AWP Quality Account 2021-2022

Quality Account
2021 – 2022
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Contents
1. Glossary of terms ...................................................................................................................................... 3
2. Quality Account statement ...................................................................................................................... 5
3. About our Trust ........................................................................................................................................ 7
4. About the Quality Account ....................................................................................................................... 8
5. Our approach to quality ........................................................................................................................... 9
6. Quality priorities ..................................................................................................................................... 13
7. Statement of assurance .......................................................................................................................... 20
8. Clinical audit ........................................................................................................................................... 21
9. Research ................................................................................................................................................. 26
10. Patient safety .......................................................................................................................................... 29
11. Learning from deaths and duty of candour............................................................................................ 34
12. Confidential enquiries ............................................................................................................................ 38
13. Safeguarding ........................................................................................................................................... 49
14. Patient Advice and Liaison Service (PALS).............................................................................................. 53
15. Patient experience .................................................................................................................................. 54
16. Service user and carer involvement ....................................................................................................... 57
17. Peer support and lived experience ......................................................................................................... 58
18. Commissioning for Quality and Innovation (CQUIN) ............................................................................. 59
19. Care Quality Commission (CQC) ............................................................................................................. 59
20. Quality of data ........................................................................................................................................ 62
21. NHS staff survey ..................................................................................................................................... 63
22. Freedom to speak up .............................................................................................................................. 68
23. Data security ........................................................................................................................................... 72
24. Feedback from our stakeholders ............................................................................................................ 74
25. Statement of Directors’ responsibilities ................................................................................................. 75
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1. Glossary of terms
ADHD
AMHE
AWP
BaNES
BHP
BILD
BNSSG
BSW
CAMHS
CBT
CCG
CLOG
CMHF
CMHT
CPA
CPCF
CQC
CPD
CQUIN
DEST
DHSC
DMS
DPAR
DSP
ECG
ePMA
FFT
FOI
FTSU
FTSUG
GMC
GP
HCAI
HEE
HQIP
HR
ICO
ICS
IGMS
IHI
IMI
IPC
IQ
KUF
LeDeR
LD
MARAC
MDT
Attention Deficit Hyperactivity Disorder
Advance in Mental Health Equalities
Avon and Wiltshire Mental Health Partnership NHS Trust
Bath and North East Somerset
Bristol Health Partners
British Institute of Learning Disabilities
Bristol, North Somerset and South Gloucestershire
BaNES, Swindon and Wiltshire
Children and Adolescent Mental Health Service
Cognitive Behavioural Therapy
Clinical Commissioning Group
Clinical Leadership Oversight Group
Community Mental Health Framework
Community Mental Health Team
Care Programme Approach
Community Pharmacy Contractual Framework
Care Quality Commission
Continuing Professional Development
Commissioning for Quality and Innovation
Dementia Enhanced Support Team
Department of Health and Social Care
Discharge Medicines Service
Drug Prescription and Administration Record
NHS Digital’s Data Security and Protection Toolkit
Electrocardiogram
Electronic Prescribing and Medicines Administration
Friends and Family Test
Freedom of Information
Freedom to Speak Up
Freedom to Speak Up Guardian
General Medical Council
General Practitioner
Healthcare Associated Infections
Health Education England
Healthcare Quality Improvement Partnership
Human Resources
Information Commissioner’s Office
Integrated Care System
Information Governance Management System
Institute for Healthcare Improvement
Intramuscular Injection
Infection Prevention and Control
Information for Quality
Knowledge and Understanding Framework
Learning from Lives and Deaths – People with a Learning Disability and Autistic People
Learning Disabilities
Multi-Agency Risk Assessment Conference
Multi Disciplinary Team
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MHA
MHSIP
MLE
MSO
MUST
NCAPOP
NCISH
NEWS
NHSE/I
NIHR
NRLS
NSPS
OACN
OPMH
PALS
PBPS
PICU
POMH
PSII
PSIRF
PSIRP
QI
RCPsych
RiO
RRP
RTS
SBAR
SCM
SEMHC
SMART
SOI
SPC
SPOC
SSC
SUI
VTE
WEAHSC
WECRN
WTE
ZSA
Mental Health Act
Mental Health Safety Improvement Programme
AWP’s internal learning platform
Medicines Safety Officer
Malnutrition Universal Screening Tool
National Clinical Audit Patient Outcome Programme
National Confidential Inquiry into Suicide and Safety in Mental Health
National Early Warning Score
NHS England and Improvement
National Institute for Health Research
National Reporting and Learning Service
National Suicide Prevention Strategy
Older Adults Clinical Network
Older People Mental Health
Patient Advice and Liaison Service
Professional Behaviours and Patient Safety
Psychiatric Intensive Care Unit
Prescribing Observatory for Mental Health
Patient Safety Incident Investigations
Patient Safety Incident Response Framework
Patient Safety Incident Response Plan
Quality Improvement
Royal College of Psychiatrists
AWP’s Clinical Record System
Reducing Restrictive Practice
Real Time Surveillance
Situation, Background, Assessment and Recommendation
Structured Clinical Management
South of England Mental Health Collaborative
Specific, Measurable Achievable, Realistic and Timely
Science of Improvement
Statistical Process Control
Single Point of Contact
Specialised, Secure and CAMHS
Serious Untoward Incident
Venous Thromboembolism
West of England Academic Health Science Network
West of England Clinical Research Network
Whole Time Equivalent
Zero Suicide Alliance
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2. Quality Account statement
On behalf of the Trust Board, I am pleased to present our 12th annual Quality Account for Avon and
Wiltshire Mental Health Partnership NHS Trust (AWP). This provides us with the opportunity to reflect on
the key successes and achievements that have happened over the past twelve months, as well as allowing
us to identify areas that we want to improve further via our quality priorities for 2022-23.
2021-22 has again presented challenges as we have continued our response to the COVID-19 pandemic,
prioritising keeping our service users and staff safe. Our Infection Prevention Control (IPC) team have again
worked hard with operational colleagues to develop COVID-19 procedures that maintain safety and reduce
infection, protecting the vulnerable and maintaining services through vaccination planning. During the final
stages of the financial year, we have also turned our head towards the future whilst living safely with
COVID-19.
Notwithstanding these challenges, I am delighted that we managed to make further progress on our
quality and safety objectives.
As a Trust, we have continued to build upon the clinical priorities set for 2021-22 and worked hard to plan
our priorities for 2022-23. These priorities include a focus on our Patient Safety Incident Response Plan
(PSIRP), our emerging clinical pathway, as well as ensuring regulatory compliance. While we reflect that
this work is ambitious, we feel that it will lead to improved quality of service for our service users, as it
supports workforce transformation and new training opportunities for staff.
I would like to take this opportunity to thank all the AWP staff who have worked tirelessly every day to
care for our service users with the additional pressures of the COVID-19 pandemic, as well as our system
colleagues for their partnership support. These combined efforts continue to improve the lives of our
service users and the communities that we support. Without them, it would not be possible.
The aim of this report is to provide you with a clear picture of our intentions to continue to deliver high
quality work and create sustainable services for the coming year.
Professor Adrian Childs
Director of Nursing and Quality
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Statement on quality from the Chair and Chief Executive
We are delighted to welcome you to this Quality Account for Avon and Wiltshire Mental Health
Partnership NHS Trust. The report covers the period 1 April 2021 to 31 March 2022.
Our aim is to be recognised as ‘outstanding AWP’, provider of specialist mental health and learning
disability services. We are committed to providing outstanding care, through outstanding people, ensuring
our services are sustainable and delivered in partnership.
This report provides an overview of the Trust’s key achievements and successes during the year, as well as
celebrating the dedication and commitment of our staff to provide outstanding, safe and caring services
for our patients, service users, carers and volunteers.
The Care Quality Commission (CQC) inspected our services in 2021 and we were please with the
subsequent report improved our rating of the ‘well-led’ domain to ‘good’, whilst retaining ‘requires
improvement’ overall for the Trust. We also heard from the CQC that our staff increasingly felt respected,
supported and valued and that Board members demonstrated a real understanding of the issues that we
face.
The Trust has continued to work on our clinical priorities, as set last year and will build upon this work in
2022-23, including the development of our clinical strategy, which will include defined care pathways,
building on our work in our Dementia network and Personality Disorder services.
We would like to express our thanks to our wonderful staff and volunteers for their continued hard work
and dedication; everything they do is aimed at delivering and improving care for people with Serious
Mental Illness and Learning Disabilities and everything that we accomplish is because of our staff.
We commend our Quality Account to you and ask that you continue with us on our journey to become
‘outstanding AWP’.
Charlotte Hitchings
Dominic Hardisty
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3. About our Trust
Avon and Wiltshire Mental Health Partnership NHS Trust (AWP / the Trust) primarily provides community
and inpatient mental health services for the people of Bristol, North Somerset, South Gloucestershire
(BNSSG) and Bath and North East Somerset (BaNES), Swindon and Wiltshire (BSW). AWP also provides
some specialist services both within and outside of these geographical locations, as part of our Specialised,
Secure and Child and Adolescents Mental Health (CAMHS) division (SSC).
BNSSG and BSW align themselves with the two Strategic and Transformation Partnerships (STPs’) soon to
become Integrated Care Systems (ICS), where our work continues in contributing to and working within the
NHS Long Term Plan and Community Mental Health Framework (CMHF). The CMHF is the guide that
underpins how we are trying to work towards transforming our community mental health services across
England. The framework describes how the NHS Long Term Plan’s vision for a place based community
mental health model can be realised, and how community services should modernise to offer wholeperson,
whole population health approaches, aligned with the new Primary Care Networks (PCNs’).
Through our dedicated CAMHS, adult and later life services, we provide assessment and intervention for
individuals of all ages, who require community and inpatient treatment for a wide range of conditions,
such as:
Severe anxiety
Severe depression
Schizophrenia
Psychosis
Obsessive Compulsive Disorder
Emotionally Unstable Personality Disorder
Dementia
Phobias
Learning Disabilities
A focus for our work remains that of treating people in or as near to their home as possible. AWP is a key
partner in the South West Provider Collaborative, a partnership of mental health providers across the
South West aiming to reduce reliance on out of area specialist services and enables more people to be
looked after closer to their homes and communities. We are continuing to expand on this response via
joint planning with the PCN’s and contributions to the implementation of the NHS Long Term Plan.
When an inpatient stay is required, our focus is on keeping our service users in hospital for the shortest
period of time possible, making sure that we provide timely and effective assessment and treatment so
that they can return home and continue their recovery with the support of their families, carers and our
community teams.
Our specialist provision
In addition to our core services, we also provide specialist care and treatment for individuals with more
specific needs, including:
Drug and alcohol services, which support individuals with drug or alcohol dependency and who may
require inpatient detoxification and treatment or community based care. This service is often
delivered in partnership with third sector colleagues.
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Perinatal services for women who have mental health needs arising from pregnancy and childbirth.
This service is provided both in the community and in our specialist inpatient Mother and Baby
Unit.
Eating disorders services for individuals who may require specialist inpatient or community based
treatment.
Medium and low secure inpatient services for individuals who have mental health disorders or
neurodevelopmental disorders who pose or who have posed significant risks to others, and where
that risk is usually related to their mental disorder. This includes a specialist community forensic
team to support a discharge into the community with a reduced hospital length of stay.
Prison services for those with mental health, drug and alcohol and neurodevelopmental disorders.
Specialist services for individuals with autistic spectrum conditions and adult Attention Deficit
Hyperactivity Disorder (ADHD).
Specialist services for individuals who are deaf and have mental health needs.
Veterans mental health services for Armed Forces personnel who have been or who are about to be
discharged from service and who have a mental health need.
Asylum Seeker and Refugee service to support those with their mental health needs and / or
trauma.
Improving Access to Psychological Talking Therapies (IAPT) services for individuals within BSW.
4. About the Quality Account
All NHS Trusts are required to produce an annual Quality Account, to provide information on the quality of
our services to service users and the public.
Within this account, a narrative has been provided to reflect the statutory requirements of the account but
also information about our priorities for improvement, agreed in partnership with our senior leadership
team, expert clinicians, service users and carers. This is a partnership agreement, to which we are very
committed.
This report aims to give a true and fair representation of the quality of our services, including information
that is meaningful, relevant and understandable. We hope that the information is useful and demonstrates
our commitment and intention to providing high quality and safe services, which is the Trust’s highest
priority and at the heart of everything we do.
External assurance
A draft version of this Quality Account is circulated for comment, in line with the statutory requirements to
the following stakeholder groups:
BNSSG and BSW Clinical Commissioning Groups (CCGs).
Six Local Authority Health Overview and Scrutiny Committees (HOSCs).
Six Local Healthwatch Groups.
A final version of this report will be sent to all our stakeholders, should they wish to reference it at a later
date.
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Further information
We would value your feedback on this document so we can improve next year’s Quality Account. If you
have any comments, would like more information, require a hard copy of this document, or have any
questions, please contact us using the details below:
By email: awp.communications@nhs.net
By telephone: 01225 362995
5. Our approach to quality
Throughout 2021-22, we have continued our response to the COVID-19 pandemic, prioritising keeping our
service users and staff safe. We were also able to continue progressing our quality agenda, working
towards the Director of Nursing and Chief Executive’s commitment for providing outstanding care, through
outstanding people, ensuring our services are sustainable and delivered in partnership.
We remain committed to managing risks and promoting safety, thus providing an environment for learning
and improvement, utilising a Quality Improvement (QI) approach, where applicable. Co-producing quality
improvements with service users and carers is our ambition and we are well supported by our Experts by
Experience in this regard.
Quality assurance
The Trust continues to monitor the quality of its services through a number of mechanisms, including:
Information for Quality (IQ)
ReportZone (our internal performance reporting / management system)
Ulysses (our incident and risk management system)
National benchmarking information
These systems align with the five CQC domains, including national and local CCG indicators for standards of
care. These systems allow us to report data from ‘floor to Board’ and enable teams to monitor their activity
against standards, and provides early notification of successes, as well as where standards are not being
fully achieved. In order to understand the impact on quality where performance is below target, it is
helpful to see the trends in level of compliance so that we can target improvement action.
An overhaul of our clinical governance arrangements was introduced in 2020, through the work of the
Quality Advisor to the Trust Board. This instilled a new governance framework, centred around the five
CQC domains, designed to strengthen reporting arrangements and the provision of the assurance to Trust
Board. For 2022-23, the Trust will strengthen the connectivity between localities, divisions and the Trusts
reporting processes to further improve the ‘floor to Board’ governance thread.
Alongside these improvements, we have also invested significantly in our infrastructure for quality and
safety work, notably capacity building in specialist areas, such as health and safety, patient safety and
significant progress in our Patient Safety Incident Response Plan (PSIRP).
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Quality improvement
A large proportion of our local QI projects that started prior to the COVID-19 pandemic remained paused
during 2021-22, due to continued acuity and clinical focus for many teams. Work to support teams to
resume these commenced in the summer of 2021, but progress has been slow. However, there are a
number of existing Trust-wide development plans for 2021-22, that have progressed our ambition of
continuous improvement. The following elements were achieved:
Specific ward based QI programmes
A substantial QI programme on our later life ward in North Somerset (Dune Ward) continued in 2021. The
successes of this programme were presented at a Trust-wide Older Adults Clinical Network (OACN) to help
share the learning and tools used in that programme to support others. In summer of 2021, we rolled out
the Dune improvement programme to a BaNES inpatient ward (Sycamore), tailoring it to their specific
identified needs. This work continues to date, with QI teaching sessions being delivered in April 2022 to the
wards senior nursing staff.
Mental Health Safety Improvement Programme (MHSIP)
In 2021, AWP signed up to the MHSIP, working alongside the South of England Mental Health Collaborative
(SEMHC), and the West of England Academic Health Science Network (WEAHSN). The three-year MHSIP
involves the following elements of focus:
Reducing Restrictive Practice (RRP)
Sexual safety
Suicide prevention
However, the focus to date has been RRP and this will continue in 2022-23 due to the impact of COVID-19
on this national programme. Three AWP wards in Secure Services have signed up to be part of this
programme, however, learning will be shared across the Trust via the RRP Trust-wide group. The three
identified wards attend the monthly collaborative QI coaching sessions and quarterly SEMHC full day
events. In addition, our internal QI team, supported by the Trust’s RRP lead, has delivered two half-day
introduction to QI training sessions to the three identified wards.
Care planning and risk assessment improvement programme
The Care Planning and Risk Operational Group, led by our Deputy Director of Nursing continues to utilise QI
methodologies to support continuous improvement in this area. This improvement programme has utilised
QI tools to understand the issues, interrogate existing data, consult with our staff via a Trust-wide survey
and use Statistical Process Control Charts (SPC) to monitor progress.
Learning disabilities improvement programme
The Learning Disabilities Improvement Group was set up in July 2021, it met just six times in total during
2021-22, but has achieved a lot to date. An intensive piece of work to benchmark our services via the
national Learning Disabilities (LD) benchmark tool was carried out in January - March 2022, a total of 135
data items / questions were completed and submitted. To gain stakeholder engagement from our teams
and have an understanding of current practice and developmental needs the national LD green light toolkit
audit was also completed and is currently being analysed. This will help support the development of a
detailed LD improvement plan.
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Royal College of Psychiatrists (RCPsych) Advance in Mental Health Equalities (AMHE) programme
In July 2021, AWP signed up to the Advance in Mental Health Equalities (AMHE) programme, led by the
RCPsych. Internally, this is led by our Deputy Medical Director and supported by national QI coaches and
the internal AWP QI team. Significant progress has been made on this QI programme to date, with great
engagement from many disciplines and leads, this programme will continue over 2022-23.
QI training
A QI training programme was developed in July 2020, but paused in December 2020 due to the COVID-19
pandemic, this however, was re-instated in April 2021. The programme was developed to provide Senior
Clinicians with in-depth QI training to enable them to undertake their role as CQC Domain Leads. The
structure and content of the course used the dosing approach, as detailed in the NHS England and
Improvement (NHSE/I) and Institute for Healthcare Improvement (IHI) (2017), building capacity and
capability for improvement.
Within the constraint of having to deliver the training online due to COVID-19 restrictions, the NHSE/I
dosing table was adapted. External resources were scoped and mapped against the dosing matrix to create
a comprehensive course that covered the key areas of Science of Improvement (SOI), learning and for
leading QI. This was split into modules and added onto our internal learning platform (MLE) for ease of
access by all CQC Domain Leads.
Using such external resources also helped introduce the CQC Domain Leads to a greater range of QI
resources and organisations. The eight-module programme of learning was set out across a twelve-week
period, supported by the QI team from April to July 2021. More recently, the modules on the internal
learning platform have been opened up and offered to anyone wanting to learn QI skills.
In addition, ad hoc QI training has been provided to individuals registering projects with the QI team, and a
20 minute featured slot on every Junior Doctor induction during 2021-22, as an introduction to QI and the
QI team. In August 2021, the QI team delivered a half-day training session for 10 core Psychiatric Trainee
Doctors on leadership in QI, which proved successful and gratefully received to support their development
of QI as they embark on more senior medical roles.
Clinical Leadership Oversight Group (CLOG)
Readers will appreciate that the evolving and ever changing nature of the COVID-19 pandemic in 2021-22
meant that we often had to adapt our services and our ways of working at pace. To ensure that we did this
safely and considered the quality impact from a safety, effectiveness, and experience perspective, as well
as being mindful of any legal, equality or information governance challenges, we established the Clinical
Leadership Oversight Group (CLOG).
For much of the pandemic response, the CLOG met daily at midday to review and authorise any clinical,
operational, policy, practice or procedural changes. The membership of the CLOG included clinical leaders
across the organisation from all different professions, as well as subject matter experts. The meeting was
chaired by either our Director of Nursing and Quality or our Medical Director. Service changes that we
made were subject to an evaluation that helped determine whether the change should be short term or
adopted as our new business as usual.
Examples of key changes we introduced are as follows:
COVID-19 staff screen tool and risk Assessment 24/7 - the purpose of this project was to follow the
national instruction for each mental health organisation to establish a ‘crisis line’ in order to field
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calls from known service users / carers and the general public relating to mental health. The
aspiration was that an established 24/7 response service would alleviate pressure on primary care
and emergency services. The requirement to establish such a facility aligned with AWP’s own
response plans to deal with the service pressures already being felt and further anticipated due to
COVID-19.
Facilities management - the pandemic brought with it much reported challenges with supplies of
Personal Protective Equipment (PPE) for staff, as well as requiring further enhanced cleaning
regimes for all of our clinical environments. This presented a significant challenge to the Trust and
required creative ways of working to ensure supplies (sometimes scarce) were targeted to priority
areas. As the supply challenges were addressed, we started to work on agreeing a sustainable
model for facilities management, now that we are operating within a ‘new normal’.
Community surge planning - throughout the pandemic, we tried to minimize the closure of services
and tried to keep as many services running as possible within the government guidelines. The
effects of lockdown were predicted to increase demand on mental health services, so as part of our
response, we undertook detailed planning work to identify where surges in demand for services
may occur and agreeing what risk management actions we would take if the demand was realised.
Infection prevention and control
We have a duty of care to ensure that our patients do not get any avoidable Healthcare Associated
Infections (HCAIs) while in our services. Robust systems, quarterly and annual audits, and actions are in
place to ensure that avoidable HCAIs within the Trust are kept to a minimum by undertaking the following
audits and actions:
IPC annual audit, based on the Essential Steps Audit Tool – the IPC team liaises with the link
practitioners / ward managers to audit clinical practice and provide assurance against the
fundamental principles of infection control. For example, hand hygiene, safe disposal of sharps and
appropriate use of personal protective equipment.
Antimicrobial auditing and stewardship monitoring.
Alert organism surveillance – reported by all inpatient wards using a surveillance tool, which is
available on our intranet ‘Ourspace’.
Outbreak management investigation.
All IPC polices are reviewed and updated accordingly with best practice and national guidelines.
Two yearly mandatory IPC training programme for all staff.
Monthly IPC link practitioner meetings are held across all divisions. The aim of these meetings and
roles is to encourage best IPC practice locally across AWP.
Response to the global COVID-19 pandemic – 2021-22
The IPC team continued to play a pivotal role in the Trust’s response to the COVID-19 pandemic. The IPC
team kept abreast of changes to national IPC guidance and implemented changes, when appropriate.
Key actions and achievements during 2021-22
Expert IPC advice to support the Trust’s response to the surge in outbreaks during the
Omicron wave.
IPC inputs in admission pathways.
Hand hygiene and PPE audits.
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COVID-19 Assurance framework – self-audits completed by all inpatient wards.
Outbreak management masterclass delivered by the Head of IPC.
COVID-19 and seasonal flu training added to our internal learning platform (MLE).
Prompt action on any outbreaks reported as per our outbreak management plan.
COVID-19 vaccinations for service users.
As part of our flu campaign, we introduced the ‘vaccination track’ system to help us manage
our online booking system for flu clinics, which resulted in a 60% uptake.
Transition from clinical waste to tiger waste for non-infectious PPE.
6. Quality priorities
As part of the Quality Account each year, we set out our quality priorities for the year ahead. The priorities
for 2022-23 include a focus on:
The NHS Patient Safety Strategy, which encompasses the Patient Safety Incident Response Plan
Our emerging clinical care pathways
Delivering CQC regulatory compliance
Our quality priorities for 2022-23
Figure 1 – our quality priorities for 2022-23
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Our success last year - priority 1 – care pathways
Table 1 – priority 1 – care pathways 2021-22 update
Improvement
project
Dementia
Success measures
Agreed pathway in
place across the Trust
Underpinned by agreed
strategy
Clear clinical leadership
in place
Evidence outcome
measures in place
2021-22 update
Community Mental Health Framework (CMHF) older
peoples workstream established since September
2021, with key partners across BSW. Workstream
agenda ensures integration with the BSW ageing well
programme and the BSW dementia diagnosis rate
working group.
Dementia Enhanced Support Team (DEST) pilot in
Swindon continues with good outcomes, this also
forms part of the CMHF workstream.
Older Adult Matron in place during COVID-19.
Recurrently funded through MHIS in 21-22 – will be
recruited as an Advanced Practitioner role in 22-23,
with a focus on clinical and quality improvement.
BSW band 8b Clinical Lead for community Older
People Mental Health (OPMH) recruited in March
2022 and will chair / lead the CMHF workstream
group
Recruitment of a full-time BNSSG band 8c Clinical
Lead for OPMH is underway. The post holder will
take a leadership role across the complex BNSSG
system, focusing their clinical leadership skills on the
community and Aging Well pathways and ensuring
that the provision of Older Adult services is a
fundamental work-stream within the CMHF.
Older Adults Clinical Network (OACN) established
with membership from all AWP localities, community
and inpatients services and all professional
disciplines. The network covers all OPMH (including
dementia) and has a key focus on QI and sharing best
practice and reports directly into the ‘effective
subgroup’. The clinical network is used in an advisory
capacity, drawing on expertise from senior clinicians
to critique policies or QI initiatives, which will impact
on later life service users.
Workshops have taken place, which were very well
attended. Suggested improvements to dementia
care pathway compiled.
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Learning Disability
Agreed pathway in
place across the Trust
Underpinned by agreed
strategy
Clear Clinical
Leadership in place
Evidence outcome
measures in place
Greenlight toolkit audit completed, findings currently
under review. Report to be completed and
triangulated with the NHSI Learning Disability
benchmark action plan (submitted March 2022) and
