Avon and Wiltshire Mental Health Partnership NHS Trust

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
• Environmental sustainability – sustainable development

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us there was a willingness from the trust to improve culture and hear from patients. We saw evidence there was attendance at Quality and Standards committee meetings by an expert by experience in April 2024 and a carer representative in May 2024. However, people felt they were not involved in decision making and information presented to patient and carer representatives did not always match their lived experience. We saw evidence the trust included service user representatives in the Care Planning Transformation Programme Board which was responsible for overseeing and monitoring all activity in relation to the co-produced Care Planning Transformation Programme and its work streams. Two service user representatives were members of this board, one of whom co-chaired meetings.

One service user representative was also included in the Quality and Treatment Programme Board which was responsible for overseeing and monitoring all activity in relation to the implementation of the trust’s Quality and Treatment transformation programmes, and associated projects, in support of their 5 year strategy.

Leaders told us they developed their strategy in 2019 but had to pause launching this during the pandemic. Their priority and focus during the Covid-19 pandemic was to keep patients and staff safe. Following the period of recovery post-pandemic, they undertook a series of roadshows and workshops with staff and patients to review and launch their 5-year strategy. Leaders recognised there had historically been cultural issues within the organisation, such as racism and closed cultures, and took this seriously. They were committed to improve these issues and had set out a number of actions to address and keep oversight of cultural issues. Staff told us senior leaders listened to them and had confidence that actions would be taken to address their concerns. However, some staff did not feel, when they escalated issues to the middle management teams, these were escalated further and appropriate actions taken. Some staff did not have confidence that communication from senior leaders were shared with them through the middle management team. We reviewed the 2023 NHS staff survey results in relation to staff response about their immediate manager. Seventy-nine percent of staff agreed or strongly agreed their immediate manager cared about their concerns compared to an average of 78% for similar organisations. The percentage of staff who agreed or strongly agreed their immediate manager took effective actions to help them with any problems they faced were similar to the average for similar organisations at 75%.

Stakeholders and partners told us the leadership team did not always engage with them on key issues such as such as commissioning, risks and quality. They told us the culture in the organisation can be defensive and deflective. Closed cultures had been identified in some part of the organisation, particular in secure services. While the senior leadership team were working towards improving the culture, mechanism to identify poor culture and address these at an early stage were ineffective.

Processes had been improved to obtain and act on feedback from stakeholders, partners, patients and staff. However, these were newly implemented and the leadership team were still working on improving these further and embedding them through a renewed governance structure and board assurance framework.

People told us they believed leaders were keen to make changes to improve mental health services in the large geographical areas the trust covered. They had seen an improvement in the last year with how the trust wanted to engage with them. However, they also felt there was a lack of patient representation at decision making level. People also wanted to be part of setting the trust strategies to ensure improvements were inclusive of people’s experience

Staff told us senior leaders were capable, compassionate and took their feedback on board. For example, they felt there had been positive changes since the Director of Nursing had been in post and they worked well with the Medical Director. However, staff also told us there were cultural issues at middle management level where they did not always feel listened to.

Feedback from partners were mixed. Partners identified individual members of the executive team were capable and had strong relationships with their teams. However, they did always work together as a unitary executive team. Key meetings were not always attended by relevant leaders and the wider executive team were not always deployed. It was noted the Director of Nursing was open and transparent and was present in most meetings relating to risks and quality. Recruitment into key leadership posts had been slow which added pressure to the existing team. This added to additional pressures to swift response and decision making to wider issues.

The trust used the Board Assurance Framework (BAF) as a structure to support the overview of risks, quality and performance through the integrated governance arrangements. A quality improvement group, which included the 2 Integrated Care Boards within which the trust operates, undertook a quality deep dive in February 2024. This identified there was a connection between frontline services and the Board through the BAF. However, it needed further improvement as it had not identified emerging issues in some services within the trust. We saw discussions that took place at board meetings to identify areas where improvements needed to be made to the BAF. This included integrating the BAF with the trust risk register and using systems to improve updating the BAF so it remained a live document.

