Safety concerns raised after inspection of acute psychiatric wards and psychiatric intensive care units

Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) provides 9 acute wards and 3 psychiatric intensive care units (PICU) for adults of working age. At this inspection, the Care Quality Commission (CQC) visited eight wards, including:

• Cherry ward, an acute, mixed-sex ward at Callington Road Hospital, Bristol
• Hazel ward, a male PICU at Callington Road, Bristol
• Elizabeth Casson House, a female PICU at Callington Road Hospital, Bristol
• Oakwood ward, an acute, mixed-sex ward at Southmead Hospital, South Gloucestershire
• Juniper ward, an acute, mixed-sex ward at Weston General Hospital (Longfox unit), North Somerset

Inspectors carried out this unannounced, focused inspection in January 2023 because they received information that raised concerns about the safety and quality of the services. They assessed the services in two areas. The current ratings following this inspection (and the rating at the previous inspection) are:

• Are the services safe? Inadequate (down one rating from requires improvement)
• Are the services well-led? Requires improvement (no change)

The overall rating for this service is requires improvement (no change). The rating for Avon and Wiltshire Mental Health Partnership (AWP) as a whole is also requires improvement. 

Following the inspection, the CQC issued a Warning Notice due to concerns that patients on the acute inpatient wards were not receiving safe care and treatment.

You can download a full copy of the report below.

Is the service safe?

Inspectors identified ligature anchor points and environmental risks on all inpatient wards. There had been two patient deaths on the acute wards in 2022 - both had involved the use of a ligature. One of these had involved the use of a fixed ligature point. Individual patient risk management plans were mostly generic, did not refer to environmental risks, and were not updated according to identified risks.

The trust and ward staff had not ensured that mixed sex wards were laid out, utilised, and monitored to mitigate associated risks and prevent sexual safety incidents. Staff did not sufficiently monitor and observe single sex spaces. Male and female corridors were unlocked and accessible to any patient or staff. 

In the last 12 months there had been 111 incidents involving 'sexual abuse' or 'sexually inappropriate behaviour' across the 9 acute inpatient wards. 2 of these were categorised as serious incidents. Inspectors also noted blind spots in the ward environments on Elizabeth Casson House, Oakwood, Juniper and Cherry wards, without mirrors or CCTV to mitigate the associated risks.

Oakwood ward was poorly maintained and there was damage throughout the ward, including stains and damages to walls. Although Juniper ward was mostly clean, we found that some areas of the ward were not, including the de-escalation area and clinic room, and there were stains and damage to furniture.

Inspectors also identified issues with seclusions rooms on some wards, including a door that was not robust enough (Juniper), limited space for de-escalation of a patient (Cherry), the door and ensuite (Oakwood), and a blind that was broken and closed (Juniper). Staff did not always check, maintain, and clean equipment. Some medication was out of date.

There were high levels of vacancies across all wards. Some staff felt there was not always enough staff on the wards to provide the level of care they wanted to e.g. areas of the ward being locked off due to inability to supervise these, a lack of activities being provided and not enough staff to manage patient safety incidents.

Staff did not always complete risk assessments for patients on admission, or update these in response to new risks and following safety incidents. This included risks such as increased suicidal ideation, violence and aggression, safeguarding concerns, patients absent without leave, and sexual safety incidents or disinhibition. Incidents of potential financial abuse between patients were also identified, and staff were not always aware that a patient's leave had been suspended.

Is the service well-led?

Leaders had a good understanding of the services they managed and the current challenges they faced. Ward managers and matrons took action to respond to  challenges for their wards but did not always feel that timely or effective action was taken when concerns were escalated to more senior managers or other divisions within the trust. Staff did not always feel respected, supported and valued.

Concerns were varied across wards but included; permanent staff being rude and unsupportive to agency staff, bed managers and duty managers overruling ward staff clinical decisions to refuse admissions, and a lack of understanding or response to the challenges and stress faced by ward staff.

Staff and leaders on all wards told us that repairs and improvements to the ward environments were delayed or difficult to arrange due to a lack of funds. Ward staff told us that there were financial pressures within the trust that compromised quality of care.

There was a trust sexual safety improvement project underway but this was in its infancy and staff had a limited understanding of the project and their role in it. Some staff and managers were unaware of the serious sexual safety incidents that had occurred elsewhere in the trust and the initial learning from these.

Have you or a loved one been cared for on an acute psychiatric ward or PICU? Please tell us about your experience by clicking the pink 'Talk to us' button below and completing our online feedback form.