the Trust’s Neurodevelopmental strategy (when
finalised). This will enable key priorities to be
planned for and actions in situ and attached to the
Learning Disability improvement group outcomes.
Clinical network established, led within Specialised
Services.
Learning Disability Consultant Nurse substantive post
created from the initial secondment status (July 2021
to date). This is a new post for the Trust and will
support the collaborative Trust-wide delivery of
mental health for people with a Learning Disability
vision across the Trust (linked to strategy). This post
provides a key clinical contact role for both staff and
patients and highlighting the profile of care and
treatment within AWP as an acute mental health
Trust.
Learning Disability awareness training availability –
ongoing work continues with support from our
learning and development team, including interim
solutions until known plans are in place regarding
the roll out of the proposed nationwide plan of the
provision of mandatory Learning Disability / Autism
awareness training for all health and social Care staff
- ‘the Oliver McGowan training’
LeDeR (Learning from Lives and Deaths – People with
a Learning Disability and Autistic People) – improved
governance in place via Serious Untoward Incidents
(SUI) and is a standing agenda item at the monthly
mortality review meetings. Embedded working and
improved liaison with BNSSG / BSW key LeDeR
contacts and representation / active involvement in
LeDeR governance meetings.
Reasonable adjustments digital flag pilot – BNSSG
CCG are an early implementer. AWP are working
with BNSSG CCG to contribute to the success of this
pilot project, which will have a nationwide impetus
when rolled out nationally. People with a Learning
Disability will be flagged via the national spine and
this will support with the provision of reasonable
adjustments needed for individuals.
Physical health agenda for people with Learning
Disabilities – to be embedded within the Trust’s
physical health policy
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Personality
Disorder
Psychosis
Agreed pathway in
place across the Trust
Underpinned by agreed
strategy
Clear Clinical
Leadership in place
Evidence outcome
measures in place
Agreed pathway in
place across the Trust
Underpinned by agreed
strategy
Clear Clinical
Leadership in place
Evidence outcome
measures in place
Working group has met to develop the pathway and
strategy (series of workshops in autumn 2021).
Core Community Mental Health Team (CMHT) /
recovery model of SCM (Structured Clinical
Management) pathway is being operationalised
across the Trust.
The CMHF year two funding to support the
development of a managed clinical network and
Knowledge and Understanding Framework (KUF) roll
out in BSW (1 band 7 Expert by Experience, 1 band 6
Training Lead, 1 band 8a Supervision and Reflective
Practice Lead). Managed clinical network / team also
being developed by the CMHF workstream in BNSSG.
Funding secured for an Early Intervention Service in
BSW (1 band 8a and 4 band 7s). BNSSG division is
also prioritising early interventions, as part of the
CMHF funding for year two.
A Psychosis care package has been agreed by the
Trust and training has begun. Over 100 staff have
been trained in the Health Education England (HEE)
‘understanding Psychosis and Bipolar’ training and
over 40 trained in Cognitive Behavioural Therapy
(CBT) informed interventions for Psychosis.
Early reports of implementation of these CBT
informed interventions for Psychosis have started to
come in with positive feedback from clinicians
regarding their effectiveness. Implementation has
been supported with the provision of centralised
clinical supervision in the short term.
Strategy to train staff in interventions relating to
Psychosis (e.g. family interventions and CBT
informed interventions for Psychosis) over the next
three years has been agreed at executive level.
Wider strategy regarding Psychosis pathways
remains in development – a significant piece of work
was undertaken in 2021-22 to ensure this strategy
was coproduced with clinicians and service users
across the Trust.
Foundations of clinical leadership is in place – two
Psychologists, specifically employed as training leads
for Psychosis, have worked hard to create training
materials with other clinical colleagues across the
Trust to allow the implementation of Psychosis
packages and pathways.
Service user outcome measures for Psychosis care
packages have been agreed and systems updated in
order to enable the capture and evidence of these
measures. Work is currently being undertaken to
encourage use of these outcome measures by
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clinicians receiving CBT informed intervention
training.
Priority 2 – Physical Health
Table 2 – priority 2 – physical health 2021-22 update
Improvement
project
Cardio metabolic
care for people
receiving
psychotropic
medication
Venous
Thromboembolism
(VTE) - Introduce a
model and audit
process
To agree a physical
health clinical
leadership model
across the Trust
Reducing
Restrictive
Practice (RRP)
Success measures
Clear and consistent
model in place
Evidence through audit
of improved checks and
outcomes
Consistent model in
place to ensure
screening and VTE
prevention - evidence
of audit
Clear physical health
care leadership
embedded across the
Trust
Evidence of a Trust
wide model to support
reduction in restrictive
practice, using a QI
approach with evidence
of reduction across all
Adult and Psychiatric
Intensive Care Units
(PICU)
Reduction in prone
restraint
2021-22 update
A programme board has been stood up to oversee
quality improvements in physical health, including
cardio-metabolic screening for people receiving
psychotropic medication.
The board has overseen work to develop a clear and
consistent model of delivery for annual physical
health checks for service users in the community with
serious mental ill-health. Phased implementation of
the model in both BSW and BNSSG will commence
through 2022-23.
Scoping of the full requirements to support digital
solutions, including changes in RiO, has commenced
as part of the work overseen by the programme
board. This includes e-observation implementation in
inpatient settings.
Physical health checks within 24 hours of admission
to hospital for inpatients has improved during the
year from 60% to 76%.
VTE work has not been taken forward through 2021-
22, as the Trust has focused on other physical health
priorities.
The clinical leadership model to support improved
physical health monitoring in community services has
been agreed and will be implemented and embedded
through 2022-23.
RRP group continues, with consistent Trust-wide
representation, including Experts by Experience. The
group has reviewed the Trust-wide work plan and
commenced updating this to identify priorities for
2022-23.
The Trust submitted its application for accreditation
for the Prevention and Management of Violence and
Aggression Training in December 2021 and has now
received feedback from the British Institute of
Learning Disabilities (BILD) on the submission. The
group will review the feedback the next steps are for
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Reduction in the use of
seclusion
BILD to quality assess the training on site before
accreditation.
The RRP group plan to undertake an audit on the
impact of COVID-19 on the Safewards
implementation and embedding of practice over the
past 2 years, this will also include a staff and service
user survey to be disseminated within quarter one of
2022, with an aim to ‘establish expectations’.
The Trust RRP policy has been reviewed and
approved. The policy brings the Trust in line with the
RRP network and BILD Standards.
There has been a sustained reduction in planned
prone restraint. Use of restraint overall across the
Trust continues on a downward trajectory.
There is a clinical review of the use of seclusion
suites to ensure that they meet the required
standards and are used appropriately.
The Trust is also ensuring that it complies with the
Use of Force Act (2018) which came into force on 31
March 2022.
Techniques for using the purchased ‘safety pods’
have now been signed off and the implementation
roll out is planned for 2022-23.
Lateral thigh Intramuscular Injection (IMI) training –
in September 2021, the RRP group reviewed and
revised the ‘Administration of Rapid Tranquilisation
Medicines using the Thigh (Vastus Lateralis Muscle),
Upper Arm (Deltoid Muscle), and Buttock
(Dorsogluteal Muscle) Procedure’, which supports
the introduction of IMI sites other than the gluteal
muscle, as part of our targeted reduction of prone
restraint.
Priority 3 – achieving CQC regulatory compliance
Table 3 – priority 3 – CQC regulatory compliance 2021-22 update
Improvement
project
Improving our
Acute and PICU
environments
Success measures
Agreed, updated
estates strategy
Improve seclusions
facilities
Clear estates funded
programme to improve
general ward
environment
2021-22 update
The estates department is currently being reviewed
by an external consultancy, ANHH. Part of their remit
is to review the estates strategy.
The Trust completed the agreed safety upgrade
works to all seclusion suites in the 2021-22 financial
year - £235k. The Fairfax and Teign wards works
were delayed because of the major refurbishment of
the Bradly Brooke seclusion suite - £400k, but all are
now complete.
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Improving the
quality of care
planning
Trust wide QI
programme
Positive feedback from
CQC / Mental Health
Act (MHA) inspections
Regular quality audits
of care plans
A programme of work was undertaken to improve
areas assessed as requiring environmental
improvement, as detailed below:
o Applewood Ward – Swindon
o Sycamore Ward – Bath
o £3m refurbishment of Ceader Ward - Hillview
Lodge (to replace Ward 4 dormitory ward at St.
Martins)
o Elizabeth Casson House - £2.1m redesign /
refurbish due for completion June 2022
o Riverside CAMHS - £3.25m inpatient redesign /
refurbish completed 1st April 2022
o CAMHS community - c£200k refurbishment of
a number of community properties. Tender
returns expected by end of May 2022
o A ligature reduction programme for the
financial year 2021-22 was also completed -
£944k
We have developed and implemented a care plan
and risk management supervision tool. The tool is
reported to have been used 547 times since its
launch this year.
We have developed and piloted care plan training
and will be further rolling out the training across the
Trust in 2022-23.
The quality improvement outcome measure relating
to the quality of the care plan has increased from
53% to 74% compliance over the year.
Reduction in QI function as prioritisation of safety
through continued management of COVID-19.
Head of QI out to recruitment in March 2022, who
will lead on supporting infrastructure, which
specifically links to; culture / organisational
development work, engagement, methodology and
patient involvement and align clinical and quality
strategies.
Established QI functions within local ICS – learn and
adapt models to fit AWP’s position / maturity and
ensure QI is linked to the overarching transformation
priorities.
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Priority 4: implement electronic Prescribing and Medicines Administration (ePMA)
Table 4 – priority 4 – ePMA 2021-22 update
Improvement
project
Implement the
system in
identified inpatient
units
Success measures
To effectively use the
system in place of
paper prescriptions and
administrative record
charts
To see a reduction in
medicine prescribing
errors
2021-22 update
Implementation delayed due to identification of a
number of inadequate functional provisions related
to medicines reconciliation, discharge
documentation and safe use of the disaster recovery
solution; ePDR.
Clinical challenge held to approve local development
where supplier was unable to deliver satisfactory
resolution.
All local developments related to the delay have
been completed. Minor changes being undertaken
following final review.
Supplier provision of ePDR fixes is scheduled for
early May 2022.
Escalation with supplier due to delay and lack of
provision of required functionality, has resulted in a
revised plan being approved by the project board
with initial go-live scheduled for 7th September
2022, and completion of trust-wide inpatient
deployment throughout October.
Training reviews initiated with a view to refining the
training provision for delivery.
Preparation for formal testing in progress. Testing of
system including provision of ePDR scheduled for
May.
Go-live preparation to determine appropriate
engagement, pre-live checks and dependencies in
progress.
7. Statement of assurance
The following statements authenticate that the Trust is striving to achieve essential standards. To do this,
we are required to demonstrate that we are measuring our clinical process and performance against both
local and national standards and that we are involved in national projects to improve the quality of our
services.
Provision of NHS service
During 2021-22, the Trust provided and / or subcontracted 18 core and specialist health services that form
part of the Trusts required registration with the CQC.
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We provided services across two CCG areas, along with a range of specialised services for other
commissioners. Our services are arranged by locality, area or specialism within our divisions and
structures, which remain the same as previous years.
Table 5 – AWP divisions
Divisions Areas Covered
East
BaNES, Swindon and Wiltshire (BSW)
West
Specialised
Bristol, North Somerset, South Gloucestershire (BNSSG)
Specialised Services, Secure Services and Children and Adolescent
Mental Health Services (CAMHS)
AWP provides community and inpatient mental health services across all of these areas, secure services for
the region and a large number of smaller services commissioned between CCGs, Local Authorities and NHS
England Specialised Commissioners.
The Trust has reviewed all the data available to it on the quality of care in all these relevant health services.
Reviewed in 2021-22, the income generated by these services represents 100% of the total income
generated from the provision of relevant health services by the Trust in 2021-22 and equates to £331,327.
8. Clinical audit
Initial communication from Amanda Pritchard, Chief Operating Officer, NHS England and NHS
Improvement, in March 2020 stated:
“All national clinical audit, confidential enquiries and national joint registry data collection, including for
national VTE risk assessment, can be suspended. Analysis and preparation of current reports can continue
at the discretion of the audit provider, where it does not impact front line clinical capacity.”
Updates from the initial suspension of national clinical audit in March 2020 were received throughout
2020-21. In January 2021, a further communication titled ‘reducing burden and releasing capacity to
manage the COVID-19 pandemic’ on page 7/10: section reporting and assurance: point number 13, stated
the following:
“Clinical audit: given their importance in overseeing non-COVID care, clinical audits will remain open. This
will be of particular importance where there are concerns from patients and clinicians about non-COVID
care such as stroke, cardiac etc. However, local clinical audit teams will be permitted to prioritise clinical
care where necessary – audit data collections will temporarily not be mandatory.’
On 27 May 2021, the following letter from Professor Stephen Powis, National Medical Director for NHS
England and Improvement to Healthcare Quality Improvement Partnership (HQIP) stated:
“In order to support the National Clinical Audit Patient Outcome Programme (NCAPOP) with monitoring
and improving patient care, please accept this letter as notice that NHS England and Improvement is
mandating a restart to data collection in England for the NCAPOP’
In December 2021, communication from Sir David Sloman Chief Operating Officer NHS England and NHS
Improvement to NHS Trusts and Foundation Trusts: reducing burden and releasing capacity to manage the
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COVID-19 pandemic’ on page 6/9: Section: B, reporting and assurance: point number 14, stated the
following:
“Given the importance of clinical audit in COVID and non-COVID care, clinical audit platforms will remain
open for data collection. It should be noted clinical teams should always prioritise clinical care over data
collection and submission.”
Despite the various pauses and permission to prioritise clinical care (where necessary) over clinical audit
participation as described above, we have still been able to participate in all national audit programmes
that fell within 2021-22 NCAPOP. Reporting and action planning on some of the paused or delayed 2020-21
national, Trust-wide or local reports were also progressed where possible, developing our actions and QI
programme around those results, where this had little impact on clinical capacity.
During 2021-22, six national clinical audits covered relevant health services that the Trust provides. During
this period, we participated in 100% of those, for which we were eligible, as shown in the table below:
Table 6 – participation in national clinical audits
*National audits that AWP was
eligible to participate in 2021-22
AWP
involvement
Cases submitted / cases required
1. National Clinical Audit and Patient Outcomes Programme (NCAPOP)
National Audit of Inpatient Falls (NAIF)
National audit of Psychosis: early
intervention In Psychosis spotlight
audit
YES
YES
a) 0/0 (100%) - ongoing, currently with
no identified cases to audit
b) 1/1 (100%) organisational
questionnaire submitted
a) Case audit –222/222 (100%)
b) Contextual audit- 6/6 (100%)
National audit of Care at the End of
Life (NACEL) round 3
YES
a) 1/1 (100%) - organisational
questionnaire
b) 3/3 (100%) - case audit
National Clinical Audit of Psychosis
Spotlight Audit 2021-22
YES 99/100 (99%)
NCEPOD transition from child to adult
services study
YES
Still collecting at time of writing, data
collection ends May 2022
National audit of Dementia - spotlight
audit in community based memory
assessment services 2021-22
2. ** Non-NCAPOP national audits
YES
1/4 possible memory teams participated
POMH 18b: Use of clozapine YES 168**
POMH QIP 14c: Alcohol
detoxification
YES 35**
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POMH QIP 19b: Prescribing for
depression
YES 133**
*Table 6 shows the national audits the Trust was eligible to participate in, those it did participate in, and
the level of completion of data requirements.
** Prescribing Observatory for Mental Health (POMH) - Royal College of Psychiatrists, has no set number of
cases required.
Quality improvement actions from clinical audit
As described within last year’s quality account, to support learning resulting from clinical audit, the Trust
has continued adopting a different approach, recognising that long detailed action plans do not always
support change, as we would wish.
Our approach continues to feed audits into any existing QI programmes, or where possible either develop
a new QI programme. Or as a minimum we try and utilise other root cause QI tools to understand the
cause of any audits demonstrating the need for improvement before deciding on an action plan. This
approach allows for small scale testing and measuring of change ideas, following audit outcomes, adapting
to effect change and then disseminating the practice across the Trust.
An example of this being the allergies and adverse drug reaction documentation clinical audit, carried out
in 2020. An action plan was approved at the Medicines Optimisation Group, which included actions such as
review of policies, Standard Operating Procedures, education etc. However, the action plan also included
the need for a focused QI project with an inpatient ward to fully understand the issue and explore change
ideas. This was completed using an Multi Disciplinary Team (MDT) approach, by carrying out a fishbone
exercise to try and understand the specific compliance issue regarding the allergy status not always being
added to the electronic patient record, in addition to it being recorded on the paper drug chart (as per
policy).
Following this exercise, a change idea to develop a regular inpatient dashboard reporting of said allergy
status with the Business Intelligence Team was explored and implemented. SPC charts have demonstrated
a gradual steady improvement over a short five-month period, with a total of 22 patients Trust-wide with a
missing allergy status on the electronic record in the month of October 2021, versus only 5 missing in April
2022, meaning a 77% decrease in non-compliance against the policy.
A further example of this can be seen following the 2020-21 physical health clinical audit across Bristol and
BaNES inpatient wards. This audit resulted in feeding the wider physical health electronic records re-design
group in changes to the form to improve physical health recording. It also developed into a further QI
project, testing Electrocardiogram (ECG) machines in community mental health teams to improve ongoing
physical health monitoring, linking with local the Cardiologist Service in nearby hospitals. The audit also
resulted in a further baseline audit and QI project / pilot of a Diabetes Clinic, supported by a local Diabetes
Nurse Specialist within a general hospital.
NCAPOP
At the time of writing this Quality Account, the results of all six NCAPOP clinical audits demonstrated in the
2021-22 NCAPOP table above are either yet to be published nationally or only recently published, and are
therefore currently going through our Trust governance processes for action planning / QI planning and
sign off.
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National non-NCAPOP clinical audits (POMH)
Of the three non-NCAPOP national audits (POMH audits) for 2021-22, at the time of writing this Quality
Account, we are unable to share results or discuss agreed action plans due to the following reasons;
POMH 19b prescribing for depression: this audit data collected in quarter four of 2021-22,
therefore the national report will not be published until latter end of quarter one in 2022-23.
POMH 14c POMH QIP 14c: alcohol detoxification: national report was received quarter 4 2021-22,
therefore this report is currently going through Trust governance processes for action planning and
sign off.
POMH 18b use of clozapine: we received the national report end of quarter three of 2021-22 and
so this is currently going through Trust governance processes for action planning and sign off. This
has had some delay internally also due to trying other mechanisms and approaches in gaining
feedback and recommendations to support action planning / QI planning with our Medical Leads.
Trust identified audits on 2021-22 workplan
Trust-wide monthly medicines safety audits and Trust-wide quarterly controlled drugs audit have
continued to be collected by the Pharmacists on the ward, these are reviewed via the Chief Pharmacist and
Trust medicines governance groups and acted upon accordingly. The final yearly summative report for both
of these audits is due for review at the medicines safety group in quarter one of 2022 and therefore at the
time of writing, we are unable to detail findings or actions.
Weekly and monthly medicines related audits in both community and inpatient settings are in place with
the findings published monthly in an excel pivot chart workbook filterable by ward. This provides instant
feedback on compliance for locality governance meetings and local action planning. However, response
rates for completion of these audits remain low due to acuity and the impact of COVID-19 on our teams.
Conversations between the Trust pharmacy directorate and nurse directorate commenced in early 2022 to
try and improve this. Trust level reports will be produced once completion rates have improved.
A total of thirteen clinical audits listed on the Trust-wide audit workplan for 2021-22 are either at the time
of writing, finishing data collection for any quarter four data, report writing, action / QI planning or
awaiting final sign off at relevant governance group. These audit topics are as follows:
National Early Warning Score (NEWS) re-audit
Medicines reconciliation
Antibiotic prescribing re-audit
Antibiotic prescribing offender health services
Medicines storage re-audit
Drug Prescription and Administration Record (DPAR) re-audit
Pharmacy interventions
Medical gases
Evaluation of community pharmacist within perinatal team
Non-medical prescribing re-audit
Green light toolkit audit- Learning Disabilities
NHS benchmarking network – Learning disabilities
Monthly records audit of care planning and risk assessments
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The reports of two clinical audits were reviewed in 2021-22 by the relevant Trust governance groups in
2020-21 and published to internal audit pages. First being the pressure ulcers re-audit and the second
being community alcohol detox re-audit. Findings and actions / improvements are detailed below:
Pressure ulcers, six-monthly re-audit
This was completed in October 2021 and report ratified in the physical health action group in November
2021. The action Plan was updated in March 2022, with some outstanding actions remaining. Areas of
good practice demonstrated that since the last audit, in 2019, there have been a few criterion where there
has been an increase in compliance. Examples of such areas are:
A small increase in patients having a pressure ulcer risk screen within six hours, rising from 40% to
43%.
Patients being re-assessed for pressure ulcers after a change of care environment, increasing from
93% to 100%.
Skin assessments for patients identified as being at risk from pressure ulcers has increased from
53% in 2019 to 67%.
Requests for General Practitioner (GP) summaries for patients at risk of developing pressure ulcers
have increased from 7% to 19%.
Areas for improvement included:
Patients should have their nutrition and hydration assessed using the Malnutrition Universal
Screening Tool (MUST) on admission to an inpatient ward, which has decreased from 89% to 85%.
Healthcare professionals responsible for screening on admission should be trained in assessing
pressure ulcer risk with management support from tissue viability nurses as Service Local
Arrangements. Going down from 85% to 64%.
Initial skin assessment of high-risk patients must include the inspection of bony prominences has
decreased from 100% to 79%.
People at high risk of developing pressure ulcers should be provided with pressure redistribution
devices and or information on how to prevent them has decreased from 80% to 37%.
Summary of recommendations and actions (with due dates)
Ensure that awareness is raised around need to complete Pressure Ulcer Risk Assessment within 6
hours of admission and transfer. (December 2021 / January 2022).
Develop brief Video Tutorial to introduce clinical staff (target group inpatient registered nurses)
how to undertake a Pressure Ulcer Risk Assessment using the WATERLOW tool. (January / February
2022).
Develop (adapt from Tissue Viability services) a leaflet for service users and carers to promote
awareness around pressure ulcer prevention. (December 2021 / January 2022).
This audit provides another example of linking in audit findings into other QI initiatives, as we fed the
learning from this audit into a current electronic patient record physical health pages re-design project. It is
hoped this can help improve recording, as well as supporting regular reporting / easy access dashboards on
pressure ulcer standards compliance in the future.
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Community alcohol detoxes re-audit
Data was collected in quarter one of 2021-22 and approved in July 2021 at the medicines safety group.
Areas of good practice included that community alcohol detoxes are carried out to a high standard
throughout the teams audited. Areas of particular good practice include that pre-detox assessments were
carried out in every case to a high standard and that all cases utilised a fixed prescribing regime, based on
the number of units consumed.
Areas for improvement included making sure that Wernicke’s assessment is documented, particularly if no
prophylactic medication is given, documenting decisions about liver function, and documenting how much
medication is supplied on each day of detox.
Summary of recommendations and actions (with due dates):
Medication administration should be documented in every case and available for review. To be
discussed in team meetings and reviewed by teams, detox nurses and admin staff to ensure clinic
paperwork is filled out and uploaded by November 2021.
When liver impairment is present, this should be commented on by a prescriber even if no
alternative medication is felt to be required. To be discussed in team meetings, pre-detox
assessment pro-forma to be recirculated and reviewed by teams by November 2021.
It is important to have documented clearly that a service user is low risk of Wernicke’s or that they
have made an informed decision to decline treatment if thiamine and pabrinex are not given, as this
did not happen in one instance. To be discussed in team meetings and reviewed by teams by
November 2021.
2020-21 audits approved and published in 2021-22
As mentioned in the opening statement for many 2020-21 audits, there was either a pause or delay of
those that originally started on the 2020-21 workplan and that would have been reported on within the
2020-21 Quality Account. The following reports were completed and ratified at governance groups during
2021-22 from the 2020-21 workplan:
Controlled drug 2020-21.
Medicines Storage re-audit 2020-21.
Allergies and adverse drug reaction documentation on System One in prisons settings.
Lithium initiation and monitoring in Bipolar Disorder.
Prescribing of Buccal Midazolam in those with epilepsy.
9. Research
During 2021-22, AWP has recruited 667 service user, carer and staff participants into National Institute for
Health Research (NIHR), across 48 studies; 42 NIHR adopted studies (3 sponsored by commercial
companies) and 6 student and non-NIHR research.
For our last full year of data (April 2020 to March 2021), the comparable figures were: 2,053 participants,
42 active studies; of which 37 were NIHR studies (4 sponsored by commercial companies) and 5 student
and non-NIHR research.
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The Trust is committed to research being part of everything we do. We support high quality research into
the prevention, treatment and management of mental health problems, addictions and dementia and aim
to put research findings into clinical practice. AWP ensures we give everyone who uses AWP services, their
carers and families (as well as staff) the chance to find out about research they could take part in. This
forms our pledge to make Research for all.
AWP works with the National Institute for Health Research (NIHR) and the West of England Clinical
Research Network (WECRN). The Trust collaborates locally with universities and acute Trusts through
Bristol Health Partners (BHP), the West of England Academic Health Science Network (AHSN) and the NIHR
Applied Research Collaboration West.
Performance indicators
Number of all research studies open to participants in AWP in 2021-22: 48
Number of NIHR* research studies open in 2021-22: 42
Number of student and non-NIHR studies open in 2021-22: 6
Number of participants recruited into all research across AWP in 2021-22: 667
Number of participants recruited into NIHR* research across AWP in 2021-22: 665
Number of participants recruited into student and non-NIHR research in 2021-22: 2
*NIHR adopt studies onto their portfolio which are of the highest quality, have been peer reviewed and
expected to lead to significant changes in the NHS within 5 years.
Current grants
The research and development department supported the following grants in 2021-22:
STRATA
STRATA is the largest multicentre clinical drug trial assessing the potential benefits of Sertraline for adults
with Autism Spectrum Disorder and anxiety that has ever been funded. Recruitment takes place across
research centres (including AWP’s Bristol Autism Spectrum Service) in the UK as well as in Western
Australia. Grant funding commenced in September 2019, led both locally and nationally by Dr Dheeraj Rai
at the University of Bristol with support from AWP research and development and the University’s Clinical
Trial Unit.
ADEPT-2
Following the success of ADEPT, a previous grant hosted within AWP. The lead researcher, Dr Ailsa Russell
(University of Bath) has been successful in securing a second NIHR grant around guided self-help for
depression in adults with Autism Spectrum Disorders. Seven NHS sites in total across England are involved.
The value of the grant income is £1.675 million (across 7 NHS sites and the university teams in Bath, Bristol
and Warwick), it opened in September 2021 and recruitment shall begin in 2022-23.
Improving the Accuracy and Efficiency of Autism Assessment for Adults
This RfPB grant is led by Dr Will Mandy at University College London and supported locally by Dr Ian Ensum
at AWP’s Bristol Autism Spectrum Service. The grant explores the potential utility of two diagnostic
27

