Avon and Wiltshire Mental Health Partnership NHS Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During this inspection we saw evidence that managers and senior leaders had taken action to respond to risk and to share learning across the service. This was an improvement since the last inspection. The service provided safe care. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

However, despite significant improvements since the last inspection, we remained concerned that some of the wards’ environments still presented safety concerns.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The majority of patients we spoke with said they felt safe on the ward, supported by staff and that they had a debrief following an incident.

Staff we spoke to reported a positive learning culture that had improved since the previous inspection. Staff were able to describe incident reporting, investigation stages and feedback process in line with the Patient Safety Incident Response Framework (PSIRF). Staff received feedback from investigation of incidents, both internal and external to the service. Staff gave examples of when learning from an incident had improved practice. For example, learning from medication incidents on Beechlydene ward resulted in an additional clinic room being added. Staff also described learning from a patient fall where training was given on completing neurological observations. Staff understood the duty of candour.

The service had an open and transparent culture, and staff gave patients a full explanation if and when things went wrong. Managers debriefed and supported staff after any serious incident.

Managers investigated incidents thoroughly. Patients and their families were involved in these investigations.

The governance structures in place allowed for learning to be shared across the service. This was primarily discussed during the quality and standards meetings and then disseminated at team meetings.

There was a process to review referrals to ensure that only those who would benefit from the service were admitted.

Staff described the process for reviewing patients prior to admission. This had improved since the last inspection in relation to reducing mixed-sex sexual safety incidents. Screening now included sexual safety risks and patients with this known risk were admitted to single-sex wards. Patients who were sexually disinhibited who were already admitted to one of the mixed-sex wards would be transferred to a single-sex ward.

We reviewed section 17 leave documentation and signing-out forms. We saw in all cases that patients had a mental state examination (MSE) prior to their leave being granted, demonstrating that staff had assessed patient risks, mental state, and signed to state whether patients could leave the hospital either escorted or unescorted. This was an improvement since the previous inspection.

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.

Patient’s we spoke with raised no concerns regarding safeguarding practices.

All staff we spoke with understood how to protect patients from abuse and how to recognise abuse. Staff were aware of safeguarding procedures and knew how to report concerns. Staff could give clear examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff received training on how to recognise and report abuse. Staff received level ` and 2 training in both adults and children’s. Staff kept up-to-date with their safeguarding training and compliance for the service was above 80%.

We observed safeguarding concerns being raised and discussed in relevant forums such as handover meetings.

Staff worked with other agencies to protect patients from harm and abuse. We saw evidence within care records of staff taking action such as raising referrals to safeguarding authority and contacted the trust safeguarding team for advice where needed.

Care records evidenced patient’s voice and inclusion into their care planning pathway.

Staff used a recognised risk assessment tool. The trust had recently rolled out a new risk assessment tool, known as the “safety assessment”. Staff had received training on this new format and described it positively.

Handovers had improved since the last inspection and included details of all patient’s identified risks, details of any recent incidents and current risk management plans and actions required.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.

All 20 patient records reviewed contained up to date risk assessments and risk management plans. Staff completed a risk assessment of every patient on admission and updated it regularly, including after any incident. Risk assessments and management plans were updated at least weekly, or where there had been a significant change in risk.

Senior staff completed weekly audits to ensure care plans and risk assessments were up to date, assessed all identified needs and contained risk management plans.

Staff followed policies and procedures for use of observation (including to minimise risk from potential ligature points) and for searching patients or their bedrooms. Staff completed therapeutic and environmental observations. When patients was placed in seclusion, staff kept clear records and followed best practice guidelines.

The majority of patients we spoke with said they felt safe on the ward, including communal areas. No patients raised any concerns regarding the safety of the ward environment.

Staff commented that since the last inspection, processes for managing and mitigating risks in the environment had improved. Staff described regular environmental checks, additional convex mirrors being installed to cover blind spots and the addition of an allocated member of staff observing bedroom corridors to mitigate sexual safety incidents. Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe with risk assessment, care planning and increased observations.

