not routinely give people information on how to make a complaint.

Updated 8 September 2016

We rated community-based mental health services for older people as good because:

• Staff demonstrated an awareness of risk. The majority of care records contained an appropriate and up to date risk assessment. Staff had safe lone working arrangements. Staff had an understanding about how to report incidents. Staff felt confident in raising concerns and knew how to escalate them if necessary.

• The teams included a full range of specialist allied health professionals to provide effective assessment and treatment. The staff in the teams worked well with other local services and with the other older adult services provided by the trust in their locality.

• Patients and carers that we spoke with reported that the staff were kind and caring. They said they felt included in their care and we saw that this was clearly documented in almost all of the care records we reviewed.

• Staff reported that management within the locality were approachable. They said that morale was generally good and that things had improved in recent years.

However:

• Some teams (North Somerset later life therapies and Swindon memory service) were not meeting the trust’s targets for assessment.

• In the North Somerset teams, although there were alarms available for staff to use, there was no record to show these had been routinely checked.
• While local management was approachable and involved, staff reported that the senior management team based at trust headquarters were not as visible.

Updated 21 December 2018

Our rating of this service improved. We rated it as good because:

• The service had taken steps to address environmental and safety concerns raised at our last inspection in June 2017. We saw that there were now safe lone working policies and staff could access personal alarms when seeing patients on site. Patient environments were assessed for risks and staff undertook checks and assessments to ensure that patients were kept safe.
• On this inspection we found that that staff assessed patients’ mental health and risk well, updating these assessments appropriately and regularly in patient records. Staff discussed patient risk frequently in handovers, complex case review meetings and had access to supervision to help them provide high quality care.
• Patients had access to experienced staff from a variety of mental health professional backgrounds. From observing care, speaking with patients and reviewing records, we saw that staff worked collaboratively with patients to develop care plans and meet the patient’s needs. Staff were able to offer a range of nationally recommended interventions (such as psychological therapies recommended by the National Institute for Health and Care Excellence) and had good links with local services to help meet patient’s needs.
• Staff routinely met their targets for assessing patients in a timely way. In the health-based places of safety this ranged from 95-97% of patients being seen in 24 hours. In the intensive teams, staff saw patients within 4 hours, or within 72 hours depending on the risks of the patient. While they were with the teams, patients had access to appropriate care environments that protected their dignity and privacy appropriately. After they had left the care of the teams, staff collected patient feedback and used this to learn and improve their services.
• Patient representatives were included in recruitment panels for new starters and managers held meetings with patient representatives to gather feedback for service developments. Staff would also meet with carers and help them receive carers assessments to meet their needs.
• Staff teams had strong bonds and reported respecting and valuing their local leadership. They felt their managers were approachable and supportive. Staff felt able to raise concerns without reprisals.

However:

• The North Bristol Intensive team reported that there were a number of shift were staffing levels had fallen below the minimum agreed staffing levels and had not been able to access bank or agency staff to cover these. This problem was made worse when they covered the out of hours cover for the Bristol intensive teams and meant they had to postpone visits.
• Medicines were not managed consistently across the intensive teams. Where we found issues with how medicines were managed, staff addressed these promptly.
• Trust policies on completing physical health checks for patients had not yet been implemented by the intensive support teams.
• The North Bristol Intensive team did not have good access to therapy rooms on site. Staff prioritised meeting patients the patients home. Some patients would have preferred meeting staff away from their homes due for privacy reasons.

Updated 22 May 2020

• There was a strong, visible person-centred culture. Staff treated patients with respect and built open relationships so that patients felt able to discuss their needs and raise concerns. The unit would invite families and advocates to be involved in meetings about the patients.
• The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Managers ensured that staffing levels were adjusted to reflect the fluctuating needs of patients and the risk levels present at that time. Any potential impact of staffing vacancies was mitigated by the use of bank and agency staff familiar with the ward and its patients.
• Staff assessed and managed risk well, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and autism and engaged in clinical audits to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• There were high levels of satisfaction within the staff groups. There was strong collaboration and team-working and a common focus on improving the quality and sustainability of care and people’s experiences. Quality improvement methodology was embedded on the ward. Staff were empowered to lead and deliver change.
• The service participated in the trust’s restrictive interventions reduction programme, which met best practice standards. The service had appointed a reducing restrictive practice lead and had embedded a Positive Behaviour Support model of care, this had been effective in significantly reducing the number of restrictive interventions.
• Governance arrangements were robust, and incidents and risks were reported, analysed and shared. Leaders had high quality management information, which showed trends and risks in the service. They were able to use this information to manage risks and improve the service.