interviews for supporting the timely diagnosis of adult’s with a suspected diagnosis of autism spectrum
disorder. Recruitment activity finished in February 2022.
Addressing the trauma-related distress of young people in care: a randomised feasibility trial across
social-care and mental health services
This AWP-hosted RfPB grant is led by Dr Rachel Hiller at the University of Bath. The grant explores the
feasibility of undertaking a future large-scale randomised control trial of a new intervention to support
looked after children (those in social-care and mental health services) effected by Post Traumatic Stress
Disorder. The grant was awarded in 2019 and recruitment activity will finish in 2022-23.
MRC Pathfinder Grant
This is a data linkage project with the University of Bristol looking at the ALSPAC cohort (‘Children of the
90’s’) to compare their mental health records in primary and secondary care; this project is using UK-CRIS
(Clinical Records Interactive Search) to link datasets which have been created and analysis is due to take
place during the next financial year (2021-22).
ERA
The ERA grant is a NIHR HTA funded trial of Arts Therapy (music / arts / dance therapy) relative to a group
counselling control group. The trial is led locally by Barbara Feldkeller and will conclude in 2022-23.
GameChange
GameChange is an NIHR grant lead by Oxford University, which aims to transform the lives of patients with
psychosis by putting powerful automated virtual reality (VR) psychological treatment into NHS mental
health services. The innovative VR treatment has been developed collaboratively with people with lived
experience, designers from the Royal College of Arts, computer scientists, and clinical psychologists. The
clinical trial was conducted in NHS services at five sites across England, of which AWP is one. The study
finished in November 2021 and the results have just been published.
Akrivia Health
AWP continues to remain a partner in implementing Akrivia Health (formally UK-CRIS), which is the largest
and richest mental health and dementia dataset to accelerate research for better treatments and care. In
AWP this will support many aspects of research, clinical audit and quality improvement in the future.
Akrivia has been on hold since March 2021 because of technical access changes, we are working through
the AWP Digital Oversight Group to enable the system to be re-activated.
Everyone Included
This method for letting services users know about research has also been on hold and in the next financial
year we will be reviewing and streamlining the process which we hope will increase recruitment and
inclusion in recruitment for research with service users and carers.
New grants due to start in 2022-23
In 2020-21 and 2021-22, AWP supported numerous academics to submit grants to the NIHR, resulting in
one being funded. These grants are due to open in 2022-23:
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EASE
Dr Paul Moran has been awarded an NIHR grant looking at perinatal emotional skills groups for women
with borderline personality disorder. AWP is the host organisation for the grant and is valued at £250k; this
will be opening in 2022-23.
SPS for Personality Disorder
Professor Mike Crawford from Imperial College London, has been awarded an NIHR grant looking at the
effectiveness and cost-effectiveness of Structured Psychological Support (SPS) for people with personality
disorder. AWP will act as one of the principle sites for the trial due to start in November 2022.
NIHR Advanced Fellowship Application
Dr Kim Wright at Exeter University has been successfully awarded an NIHR Fellowship looking at
interventions for people with inter-episode bipolar symptoms. AWP will work with Dr Wright to support
her fellowship and engaging with clinicians and service users in 2022-23 to deliver studies resulting from
her award.
Business planning
Our main funder (the CRN) have confirmed a slight uplift in funding for 2022-23 (3%) which covers
increased year-on-year staffing costs. We will be able to retain staff and cope with a small amount of
turnover in year meaning break even financial position by year-end. We have a staff group who have
adapted as well as can be expected to the Covid-19 pandemic, restrictions and reduction in studies.
We have prioritised projects relating to reducing health inequalities in research and increasing inclusion,
for which we received a CRN award in March 2022 for our work on Equality, Diversity and Inclusion. We are
looking forward to continuing that work and research becoming even more visible to service users, carers
and staff in 2022-23.
We have adjusted our plans for the coming year to account for a return to usual working practice, but
continue to work on innovative and collaborative projects, along with prioritising relevant research for
service users and staff that brings benefit to them and improvements to services. We will also work on
sustainability and ensuring break even at year end; we will maintain and build our partnerships locally,
nationally and internationally to increase the research opportunities we have on offer.
10. Patient safety
We remain committed to improving the quality of incident investigations and recommendations to support
Trust-wide learning and improvement. Work to strengthen our governance and quality processes in
relation to investigations has been undertaken, working collaboratively with commissioners and other
stakeholders.
Patient safety data
In line with national requirements set out by NHSE/I, the Trust collects patient safety data and uses the
data to understand why incidents happen and to inform changes to improve patient safety. The
information is also submitted to the National Reporting and Learning Service (NRLS), who use it to
understand national safety data trends, which in turn drive national patient safety initiatives.
29

