A mental health trust has been ordered to make urgent improvements to the safety of its services by the Care Quality Commission.
The regulator found widespread short staffing at Avon and Wiltshire Mental Health Partnership Trust’s inpatient units and a failure to investigate and learn from all patient safety incidents.
“Frontline staff showed us they wanted to provide high quality care, despite the challenges of staffing levels”
Inspectors also highlighted a number of environmental issues affecting patient safety, including potential ligature points in bedrooms and bathrooms, and pressure on bed capacity leading to patients being moved or treated out of area.
The trust was issued with four warning notices and given 32 areas where it must improve.
Overall, however, CQC found that staff were kind and caring and were skilled in the delivery of care.
Dr Paul Lelliott, deputy chief inspector of hospitals, said: “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.”
However, he said it was a “matter of concern” that some of the issues uncovered had been highlighted by the CQC in previous inspections and had not been addressed.
He noted that there had been a change in the trust’s leadership and it had 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,” said Dr Lelliott.
Iain Tulley took over as chief executive in November 2012, following his predecessor’s departure in the wake of highly critical reports on the trust and its leadership. The entire executive team has since been replaced.
The trust was one of the first mental health trusts to be inspected under the CQC’s new methodology, and as a result has not received a formal rating under the regulator’s new four point scale.
A team of 70 people inspected 39 wards and 27 community services, as well as other specialist services, across the six clinical commissioning group areas covered by the trust.
Following the inspection the trust and its commissioners have set up three system led working groups focusing on the acute care pathway; workforce capacity and system wide learning from incidents.
CQC report and information supplied to HSJ