However,

• Medication records had a number of missing signatures and review dates. We raised this at the time of inspection and the manager agreed to follow up.

Updated 7 March 2023

Avon and Wiltshire Mental Health Partnership NHS Trust have four long stay and rehabilitation mental health wards for working age adults. During this inspection, we visited 3 wards; Alder ward (10 beds), Windswept ward (14 beds) and Whittucks road (15 beds) which are based in Bristol, Swindon and South Gloucestershire respectively. We did not visit Elmham Way in North Somerset.

During this focused inspection we inspected the safe and well led domains due to having concerns around the safety on the wards.

We rated this service as good because:

• Staff assessed and managed risks to patients and themselves well. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff assessed the physical and mental health of patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. They involved patients and gave them access to their care planning.
• Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the service they managed and were visible and approachable for patients and staff.
• Staff felt respected, supported and valued. They said the service promoted equality and diversity and provided opportunities for development and career progression. They could raise any concerns without fear of retribution.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, not all of the matrons or managers had received level 3 safeguarding training in line with the safeguarding intercollegiate document.
• While staff had received basic training to keep patients safe, none were aware of the Oliver McGowan training for patients who may require support with learning disability or autism.
• Bedrooms on Alder ward and Whittucks Road were located on the 1st floor. While there were evacuation chairs in situ none of the staff had received up to date training to use the equipment. Staff informed us individual evacuation plans would be implemented when needed. It was noted during the inspection, that none of the patients required a personal emergency evacuation plan.
• Not all staff had received prevention management of violence and aggression (PMVA) training and felt vulnerable when requested to support patients on the acute wards.
• While the service had enough nursing staff and consultants on Alder ward and Whittucks Road, Windswept ward did not have a substantive medical cover and were dependent on medical cover from an acute ward. The service had limited access to junior doctors. Staff told us the availability of a doctor attending the ward quickly in an emergency was on occasions difficult. However, there had been no adverse incidents identified within the records seen.While there were systems and processes to safely prescribe, administer, record and store medicines, we found that prescriptions charts were not always updated to provide accurate information to staff. There were gaps in the calibration of blood monitoring machines on Alder ward and Whittucks Road.
• While monthly quality assurance data was completed and analysed, we saw these were not always accurate. We found no cleaning records available on Alder ward and those on Whittucks Road had gaps in recording. Blood monitoring machines had also not been calibrated which may result in patients receiving inaccurate readings. This meant that audits were not picking up issues on compliance.
• Outcomes data and quality improvement opportunities and evidence-based policies and procedures were reviewed within the clinical governance framework. However, we were not assured how this information was shared with staff. Most staff spoken with said they did not know how well the service was performing.

Information about the service

We inspected 3 long-stay and rehabilitation mental health wards for adults of working age under Avon and Wiltshire Mental Health Partnership NHS Trust. These were; Alder ward (10 beds), Windswept ward (14 beds) and Whittucks Road (15 beds) which were based in Bristol, Swindon and South Gloucestershire respectively. All wards provided support to both male and female patients.

Windswept ward was currently running as an 8-bed mixed sex rehabilitation ward for adults of working age. The ward was closed during the pandemic and reopened towards the end of 2021. There were no plans to extend the number of patients due to not having substantive medical cover.

Whittucks Road was a standalone unit which provided accommodation for 5 female and 4 male patients. The remaining 6 beds provided independent step-down accommodation for 3 male and 3 female patients. The step-down beds were for patients who were able to live a more independent life and aimed to help them prepare for a return to the community.

The trust described these locations as community rehabilitation units as they provided care to patients who were at a point where they might be discharged into supported accommodation, or into the community.

