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Provider: Avon and Wiltshire Mental Health Partnership NHS Trust Requires improvement

Listen to an audio version of the report for Avon and Wiltshire Mental Health Partnership NHS Trust from our inspection on 04 September - 04 October 2018, which was published on 21 December 2018. Listen to the report.
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Reports


Inspection carried out on Tuesday 25 February 2020 to Wednesday 25 March 2020

During a routine inspection

This report includes the findings from the completed service level inspections, but the well-led inspection was not completed. CQC is only able to update findings on well-led at the overall trust level or update the other trust-level ratings when we have inspected the well-led component. As a result, the ratings for the overall trust and five key questions included in this report are from a previous inspection.


CQC inspections of services

Service reports published 22 May 2020
Inspection carried out on Tuesday 25 February 2020 to Wednesday 25 March 2020 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on Tuesday 25 February 2020 to Wednesday 25 March 2020 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on Tuesday 25 February 2020 to Wednesday 25 March 2020 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 22 May 2020
Service reports published 21 December 2018
Inspection carried out on 4th Sept 2018 – 4th Oct 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 4th Sept 2018 – 4th Oct 2018 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 4th Sept 2018 – 4th Oct 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 4th Sept 2018 – 4th Oct 2018 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 4th Sept 2018 – 4th Oct 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 21 December 2018
Service reports published 3 October 2017
Inspection carried out on To Be Confirmed During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 20 June 2017 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on 20th June 2017 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Inspection carried out on 19 June 2017 – 29 June During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 19 June 2017 – 29 June 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 20-29 June 2017 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 27 & 28 June and 7th July 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
See more service reports published 3 October 2017
Service reports published 8 September 2016
Inspection carried out on 23 - 27 May 2016 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 16th May 2016 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)
Inspection carried out on 24 -27 May 2016 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Inspection carried out on 23 - 27 May 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 17 – 26 May 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 16 – 19 may 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 16 - 27 May 2016 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 17/05/16-26/05/16 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
See more service reports published 8 September 2016
Service reports published 25 February 2016
Inspection carried out on 08 and 09 December 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Service reports published 24 July 2015
Inspection carried out on 10-13 June 2014, 11 december 2015 and 17-18 December 2015 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Service reports published 18 September 2014
Inspection carried out on 10-12 June 2014 During an inspection of Adult solid tumours Download report PDF (opens in a new tab)
Inspection carried out on 10-13 June 2014 During an inspection of Reference: NA not found Download report PDF (opens in a new tab)
Inspection carried out on 4th Sept 2018 – 4th Oct 2018

During a routine inspection

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

  • We rated safe, responsive and well led as requires improvement and rated effective and caring as good. Our rating for the trust considered the previous ratings of services not inspected this time.
  • We rated well led for the trust overall as requires improvement. The rating for well led is based on what we found during our well-led inspection but also takes into account the aggregated ratings from each of the core services. Ratings for other key questions are derived from aggregating the ratings from each of the core services.

  • Whilst the chief executive provided positive and passionate leadership working with two strategic transformation plans (STPs) took up a considerable amount of time. The trust had not progressed a number of required improvements as quickly as it should have done. We were concerned that the trust did not have the leadership capacity it needed to deliver its vision and strategy, as well as focus on day to day delivery.

  • Although the trust had a vision for what it wanted to achieve staff were not fully aware of the trust plans to turn this into action. The relatively new trust strategy had not really been embedded across the trust and staff were unclear as to the direction of travel and how they played a part in achieving the strategy. The measures or milestones to demonstrate progress with the strategy were not clear and were not well understood. However, the trust had structures, systems and processes in place to support the delivery of its strategy including committees, sub-committees and team meetings

  • The trust did not use a systematic approach to continually improve the quality of its services or safeguard standards of care. There was a lack of quality governance systems in place. However, there were some good local initiatives to improve services being progressed in different services across the trust. It was unclear how some of the assurance frameworks used by the trust related to one another. For example, there was no clear alignment between the board assurance framework and corporate risk register although the trust was subsequently reviewing this. However, the trust had structures, systems and processes in place to support the delivery of its strategy including committees, sub-committees and team meetings. In 2018, the trust underwent an external review of its committees and their terms of reference. The review identified the need for more robust quality governance reporting systems.

