The Care Quality Commission (CQC) has downgraded the rating for how well-led Avon and Wiltshire Mental Health Partnership NHS Trust is overall from good to requires improvement following an inspection in July last year.
The trust provides mental health services across Bath and North East Somerset, Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. It serves a population of approximately 1.8 million people across a geographical region of 2,200 square miles, operating from over 90 sites including eight main inpatient facilities.
The inspection was undertaken because of concerns raised about the quality of care in various services. Prior to the well-led inspection, CQC also looked at acute and psychiatric intensive care units, as well as community mental health services for working-age adults. This was to see if the trust’s plans and safety measures matched what was happening in local services. These services were both rated good and the reports are available on CQC’s website.
At this inspection CQC found two breaches in regulation, one relating to safeguarding and the other regarding good governance (how the trust was being managed). The trust submitted an action plan setting out how they planned to address the issues around safeguarding.
The trust’s previous rating for well-led was good, but this has now been downgraded to requires improvement.
Catherine Campbell, CQC deputy director of operations in the south, said:
“Our inspection found a decline in some aspects of leadership which the trust needed to address.
“CQC identified closed cultures in parts of the trust, especially secure services. Senior leaders had started improvement work and introduced mechanisms to identify poor culture early, however at the time of the inspection it was too soon to measure the effectiveness of this improvement.
“Some stakeholders said the trust’s culture felt defensive. They didn’t feel consulted on key issues like commissioning, risks and quality. Partners told us information from the trust lacked timeliness and details, causing delays in Integrated Care System decision-making that impacted people. However, lately they noted things have started to improve.
“Leaders had started to tackle governance issues by reviewing how responsibilities were shared, to make sure senior staff were clearly accountable for different areas of work. They also set up new sub-committees, made up of senior staff, to focus on important topics like quality, safety, staff wellbeing, workplace culture, and leadership. These changes were positive steps forward, but they were still too new at the time of the inspection for the trust or the CQC to say how well they were working.
“We told the trust at the time of the inspection where they needed to make improvements, we will continue to monitor their progress to make sure people are safe while this happens.”
Inspectors found:
- The breaches in regulations were identified because the trust had not ensured leaders consistently and fully engaged with system partners on strategic issues. They had not ensured Freedom to Speak Up processes were effective, that racism and discrimination were addressed across all services and safeguarding systems and processes were effective. Leaders told CQC they were committed to improving these issues and had set out a number of actions to address and keep oversight of cultural issues.
- The trust was under enhanced surveillance oversight by its two local integrated care systems due to the serious quality concerns they also had over safeguarding and quality of processes.
- The Board’s Assurance Framework needed further improvement as it wasn’t always identifying emerging issues in some services.
- Staff felt a disconnect between senior leadership and middle management. While staff had confidence in senior leaders, they didn't feel issues escalated to middle management were passed up to senior management to secure the appropriate actions.
- Inspectors found issues with the trust’s Freedom to Speak up process. Data showed that concerns raised openly had decreased while anonymous concerns had increased between April 2023 and March 2024. Staff told us that this was because they felt there would be a fear of retribution if they spoke up using their real names.
However, inspectors also found:
- The trust had reviewed their governance arrangements and started making improvements. Leaders recognised shortfalls in governance processes and had used the CQC Warning Notice from January 2023 to focus on required improvements.
- The trust had an impressive environmental, green plan with clear goals and vision, aiming to be carbon neutral by 2030. They had also established a climate change emergency action group with 125 members that met six times per year with board-level leadership.
- Leaders had significantly reduced agency staff expenditure over the past year and recruited internationally educated nursing staff to fill substantive vacancies across inpatient services. This benefited people using the services as there was more consistency in the care they were being given and able to build relationships with people who knew their likes and dislikes.
- Leaders had an improved understanding of health inequalities, understanding their roles and responsibilities in collaborating with system partners to improve mental health provision. They showed good understanding of health inequalities and had developed specific strategies to address these issues across their services.
Due to a large-scale transformation programme at CQC, this report has not published as soon after the inspection as it should have done. The programme involved changes to the technology CQC uses but resulted in problems with the systems and processes rather than the intended benefits. The amount of time taken to publish this report falls far short of what people using services and the trust should be able to expect and CQC apologises for this.
While publication of some reports has been delayed, any immediate action that CQC needed to take to protect people using services has not been affected. CQC is taking urgent steps to ensure that inspection reports are published in a much more timely manner.
The full inspection report will be published on CQC’s website in the coming days.