NHSE/I considers high levels of incident reporting by Trusts to be an indicator of a positive reporting
culture, particularly when the proportion of serious incidents is low and the proportion of no harm
incidents is high. Positively, our Trust has maintained a stable trend in the total number of reported patient
safety incidents and rate of incidents per 1000 bed days, as shown in the table below:
Table 7 – patient safety incidents – national data
Reporting period (6
months)
AWP score England Highest score Lowest score
Number Rate average nationally nationally
Rate of service user incidents reported per 1000 bed days
01/10/16 to 31/03/17 4183 47.4 46 88 11
01/04/17 to 30/09/17 4741 54.33 52 126 16
01/10/17 to 31/03/18 4065 48.19 51 97 15
01/04/18 to 30/09/18 4389 52.8 55.57 114.3 24.9
01/10/18 to 31/03/19 4050 48.34 57.3 118.9 14.9
01/04/19 to 30/09/19 4724 56.6 62.9 130.8 17.2
01/10/19 to 31/03/20 4181 52 61.9 145.5 18.1
01/04/20 to 31/03/21* 11090 83.06 73.84 235.78 21.37
*This final line represents 12 months worth of data due to changes in reporting periods.
Figure 2 – total number of Trust-wide incidents reported compared against national benchmark
This information demonstrates a positive reporting and learning culture within our organisation. This is
supported by data published by NHSE/I, however at this time, the benchmarking for potential under
reporting of incident to the NRLS for 2021-22 is not yet available.
Within the Trust, the proportion of incidents resulting in severe harm or death remains low and the highest
number of reported incidents result in no harm or low harm. Of the incidents categorised as catastrophic a
significant proportion relate to deaths of older adults, residing in community and care homes, for whom
AWP provides a prescribing service.
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Figure 3 – total number of 2021-22 incidents reported, by level of harm
Figure 4 – potential under reporting to the NRLS – October 2019 – March 2020 (most recently published)
Serious incidents
Within the National Framework, a serious incident is defined as ‘any event or circumstance arising that
leads to serious unintended or unexpected harm, loss or damage’.
Within our Trust, when a reported incident is serious, in keeping with national thresholds, we will
commission a review. A member or staff trained in undertaking serious incident reviews will lead this,
supported by a supervising reviewer and clinical experts.
All completed serious investigation reports are subsequently reviewed by a multidisciplinary team
including executive level staff to ensure that reports are honest and transparent and reflect organisational
learning when things go wrong. All review reports undergo further scrutiny by our commissioners.
Throughout the review, we commit to being honest and transparent with service users and carers and
involve them wherever possible. We seek to understand why the incident occurred and to share lessons
learned to prevent or reduce the risk of reoccurrence. We will provide service users and carers with the
detail around lessons learned and actions taken if they so wish.
Investigation improvements
This year, the Trust has focused on expanding the team resources available to conduct serious incident
reviews. Additional staff have been recruited and subsequently trained, while taking the opportunity to
develop new tools for use in the reviews and utilise a thematic approach to identify learning across
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services and the organisation. In addition, the team have progressed with a backlog of reviews due to the
impact of COVID-19 and deployment of staff to support front line services.
Figure 5 – total number of reported serious incidents – April 2020 – March 2022
Incident trends
Suspected suicide in the community is the most commonly reported serious untoward incident in the
Trust. AWP has a suicide prevention strategy that is leading the organisation through a framework aimed
at reducing the number of service users whose lives end following suspected suicide. This is supported by
the recruitment of a Suicide Prevention Lead and a newly formed Suicide Prevention Group to support
delivery of the strategy.
Learning from serious incidents
Any learning recommendations from serious untoward incident investigations will have a Specific,
Measurable Achievable, Realistic and Timely (SMART) action plan developed. These action plans are
monitored within our quality governance structure, which include the Trust’s learning and improvement
panel to support learning from serious incidents. Action plans are reviewed for completion and evidence of
improvement is examined to ensure there is learning from experience is evidenced.
All actions are additionally recorded on to our incident and risk management system, Ulysses, which
enables us to establish a greater level of understanding through presented data and link directly to reports
related to the incident.
Patient Safety Incident Response Plan (PSIRP)
The national Patient Safety Incident Response Framework (PSIRF) is expected to be launched in spring 2022
and will replace the current national Serious Incident Framework. The framework outlines how NHS
providers should respond to patient safety incidents and when patient safety incident investigations should
be undertaken. In preparation for the launch, AWP is currently developing a draft Patient Safety Incident
Response Plan (PSIRP), which will be launched and implemented in 2022-23.
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All NHS providers will be required to have a PSIRP from the launch of the PSIRF. The current AWP draft plan
is based on the introductory of the PSIRF, which is currently being used by early adopter sites and
incorporates their feedback and learning.
The PSIRF is significantly different to the current Serious Incident Framework and will require a complete
organisational change to incident management, investigation and learning from incidents. Our PSIRP will
help us to improve the efficacy of our local Patient Safety Incident Investigations (PSII) by:
Refocusing PSII towards a systems approach and the rigorous identification of interconnected
causal factors and systems issues.
Focusing on addressing these causal factors and the use of improvement science to prevent or
continuously and measurably reduce repeat patient safety risks and incidents.
Transferring the emphasis from the quantity to the quality of PSII’s, such that it increases our
stakeholders’ (notably service users, families, carers and staff) confidence in the improvement of
patient safety through learning from incidents.
Demonstrating the added value from the above approach.
We have held a number of focus groups with stakeholders to review our thematic analysis and agreed key
areas of focus for our PSII and patient safety improvement work, we are currently developing our new
approach to both PSII and our patient safety improvement.
National guidance recommends that 3-6 PSII per priority be conducted per year, this will likely result in
approximately 40- 50 investigations per year, plus those PSII that must be investigated under the PSIRF.
Attempting to do more than this will impede our ability to adopt a systems-based learning approach from
thematic analysis and learning from excellence. Our objective is to facilitate an approach that involves
carefully using the resource we have to maximise learning opportunities. To identify common causal
factors and interconnections we will investigate the similar incidents separately with skill and rigour and
then undertake thematic analysis of the similar cases. This will enable us to gather detailed analysis of our
organisations system and develop recommendations and actions to support sustained patient safety
improvement.
Alongside these investigations, we will define key subjects for selection for patient safety reviews, patient
safety audits and patient safety risk assessments.
We have made progress and have developed our draft PSIRP. We are now focussing on how we support
and involve the people affected, including families, when we identify a serious incident that will not be
reviewed using full patient safety incident investigation methodology. It is important to note that we will
continue to undertake a first level review of all potential serious incidents to:
Understand what has happened and how it happened.
Identify any immediate learning and remedy and further potential patient safety issues.
Identify whether there are further learning opportunities that are not identified within out PSIRP
and where there are commission appropriate review or investigation.
Share what we know with the people affected, including families.
Answer any questions the people affected may have.
We are working in coproduction with Making Families Count, which is an organisation made up of people
who are recognised experts in their respective fields, and a number of other mental health care providers
across England to continually improve the way we support and involve families following serious incident.
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We are focusing on developing a toolkit to enable staff to effectively support and involve families with
three key work streams:
Supporting and involving families effectively alongside the Patient Safety Incident Response
Framework (PSIRF).
Enabling staff to feel capable and confident when they are supporting and involving families.
Developing a process to gain insight from families about their experience of support and
involvement so we can continually improvement.
Once we have a draft toolkit in place we plan to share our work via the regional patient safety and patient
experience network to get wider engagement and agree the final toolkit.
Patient safety partners
The national framework for involving patients in patient safety was announced as a key priority in the NHS
Patient Safety Strategy, published in 2019.
AWP already has established patient, service user and carer involvement, which includes strategic experts
by experience and we will be developing the role of Patient Safety Partners alongside our wider AWP
involvement strategy. We have recently recruited Patient Safety Partners to three key work streams:
AWP Patient Safety Strategy Development Group
Learning from Experience Group
Trust Quality and Standards Committee
Patient Safety Partners will work alongside AWP to improve patient safety in partnership with staff,
maximising the things that go right and minimising the things that go wrong for people receiving
healthcare. As part of this work, we are developing quality metrics to help us monitor improvement.
11. Learning from deaths and duty of candour
During 2021-22, 794 of our service users died. There was a clear increase in reported deaths noted on
quarter one; the number of deaths reported in quarter two, quarter three and quarter four is within
expected reporting levels. Interrogation of the data in quarter one revealed that there was a significant
number of deaths reported in community later life teams, the majority of deaths in this group are reported
as natural causes with twelve attributed to COVID-19. This finding is congruent with national reporting in
relation to increased deaths reported during this timeframe.
Table 8 – number of deaths
Quarter (2021-22)
Number
Quarter one - April to June 190
Quarter two - July to September 177
Quarter three - October to December 218
Quarter four - January to March 209
As at 31 March 2022, 101 case record reviews and 52 investigations had been carried out in relation to
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19% of these deaths.
In five cases, a death was subjected both to a case record review and an investigation. The number of
deaths in each quarter for which a case record review or an investigation was formally carried out is
highlighted in the table below:
Table 9 – number of deaths per quarter for which a case record review / investigation was carried out
Quarter (2021-22)
Number
Quarter one - April to June 35
Quarter two - July to September 35
Quarter three - October to December 44
Quarter four - January to March 39
Five of the above patient deaths, during the reporting period were upgraded from a case record review to a
serious incident investigation, for the following reasons:
Acts and / or omissions of care that may have contributed to the incident were identified during the
early stages of the case record review investigation, along with significant multi-agency learning.
Following consultation with the ratification panel, the investigation was upgraded to a PSII.
Case record review was completed with a resulting score of good care, however a number of family
questions were posed and it was deemed prudent to explore these through a serious incident
investigation.
Case record review noted that two potential opportunities were missed which may have had an
impact on patient care. Following consultation with the ratification panel, it was agreed to report
via STEIS but not commission further investigation as all learning identified and an action plan had
been developed.
In line with national changes, we are not identifying direct casual factors related to avoidability of death
within our reviews. In its place, we are focusing on learning and implementing change, as a result of
learning. Where an incident is rated with an impact grade of moderate or higher, learning and evidencing
change is escalated within our governance structure to a panel for assurance. The impact grades are
assessed based on the impact to the service user directly linked to the incident.
In relation to percentage of deaths per quarter, this consisted of:
Table 10 – percentage of deaths contributed to by care problems
Quarter (2021-22)
Percentage
Quarter one - April to June 0.5%
Quarter two - July to September 0.2%
Quarter three - October to December 0.2%
Quarter four - January to March 0.2%
*Data is subject to change and includes outstanding outcomes of reviews and investigations currently
being undertaken.
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Duty of candour
The Trust has focused on improving how we evidence compliance with duty of candour responsibilities.
This has been undertaken by continuing to audit and review our compliance around duty of candour, in
relation to incidents identified and declared as serious incidents.
Our review and findings related to:
An offer to discuss events with the patient / family as soon as possible after the incident and a verbal
apology.
A note in the health record of the discussion with the patient/family and apology.
A formal letter to the patient / family, summarising what is known so far and a written apology.
Involving the patient / family in the serious incident investigation.
Sharing the final serious incident report with the patient/family.
We completed a quality improvement project, which had a positive impact on our duty of candour compliance.
However, during the COVID-19 pandemic, our ability to evidence compliance has dropped. In order to
achieve the standard of 100% compliance, each of the five aspects of duty of candour outlined above, and
a locally set target by commissioners to send a letter within 10 days. The central patient safety team are
responsible for the monthly compliance audit and evidence is gathered from the initial investigation
reports, copies of letters submitted from clinical teams and from documentation included in serious
incident investigation reports. In all cases, we have met Regulation 20 of the Health and Social Care Act,
where it is applicable.
We have focused on developing robust systems to enable to staff to effectively evidence compliance with
each stage of duty of candour. We have strengthened our governance process at the AWP ratification
panel, which is responsible for commissioning and ratifying serious incident investigations and reports.
Figure 6 – duty of candour compliance – March 2020 – February 2022
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Mortality reviews
Since the 1 April 2021, we have completed 73 mortality case record reviews for deaths that occurred
during 2021-22 and 21 serious incident investigations. During this timeframe we have commissioned
further case record reviews and serious incident investigations which are currently in process.
The multi-disciplinary Trust incident review meeting review all reported deaths and escalate any reports
that meet the threshold for further review. The multi-disciplinary Trust ratification panel, attended by the
Director of Nursing, Medical Director or delegated Associate Director, review all potential serious incidents
related to deaths.
The panel will commission an investigation and review if the incident falls within the framework of a
serious incident or mortality review. The majority of reported deaths will not undergo further investigation
unless they fall within selection for mortality review, this reflects a significant number of deaths that are
reported by later life and memory services, where the Trust is providing a prescribing service.
Learning from reviews
Aggregated analysis of mortality reviews and serious incident reviews has identified the following learning
points:
Compliance to standard operating procedures
Consistent application of risk formulation and mental health triage tool ,
Consistent recording within clinical record systems
Communication.
Interagency collaboration
Identifying and following Safeguarding protocols
Triangle of Care through involving carers or family in care discussions
Discharge practice through involvement either in planning or sending information to relevant
parties.
Delays to process or taking action
Staffing capacity within the demands of busy services.
Sharing our learning
A range of approaches currently undertaken to share our learning include:
Patient stories at Trust Board meeting
AWP learning from experience group
Trust mortality review group
AWP learning and improvement panel
Quality summits
Divisional and locality quality and standards meetings / Learning from Experience meetings
Learning from deaths by suicide meeting – Bristol locality
Hotspot reviews
Immediate learning via the Trust wide alerts process – incorporating national and local learning
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Quarterly learning from deaths report
Individual clinical supervision.
12. Confidential enquiries
National picture
Currently, AWP has a higher suicide rate (for people who are under the care of mental health services at
the time of their death) when compared to a number of other Trusts in England. In 2021, the NCISH
(National Confidential Inquiry into Suicide and Safety in Mental Health) confirmed our patient suicide rate
was 7.14, which is above the median (5.25) for England, but lower than the maximum reported rate of
11.4, as shown in the following graph.
Figure 7 – AWP suicide rates 2011-18, compared against national average
Suicide prevention strategy
The AWP Suicide Prevention Strategy objectives are aligned to the National Suicide Prevention Strategy for
England (NSPS), and aims to reduce the suicide rate in the group of people who come into direct and
indirect contact with our services. We also aim to provide better support for those bereaved or affected by
suicide.
The focus of our efforts will centre on the seven main NSPS objectives:
1. Reduce the risk of suicide in key high-risk groups
2. Tailor approaches to improve mental health in specific groups
3. Reduce access to means of suicide
4. Provide better information and support to those bereaved or affected by suicide
5. Support the media in delivering sensitive approaches to suicide and suicidal behaviour
6. Support research, data collection and monitoring
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7. Reducing the rates of self-harm as a key indicator of suicide risk
The Trust will review and refresh the current suicide prevention strategy during 2022-23, in line with the
NSPS fifth progress report, which was published in March 2021.
Zero suicide alliance
AWP became a partner in the national Zero Suicide Alliance (ZSA) in 2019. We have developed a ZSA plan
to assist us on this journey and to provide additional structural elements to our overarching suicide
prevention strategy. It is recognised this will be a long-term plan requiring focus and commitment, but it
provides clarity around our approach, identifying 10 key areas of focus, as shown in the diagram below.
Our zero suicide ambition
We see every life lost to suicide as a tragic and catastrophic event, and our zero suicide ambition is a longterm
one. We believe that no suicide death is inevitable and it is this that will help us identify more and
more suicide prevention opportunities. Our drive for zero suicides is an ambition and aim, not a
performance target.
Figure 8 – AWP’s zero suicide ambition – 10 key areas of focus
39