  • Prior to undertaking an inspection CQC asks trusts to submit a range of up to date information about it how managers and delivers its services. The trust was unable to provide us with the full range of information requested. The trust appeared to hold information at service level but we were told it was difficult to pull this together to give a trust wide picture. This led us to question whether the trust board had all the information it needed to assure itself of the quality of care delivered across the trust.

  • Across the acute wards and psychiatric intensive care units the trust had not made the improvements that we told it must be made at the two previous inspections in 2016 and 2017. At this inspection we found that there were still improvements required to ensure that environmental risks related to ligatures and seclusion practices were effectively managed.
  • Within the child and adolescent inpatient unit, we found that some of the environmental risk issues that we identified at the last inspection remained. During a period of building works, the ward was unable to admit young people with a high level of risk because it could not care for them safely. Although the trust planned to relocate the ward to complete the next phase of building works it was unclear when this would take place.
  • Community child and adolescent mental health teams were understaffed and there was a high turnover of staff. We found staff had increased levels of stress caused by a combination of complex caseloads and the pressures of long waiting lists.
  • We rated the Daisy unit, an inpatient service for people with a learning disability, as inadequate overall. We found that there were a high number of physical interventions used to manage the behaviour of patients but that the unit did not have a plan to reduce the use of these practices. The model of care was not clear. The unit did not have a focus on enabling people to leave hospital and integrate back into the community in line with national guidance and best practice.
  • Staff, including managers, did not know about the Freedom to Speak Up Guardian and some staff were not aware of the whistleblowing procedure.
  • Many staff we spoke with were concerned about a current review of the administration staff roles and were concerned this would lead to a reduced number of administration staff.
  • The roles and purpose of infection prevention and control (IPC) within the trust needed further development. IPC was not a high priority throughout the trust. However, the new Director of Nursing and Quality had taken on the director of infection prevention and control role and was planning to ensure this was given a higher priority to ensure patients were not put at risk of infection whilst receiving care at the trust.

However:

  • The trust board and senior leadership team had a wide range of skills and experiences and were passionate about wanting to deliver safe, high quality services for the patients that used the trust services. The non-executive directors brought a range of expertise from their professional backgrounds, such as organisational change and financial performance. The board was building a new leadership team; there had recently been a number of new directors appointed. Following the appointment of the director of finance there was now assurance that, while there was still more to do, there was movement towards a more robust and transparent financial position. The new director of human resources had made good progress to address recruitment issues and the newly appointed Director of Nursing and Quality had a good grasp of what needed to be done to address the quality governance issues.
  • The culture of the organisation had improved since our last inspection. The majority of staff said they felt respected, supported and valued by the trust. Staff felt that the senior leadership team had supported a number of significant improvements in services and as such staff now had more confidence in senior leaders.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs. We observed staff responding well to individual patient need. Staff usually involved patients and those close to them in decisions about their care and treatment.
  • The trust had a structured approach to engaging with people who used services, those close to them and organisation representing them. The wards, teams and divisions had access to feedback from patients, carers and staff and were using this to make improvements.
  • Within the core services staff, analysed, managed and used information well to support all its activities, using secure systems with security safeguards. The wards and community teams had good systems and processes in place to assess and monitor quality and safety. Staff participation in audits was good and there were regular audits conducted including infection control and medication audits.

  • Acute wards had moved towards a trust wide approach of bed management with the aim of ensuring a bed could be found as near as possible to where they lived for anyone who needed to be admitted. The trust had introduced a daily bed management call for all ward managers and matrons to manage the effective discharge of patients, and any potential barriers to discharge.
  • Staff assessed the mental health and physical health of patients on admission. Staff supported patients with their physical health and encouraged them to live healthier lives.