Staff were aware of the Freedom to Speak Up process (FTSU) and knew who the FTSU champions and leads were. However, staff indicated a fear of retribution when speaking up. They told us if they raised anonymous concerns through the FTSU, their concerns would not be taken forward. Leaders told us they had implemented an app to make it easier for staff to raise concerns. Some staff we spoke with did not feel safe in completing staff surveys. They told us they tried to put their concerns and feedback as a team rather than individuals. In some teams, staff we spoke with felt the local management teams reviewing the feedback were trying to identify which staff member had said what.

Staff told us there were issues with communication between floor to board, and they did not have confidence that their concerns were escalated to the executive team. However, they told us the executive team were working hard to address the speaking up culture and responded to teams and individuals if they heard directly from them.

Staff did not feel completely safe to raise concerns. The trust board report for July 2024 stated that the use of the FTSU app was increasing due to it being completely anonymous and concerns being reported in their entirety and actioned immediately. Data from the trust for the period April 2023 to March 2024, showed concerns raised openly had decreased between the first and second quarter from 33 to 11; Quarter 3 and 4 remained the same at 10 each. Five concerns were raised via the app in quarter 1 and 4 were raised in each quarter for the remainder of the year. Twelve anonymous concerns were raised in quarter 1, 24 in quarter 2, 19 in quarter 3 and 23 in quarter 4. This showed more anonymous concerns were raised than open concerns between quarter 2 and quarter 4.

The trust’s bi-annual FTSU report for July 2024 states feedback collated either through the trust’s feedback form or verbally from staff who came forward was positive with 96% of staff stating they would speak up again. Many of those staff have also become FTSU champions.

The FTSU Guardian was knowledgeable about their role and the issues within the trust. The trust had identified vulnerable groups within the organisation and had undertaken workshops and training to ensure vulnerable and seldom heard groups had access to a FTSU champion and were aware of how to raise concerns.

There were concerns from partners that the FTSU process had not ensured the board were not fully sighted on key issues that existed within some of the services.

Leaders recognised the FTSU process needed to be improved and had recruited more FTSU champions to increase visibility across the trust. The July 2024 trust board papers showed there were 115 FTSU champions in the trust and they were recruiting more.

Representation from the FTSU champions covered a range of professions including facilities staff, bank staff, unregistered practitioners and administration staff.

There were several routes for staff to raise concerns which included:

• A dedicated phone line or email.
• The FTSU app
• To an Executive or non-executive director.
• To their managers.
• Directly to the FTSU Guardian and/ or champions.

Leaders however, recognised there were more work to do to improve the culture around FTSU despite the infrastructure to raising concerns being available.

Staff reported a disconnect between the board and their work related lived experience. They reported dismissive and inappropriate remarks on a number of occasions which were not in keeping with the Equality, Diversity and Inclusion (EDI) ambitions articulated by the organisational strategy or the values described by the organisation. The trust EDI network and representatives spoke about a performative culture where senior leaders spoke of inclusion, but there was a lack of action on how the trust truly achieved this. For example, senior leaders told us they had employed independent panel members to attend disciplinary meetings. However, when we examined the data at the time of the assessment, only one of the recently suspended staff members had received this support.

Staff felt their career progression and opportunities could be compromised if they disclosed information about their protected characteristics. Staff network groups told us staff declarations related to their protected characteristics were poor, but rates had improved in areas where work had been done.

EDI groups told us staff did not always formally disclose their disability. They were working to understand the reasons behind this. The trust Workforce Disability Equality Standard (WDES) 2023-2024 report showed there was an increase of 1% in disability declarations compared to the previous year.

Staff told us when patients exhibited racist behaviours towards them, actions were taken in most cases in line with the trust’s ‘zero tolerance’ policy towards racism and discrimination. However, they felt there was a culture of racism and discrimination by staff within some services and these were not always addressed in line with trust policies or values.

Staff reported issues had not been addressed within a timely manner and there was a lengthy process to implementing actions to address Equality, Diversity and Inclusion issues. For example, we were told by a staff network lead that the Patient and Carer Race Equality Framework had stalled and they were frustrated by their view of the trust’s lack of commitment. However, we noted this was reported as being discussed in the trust-wide EDI group meeting in May 2024 and noted as work that was ongoing.