Achievements and next steps
The following table summarises our initial ZSA ambitions, our progress during 2021 and individual
deliverables against each of the 10 elements of our ZSA plan.
Table 11 – AWP’s ZSA plan
What we said we would do
1 Our partners
We will collaborate and remain
actively involved with all local
networks and suicide
prevention forums.
We will support and participate
in the work of our local
authority public health partners
with community-wide suicide
prevention activities.
We will work with our local
universities and further
education colleagues to
support their work to improve
access for students to mental
health care provision, and
suicide prevention activities.
We will be an active participant
in the national Zero Suicide
Alliance network.
What we have been doing throughout
2021-22
We have strengthened existing
networks and made new ones over the
past year. Examples include:
Contributing to both BNSSG and
BSW system-wide suicide
prevention forums.
Contributing to both BNSSG and
BSW system-wide Real Time
Surveillance (RTS) meetings with
our CCG, Police and Local
Authority Public Health
colleagues. The RTS meetings
provide an opportunity for the
organisations to review real time
suspected suicide deaths and
identify key themes and learning,
which is then shared across the
system.
Contributing to local suicide
prevention forums for each
locality across the Trust.
The Trust secured funding through the
national suicide prevention
transformation workstream (wave two
government funding) to develop a
collaborative suicide prevention QI
programme with our CCG and third
sector colleagues across BSW
secondary care services.
What we plan to do during
2022-23
We will collaborate and
remain actively involved with
all local networks and suicide
prevention forums.
We will continue to support
and participate in the work of
our local authority public
health partners with
community-wide suicide
prevention activities.
We will work with our local
universities and further
education colleagues to
support their work to
improve access for students
to mental health care
provision, and suicide
prevention activities.
We will be an active
participant in the national
Zero Suicide Alliance
network.
The Trust will continue to
support and promote the use
of the Stay Alive online and
app platform.
Participation in the student mental
health network organised by local
universities, to ensure appropriate and
timely responses for students
experiencing a mental health crisis.
Our local operational service managers
have input to this forum as a way of
ensuring a timely response to any
highlighted areas of concern.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
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2 Inpatient suicide prevention
We will make suicide
prevention within inpatient
services a priority.
We will use the NCISH
template, Improving Safety in
Mental Health Services to guide
our work.
We will link this with our work
to improve environmental
safety in inpatient settings.
We will work hard to improve
discharge planning and
aftercare, with the focus on
patient safety.
We will implement a plan to
reduce ‘restrictive practices’
and enhance engagement and
therapeutic observation.
The Trust continues to be an active
member of the Zero Suicide Alliance
and mandatory completion of their
suicide prevention awareness training
for all staff.
The Trust continues to be an active
member of the National Suicide
Prevention Alliance (NSPA) and we
look forward to working with them
over the next 12 months.
The Trust continues to support and
promote the use of the Stay Alive
online and app platform.
We have developed measures
(performance metrics) for four of the
ten elements of the NCISH ‘improving
safety in mental health’, this includes:
Out of area admissions
Staff turnover
Number of ward ligature
incidents
Percentage of patients receiving
face-to-face follow-up within 72-
hours of hospital discharge
The Trust continues to work on
developing metrics for the remaining
six domains.
We have established a ligature
reduction group and have developed
an incremental plan to address
ligature risks across our inpatient
wards. There is wide representation,
including Psychologists and trauma
informed leads to understand effective
means of reducing incidents and
support for staff. We also utilise the
Trust’s library services to share
research and best practice with
colleagues.
The Reducing Restrictive Practice (RRP)
group continues to meet on a regular
basis to coordinate the development
and oversee the implementation of
quality improvement work in this area.
Develop metrics and
measures to capture the
remaining six NCISH safety
elements, and incorporate
these into our monthly
suicide prevention
dashboard.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
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3 Leadership
Reducing suicides and
improving patient safety will
always be our number one
priority.
Our suicide prevention work
will be led and overseen by our
Director of Nursing, including
input from other executive
directors.
To keep suicide prevention at
the heart of our work we will
identify a non-executive
director to take on the role of
Zero Suicide Champion.
The Zero Suicide Ambition will
be at the centre of all our
suicide prevention activity.
We will produce annual reports
on the progress of our suicide
prevention work.
4 Community-wide suicide prevention
Reducing suicides and
improving patient safety will
always be our number one
priority.
Our suicide prevention work
will be led and overseen by our
Director of Nursing, including
input from other executive
directors.
To keep suicide prevention at
the heart of our work we will
identify a non-executive
Board-level commitment and sign-up
to suicide prevention as one of AWP’s
four core priorities.
Direct reporting and oversight of
suicide prevention activity by the
Director of Nursing. A suicide
prevention group reports to the
Director of Nursing’s ‘safe’ governance
group.
Identification of a non-executive
director as a Zero Suicide Champion.
Monthly oversight and review at
executive level of all suicide
prevention work, as part of our safe
sub-group
We produce quarterly reports, as part
of our learning from deaths report,
which is scrutinised by the Trust Board.
Re-established a dedicated suicide
prevention group, which meets
regularly and feeds in to the safe subgroup.
There is wide representation,
including Psychologists and trauma
informed leads to understand effective
means of reducing incidents and
support for staff. We also utilise the
Trust’s library services to share
research and best practice with
colleagues.
We have been very active in our
various suicide prevention groups and
networks across BNSSG and BSW with
our local authority, CCG and third
sector colleagues.
The Trust secured funding through the
national suicide prevention
transformation workstream (wave two
government funding) to develop a
collaborative suicide prevention QI
programme with our CCG and third
sector colleagues across BSW
secondary care services.
Ensure we promote and
reinforce the suicide
prevention messages as part
of our ZSA commitments,
both internally and
externally.
Continue to monitor and
analyse suspected suicide
deaths that have occurred in
people being cared for by
AWP services.
Share the learning and
improvements that are
highlighted from our reviews
and analysis, and ensure this
informs our wider suicide
prevention work.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
To continue participating in
local, regional and national
suicide prevention groups
and networks.
To commence testing of QI
initiatives, as part of the BSW
suicide prevention QI
programme of work.
Primarily focussing on
assertive signposting and
personal safety planning
across our secondary care
services.
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director to take on the role of
Zero Suicide Champion.
The Zero Suicide Ambition will
be at the centre of all our
suicide prevention activity.
We will produce annual reports
on the progress of our suicide
prevention work.
5 High risk service users
We will work hard to ensure
that all high-risk service users
have their needs assessed with
a focus on suicide risk and
suicide prevention.
We will improve our electronic
documentation to ensure it
supports the most effective
level of risk assessment.
We will work to develop and
implement a safe and effective
care pathway for people with
personality disorder.
We will develop and improve
our guidance and support for
staff caring for people with a
history of self-harm.
6 Medicines safety
Our medicines safety work plan
will be overseen by our Chief
Pharmacist.
We will maintain a Medicines
Safety Group, chaired by our
Medicines Safety Officer (MSO).
We will develop a medicines
safety plan focusing on the
‘high risk’ drugs lithium
Personality Disorder pathway working
group established and work
commenced to develop the pathway
and strategy through a series of
workshops.
Community Mental Health
Framework, year two funding secured
to support the following Personality
Disorder pathway work:
Early Intervention Service in
BSW - BNSSG is also prioritising
early interventions, as part of
the CMHF funding for year
two.
Development of a managed
clinical network and
Knowledge and Understanding
Framework (KUF) roll out in
BSW.
Development of managed
clinical network / team also by
the CMHF workstream in
BNSSG
Sharing and promoting guidance
regarding the management of selfharm
with our staff.
Regular meeting of the Trust-wide
Medicines Safety Group. This forum
focuses on medication-related
incidents and hazards, as well as
identifying learning from these.
Completed a national POMH audit for
clozapine prescribing and monitoring,
mapped against national standards and
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
Personality Disorder working
group to continue, focusing
on the development of the
pathway and strategy.
Developing further guidance
and resources for staff about
working with high-risk service
users, specifically those at
risk of suicide.
Implement a QI project with
access teams across BSW,
which focuses on improving
the engagement and postassessment
support offered
to high-risk individuals who
do not necessarily meet
mental health service
treatment thresholds.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
The MSO proactively
contributes to weekly
incident review meetings and
ratification meetings. They
also network regionally and
nationally.
We will further develop the
medicines incident
dashboard, to provide
43

carbonate, clozapine, and
sodium valproate.
We will ensure that learning
arising from medicines
incidents is disseminated and
implemented across all clinical
services.
identified QI and practice development
work as a result.
comprehensive data for
quarterly medicine incident
reports. These reports are
compiled and reviewed by
the MSO, to identify trends
and subsequent learning
opportunities; includes
controlled drugs and high-risk
medicines (clozapine,
valproate and lithium).
Trends and learning from
medicine incidents are
discussed at bi-monthly
medicines safety meetings,
and disseminated Trust-wide
in medicines safety bulletins
and alerts
We will undertake the
scheduled audits agreed in
our AWP medicines audit
schedule, including POMH
audits. All audits are
prepared with action plans,
which include identifying any
learning needs and ways in
which these can be
addressed. The POMH audits
this year include:
Prescribing high dose
and combined
antipsychotics (POMH
1h&3e)
Prescribing for
depression in adult
mental health (POMH
19b)
Antipsychotic
prescribing in people
with a learning
disability (POMH 9d)
Participation in the NHSE/I
National Overprescribing
Review Implementation
Programme, to monitor
overprescribing and promote
appropriate de-prescribing.
44