Inspection carried out on 26-30 June 2017

During an inspection looking at part of the service

Following the inspection in June 2017, we have not changed the overall rating for the trust from requires improvement because:

  • During the comprehensive inspection of the trust in 2016 we told the trust it must make improvements in a number of areas. The two main areas of concern were the health based places of safety which we rated as inadequate, and wards for older people which was rated as requires improvement. Whilst we found on this inspection improvements had been made across all the areas we inspected, not all of the planned improvements had been made.

  • In May 2016 at the previous inspection we rated six out of 10 core services as requires improvement. At this inspection the number requiring improvement is now seven out of 13 core services.

  • Within the wards for older people core service, ward 4 at St Martins hospital in Bath still had dormitory style shared accommodation. The trust was continuing to work with commissioners to try and address the issues. However, this will require significant capital investment. Aspen ward at Callington Road hospital, had blind spots and there were no convex mirrors in place, which meant that staff could not fully observe patients. Laurel ward, at the same site, had been closed suddenly by the trust two weeks prior to this inspection and was the subject of an ongoing safeguarding inquiry by Bristol City council.

  • Within acute wards and psychiatric intensive care units, we found that the work to minimise ligature risks was ongoing. A ligature point is anything that could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. Although progressing, works to address all ligature risks across the service remained outstanding. Arrangements for the safe administration of rapid tranquilisation had improved, and work to address the privacy and dignity issues around the use of seclusion was ongoing. However, access to seclusion from Silverbirch ward at Callington Road hospital remained a concern. Although the trust was holding a consultation about the future use and provision of its seclusion arrangements, during the inspection. Alarm systems on Beechyldene and Ashdown unit were inadequate. The checking of medical equipment and emergency drugs was not always being done in line with organisational policy.

  • In the Devizes health based place of safety, staff had not identified some potential ligature points as part of the risk assessment, and there was a lack of clear plans in place to mitigate the risks. There were significant problems accessing beds for people requiring admission to hospital. We saw examples of patients waiting 32 to 50 hours after being assessed in the place of safety before admission to hospital. This also put pressure on the crisis teams who had to deal with patients requiring a high level of care in the community.

  • From 1 April 2016 the trust had taken on responsibility for children and adolescents mental health services (CAMHS) in the wider Bristol area. This included community teams and an inpatient unit (the Riverside unit). This service had lost its service managers during the transfer and many management tasks now fell to senior clinicians. In addition, there were shortfalls in staffing in young peoples’ community mental health team, which had led to increased waiting times. Staff morale was variable in the service and the lack of a consistent contract with NHS England was having a negative impact. We found the current level of risk on the Riverside unit to be manageable, given the current level of challenges staff face with the children currently admitted to the ward.

However:

  • The majority of the issues we previously identified with the environment at the places of safety had been addressed .There had been a reduction in the number of people exceeding the maximum 72 hours in the place of safety. This had occurred on two occasions in the previous year. This was in comparison to eight occasions in the year before our last inspection. The trust had introduced systems to alert managers to delays in the place of safety. There regularly remained significant delays in assessments commencing at the places of safety.

  • At the time of this inspection, the trust was going through a significant period of change. The trust had a relatively new senior leadership team, with a range of appointments made over the last 12 months. This included a new chair, medical director, finance director, operations director and two non-executive directors. A new appointment to the director of human resources role was due to commence in post shortly after the inspection.The trust chair was implementing a considerable change programme. This included a new focus on the governance and reporting arrangements for the board, in order to improve its overall effectiveness. The trust was implementing a new divisional structure aligned to the two Sustainability and Transformation Plan footprints which maintained oversight of the six locality and three specialist delivery units. The Trust has embarked on a significant cost improvement programme which had been caused by an overspend the previous year. The details of this cost reduction plan were still to be agreed by the trust board and commissioners; however the scale of the savings over the next 12 months will have a significant impact on the future operating model of the trust.