Since the inspection, the Chief Executive Officer (CEO) had produced a number of personal pledges and pledges on behalf of the board, to ensure there was continuous focus on EDI matters. We were told by leaders that the pledges were co-produced with the Executive team and EDI Network Chairs during the Autumn of 2024, and then agreed by the Board in December 2024.

System partners and stakeholders told us senior leaders and executive teams were engaged in Mental Health strategy within the Integrated Care Systems they operated within. They told us there was a focus on recruitment and there was a need to continuously drive plans to reduce turnover and vacancies.

However, partners had also received feedback from trust staff that, in some cases, there was a disconnect between staff and senior leaders.

The trust also launched their people strategy “A Great Place to Work”. Within this strategy, a set of actions were identified to achieve their aims over the next 5 years. The strategies were aligned with national priorities such as the NHS Long Term Workforce Plan. As these were recently launched, they were not fully embedded.

The trust had processes to capture the views of staff. EDI networks had Executive sponsors, however, attendance of executive sponsors at network meetings were not always consistent as demonstrated in meeting minutes. Trust leaders told us these meetings were intended to be a safe space for people to talk about their experiences and were therefore advised by their human resources department and the EDI networks to only attend occasionally to support that intent.

Minutes of EDI Group meetings showed hot topics were discussed and there were learning events. However, the EDI lead was not invited to Board meetings to present their annual report nor had sight of the agenda where EDI was reported. There was also no allocated budget for EDI.

The trust’s “Central Health and Wellbeing Group Strategy” had set out a number of actions over the next year to improve staff health and wellbeing. Within this, we saw that anti-discriminatory behaviour and wellbeing was included to be delivered in September 2024.

The trust’s Workforce Race Equality Standard 2023-2024 report showed an increase of 36.6% in staff from Black and Minority Ethnic group between March 2023 and March 2024. These staff made up 17.4% of the trust workforce.

We saw the trust had identified actions to address racism and discrimination within this report.

Staff were clear on the governance processes and reporting structures. Leaders told us they had good relationships with each other and could challenge decisions. For example, the director of nursing, medical director and director of finance worked together to ensure quality of care was not compromised by financial constraints.

Leaders recognised there were shortfalls in governance processes and had used the CQC Section 29a Warning Notice from January 2023 to focus on improvements required. They understood their responsibilities as part of the 2 integrated care systems and had improved systems based on feedback and independent reviews such as NHSE’s Early Warning Signs quality review.

Leaders told us the trust was compliant with the National Emergency Preparedness, Resilience, and Response (EPRR) for the third year running. National EPRR standards arethe minimum requirements all NHS-funded organizations must meet to demonstrate their ability to respond to emergencies while maintaining critical services.

They also told us they had been able to deliver on its savings programme and had made significant improvements in out of area bed reduction.

The trust was under Enhance Surveillance Oversight within the two Integrated Care Systems (ICSs), as aligned to National Guidance on Quality and Risk Response and Escalation in ICSs. 

Quality Improvement Group (QIG) was stood up following the last CQC inspection in 2023, with membership including the trust, ICB, NHSE, the Provider Collaborative and CQC. A deep dive exercise into Safeguarding and Quality processes raised key issues for enhanced contractual oversight. QIG was stood down in May 2024 and the Enhanced Quality Oversight Group subsequently stood up to maintain enhanced oversight of these 2 areas.

Partners told us information from the trust were not always timely and did not always include the relevant information. Some of these delays had impacted on timely decision making across the ICS. However, following the deep dive exercise, the trust had reviewed and improved their quality reporting to align with the areas under enhanced surveillance. The reports were also clearer to align with the ICB areas within which the trust operate.

There was a renewed approach to oversight of risks. Sub-board committees had been reviewed, restructured and implemented in 2024. This included the addition of both a People, Culture and Leadership Committee and Digital and Estates Committee. The trust also made minor changes to all other committees. There was good representation from Executive Directors and Non-Executive Directors at these groups. However, some of those groups were newly implemented and it was too early to evaluate the effectiveness and impact of these.