Discharge Medicines Service
(DMS) became a new
Essential service within the
Community Pharmacy
Contractual Framework
(CPCF) on 15 February 2021.
NHS Trusts are able to refer
patients who would benefit
from extra guidance and
support around prescribed
medicines for provision of the
DMS at their community
pharmacy. AWP
implemented this in the
beginning of 2022. This
service, plays a key role in
patient safety in prevention
of self-harm and suicide, by
communicating limiting
quantities of medication, for
those at risk.
7 Environmental safety
We will continue to monitor
and address environmental
risks in all inpatient areas.
We will implement a new
approach for assessing ligature
risks within our inpatient units.
We will implement a three-year
programme of improvement
work to ensure that all
inpatient areas meet new
national standards.
Ligature Reduction Group have
developed a plan for ligature reduction
across the AWP inpatient estate.
Monitoring of high-risk settings and
buildings, including sharing learning
and improvements across the
inpatient network.
Implemented a revised environmental
and ligature risk assessment tool.
Ensured annual environmental risk
audits are undertaken and relevant
improvement plans are implemented,
where appropriate.
Developed reporting metric for all
reported inpatient ligature incidents as
part of the suicide prevention
dashboard.
Continual capital investment to reduce
fixed ligature points, such as doors. An
action plan has been developed to
focus on clinical risk management and
the CQC themed actions, this work is
overseen by the CQC oversight group.
Continual monitoring and
assessment of all ligature and
other environmental risks
within inpatient settings.
Undertake a detailed review
of incident cases and identify
key themes and associated
learning and
recommendations for
improving ligature safety.
Use the intelligence arising
from ligature incident
reporting to complete an
audit and analysis of a sample
of incidents in order to
identify learning in relation to
prevention.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
45

8 Staff competency
We will review our suicide
prevention and risk training and
professional development
programmes, ensuring all of
them meet the national
competencies regarding suicide
prevention.
We will ensure all staff, in both
clinical and non-clinical roles,
have completed a programme
of suicide prevention
awareness.
Risk task and finish group established
and is led by our Deputy Director of
Nursing. The group has been focussing
on revising the Trust’s current risk
training, including the development of
a staff survey to help understand the
views and needs of staff more clearly,
which in turn will help the risk task and
finish group in devising the new risk
training modules.
During 2021-22, our Advanced Clinical
Practice Development Facilitator for
Suicide Prevention has delivered a
significant number of Continuing
Professional Development (CPD)
sessions to clinical teams across the
Trust. This work will continue
throughout 2022-23. CPD Sessions
have been tailored for each and
individual team in terms of content,
length of session, time of day, delivery
method (‘live’ via MS Teams or face to
face in clinical settings or suitable
conference/large meeting rooms).
Teams have appreciated the tailored
nature of sessions and this is reflected
in the consistently positive feedback.
Monitor and report
performance regarding staff
compliance with mandatory
training as part of our suicide
prevention dashboard.
Continue the CPD suicide
prevention programme of
work in order to provide
support, guidance, role
modelling, reflection and
other learning for clinical
teams.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
AWP’s CPD Team have created two
CPD development packages delivered
face to face over six days – a
preceptorship package, which is open
to all newly qualified nurses and allied
health professionals joining the Trust,
and a Charge Nurse development
package. Suicide Prevention sessions
are incorporated into both of these
packages and are run all year round.
9 Families and carers
We will develop a post for
someone with lived experience
of bereavement by suicide, so
that they can work with us to
ensure that the needs of this
group are at the centre of all
our suicide prevention activity.
We will seek participation and
input from people who have
Re-established a dedicated suicide
prevention group.
Developed two specific posts of Family
Liaison Officer. These roles will focus
on providing support to families
following bereavement.
Ensure both experts by
experience and service users
and carers are included in the
membership of the new
suicide prevention group.
Ensure input from experts by
experience into the emerging
QI suicide prevention project.
46

survived an attempt to end
their life to the review,
monitoring and delivery of staff
training.
We will constantly review the
support we provide to people
who have been bereaved
following suicide.
Sharing ideas for updated suicide
prevention training through local
networks.
Ensuring that the role and needs of
family members and carers are a
fundamental element of our
mandatory suicide prevention and risk
training.
With a new Suicide
Prevention Lead in post, the
Trust intends to review the
previous work and identify
key priorities for the year.
Participation in local systems
discussions regarding the development
of:
A robust and secure alert system
for those families bereaved
following a suspected suicide.
Discussing how to progress the
development of a postvention
suicide response/support service
with local stakeholders and
partners.
10 Learning
We will develop a post for
someone with lived experience
of bereavement by suicide, so
that they can work with us to
ensure that the needs of this
group are at the centre of all
our suicide prevention activity.
We will seek participation and
input from people who have
survived an attempt to end
their life to the review,
monitoring and delivery of staff
training.
We will constantly review the
support we provide to people
who have been bereaved
following suicide.
Making Families Count have delivered
specific workshops for staff across
AWP to strengthen the offer from
AWP to bereaved families following a
suspected suicide.
A range of approaches currently
undertaken to discuss and share our
learning include:
Patient stories at Trust Board
Learning from experience group
Mortality review group
Learning and improvement
panel
Quality summits
Divisional and locality quality
and standards meetings /
Learning from Experience
meetings
Real time surveillance meetings
across BSW and BNSSG with
our Police, CCG and Public
Health colleagues
Developed the role of Family Liaison
Officer to support families following
bereavement.
Deliver the new Patient
Safety Incident Response
Framework (PSIRF), which
will be launched in 2022-23.
Make as much information
regarding suicide and suicide
prevention available
publically, within the limits of
confidentiality and the need
to avoid the inadvertent
promotion of suicide.
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Suicide prevention dashboard
The Trust continues to utilise and monitor the suicide prevention dashboard. Measures were developed for
four of the ten elements of the NCISH Improving Safety in Mental Health, these include:
Number of out of area
admissions
Staff turnover
Number of ward ligature
incidents reported
Percentage of patients
receiving face-to-face followup
within 72-hours of
hospital discharge.
Figure 9 – suicide prevention dashboard – February 2022
Interpretation
1. Skills, training and competencies (BANK STAFF ONLY) Target Latest Variation Trend Shift
1.1 Percentage of staff completing CPA & Risk training (mandatory e-learning) 90% 85.6% Common
Cause
No
No
100%
50%
100%
1.2 Percentage of staff completing Suicide Prevention Awareness (ZSA online
program)
90% 94.1%
Special
Cause
No
Up
40%
2. Skills, training and competencies (SUBSTANTIVE STAFF ONLY)
2.1 Percentage of staff completing CPA & Risk training (mandatory e-learning) 90% 83.0% Common
Cause
No
No
100%
90%
80%
100%
2.2 Percentage of staff completing Suicide Prevention Awareness (ZSA online
programm)
90% 94.8%
Special
Cause
No
Up
50%
2.3 Percentage of CPA Service Users with a completed risk assessment 90% 99.9% Common
Cause
No
No
100%
95%
90%
100%
2.4 Percentage of CPA Service Users with a completed crisis & contingency
plan
90% 98.4% Common
Cause
No
Down
95%
90%
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3. Total reported incidents
20
3.1 Total number of suspected Trust suicides in a month 0 7
Common
Cause
No
No
10
0
20
3.2 Total number of suspected suicides of current patients 0 4
Common
Cause
No
No
10
0
4
3.3 Total number of suspected suicides of recent referrals 0 2
Common
Cause
No
No
2
0
10
3.4 Total number of suspected suicides of patients discharged from AWP
services
0 1
Common
Cause
No
No
5
3.5 Total number of suicides within 90 days of hospital discharge 0 1
Common
Cause
Interpretation
4. 10 Ways to Improve Safety (NCISH, 2019) Target Latest Variation Trend Shift
4.1 Number of out of area AWP inpatient admissions 0 34
Common
Cause
No
No
No
No
4
3
2
1
0
0
100 20
0
50%
4.1b Out of Area AWP inpatient admissions as % of total inpatient admissions 0% 27%
Common
Cause
No
No
0%
20%
4.2 Turnover - Trust Measure (Rolling 12 months WTE up to Month 10) 12.9% 15.22% Special
Cause
Up
Up
15%
10%
5%
100
4.3 Number of inpatient ward ligature incident reports 0 42
Common
Cause
No
Up
50
0
100%
4.4 Percentage receiving face-to-face follow-up within 72-hours post-discharge 100% 75.0% Common
Cause
No
No
80%
60%
13. Safeguarding
The safeguarding team in AWP is embedded within the Nursing and Quality Directorate. The Director of
Nursing holds executive responsibility for safeguarding, supported by the Head of Safeguarding and the
Deputy Director of Nursing, with portfolio for Safeguarding. The Safeguarding team consists of
safeguarding professionals for adults and children including the Named Nurse and Named Doctor for
CAMHS and a Domestic Abuse Lead. An experienced Named Doctor for Adult Services commenced work in
April 2021. Administrators and a Business and Project Co-ordinator are also essential members of the
team.
The team have extensive relevant experience including:
Mental Health Social Care
Acute and community Physical Health
Children’s Social Care
49

Forensic Mental Health
Mental Capacity Act
CAMHS
Children’s Nursing
Midwifery & Health visiting
Older Adults
Commissioning
Local Authority experience of Safeguarding adults and Children
This reporting period coincides with the ongoing impact of the global COVID-19 pandemic, with the
services experiencing significant staffing challenges alongside ongoing protective measures.
Activity significantly increased during the year 2021-22 and has maintained the level as indicated in the
graphs in activity section. The programme of service improvement was re-instated in a limited capacity
with Single Point of Contact (SPOC) being supported by a triage desk staffed by safeguarding practitioners.
Other developments / achievements in year include:
Hosting a domestic abuse conference, facilitated by our Domestic Abuse Lead and supported by
external agencies and well attended by our partners.
Consolidation of the safeguarding huddle process to bring together clinical services and
safeguarding when a potential safeguarding concern is identified. We have improved data
collection from the huddles to enable identification of trends for further analysis.
A Multi-agency Review Coordinator role has been introduced to support management of the high
volume of multi agency reviews AWP are asked to support.
A process to centrally report and oversee all learning and actions arising from multi-agency reviews
has been implemented. This ensures greater oversight of the completion of actions and the
embeddedness of learning. Safeguarding Associate Practitioner role to support the Domestic Abuse
Lead has been consolidated in the team, supporting partnership work in relation to domestic Abuse
with particular support provided around domestic homicide reviews and Multi-Agency Risk
Assessment Conference (MARAC) queries.
Development of a template to support safeguarding enquiries where AWP are asked to carry out
initial investigations, (known as caused enquiries), to support consistent investigations.
Successfully introduced a development post to support succession planning, the post holder has
been supported to achieve safeguarding competencies in accordance with the intercollegiate
guidance, produced reflective pieces of work and has been mentored by a senior practitioner in the
team.
Activity
In line with the national picture and compared to the previous reporting period, safeguarding activity has
remained at the level of 2020-21, following a significant increase during the first year of the pandemic. The
level of complexity has remained with common themes around self-neglect and domestic abuse.
50

Figure 10 – total safeguarding activity, by month – 2021-22
Figure 11 – total number of safeguarding referrals received, by locality – 2021-22
Domestic abuse
Figure 12 – number of domestic abuse concerns, by month – 2021-22
51

The domestic abuse activity has settled at a level above pre-pandemic levels; the chart reflect contacts
with safeguarding identified by operational practitioners as domestic abuse. In practice, Safeguarding
Practitioners are identifying domestic abuse in many of the contacts with the team and in incidents
reviewed through the Trust governance processes.
Organisational abuse investigations
There have been no organisational safeguarding investigations commenced during this reporting period;
one investigation from the previous year relating to perinatal mental health services was closed in year,
following presentation of the internal investigation and learning report to the relevant Safeguarding Board.
Training
At the end of this reporting period all training was compliant with commissioned targets, including
safeguarding level three.
Bespoke training sessions have been delivered and training packages developed in relation to
organisational safeguarding, self-neglect and domestic abuse.
Safeguarding supervision has been provided various teams including CAMHS, Perinatal Mental Health,
Mother and Baby unit and Eating Disorder services.
Partnership working
Despite this period of disruption due to COVID-19, the Trust has continued to prioritise, where possible,
attendance at safeguarding boards and sub groups, where appropriate (including Safeguarding Practice
Reviews, Safeguarding Adult Reviews, Mental Health Homicide Reviews or Domestic Homicide Reviews).
The Trust has also submitted data to NHS Digital on Prevent and Female Genital Mutilation.
AWP safeguarding team supported 372 external safeguarding meetings from April 2021 - March 2022.
Figure 13 – number of external safeguarding meetings – April 2021 – March 2022
Staffing establishment
During this reporting period, the Deputy Head of Safeguarding was resigned and subsequent recruitment
process was unsuccessful.
52

Recruitment of suitably qualified and experienced staff is a challenge and remains ongoing. The team are
also working to develop a new role and introduce development roles to support the workforce pipeline.
14. Patient Advice and Liaison Service (PALS)
The PALS service provides free, confidential, impartial advice to service users, families and carers. PALS can
help by providing the opportunity to discuss in confidence, any concerns or comments regarding care and
receive positive feedback and praise from service users and families.
The PALS officers can visit inpatient wards or community sites to speak with service users or carers face-toface
to help them to raise their concerns. The team also works closely with local advocacy services to
ensure people can access support to make complaints or resolve their issues if wanted.
In investigating the complaint, our intention always is to listen to the service user or carer experience and
use their comments, and our findings, to improve safety, experience and the quality of healthcare services
we provide.
Over the past year, the team have received 1192 PALS enquiries.
Praise
Over the past year, the PALS team have received 863 compliments sent through by staff and services.
Complaints
As an organisation, we work hard to respond positively to complaints and concerns. Our complaints policy
follows the principles of the NHS Complaints Procedure and information on how to complain or raise a
concern is available publicly to make the service easily accessible.
This year, we received 384 formal complaints compared to 246 last year. The increase was due to
significant changes in the way complaints were handled during the COVID-19 pandemic. Sharing the
learning from complaints and concerns helps us to make changes to practice, processes and systems, so
that the risk of harm or recurrence is reduced. Information from PALS and complaints cases are used
alongside information from incidents and the Friends and Family Test to help the Trust to shape services,
to identify ‘hot spots’ and to act as an early warning system for the Trust to identify potential issues.
This year, we received 170 informal complaints.
Themes
In reviewing our complaints, we can helpfully draw themes that can highlight trends and identify any areas
of concern. We align these themes to the five CQC domains and our findings for 2021-22 is shown below.
Our intention, as with direct user and carer feedback is to use this information to improve safety,
experience and the quality of healthcare services we provide.
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Table 12 – PALS, complaints and praise overview, by year
2014-
15
2015-
16
2016-
17
2017-
18
2018-
19
2019-
20
2020-
21
2021-
22
PALS cases 1887 1802 1881 1449 1190 1167 1243 1192
Praise
received
Formal
complaints
Informal
complaints
Total
complaints
Investigated
by the
Ombudsman
724 1122 1290 1051 1098 928 723 863
314 360 384 302 305 277 246 384
72 78 76 112 98 114 150 170
386 438 460 414 403 391 396 554
12 4 6 5 11 2 4 2
Table 13 – PALS and complaints key themes
Five themes from our feedback
Complaints
(inc informal)
PALS
Safety (includes medication, nutrition, personal safety,
safeguarding, personal property)
Effective (includes clinical care, CPA, discharge from services,
MHA, physical healthcare)
Caring (includes attitude of staff, privacy and dignity,
communication)
Responsive (includes access to services, responsiveness to
referrals and inpatient bed management)
Well led (incudes policy and procedure, health records,
complaints handling, requests for information, signposting,
user and carer involvement)
101 62
141 147
108 251
110 194
31 273
TOTAL 491 927
15. Patient experience
Friends and family assessment of care
We take part in the national Friends and Family Test (FFT), which is an important way for us to hear what
people think of our services. At its heart, the test asks whether people would recommend the services they
have used to their friends and family. It is designed to highlight areas of good practice, as well as areas for
improvement. To make the results of the test meaningful, it is important that the Trust encourages as
many people as possible to complete the test.
54

