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Chief Inspector of Hospitals finds that Mental Health Trust must improve

17/09/2014

England's Chief Inspector of Hospitals, Professor Sir Mike Richards, has published his first report on the quality of services provided by Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).

Following an inspection in June, the Care Quality Commission has found that while staff were caring, the trust must take significant steps to improve the quality of their services. Under CQC's new inspection regime, a team of 70 people which included doctors, nurses, hospital managers, trained members of the public, a variety of specialists, CQC inspectors and analysts spent four days at the trust, meeting patients and staff.  They inspected 39 wards and 27 community services, as well as other specialist services, across Bristol, Wiltshire, Swindon, South Gloucestershire, North Somerset, and Bath and North East Somerset.   The full reports are available at http://www.cqc.org.uk/provider/RVN

Overall CQC found that staff were kind and caring and were skilled in the delivery of care. Inspectors noted positive examples of staff providing emotional support to people in challenging conditions. However, the inspection team had a number of concerns about safety; particularly on the mental health admission wards and forensic mental health wards. The design of some wards made it difficult for staff to observe vulnerable patients and some wards had ligature points that could endanger people at risk of suicide. There were also wards where male and female accommodation was not fully segregated. These problems were compounded by significant staff shortages on some wards that the inspection team concluded may have affected patients’ care and safety.  

There were also times when beds were not available.  This meant that adults of all ages who needed inpatient care were sometimes admitted to a ward a long way from their home. It also meant that people were sometimes moved from one ward to another or discharged early. 

At the time of the inspection, CQC pointed out its immediate concerns to the trust. Subsequently, the Care Quality Commission has issued four warning notices requiring the trust to take urgent action to improve.

  • At Hillview Lodge, in Bath, inspectors found that the premises had not been well maintained and the design, layout and décor were not appropriate as a therapeutic environment or one in which people’s privacy and dignity were promoted or protected.
  • At Blackberry Hill Hospital in Bristol, the trust had failed to meet guidance on medium secure units in relation to the safety and suitability of premises. Potential ligature points had not been dealt with.
  • At Fromeside Hospital a number of units were experiencing significant staff shortages which may have impacted on patient care and safety. Supervision arrangements for new staff were insufficient.
  • The trust had failed to assess and monitor the quality of its services. It had not made necessary changes following previous inspections and had not taken prompt and appropriate action to manage risks identified by serious incidents and concerns, or respond to staff concerns.

 CQC has identified 32 areas where the trust must improve.  As a first step, the trust must provide a plan setting out how it will address each requirement.

Inspectors identified a number of areas of good practice, including:

  • The two hour target to complete assessments of young people at Mason place of safety service in Bristol was being met both in the day and out of hours. Young people under the age of 18 years old had a separate part of the unit if required.
  • The later life mental health liaison service for Bristol and South Gloucestershire provided an innovative service, working with other providers to meet the mental health needs of older people in local hospitals.
  • The Bristol intensive service had employed a recovery co-ordinator as a carers’ champion, significantly improving carers’ involvement in the care and treatment of their relative.
  • The Swindon psychiatric liaison service was working well with the Great Western Hospital to manage people's distress. It was also working together with the local suicide prevention project.
  • The ADHD team cut the waiting time for assessments, from of 18 months to eight weeks, by refocusing the team’s priorities, and creating time for more appointments.
  • The STEPS eating disorder unit has been instrumental in developing and publishing research on a national scale.

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals, said: “Avon and Wiltshire Mental Health Partnership has room for improvement in many areas. It is a big trust - with an important job to do. Many thousands of people depend on its services. On our inspection, we found staff treating patients with respect and communicating with them effectively.  People we met during our inspection were mainly positive about the staff and felt they made a positive impact on their experience on the wards. Frontline staff showed us that they wanted to provide high quality care, despite the challenges of staffing levels and some poor ward environments.

“We had a number of concerns about safety - including unsafe ward environments that did not promote the dignity of patients, insufficient staffing levels to safely meet patient’s needs and inadequate arrangements for medication management.   Some of these are not new and were known to the trust before our inspection - so it is a matter of concern that these issues have still not been addressed. The trust have told us that they have developed strong relationships with local communities, the people who use the services, commissioners, local authorities and other providers over the last year.  They will need to build on these relationships, to confront the issues which we have reported on so that they deliver a better quality of care.

