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

The service provides safe care for people using the service. We reviewed breaches of regulation 12 and 17 found at the previous inspection involving medication management were now met . Measures had been implemented to ensure medicines were stored, reconciled and administration procedures were robust.

We saw evidence of learning from incidents and staff escalated concerns when required.

People’s care plans documented their care pathway and individual patient risks were documented with interventions appropriate to their needs. The trust safeguarding policy and procedures were not clear for all staff to understand, specific parts of the procedural elements were open to interpretation. This meant there could be delays in referring safeguarding concerns. However, documents we reviewed and staff feedback showed likely negligible impact due to staff’s understanding of the importance to refer safeguarding matters without delay.

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.

Considerations and adjustments were made for people attending clinics to ensure privacy, dignity and respect met individual needs was improved.

Staff we spoke to reported a positive learning culture. Staff were able to describe incident reporting, investigation stages and feedback process in line with the Patient Safety Incident Response Framework (PSIRF).

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.

Most people we spoke with understood their care pathway and were included in decisions made about their care, this included transitions between services and how this would affect them . However, some people told us they did not feel they were involved in their care planning or that their views were considered.

Staff and leaders spoke about services they linked in with, such as various community-based wellbeing and life-skill interventions, and ensured people were able to access them. They described a range of services people may require additional support from and explained processes and actions staff take to ensure those pathways are effective.

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

Teams across the trust had systems in place for people to access the service. Small waiting lists in some locations were effectively managed. People’s needs were prioritised, and teams had clear strategies to take with each person. The teams were effective in making relevant referrals and were involved in transitions with internal and external services.

People 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 practices and knew how to report concerns. Staff gave clear examples of how to protect people who use the service from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff received training on how to recognise and report abuse, Staff kept up-to-date with their safeguarding training , However, training levels were not always in line with inter-collegiate guidance.

Staff worked with other agencies to protect people from harm and abuse. We saw evidence within care records of staff taking appropriate action and contacted the trust safeguarding team for advice where needed. However, the safeguarding policy was not clear on processes staff were required to take.

Not all people told us they felt included in planning their care. However,

care records we reviewed evidenced people’s voice and inclusion into their care planning pathway.

Staff explained how they worked holistically with people to capture their needs and involve them within the care planning process. Staff told us peoples care plans are reviewed with them, their needs and views were documented within care plans. We observed staff discussing strategies with a person using the service during a telephone call to manage risks during a time of crisis, this was done compassionately and included the views of the person.

A computerised system was utilised to document evidence of people being included in their care planning pathway. Key performance indicators were also used to ensure staff were meeting agreed timelines of involving people to review and update risks and key specific information relevant to that person.

People we spoke to raised no concerns relating to clinic environments they visited.

Staff explained the environmental risks and how these were documented and mitigated. Staff had clear understanding of their duties to support and promote a safe and suitable environment.

Access areas within locations were risk assessed and strategies for managing potential risks were effective. Clinic rooms within locations were safe and used for the intended purpose.

Risk assessments were in place to identify any environmental risks for patient access areas. These risk assessments were regularly reviewed and following incidents.

People benefitted from staff teams utilising agency staff support to ensure routine appointments and clinics continued.

Staff told us about challenges they faced regarding staffing levels, this included understanding of vacancies and how managers are covering this by using regular agency staff.

Teams across the trust managed staffing issues well. Where there were vacancies, managers used agency staff that were familiar with the service and had significant lengths of time working with the teams. Staff received regular supervision and worked collaboratively with others.

People benefitted from effective infection prevention control measures undertaken within local hubs. People also had access to hand gels to sanitize their hands when they entered clinics.

Staff told us how they used rota’s and followed procedural checks to ensure effective infection prevention and control to all working areas including the clinic room.

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

The clinics had effective infection, prevention and control systems. There were bacterial handwipes, hand-gels and bacterial cleaning agents available for staff and people to use.

The majority of people told us they had received information regarding their medications from staff and no issues around availability or mismanagement were reported.

Staff across the locations told us that systems of medication management was much improved since the previous inspection. Staff understood their roles and responsibilities. This was corroborated during our observations of clinic rooms.

Since the previous inspection, medication management had improved and did not highlight a repeat of previous concerns that resulted in breaches of regulation. The inspection team consider the previously found breaches to have now been met.

Process were robust, recording, reconciliation and storage of medications were observed to be of a good standard.

Management, storage and administration of medicines were robust. The trust ensured audits were carried out across locations that showed previously identified breaches of regulation at the last inspection were met. Clinic rooms were clean, well-organised and storage of medicines were well managed.