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

The service was well led and the governance processes ensured that ward procedures ran smoothly. However, we have identified concerns related to the timeliness of environmental risks being addressed due to a number of long-standing estates related entries on the risk register with no assigned actions for completion, despite being flagged as urgent and priority works.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff across all levels and professions described a positive culture and shared direction for their service. Staff were passionate about the work they do and spoke about a shared vision to provide person-centred, recovery-focussed care to patients. However, not all staff were aware of the trust’s values.

Although staff experienced some stress in their roles, most staff felt that the ward teams were happy and worked well together.

Since the previous inspection, leaders had worked to improve the direction and culture of the wards. They had a shared vision. The leadership team were still working on improving these further and embedding them through a renewed governance structure.

Leaders had the skills, knowledge and experience to perform their roles. All wards had a ward manager and matron in place. Leaders had a good understanding of the services they managed and the current challenges they faced.

Staff described having inclusive leaders who understood the context in which care, treatment and support is delivered. Leaders embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity, openness and honesty.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had credibility to lead effectively. They did so with integrity, openness and honesty.

Generally, all staff knew how to contact the trust’s Freedom to Speak Up Guardian and what this process involved. Those who did not know the process knew how they would find the information if needed. None of the staff we spoke to raised any significant concerns regarding management or trust senior leaders but were aware of how to contact CQC and the whistleblowing process. Staff felt able to speak up without a fear of retribution.

The trust had processes in place for staff to raise concerns to a Speak Up Guardian.

Staff felt valued and described an inclusive and fair culture. Staff raised no concerns regarding equality, diversity and inclusion in relation to the service they worked for. Some staff described where managers had made reasonable adjustments for them to allow them to continue working on the ward. This included, for example, allowing a change in shift pattern to accommodate childcare arrangements.

The provider had processes to capture the views of staff and there was an equality, diversity and inclusion network for staff to join.

Staff were clear on the governance processes and reporting structures. Leaders told us they had good relationships with each other but could not always challenge decisions from more senior leaders. For example, in relation to environmental concerns on the wards described below.

There were risks within the ward environments that staff had put on the risk registers. These risks had been regularly reviewed by ward leaders but there was insufficient details and updates to evidence progress and plans to resolve these from relevant corporate teams such as health and safety and estates. Some of these risks had been on the risk register 6 years ago.

There were 7 estates and facilities risks on the ward’s risk register. One risk described the condition of the building and lay out of ward needing to be redesigned and repaired urgently however an entry from March 2024 stated that issues and risks had been escalated, but no actions were recorded to reduce or remove the highlighted risks.

A risk entered in June 2023 stated the seclusion suite did not have air-conditioning. At the time of the inspection air conditioning was not in place and it was also raised there was no window to allow air flow. Following the inspection, the trust informed the commission that air conditioning had been installed in the seclusion suite.

A risk entered in March 2017 described a number of windows on the ward that were not anti-ligature. At the time of the inspection these windows had not been replaced with an anti-ligature design.

Another risk was entered September 2019 which highlighted that the anti-climb fixings in the garden did not extend around the length of the fence. This was raised as an urgent concern by the ward and an action was recorded that a trustwide project was underway to improve however at the time of the inspection there remained a large portion of the fence without anti-climb fixings.

The service had a regular quality and standards meetings, which also included the community mental health services. These meetings were held in each geographical locality. Each meeting discussed key clinical governance issues such as reviewing and learning from incidents and complaints, reviewing service risks, safeguarding concerns and policy updates. These meetings also reviewed and logged actions from previous meetings. The service also holds learning from excellence meetings to discuss and share learning from incidents. Information from both these meetings are shared within the ward senior leader’s meetings and team meetings. The ward leaders also attended a compliance and assurance governance meeting.

Patient’s raised no concerns regarding this quality statement.

Staff and leaders understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners such as locality authority and community mental health teams.

Senior leaders engaged with other local health and social care providers to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population. Managers from the service participated in the work of the local transforming care partnership.

As part of routine monitoring of the service, the integrated care board (ICB) had raised no concerns to the commission in relation to this quality statement.

Staff described a positive learning and improvement culture that had improved since the last inspection. Staff had attended team away days which covered a variety of learning topics. Ward leaders were keen to improve their services.

Leaders described improvement in relation to staffing vacancies. For example, agency staff spend had been significantly reduced in the last year. They also successfully recruited internationally educated nurses.

There were processes to ensure learning from events took place and were shared across localities. 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.