  • In May 2016, the trust did not ensure staff adhered to Mental Health Act (MHA) legislation and the standards described in the MHA code of practice. When we visited in June 2017, we found managers had made improvements, so staff worked appropriately within the legislation.

The full report of the inspection carried out in May 2016 can be found here http://www.cqc.org.uk/provider/RVN

Inspection carried out on 16 - 27 May 2016

During a routine inspection

We rated one of the core services inspected as ‘inadequate’ and one as ‘requires improvement’. We rated five of the core services ‘good’ overall. We rated the specialist services as ‘good’ overall

We rated the trust as requires improvement overall because;

  • We have served two warning notices in the past six months which imposed a legal duty on the trust to make significant improvements. We served one warning notice in December 2015 because we had significant concerns about the Bristol crisis, assessment and recovery services delivered to adults of working age and one during this inspection (May 2016) because of serious concerns about the quality of care in the health based places of safety across the trust. On both occasions we found that the trust did not have effective governance arrangements in place to enable it to assess, monitor and improve the quality of services (including the quality of the experience of service users in receiving those services). The trust had little knowledge of either of the issues until we raised these at the respective inspections and as such, we were not assured that governance arrangements and board oversight were robust enough to identify, address and learn from key risks in a timely manner.

We had serious concerns about the trusts ability to deliver safe, effective and responsive health based place of safety services. Patients were regularly taken to police cells (used as health based places of safety) because of the lack of availability of beds in the trust’s health based places of safety (police cells should only be used in exceptional circumstances). In addition, if the Mason unit at Bristol was full patients would be taken to the emergency departments at the local general hospitals. Emergency department staff raised concerns as this was felt to potentially put patients and staff at risk. Patients waited too long for a Mental Health Act assessment in the health based places of safety. Patients regularly waited over twelve hours for assessment and then waited many more hours for admission to a suitable ward if they needed inpatient care. In addition we had concerns about the safety of the environments of some of places of safety. at The new health based place of safety at Devizes had only been opened the week prior to our inspection despite us telling the trust that the old health based place of safety was not suitable for use during our inspection in 2014. It was not fit for purpose and did not have an appropriate emergency response system.There were on-going environmental issues with legionella at the Mason unit in Bristol as well as multiple known ligature points (environmental features that could support a noose or other method of strangulation).

  • All crisis and health based place of safety staff we spoke with told us of the lack of bed availability across the trust which caused significant delays in getting patients into a bed following admission and had a serious impact on the capacity of staff (for example, taking clinician’s a whole shift to find a bed) and on the care of patients.

  • The trust board was going through a period of significant change. The chief executive had only been in post three months during our inspection. The trust was recruiting to a number of director posts, including the medical director and finance director and was waiting for a new director of operations to commence in post. In addition, the chair was coming to the end of his term of office. Once the chair left post an interim chair would cover until a perminant appointment could be made. A number of non-executive director posts were also in the process of being appointed to. Alongside this, there had been a whole scale review of senior roles and strengthening of nursing leadership with the director of nursing and quality taking the lead for quality governance. This had caused significant instability, a lack of clear leadership and accountability for some initiatives and delivery of functions and some lack of engagement between senior leaders and staff. Staff reported that senior management based at trust headquarters were not as visible as they would like them to be.

  • The triumvirates (locality and speciality management arrangements), whilst generally working well locally, often worked independently of each other and staff felt that they sometimes worked in silos, resulting in a lack of sharing and learning across the trust.

  • We found that seclusion practices at Callington Road Hospital were not safe and that Silver Birch ward did not have adequate resources or facilities to care for people requiring seclusion. On some wards when seclusion was required patients were escorted, under restraint, out of the ward and across the hospital grounds to an available seclusion room. We felt that this placed patients in significant danger and did not preserve their dignity. The trust had advised that Silver Birch used secure transport to transfer patients to wards with seclusion facilities. However, the secure transport often took in excess of five hours to respond causing further delays in ensuring patients received the appropriate care at the right time.