In April 2020, the FFT question was revised by NHS England, with the intention of becoming a more
effective tool for gathering patient feedback that helps to drive local improvements in healthcare services.
Unfortunately, shortly after this refreshed FFT guidance was introduced, a national pause was
implemented by NHS England on the collection of FFT responses, to divert staff to COVID-19 efforts. In
2021, the FFT collection resumed and since then we have seen a slight, yet steady increase in responses.
Response rate 2018-2022
Figure 14 – FFT response rate – April 2018 – March 2022
Figure 15 – FFT positive response rate – April 2018 – March 2022
As the organisation has returned to ‘business as usual’ after the effects of the pandemic, we are seeing a
general increase in the number of responses. Since we relaunched the FFT, we have worked on making the
survey more accessible, including QR code links on Trust envelopes and having the survey translated into
numerous other languages to increase diversity in responses. It is now hoped that with the introduction of
the new Trust communication techniques, that text messages will be delivered to service users after
receiving care with an automated link to the survey and we should see the results of this by 2023.
55

As part of the relaunch of FFT, we looked at the way we are analysing and distributing feedback for our
localities and teams. The comments received are often quite detailed, however the ability to split these
into the key CQC domains has proven to be difficult and time consuming, as quite often a comment will
cover numerous, or even all of the domains and so it was decided that this should be stopped. Instead, we
have created new quarterly reports, delivering key information back to the localities and have granted
increased access to the IQVIA survey system to team leads and supporting administration teams in order
for analysis to be undertaken, not only within the Nursing and Quality Directorate but also at a locality and
team level.
Table 14 – locality inpatient ward FFT responses – April 2021 – March 2022
Locality Positive comments Negative comments
BaNES 32 6% 1 2%
Bristol 179 31% 16 36%
CaMHS 6 1% 1 2%
North Somerset 62 11% 3 7%
Secure 18 3% 2 4%
South Gloucestershire 3 1% 0 0%
Specialised 87 15% 4 9%
Swindon 54 9% 0 0%
Wiltshire 132 23% 18 40%
Total 573 100% 45 100%
Table 15 - locality community FFT responses – April 2021 – March 2022
Locality Positive comments Negative comments
BaNES 53 3% 6 4%
Bristol 359 19% 29 20%
CAMHS 0 0% 1 1%
North Somerset 260 14% 36 24%
South Gloucestershire 328 18% 24 16%
Specialised 87 5% 4 3%
Swindon 513 27% 20 14%
Wiltshire 272 15% 27 18%
Total 1872 100% 147 100%
Patient surveys
In November 2021, the Trust received the results of the annual community mental health survey,
commissioned by the CQC. The survey was undertaken between February and June 2021 and 1250
community mental health service users were asked to comment on the care they had received. 324
surveys were returned, giving a response rate of 27%, a 2% reduction compared with the previous year.
Out of the 28 questions on the survey, AWP’s results were better than most Trusts for four questions, and
somewhat better than most for two questions.
56

Each section of the questionnaire is given a score out of 10 (the higher the score, the better). Each trust
receives a rating from the CQC of ‘about the same’, ‘better’ or ‘worse’:
Better: the Trust is better for that particular question compared to most other Trusts that took part
in the survey.
About the same: the Trust is performing about the same for that particular question as most other
Trusts that took part in the survey.
Worse: the Trust did not perform as well for that particular question compared to most other
Trusts that took part in the survey.
Table 16 – community mental health survey feedback – 2021
Category
Your health and social care
workers
2021 summary
(out of a maximum score of 10)
Compared with other
trusts
7.4 About the same
Organising your care 8.8 Better
Planning your care 7.0 About the same
Reviewing your care 7.7 About the same
Crisis care 7.0 About the same
Medicines 7.4 About the same
NHS Therapies 7.9 Better
Support and Wellbeing 5.3 About the same
Feedback 2.2 About the same
Overall views of care and
services
7.4 About the same
Overall experience 7.2 About the same
Care during the COVID-19
Pandemic
6.8 About the same
This is very positive feedback for the Trust. However, there is room for improvement in a number of areas
and we are reviewing plans and developing improvement, in particular in these categories:
Support and Wellbeing
Feedback
Crisis Care
16. Service user and carer involvement
We have been working to ensure we engage, involve and move towards meaningful co-production, where
service users and communities are involved in planning and delivering care, as reflected in the strategic
57

priorities outlined last year. Due to COVID-19, we have not been able to hold the same number of
engagement events as previous years with our stakeholders.
The majority of the efforts this year from engagement and involvement staff has focused on maintaining
existing links with service users and carers throughout the reduced contact periods during the global
pandemic. Some staff were redeployed to support clinical services, while others worked to maintain
relationships.
Due to lockdowns, shielding and other physical travel restrictions some face-to-face events moved to
virtual events. The Involvement teams and patient experience team worked hard to ensure that
involvement continued via these virtual platforms.
The Strategic Experts by Experience Group meetings moved to virtual meetings. Since moving to a virtual
platform, they have continued to champion the service user voice within corporate services. The Strategic
Experts by Experience group have now moved into the quality improvement structure and now report
directly to the Director of Nursing and Quality.
To further value and bolster the carer voice within the organisation, Carer Expert by Experiences have been
appointed to the Carer Lead meeting and subsequent subgroup. The group focuses on the triangle of care,
carer awareness training and carer champion training, aiming to further embed active involvement and
inclusion of carers and families in our everyday working.
The Local Involvement Coordinators, although restricted, as and where possible, continued to champion
and embed the service users and carer voice within projects where possible.
Triangle of care
The Triangle of care is the way service users, carers and health professionals’ work together to provide
care. We currently hold a 2-star triangle of care membership and are actively engaged in the regional
collaborative network focused on improvement for carers.
Locally, there are carer champions meetings, which are held to discuss local teams and their locality
requirements, as well as the preparation, assessment and subsequent action plans from the triangle of
care. We also hold monthly carers lead meetings to ensure delivery of the triangle of care against the
standards as well as coordinating Trust-wide improvement work. The monthly carers lead meeting is
attended by the carers lead for each locality.
17. Peer support and lived experience
During 2021-22, we have been working on the development of a Peer Support and Lived Experience
workforce. The team is led by the Trust’s Peer Support Lead, who also has lived experience, which is
recognised as good practice across the NHS. The Peer Support Lead has been actively recruiting and
leading the implementation of the peer and lived experience workforce and this work will continue
throughout 2022-23.
We have developed a monthly community of practice, which is the professional meeting for Peer Support
and Lived Experience workers. We have also started working with Peer Hub CIC, which is a user-led
community organisation that specialises in peer support.
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Next steps for 2022/23
The team will be focusing on developing / implementing the following actions throughout 2022-23:
Peer practice framework launch
Code of conduct launch
Peer values and principles launch
Supporting staff with known lived experience policy to be developed
Peer development team in place
Training package in place
Peer practice supervision in place
18. Commissioning for Quality and Innovation (CQUIN)
In March 2021, notification was received that the Commissioning for Quality and Innovation (CQUIN)
scheme remained paused until further notice, as a continuation of the pause in March 2020. In October
2021, following the publication of the 'guidance on finance and contracting arrangements for H2 2021-22',
it was confirmed that there would be no CQUIN scheme for the remainder of 2021-22
The CQUIN scheme for 2022-23 was consulted on in early 2022, and version 1.2 published in March 2022.
Commissioners and AWP have agreed the following CQUINs will be completed in 2022-23:
CCG1: Flu vaccinations for frontline healthcare workers
CCG9: Cirrhosis and fibrosis tests for alcohol dependent patients
CCG10a: Routine outcome monitoring in CYP and perinatal mental health services (although agreed
to exclude CYP due to contracting)
CCG10b: Routine outcome monitoring in community mental health services
CCG11: Use of anxiety disorder specific measures in IAPT services
CG12: Biopsychosocial assessments by MH liaison services
PSS6: Delivery of formulation or review within 6 weeks of admission, as part of a dynamic
assessment process for admissions within Tier 4 CYPMH settings
PSS7: Supporting quality improvement in the use of restrictive practice in Tier 4 CYPMH settings
PSS8: Outcome measurement in perinatal inpatient services
19. Care Quality Commission (CQC)
Like all NHS providers, we are required to register with the CQC our status with no conditions attached to
the registration.
The CQC regulate NHS services and provide assurance to the public that we are meeting the required
standards of care against regulations set down within five key domains as shown below. When carrying
out an inspection the CQC use a framework of fundamental standards and against these standards will give
individual rating to services within the Trust and an overall rating for the Trust as a whole.
59