The trust had reviewed their governance arrangements and had started to make improvements to ensure improved oversight of activities from ward to board. There was shared ownership of risk and staff and leaders understood their roles and responsibilities. There was a good range of accurate and timely data and information available to understand performance and quality and improvements were made as needed.

We identified during our inspection there were significant shortfalls in safeguarding processes. We found during the inspection of Community Mental Health Services, 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. This was because the safeguarding policy was unclear to staff. However, staff working in the acute wards for adults of working age and psychiatric intensive care units, staff were aware of safeguarding procedures and knew how to report concerns. We found during the Trust Well led assessment, the safeguarding team were not adequately resourced to ensure safeguarding concerns were processed in a timely manner. This led to delays in responding to the local authorities’ safeguarding teams. This was consistent with the feedback received from partners. Since the inspection, the trust sent us information to demonstrate they had recruited additional resources to support the safeguarding team. Additional resource to support leadership within the team had been created and a Head of Social Care and Safeguarding - Principal Social Worker started in post on 10 March 2025. Their work plan was focused on delivery of a safeguarding improvement plan between 2025 -2027 as well as strengthening partnership working.

The trust’s systems and processes were not effective in monitoring staff were trained to safeguarding levels in line with relevant guidance. At trust level there was no oversight of who had completed safeguarding training and there was no assurance staff knew what to do if they encountered a safeguarding issue. However, at local level, managers had oversight of safeguarding and staff training.

We found that not all staff were trained to safeguarding levels in line with the national ‘Safeguarding children and young people: roles and competences for health care staff intercollegiate guidance’. The safeguarding children training available to staff was also not fit for purpose as it was generic and not specific to the staff group working in a mental health trust.

​​​​​​​Level 3safeguarding adults training will not be completed by inpatient staff at band 7 and above until March 2025, and will then be rolled out to community teams. There did not appear to be a plan for training Band 5 and 6 inpatient and community staff. There was not sufficient mitigation until the training was rolled out and staff were sufficiently trained in safeguarding to fulfil their safeguarding responsibilities. We raised this as an immediate concern and the trust responded with actions they were taking urgently to address these concerns.

Since the inspection, the trust had updated their safeguarding improvement plan following our feedback. Progress against this plan was reported quarterly to the Quality and Safety Committee. As of March 2025, 78% of inpatient registered staff had received training in mental health specific safeguarding children. The trust had also further mitigated the risks of training not being available by providing safeguarding supervision to staff. The Head of Safeguarding and Head of Learning and Development were working together to develop a strategy for safeguarding adults training. The fill training approach was to be rolled out during 2025-2026.

During the assessment, the trust was under Enhanced Surveillance Oversight within its 2 host Integrated Care Systems (ICSs), as aligned to National Guidance on Quality and Risk Response and Escalation in ICSs.

Patient representatives felt they were not always involved in strategic decision making. They felt there was a missed opportunity for their lived experience and knowledge of specific areas of mental health services that needed to be improved, being captured as part of informing the strategic direction. We reviewed the Community Mental Health Service User Survey 2023 which showed the trust performance was similar to similar organisations surveyed. There were 4 recommendations, 2 relating to accessing care and treatment, 1 relating to the mental health team, and 1 relating to people’s care.

Leaders were clear of their roles and responsibilities to collaborate with system partners and work in partnership to improve mental health provision. They understood health inequalities and had strategies to address these.

Staff representatives told us senior leaders embraced partnership working and this was improving. There was an emerging connection between what was of concern to staff and leaders. For example, staff representatives were concerned about the culture of staff being able to speak up without fear of retribution and this was a priority for senior leaders and the board.

Partners told us in some cases the senior leadership had not consistently engaged with partners and often decisions had been deferred due to the trust’s key leaders not being present at key strategic meetings.

We were told there had been missed opportunities to lead collaborative working and reach out to system partners. For example, working with primary care providers to deliver service transformation. Partners also told us the trust did not always respond to safeguarding queries in a timely way and led to delays in investigations.

However, we also received positive feedback about clinical teams establishing positive working relationships within the integrated care systems.

Leaders at the trust told us the Chief Operating Officer and the community programme Director led the Bristol, North Somerset and South Gloucestershire Community Mental Health Transformation programme. This work brought together primary and secondary care leads, the voluntary sector and lived in experience partners.