  • Older people’s wards across the trust, with the exception of ward four at Bath, did not provide appropriate environments to care for people with dementia. Laurel, Amblescroft North and Dune wards had made minimal adjustments to ensure they were ‘dementia friendly’. Laurel and Amblescroft were bleak and sparse with little in the way of decoration and no dementia friendly signage. Staff had made some changes on Dune, with some tactile artwork, appropriate signage and brightly coloured furniture. In some older peoples wards staff did not always report all incidents that occurred as there was a culture of acceptance about aggression exhibited by elderly patients with mental health problems, including dementia.

In the rehabilitations wards the trust was not meeting guidance on same sex accomadation. For example, Whittucks Road only had bathrooms

in female areas, which meant staff had to supervise if male patients requested a bath.

  • In the acute wards and psychiatric intensive care units bed availability caused significant issues. Patients were regularly cared for in an ‘out of area’ bed, sometimes a long way from home. When patients went on leave there was often not a bed in the same ward that they left to come back to.

  • The trust faced major challenges with maintaining safe staffing levels. In some services, particularly in crisis services the trust had difficulty providing data outlining the staffing establishments and when it did provide this it provided different information prior to inspection, during inspection and directly from the teams. This made it difficult to understand the staffing arrangements of the teams but all the data reflected that there were significant numbers of vacancies in some teams. The trust had undertaken a review of staffing levels on inpatient wards and for most staffing levels increased. This had resulted in a number of vacancies but the trust was proactively recruiting to fill these. In community and crisis teams, the trust had commissioned a review of working practices and caseloads and as a result staffing numbers had been reduced in some teams, for example the Wiltshire crisis team. Staff were not happy about this and reported that they felt there were not always enough staff to safely meet the needs of the service. There were high vacancy, turnover and sickness rates in a number of services including, forensic, acute inpatient and psychiatric intensive care, older people’s wards and substance misuse services. All areas used bank and agency staff but all areas tried to use the same staff to ensure continuity of care. Ward managers and team leaders were able to adjust staffing levels when bank staff were required. If bank staff were not available, ward managers and team leaders had to seek authority to use agency from service managers.

  • In community based mental health services for older people targets for waiting times for memory service assessment were not always being met and in services for people with learning disabilities there was no information kept about waiting times.

However:

  • Generally, the trust were aware of areas that required improvement. When we raised issues that the senior team wasn’t as sighted on as they thought they were the response was immediate, really positive and they put in mechanisms to ensure they would be sighted in the future. Throughout the inspection the trust were very receptive to any comments that we made and took immediate action when we raised a concern. For example, the trust undertook an immediate review of seclusion practice at Callington Road Hospital, it put in a senior nurse to support staff and immediately changed transport arrangements so patients could be transported to seclusion facilities in around 10 minutes. It made changes to the health based place of safety environment at Devizes and ensured appropriate emergency equipment and an emergency response system was available.

  • We found that the trust had made some significant improvements to the safety and quality of services, staffing levels and governance arrangements across the Bristol community teams. During this inspection we were able to lift the warning notice that we had served during an unannounced, focussed inspection in December 2015. However, we identified that some further improvements were still required in the Bristol north team and asked the trust to provide written assurance by 13 June 2016 of action it would take to ensure the required improvements were made.

  • Without exception patients and carers spoke positively about the care they received and patients said they felt safe. Staff were caring, enthusiastic and committed to delivering high quality care and treating patients and carers with dignity and respect. We observed therapeutic, compassionate and relaxed relationships between staff and patients. Across the majority of services patients had good access to emotional support and there was clear evidence that staff considered patient’s diverse and cultural needs.

  • There were some impressive services with staff going the extra mile to deliver innovative service in challenging circumstances. For example, substance misuse services where there was a real evidence base to the service delivery with, creative, strong pathways, comprehensive assessments, positive working relationships with commissioners, good partnership working across services. In addition, forensic services had transformed service delivery since our last inspection with a good environment, good risk assessments, some excellent practice around the minimal use of restraint and seclusion. The triumvirate were working well together and had developed a positive culture which staff bought into.