There had been significant improvements in how the trust monitored and removed or mitigate environmental risks on the ward. We found there had been significant improvements in how ward staff prevented sexual safety incidents occurring.

This had been raised as a significant concern at the previous inspection.

Beechlyedene ward was undergoing a refurbishment, to become a single-sex ward with a wing for females and a wing for males. The remaining mixed-sex wards were not undergoing a refurbishment but had introduced an allocated member of staff to conduct observations of bedroom corridors to prevent mixed-sex sexual safety incidents. However, we identified concerns with Juniper ward’s environment. The ward was mixed-sex with 18 beds but had only 5 communal bathrooms, which is less than the Royal College of Psychiatrists standards for an acute mental health ward. At the time of the inspection there were no toilet facilities in the seclusion suite. Following the inspection the trust informed the commission that toilet facilities have since been put in place.

Staff completed and regularly updated environmental risk assessments of all wards areas, and removed or reduced any risks they identified. Environmental checks were completed regularly by staff throughout the day. Since the previous inspection, the trust had changed the tool used to complete ligature audits. Each ward had a current ligature audit, which identified all ligature anchor points, risk rated them and detailed controls to mitigate or remove the risk. These audits were completed annually and wards were due their review for this year.

We identified concerns with the management of environmental risk at a trust-level. Local ward managers had reported concerns, recorded on a risk register, and mitigated the associated risk locally however the majority of risks associated with estates and facilities had not been adequately actioned, with some environmental risks present on the risk register for over 6 years.

The majority of patients commented that there were enough staff, they had regular leave which was rarely cancelled due to staffing shortages and that staff were supportive and available.

Majority of staff were up to date with statutory and mandatory training or were booked on upcoming training courses. Staff described the training available to them, including additional training specific to their role. Staff received effective support, supervision and development.

On the day of the assessments the wards had adequate staffing in place. We observed staff interacting with patients and attending to their needs without delay.

The service had enough nursing and support staff to keep patients safe. There were some vacancies across the teams, but shifts were covered with bank or agency staff. Those who completed the roster ensured there was appropriate skill-mix on each shift, which included those who were trained to complete therapeutic observations, physical emergency response and physical intervention.

We reviewed training statistics for each ward, and in all cases 75% or above of staff had completed statutory and mandatory training.

We spoke with 28 patients; 14 of which commented on the cleanliness of the ward. Ten of these patients said the ward, bedrooms, toilets and communal areas were always clean and tidy. Four patients commented that the bathrooms were not always clean and communal areas weren’t always tidy.

Staff assessed and managed the risk of infection by adhering to hand hygiene principles and other processes as applicable relating to infection prevention and control.

On the day of the assessment we observed no concerns relating to infection prevention and control. The wards were clean, tidy and well maintained.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with external agencies as required.

The majority of patients were aware of what medication they were on, why they had it prescribed and had regular reviews with their doctor regarding their medication

During the assessments we spoke with consultant psychiatrists and other medical staff such as junior doctors and pharmacists. All of the staff we spoke with described how they regularly reviewed and discussed patient’s as required medication (known as PRN) to ensure it was appropriately prescribed and administered in line with guidance. This was an improvement since the last inspection.

Management, storage and administration of medicines were robust. We reviewed clinic rooms, including the medication stock and equipment, and completed a check of medication prescription charts. We found no concerns regarding clinic rooms, equipment, medication stock or medicines management. This was an improvement since the previous inspection.

Each ward has a checklist in place to ensure oversight of the clinic rooms and medication. The wards also had support from the trusts’ pharmacy services. This varied across different hospitals but included medication processes reviewed by pharmacists, pharmacy technicians completing additional checks and audits of prescription charts and medication stock. Since the previous inspection the trust had moved from paper-based to an electronic prescribing system. This had improved the speed of which prescriptions could be put in place and actioned by staff.