The rehabilitation services worked with a client group who experienced long-term complex mental health problems, offering an extended period of engagement.

The service was registered for the following regulated activities:

• Assessment and/or medical treatment based for persons detained under the Mental Health Act 1983.
• Diagnostic and screening procedures.
• Treatment of disease, disorder or injury.

The service was last inspected in 2017 where it was rated as good overall. We rated safe as requires improvement while effective, caring, responsive and well-led were rated good. During this inspection we reviewed the rating for safe and well-led only.

During the last inspection which was carried out on 20 June 2017 the Care Quality Commission (CQC) imposed a breach of Regulation 10, (Dignity and Respect) at Whittucks Road. During this inspection we found this breach had been met.

Updated 10 November 2021

Updated 8 September 2016

We rated Avon and Wiltshire Mental Health Partnership Trust’s substance misuse services as Good because:

• Staff were following ‘Drug misuse and dependence: UK guidelines of clinical management (2007) and National Institute for Health and Care Excellence (NICE)’ guidelines for substitute prescribing and psychological therapy, which also informed trust policies and procedures.

• Staff monitored clients in the community safely and regularly throughout the treatment period. Medical cover was available over a 24 hour period and there were emergency procedures in place.

• Staff completed and updated risk assessments. They had a clear understanding of individual risks and were highly skilled and experienced. Risks were managed well both in community and inpatient settings. Recovery care plans involved the client and were clear and holistic and contained detailed information regarding client’s care and treatment..

• Environments, including clinic rooms, were clean and well maintained and laid out in a way which protected privacy. Information was freely available specific to substance misuse problems. For example other agencies, social services and advocacy.

• Medicines management was effective throughout the services. Where medicines were kept on site they were stored, monitored and audited safely.

• There were sufficient staff numbers to meet the needs of people using the services. The community specialist substance misuse services (SDAS) had reduced their staffing numbers when they redesigned their service models. Managers had worked creatively to ensure client safety through the redesign of the service.

• Community SDAS and inpatient services provided support for all healthcare needs associated with substance misuse. Staff supported people with blood-borne virus testing. Electrocardiograms were taken for people receiving high doses of methadone to monitor the effects on the heart. Some services provided specialist input into general practitioner (GP) surgeries, which was considered by GP’s as a highly effective service.

• Staff were very caring and demonstrated a high level of positive regard and respect to people accessing the services. Staff attitudes towards people were warm, kind, non-judgemental and thoughtful.

• The services were managed by highly committed and inspirational leaders. They demonstrated a clear determination to ensure that needs and safety were not affected by the redesigns and upcoming retendering processes. For example, Avon and Wiltshire Mental Health Partnership Trust provided the South Gloucestershire service. However in the near future other health organisations would have to opportunity to bid to manage this service instead. Staff told us they felt supported, supervised and positive about their place within the teams.

• The trust gave staff opportunities to develop leadership and specialist skills across the different roles within the service. Poor performance issues were managed well.

However:

• Although we saw that risks were discussed, reviewed and updated on Acer Unit, locating where updated risk assessments was difficult in patient records. There was no clear system in place.

• The redesign of the Bristol recovery orientated alcohol and drugs service specialist drug and alcohol service (Stokes Croft) had resulted in pressure and a backlog within the rapid prescribing service. This team was holding high caseloads as they waited to transfer clients to their Colston Fort specialist drug and alcohol service.

Updated 28 August 2014

The six rehabilitation wards are based in five hospital sites across Bristol, Weston Super Mare and Swindon. All provide inpatient mental health services for adults.

Risks were usually assessed and staff understood their responsibilities regarding safeguarding. However we found that incidents had not always been reported, investigated or learnt from, though this did not always translate in to changes in practice.

Overall, we saw good multidisciplinary working and staff working well with external services to ensure a positive care pathway for people.  Staff were compassionate and caring. People we spoke with were mainly positive about the staff and felt they made a positive impact on their experience on the ward.

We found good evidence that patients were involved in the planning of the services. Both staff and patients knew how to make a complaint and many were positive regarding the response they received.

Staff generally felt supported by the managers at ward level however leadership from above ward level was not as visible to all staff.