“I recognise that there has been a change in the most senior leadership of the trust, which has now embarked on a programme of service improvement.  We found that the board and senior management have a clear vision with strategic objectives.  The onus is on them now to make the urgent improvements we require - and then to sustain that improvement in the long term.   We will continue to monitor their progress – and take further action if that is required”


"The Care Quality Commission has already presented its findings to a local Quality Summit, including NHS commissioners, providers, regulators and other public bodies. The purpose of the Quality Summit is to develop a plan of action and recommendations based on the inspection team’s findings.

The inspection team always looks at the following core services:

  • Acute admission wards
  • Health-based places of safety
  • Psychiatric Intensive Care Units
  • Services for older people
  • Adult community-based services
  • Community-based crisis services
  • Forensic service
  • Specialist services

"On this inspection, we visited all of the trust’s hospital locations and sampled a number of community mental health services. We inspected 39 wards across the trust including 14 adult acute and rehabilitation services, three psychiatric intensive care units (PICUs), ten secure wards, nine older people’s wards, and specialist wards for eating disorders, mothers with babies and drug and alcohol. We looked at four places of safety under section 136 of the Mental Health Act and the two electroconvulsive therapy (ECT) suites based at the trust. We inspected 27 community services including all of the trust’s intensive services, four recovery teams, three early intervention teams, seven older people’s complex intervention teams and the psychiatric liaison service based at the Great Western Hospital in Swindon. We also inspected specialist teams for people with forensic needs, people with ASD, people with ADHD and people with additional deafness needs.

Avon and Wiltshire Mental Health Partnership NHS Trust provides services for adults with mental health needs and those whose needs relate to drug or alcohol dependency across Bristol, Wiltshire, Swindon, South Gloucestershire, North Somerset, and Bath and North East Somerset. They also provide secure mental health services across South West England and work with the criminal justice system. A number of specialist services are delivered including an eating disorder service, a mother and baby unit and assessment services for people with ADHD, autism and hearing difficulties. There is also a small diagnostic service that provides assessment for children and adolescents in partnership with other local providers. In 2012/13, the trust staff saw 36,659 individuals


Avon & Wiltshire Mental Health Partnership NHS Trust responded to the report:

In June, AWP was one of the first mental health trusts to be inspected by the Chief Inspector of Hospitals.  The Care Quality Commission (CQC) has today published its report into the Trust, which is now available via the CQC website (http://www.cqc.org.uk/provider/RVN) and our website. http://www.awp.nhs.uk/cqcreport

The CQC report reflects both the verbal feedback the team gave the Trust and the problems we highlighted to the inspection team in June and which we were already tackling with our commissioners. As a result many actions have been completed and improvements made such as increased recruitment, staffing being more closely matched to capacity and needs,  an accelerated replacement and refurbishment programme to deal with estate issues, more training and changes to some of our systems.  We are confident that by continuing to work with our commissioners we will strengthen our services and meet the CQC requirements.

We are pleased that the inspection team recognised the kind, caring and responsive approach of our staff and noted their high skills in the delivery of care.  Evidence based practice, centres of excellence in specialist services and motivated clinical leadership were also examples of good practice highlighted. These positive comments reflect the significant change in the Trust over the past couple of years as we have transformed the organisation into a quality focused, clinically led and locally integrated organisation.  In doing so, we have improved many aspects of the Trust, building on best practice, improving the quality and responsiveness of our service.

Having radically overhauled the way the Trust is managed and run, we wanted our progress to be independently assessed and so pressed to be part of the mental health pilot inspections being undertaken by the Chief Inspector of Hospitals team.  During the five day visit to the Trust, we made a particular effort to be totally open and transparent with the 70 strong team, alerting them not just to areas where we knew further action was needed but also explaining to  them the plans we had put in place with our commissioners to tackle them.   

The warning and compliance notices issued by the CQC have highlighted the need to re-prioritise some of the planned actions and to make sure that changes are made faster.  Our Trust accepts the inspectors’ conclusions and reaffirms its absolute commitment to delivering consistently the required standards. At the quality summit hosted last week by the CQC and the NHS Trust Development Authority (TDA) the CQC expressed its confidence in the leadership of the Trust to resolve the inspection issues and to take the Trust forward.

The solution to some of these historic issues will require a coordinated push from the Trust, commissioners and social care colleagues as well as support from the CQC and the TDA. We are confident that by working closely with our staff, commissioners, social care colleagues and those who use our services, we will be successful in continuing to transform our Trust into an organisation which provides the highest quality mental healthcare that promotes recovery and hope.

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