  • It is our view that the provider had made significant progress in developing services and bringing about improvements since our last comprehensive inspection in 2014. The new chief executive and director of nursing and quality had brought a real focus on quality and a proactive style of leadership. The ‘can do’ attitude of the senior leaders was having a positive effect on changing culure and there was a real commitment to actively engage with staff, patients, the public and partner organisation. Given time, we believe, that with a continued focus on quality and the establishment of a stable trust board to lead and drive through changes the provider will realise its vision. However, some significant work is still required to improve quality and consistency of services and effectiveness of working practices across the trust.

  • We will be working with the trust to agree an action plan to assist them in making the improvements the standards of care and treatment.

Inspection carried out on 10-13 June 2014, 11 December 2015 and 17-18 December 2015

During an inspection looking at part of the service

We found that there are some areas of improvement needed to ensure the delivery of a safe, effective and responsive service.

While the board and senior management had a clear vision with strategic objectives, and a clearer management structure had been put in place, staff did not feel fully engaged in the improvement agenda of the trust.

The trust told us that executives and board members had been involved in a number of initiatives to engage with staff and give staff the opportunity to talk directly about issues that affect them. However, staff told us that leadership from above ward level was not visible or accessible to all staff.

We found that while performance improvement tools and governance structures had been put in place, these had not always facilitated effective learning or brought about improvement to practices.

We found that both staff and patients knew how to make a complaint and most were positive about the response they received. There had been a number of positive initiatives to engage service users, carers, and wider stakeholders in the development of the trust. However throughout this inspection we heard from service users, carers and local user groups who felt that they had not been effectively engaged by the trust in planning and improvement processes.

We had a number of concerns about the safety of this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patient’s needs; inadequate arrangements for medication management; and safety and fire equipment that was not fit for purpose. 

We were also concerned that while the trust had systems in place to report incidents, improvement was needed to ensure that all incidents were reported, investigated and learnt from, and that changes to practice were made as a result. We found a number of concerning incidents across the trust that had not resulted in learning or action.

Some staff had not received their mandatory training and many staff had not received regular supervision and appraisal. However overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.

Most teams were using evidence based models of treatment and made reference to National Institute for Health and Care Excellence (NICE) or other relevant national guidelines. However, we found incidents of restraint and seclusion that had not been safeguarded in line with the guidance of the Mental Health Act Code of Practice.

A lack of availability of beds was a trust-wide issue, with intensive, acute and older people’s beds always in demand. This meant that people did not always receive the right care at the right time and sometimes people may have been moved, discharged early or managed within an inappropriate service.

We found that generally there was evidence of different groups working together effectively to ensure that patients’ needs continued to be met when they moved between services. Overall, we saw that staff were kind, caring and responsive to people and were skilled in the delivery of care. We observed some very positive examples of staff providing emotional support to people, despite the challenges of staffing levels and some poor ward environments.

It is our view that the trust needs to take significant steps to improve the quality of their services and we find that they are currently in breach of regulations. 

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they had taken to address our concerns.

We gave the trust some Enforcement Actions which gives a strict timescale for them to improve. We will be working with them to agree an action plan to assist them in improving the standards of care and treatment.

We returned to the trust on 11 December, where we interviewed senior manager and members of the board. We also carried out unannounced focussed inspections on the 17 and 18 December 2014. We carried out focussed inspections at Hillview Lodge, Fromeside, Juniper Ward, Elizabeth Casson, Range Ward at Callington Road, crisis team Swindon, community team South Gloucester and North Somerset. The inspections focussed on the trust's compliance with he requirements of the enforcement actions, the four warning notices. 

The trust had taken all reasonably practicable steps to comply with the warning notices within the timeframe provided. The Enforcement Actions, namely the four warning notices have been removed. These focussed inspection did not review the existing compliance actions, these remain in place. Please see the safe domain of the report for further details of our findings.

Inspection carried out on 10-13 June 2014

During a routine inspection

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Organisation Review of Compliance


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.