From September 2020, the CQC introduced a transitional methodology. This will draw on the five key
questions it asked previously (safe, caring, effective, responsive and well-led) but will be much shorter. It
will involve some visits and some remote assessment of data.
The Trust has not taken part in any special reviews or investigations by the CQC under section 48 of the
Health and Social Care Act 2008, during 2021-22.
CQC inspection
The Care Quality Commission (CQC) completed a comprehensive routine inspection of the Trust between
July 2021 and September 2021 that included two core services, wards for older people with mental health
problems and specialist community services for children and young people. The CQC also completed a
‘well-led’ assessment during the same period.
The Trust’s overall rating remains at ‘requires improvement’, although the ‘well-led’ element has improved
and is rated as ‘good’. The CQC were clear that staff increasingly felt respected, supported and valued, that
the Board members demonstrated a real understanding of the issues that faced the Trust and were clear
that it faced many challenges. However, both core services, older adult and CAMHS services were rated as
‘requires improvement’, a downgrading since the last CQC inspection.
Wards for older people with mental health problems
The CQC made the following recommendations:
That the Trust must ensure actions are identified and implemented to mitigate environmental risks
on all wards, including ligature and blind spot risks.
The Trust must also ensure that patient risk management plans are individualised, consider
environmental risks, and updated following identification of new or changing risks.
The Trust must ensure that ward 4 staff develop individualised care plans to manage risk of selfneglect
and evidence consideration of least restrictive options. Use of restraint during personal care
must be proportionate and necessary to manage the risks to the patient.
The Trust must ensure that all staff treat patients with dignity and respect, when interacting with
them and entering their personal areas, such as bedrooms.
Specialist community services for children and young people
The CQC made the following recommendations:
The Trust must ensure that risk assessments are updated when young people’s risk changes.
The Trust must ensure that waiting lists for young people and staff caseloads are monitored and
reduced.
The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and
experienced people to meet the care and treatment needs of the young people.
The Trust must ensure that premises are safe, clean, well equipped, well furnished, well maintained
and fit for purpose.
Well-led inspection
The CQC highlighted the following:
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Culture - staff increasingly felt respected, supported and valued, but there was further work
required, staff felt increasingly positive and proud about working for the Trust and their team
Board members demonstrated a real understanding of the issues that faced the Trust and were
clear that it faced many challenges including a difficult financial position, challenges with the estate,
a low bed base per population and a number of infrastructure and system issues. All members were
clear where investment was needed to improve the quality of services.
The Board had clear areas of responsibility and accountability. Board members including nonexecutive
directors chaired specific committees or were leads on specific areas of work.
The Trust Board and senior leadership team displayed integrity in carrying out their roles.
The Trust leadership team had a comprehensive knowledge of current priorities and challenges,
and actions were identified to address them.
Governance – the Trust’s new governance framework was aligned with the CQC domains of safe,
effective, caring, responsive and well led. There were clear lines of accountability and governance
arrangements in place to provide ward to board assurance. There were a range of mechanisms in
place for identifying, recording and managing risks, issues and mitigating actions. Individual
services maintained their risk registers, which were submitted to the Trust’s electronic risk
management system.
However, the CQC also stated that:
Estates strategy - the Trust did not have a well-developed estates strategy, despite estates being
identified as a key issue.
Trust strategy long-term financial plan - the Trust strategy was not supported by a long-term
financial plan and indications were that this was some way off in the context of significant changes
to the national financial architecture. The Trust were unable to credibly evidence that it had a
strategy that was affordable or financially sustainable.
Engagement and involvement strategy - the Trust did not have a clear, strategic, structured and
systematic approach to engaging people who use services, those close to them and their
representatives despite some examples of positive engagement.
Staff involvement (strategy) - not all staff the CQC spoke with, as part of the core services
inspection, felt involved in developing the Trust strategy and did not understand how this might
impact on them or what might be required of them. Some staff felt the strategy was something that
had been “done to” them, rather than with them.
Senior visibility - there had been variability in the visibility, openness and transparency of senior
and service leaders during the pandemic. This had impacted on the experience of staff in some
areas where visibility, openness and transparency was seen to be poor. The CQC heard about a
disconnect in some areas between front line staff, service managers and executives.
An overview of the Trust’s CQC rating is shown below:
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Table 17 – AWP’s CQC rating overview
Domain CQC rating 2021-22 CQC rating 2022-23
Overall rating Requires Improvement Requires Improvement
Safe Requires Improvement Requires Improvement
Effective Good Good
Caring Good Good
Responsive Requires Improvement Requires Improvement
Well-Led Requires Improvement Good
20. Quality of data
The Trust has a comprehensive and systematic approach to the management of the quality of data held on
its patient information systems.
Hospital Episode Statistics (HES)
During December 2021, the Trust submitted records to the Secondary Uses Service (the single,
comprehensive repository for healthcare data in England, which enables a range of reporting and analyses
to support the NHS delivery of healthcare services).
This information was included in the Hospital Episode Statistics data and showed full compliance in the
required fields:
Table 18 – submitted HES data, December 2021 (most recently published)
Valid NHS number for admitted patient care: 100%
Valid General Medical Practice Code was: 100%
Electronic Patient Record
On a monthly basis, the Trust undertakes an audit of the electronic patient record. Senior clinicians in all
teams and wards are required to review five randomly selected records to assess their quality against 14
sets of criteria (related to assessment, risk and care planning). The records management audit is reviewed
annually to determine its efficacy and consider improvements.
Data from these audits is supported by results on the NHS Data Quality Maturity Index (DQMI), as well as a
number of ‘completeness’ metrics, which check that key information is available in the patient record.
Results are included below.
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Table 19 – data quality indicators 2019 - 2022
Data Quality Indicator Target 2019-20 2020-21 2021-22
National indicators
Data Quality Maturity Index (combined) 95% 93% 93% 93%*
DQMI – Admitted Patient Care 95% 88% 87% 87%*
DQMI – Mental Health Services
Dataset
90% 93% 94% 94%*
DQMI – IAPT Minimum Dataset 95% 99% 99% 99%*
Local indicators
Records management: monthly audit 75% 85% 84% 84%
Completion of crisis, relapse and
contingency plans
90% 99% 99% 98%
Completion of risk assessment 95% 99% 99% 99%
* the 2021-22 results use data published by NHS Digital, but at time of writing, this only includes up to
December 2021.
Clinical coding
AWP was not subject to the payment and tariff assurance framework clinical coding audit (formerly
payment by results) during the reporting period.
Plans for improvement in 2022-23
To continue improving the quality of our data, the Trust will review metrics used to drive the Data Quality
Maturity Index and work towards achievement of 95% compliance across all elements.
21. NHS staff survey
Every year, all of our substantively employed members of staff are invited to complete the NHS Staff
Survey. The key priorities in 2021 saw positive movements, in particular the response rate, which has
significantly increased from 45% to 56%, 2524 members of staff completed the survey in 2021.
For the 2021 survey onwards, the questions in the NHS Staff Survey are aligned to the People Promise.
Because of this, some of the questions have changed since 2020. This sets out, in the words of NHS staff,
the things that would most improve their working experience.
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Figure 16 – NHS people promise
In support of this, the results of the NHS Staff Survey are now measured against the seven People Promise
elements and against two of the themes reported in previous years (staff engagement and morale).
The reporting also includes new sub-scores, which feed into the People Promise elements and themes.
Figure 17 – NHS staff survey people promise scores
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Summary of findings – staff survey 2021
Figure 18 – summary of findings – 2021 staff survey
The results of the staff survey were generally positive, with significant improvements in 3 out of 4 of our
key priorities in 2021.
Highest and lowest scoring scores 2021
Figure 19 – 2021 staff survey – highest and lowest scoring scores
When compared to 2020, 10 questions were seen to be ‘significantly better’ in 2021.
Our most improved scores were:
Q17a - would feel secure raising concerns about unsafe clinical practice 79% (+6%).
Q3h - have adequate materials, supplies and equipment to do my work 58% (+5%).
Q9c - immediate manager asks for my opinion before making decisions that affect my work 66%
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(+5%).
Q9b - immediate manager gives clear feedback on my work 71% (+4%).
Q11e - not felt pressure from manager to come to work when not feeling well enough 85% (+4%).
Q17b - would feel confident that the organisation would address concerns about unsafe clinical
practice 60% (+4%).
The themes for our most declined scores were more in line with workload balance and staff engagement.
There being enough staff at the organisation for people to do their job properly, coming into work when
feeling unwell and dissatisfaction with levels of pay.
When we look at ‘Q22a - I don’t often think about leaving this organisation’, this is one of our most
declined scores. This moved from 45% to 42%, which was the same level in 2019. If we look at the other
parts of the question ‘Q22b - I am unlikely to look for a job at a new organisation in the next 12 months’
and ‘Q22c - I am not planning on leaving this organisation’, this has remained the same as last year and in
line with the Picker average.
Key priorities
In 2020, we set four key priorities, and we saw some positive improvements in the 2021 results:
56% of our people completed the survey versus 45% in 2020 (increase of 11%).
67% reported that their manager asks for their opinion before making decisions that affect their work
(increase of 6%).
71% reported their manager is giving feedback on their work (increase of 4%).
Together, we made improvements last year by having specific priorities and focuses. As such, we will be
taking a similar approach and we have picked four key priorities for 2022, based on our feedback, and
consultation from various groups within the Trust. These are:
We take action on health and wellbeing
The health and wellbeing of our people is fundamental and we continue to want to do as much as we can
to support your health and wellbeing at work. This is a new question in the survey, so we have no
comparative score. However, this was one of our bottom 5 scores versus the Picker average. We decided
this would be an important priority for 2022, not only as this was one of our lowest scores versus the
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average, but also has a huge impact on sickness, retention and how attractive we are as an employer. Not
to mention how this affects the individual, and the care we are able to provide by extension
Appraisals reflect how we value our peoples work
We want our appraisals to be seen as less of a tick-box exercise and more of a tool to check in on all
elements of working at AWP for people. Building a strong induction programme, regular appraisals and
one-to-one meetings between managers and staff should play a key part of any retention strategy in
making sure our people feel clear about their role and valued for their work. Although the score for this
improved from 21% to 32% last year, and is in line with the picker average, it was felt that there will still
room for improvement, and a lot to gain if we can get this right.
We take action on reducing bullying and harassment
Last year we looked at reducing bullying from service users and the public. This improved by 1% to 69%,
but was still lower than the picker average of 73%.
When we look at the statistics, we found:
15% of staff report that they have received harassment, bullying or abuse from other colleagues.
11% of staff report that they have received harassment, bullying or abuse from managers.
31% of staff report that they have received harassment, bullying or abuse from patients / service
users or members of the public.
Therefore, we wanted to expand this priority and take action on reducing bullying and harassment from
anyone. Any form of bullying and harassment is not acceptable and we want to ensure that we do
everything we can to support our staff to prevent bullying and harassment as well as have the appropriate
support should anyone have a negative experience in this area. We want all teams to share the message
that we do not tolerate any form of discrimination, bullying or violence, and call out inappropriate
behaviour in a professional, respectful way.
There are enough staff for people in our teams to do their job
A big challenge we face as a Trust is filling our vacancies, and retaining our staff. In 2021, 28% of
respondents said there was enough people in their teams to do their job properly. This was a drop of 8%
versus 2020, however is in line with previous years. From a people directorate point of view, recruitment
and retention is a huge focus, and we all have a role to play.
Next steps and action planning
Each locality and corporate team also receive survey results that reflect in detail the experience of their
own staff in that area. Managers use these results to discuss with staff where we can improve and, as a
team, jointly develop department-specific responses that reflect their situation and experiences.
We are also reaching out to different groups such as Freedom to speak up to create different resources
and opportunities to improve on our priorities for 2022.
Staff friends and family
Two key questions asked in the staff survey are the friends and family questions asked to staff. Below are
our results of those staff who responded ‘strongly agree or agree’:
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Recommend as a place to work – 55% (decrease of 3% from 2020, but this was still higher than
previous years).
Recommend as a place to receive treatment – 55% (decrease of 1% from 2020, but again still high
higher than previous years).
Figure 20 – 2021 NHS staff survey – friends and family results
22. Freedom to speak up
Overview
Freedom to Speak Up (FTSU) has three components:
Improving and protecting patient safety.
Improving and supporting staff experience.
Visually leading and promoting learning cultures that embrace continual improvement.
The Freedom to Speak up Guardian (FTSUG) role specifically supports the national drive for positive
cultural change by giving workers the freedom to speak up and raise concerns so that this becomes
business as usual for all NHS staff.
There are many existing routes for workers to raise concerns. Through incident reporting mechanisms, via
their line manager or educational supervisor, or directly to an Executive or Non-Executive Director,
amongst others. However, it is recognised there may be occasions where none of these routes are suitable
and staff may wish to raise a concern confidentially or anonymously through the FTSUG.
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The current AWP FTSUG, Elizabeth Bessant, took up the substantive role in February 2021.
This year, there has been 112 concerns raised, through the freedom to speak up route. Bullying and
harassment / staff relationships remains the main issue of concern raised, followed by patient safety
concerns.
Freedom to speak up champions
The FTSU champions have continued to be recruited into posts across the Trust and there are now 60 Trust
champions who actively participate in managing cases, with a further 18 undertaking their training. There
is representation from all localities and professions across the Trust, which include:
Unregistered practitioners
Admin and clerical staff
Allied Health Professionals
Consultant Psychiatrists
Registered Nurses
Healthcare Assistants
Bank staff
Student nurses
Ward Managers
Matrons
Head of Operations - Secure Services
The Trust lead for Equality Diversity and Inclusion
Deputy Medical Director
There are two FTSU training modules that the champions have to undertake, these were developed by the
National Guardians Office and are available to other Trust staff. A third module will be implemented in
April 2022. The FTSUG has developed a quarterly training programme for the champions and this came into
place in March 2022. There are six weekly FTSU locality and divisional meetings that the champions attend
for networking, support and learning. The Trust FTSU forum occurs quarterly and reports into the Trust’s
safe sub group.
Achievements throughout 2021-22
We have successfully hosted two full day Professional Behaviours and Patient Safety (PBPS) workshops
with the General Medical Council (GMC) regional lead. Alongside these workshop’s, we have had follow-up
sessions; reviewing the skills and tools staff have managed to use in the work place. Staff have shared their
experiences of witnessing unprofessional behaviour and the difficulty of challenging colleagues in these
situations. The feedback from the workshop has been extremely positive; the GMC regional lead was
incredibly complimentary about AWP staff being very open and honest about their experiences and
positive attitude to change.
The FTSUG is part of the compassionate and inclusive leadership programme within the Trust. Along with
the PSPB workshops, we have also been running themed FTSU half-day sessions, where we have promoted
development and learning (internally and externally) to AWP, including colleagues from acute, Mental
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Health Trusts, NHS England and Improvement and the South West FTSUG. These events have been
extremely well attended from across the Trust.
We have purchased a FTSU app through ‘Working in Confidence’. This is designed to raise ideas and
concerns with designated colleagues in AWP as anonymously as they would like. The lead administrator
(FTSUG) will be able to have access to timelines, meeting dates, themes and outcomes without knowing
specific details about the staff member raising the concern. This will be confidential between the person
raising the concern and the person it is reported to. As the app is a computerised system, it will replace our
current manual process of recording cases and data. This will be a much more efficient way of recording up
to date, accurate information. This was launched on 1 April 2022 and promotion continues across the
Trust.
Concerns raised
From April 2021 – December 2021 (9 months), 112 concerns have been raised through the FTSU route,
either directly to the FTSUG in an email, text or by phone, through the FTSU central email address or via
the FTSU champions. Every member of staff that has come forward has given their name and place of
work. One of the CQC inspectors reported that in their last visit (four years ago), staff were reluctant to be
named when raising a concern.
A summary of these concerns is detailed below:
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Table 20 – Freedom to speak up concerns – April – December 2021
Freedom to speak up concerns
April – June
2021
July – Sept
2021
Oct - Dec
2021
Concerns
raised
Total concerns raised 24 54 34
FTSUG 16 43 24
AWP FTSU champions 8 11 10
Theme Patient safety / quality 3 1 8
Bullying / harassment / staff
relationships issues
Cases where staff feel they are suffering
from detriment of speaking up
17 53 25
0 0 0
Other 4 0 1
Raised Openly 24 54 34
Anonymously 0 0 0
Role Registered Nurse 6 7 4
Healthcare Assistant 7 38 21
Medic / Consultant / Doctor 3 1 1
Allied Health Professional 1 1 2
Admin / Clerical 4 6 4
Corporate Services 2 0 2
Student 1 0 0
Apprentice 0 0 0
Preceptor Nurse 0 0 0
Other 0 1 0
Overall, there has been an increase in the level of reporting by unregistered staff, followed by registered
staff. There is a slight increase in corporate and medical staff raising concerns; this could be due to the
FTSU awareness raising sessions that have been delivered throughout the year.
The peak of which is likely to have been influenced by the awareness campaign and the new recruitment of
the AWP FTSU champion. There has been three cases of racism reported since by BAME staff. Other cases
raised by BAME staff have been in relation to bullying and intimidation. There has been a positive response
from senior managers in FTSU concerns being raised and a supportive approach in finding a resolution.
Only three cases have led to a formal investigation.
Bullying and harassment / staff relationship issues is the main category of concern raised, which is in line
with national reporting, this is followed by concerns relating to patient safety and culture. Each case has
been resolved by individual work by the team manager and members of staff, team development and FTSU
awareness and training, culture change work.
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Next steps
The Deputy HR Director and the FTSUG produced a Situation, Background, Assessment and
Recommendation (SBAR) report in August 2021 for the Executive Team. The Executive Team were asked to
support further work to ensure that the message that bullying and /or harassment is unacceptable within
AWP. This may include signposting staff to other resources. A Trust-wide workshop has been arranged for
26 April 2022 and will be hosted by the Deputy HR Director and the FTSUG. This will provide an action
planned approach to reducing our levels of bullying and intimidation. This will be one workshop (of a
series) throughout 2022.
A full review is required of the current resources dedicated to the FTSU team, of which there is 1.0 Whole
Time Equivalent (WTE) FTSUG and 0.6 WTE band 3 Bank Administrator.
23. Data security
Information Governance
The Trust has put in place a comprehensive Information Governance Management System (IGMS) to
ensure the security of data under its control. This is based on high-level information governance and
information security policies, which are designed to ensure the integrity, confidentially and availability of
information in compliance with the NHS Information Governance Guidance on Legal and Professional
Obligations. Additionally the Trust implements technical and operational controls to ensure compliance
with the cyber security standards defined in the NHS Digital’s Data Security and Protection Toolkit (DSP)
and guidance issued by NHS Digital, CareCERT and the National Cyber Security Centre.
Data security and protection toolkit 2021-22
The Trust was selected by NHS Digital for an external audit of our DSP toolkit position. This was performed
by KPMG in March 2022. They reviewed 49 evidence items from 13 assertions in the DSP (out of 110
assertions in the toolkit). A draft report has been produced that reported that identified no critical or high
risk issues, three medium and four low risk items, resulting in an overall report of ‘significant assurance
with minor improvement opportunities’. The finalised report will be provided in May 2022. An action plan
has been agreed to address the identified issues prior to the DSP deadline in June.
Information governance incidents
In 2021-22, there were 317 information governance incidents reported via the Trust’s incident and risk
management system, Ulysses; of those, one met the criteria to be reported to the Information
Commissioner’s Office (ICO).
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Table 21 – information governance incidents
Category and description
Telephone call received by concerned
community patient who whilst googling
the name of their new Care Co-ordinator
found an online document which included
patient confidential information
pertaining to a young person's CPA review
on Riverside.
Advised communications team of this
document available online to support its
removal.
Feedback
from ICO
No Further
Action to be
taken
Action taken By AWP
AWP Senior IG Manger worked with the
supplier to have the information removed
and worked with them to identify the root
cause and agree an action plan to prevent
further occurrences.
Advised CAMHS colleagues of the breach
and request they speak with the affected
service user.
Information governance audits - team level
We have introduced a more robust audit process for identifying operational information governance issues
at a team level. This is in the form of a questionnaire for team managers to complete, which is then reviewed
by the information governance team, with a follow on action plan being produced and agreed with the
managers, where needed.
Freedom of information
Over the last year, the Trust has reviewed and improved its approach to Freedom of Information (FOI)
requests. Despite a challenging year, staff responded well, meaning that the Trust has remained compliant
with Freedom of Information targets. Results are included below:
Table 22 – FOI breaches and response rate for 2021-22
Freedom of information
breaches
Month
Number of
breaches
Month
20 day response compliance
Number of
requests
Response rate
Apr-21 0 Apr-21 40 100%
May-21 2 May-21 20 90%
Jun-21 6 Jun-21 42 86%
Jul-21 0 Jul-21 30 100%
Aug-21 0 Aug-21 25 100%
Sep-21 1 Sep-21 20 95%
Oct-21 2 Oct-21 18 82%
Nov-21 1 Nov-21 43 98%
Dec-21 0 Dec-21 27 100%
Jan-22 3 Jan-22 29 90%
Feb-22 0 Feb-22 34 100%
Mar-22 0 Mar-22 24 100%
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Subject Access Requests (SAR)
The Trust has seen Subject Access Requests become more complex in nature, especially during the COVID-
19 pandemic and therefore, this involves a lot more communication with clinicians, requesting parties and
others who will be involved with scrutiny and disclosure. This includes liaising with clinical staff in making
sure they are working through the SAR process and also feel comfortable that they have considered
reasons for disclosure and non-disclosure and therefore have an auditable trail to reflect this.
24. Feedback from our stakeholders
Response to the 2020-21 stakeholder feedback
Following the publication of last year’s Quality Account, our stakeholder groups made some helpful
comments:
Bath and North East Somerset Council
We would like to hear more about the suicide prevention strategy work.
Healthwatch Wiltshire
Welcomes the glossary of terms, however acronyms are used quite heavily throughout the
document and it would be useful for these to be written out in full.
We note that the Trust was identified as an outlier with alarm status for standard 6 – service user
receives a physical health review annually and would be interested to learn more about the actions
being taken to remedy this.
Community mental health survey - we noticed that the feedback category, even though comparable
with other trusts seemed to have a low score compared to the other categories. We wonder what
this category entailed, if the low score was impacted by COVID-19 and any plans to address this. We
also note the areas that have been identified for improvement and would be keen to hear more
about plans put in place.
Wiltshire Council
Would like locality specific information.
Would like a more detailed response plan around the level of bullying / staff harassment concerns.
As the country continues to progress along its road map out of the pandemic, the committee is
particularly interested in understanding the plans in place for AWP as it moves from a ‘response’
mode to one of ‘recovery’.
Bristol, North Somerset and South Gloucestershire CCG
The commissioners would like to see further information regarding the projects related to
improving the quality of care planning and expect that this will include developments in risk
assessment and risk management approaches.
Commissioners expect that the Trust will continue to be involved in the wider system working to
develop their response to the Patient Safety Incident Response Framework, which is expected to
come into place in mid 2022.
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The commissioners would welcome additional information with regards to the positive impact and
outcomes that are being achieved through the research and development work streams.
The commissioners would like to see the outcomes of service user engagements and how they have
led to any changes for services users.
We welcome this feedback from our stakeholders and can report:
We have used the services of our communications team in order to improve the readability of the
document.
We have provided greater detail on:
o Suicide prevention
o NHS staff survey
o Physical health
o Patient Safety Incident Response Framework
Community mental health survey – the ‘feedback’ category has been identified as an area for
improvement for 2022-23 and we are currently developing improvement plans.
We recognise the desire for localised information and are somewhat constrained in including such
in-depth detail in an already lengthy report, particularly as we do not wish to compromise
readability. Our commitment is to work with our local stakeholders to provide the details that they
need in other ways.
2021-22 feedback received from our stakeholders
To be developed once feedback has been received – deadline for feedback from stakeholder groups is
01/06/22.
25. Statement of Directors’ responsibilities
To be included, following Trust Board
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