The trust had a “Working Together” strategy that was revised in 2023. This strategy had been built on the trust vision of “working together” to ensure that people feel valued, supported and heard to participate meaningfully in equal partnership to design, develop and deliver services, build and strengthen communities, in order to bring about positive change”.

Within this strategy, they had identified priorities and workstreams required for successful delivery. However, the plan lacked clear timescales and ownership.

There were processes for working with other partner agencies to review safeguarding issues. These were led by the safeguarding adult board. We saw the trust participated in these reviews.

The trust board meeting included an invitation to patients to share their experience and we observed this during the public board meeting in July 2024. There was an ambition from the senior leadership team to listen and learn from people’s experience of mental health services.

Leaders were able to evidence improvements they had made to ensure sustainable services. For example, agency staff spend had been significantly reduced in the last year. They had also successfully recruited internationally educated nursing staff to fill their substantive vacancies across inpatient services.

Partners told us the clinical team at the trust were engaged in sharing learning with system partners and they had engaged in regional and national innovation programme.

There were processes to ensure learning took place when things went wrong, this was supported by leaders who adopted a reflective and problem-solving approach.

Learning briefs and internal safety alerts were issued to localities and divisions to share learning and implement actions following incidents and events. The trust recognised they needed to improve sharing of learning from safety incidents to ensure these were shared more widely across the organisation. They had a plan to improve this however, this was in its early stages.

Each locality undertook monthly learning from events meetings where incidents, complaints, and duty of candour were reviewed. These meetings identified further actions required to improve safety. Clinical leads had oversight of the completion of those actions.

The Trust had a Green Plan, in line with national guidance, and were undertaking a mapping of their carbon emissions from procurement with a focus on medicines. There was appropriate governance to ensure performance against targets and a board level lead for Net Zero. The trust board was updated on the Green Plan progress within the Annual Report and had had a board seminar to ensure members were aware of the trust’s Net Zero goals. Furthermore, the climate emergency group was invited to a public board meeting to ask questions and receive robust answers.

Leaders were engaged with the Trust’s ‘Green Plan’ and had clear goals and a vision for the Trust’s journey to become more environmentally sustainable. The trust declared a climate emergency in 2020 recognising that urgent action was needed to tackle climate change and setting a target of being carbon neutral by 2030. They had since established a clear pathway for staff to engage and report to board. This pathway was developed via a Climate Change Emergency Action group, with 125 members, which met six times a year and was attended by a board level lead.

There was support for research within sustainability, including on green social prescribing with time and resources allocated to support. Education was available to staff on sustainable healthcare, via the e-learning platform. However, there does appear to be a challenge with engagement across all members of the workforce, particularly clinicians. This was understandable given the vast area the trust covered, and this challenge was recognised by the sustainability lead. There was a strategy to engage staff in the future including a short film co-produced with service users and attempts were made to engage staff with newsletters. There was encouragement to take part in national initiatives such as the ‘gloves off’ campaign and ensuring sustainability in procurement.

The trust sustainability lead appeared to be engaged well with both ICBs they covered, though more so for Bristol, North Somerset and South Gloucestershire (BNSSG) as it had a more developed sustainability approach. The trust was cited on both ICBs Green Plans as contributing partners. The trust met regularly with ICB sustainability teams and had close links with the Greener NHS regional lead. The Trust was committed to work within the system towards the ICS Green Plan targets, and recently secured funding from BNSSG for sustainability initiatives. The trust was engaging with colleagues across the country in national initiatives for reducing emissions in the NHS for example within medicines, estates and procurement.

Within some areas, such as estates, there was a clear understanding of where reduction in emissions could be achieved, and the Trust had been successful in these initiatives. An example of this was the securing a grant through the Public Sector Decarbonisation Scheme for solar panels, LED lights, and building management systems.

However, the trust recognised that there was further work to be done in ensuring the principles of Net Zero were embedded into all areas of the planning and delivery of patient care. The trust had already identified the need to improve how it engaged with frontline staff on how to reduce emissions associated with clinical pathways and work together with staff to deliver this.