AWP fails Inspection.

As we have indicated in previous posts the Avon and Wiltshire Mental Health Partnership has been severely criticised by the Unison trade union for failing mental health patients in the Bristol area. Now we have heard that AWP has failed an unannounced inspection by the Care Quality Commission.

Full details can be found AWPinspection.

“This warning notice serves to notify you that the Care Quality Commission has formed the view that the quality of health care provided by Avon and Wiltshire Mental Health Partnership NHS Trust for the regulated activity above requires significant improvement:

On the 7 and 8 December 2015 an unannounced inspection was carried out by inspectors from the Care Quality Commission. Inspectors visited the Bristol crisis team, Bristol north assessment and recovery ream, Bristol central and east assessment and recovery team, Bristol south assessment and recovery team.”



The reasons for the Commission’s view that the quality of healthcare you provide requires significant improvement are as follows:

  1. Care and treatment was not always provided in a timely way.
  2. There was a lack of safe care and treatment.
  3. There was a lack of governance systems in place to manage the quality and effectiveness of the service.
  4. Staff providing care to patients did not always have the competence or experience to provide care safely.


  1. Staff did not always take steps to safeguard patients from abuse.
  2. The premises and equipment were not suitable at Brookland Hall and the Greenway Centre.

Significant improvements are required to the quality of the healthcare provided by the trust in relation to the regulated activity set out in this notice, by way of having effective systems in place that address the points numbered 1- 6 above”.


Crisis in Bristol Mental Health Provision

After The CQC Visit To Bristol Community Teams: Commissioners Must Feel The Heat

The following information has been widely distributed by the Wiltshire and Avon Health Unison branch.It should concern all who care about mental health support services in Bristol.


Most staff will already be aware of the recent Care Quality Commission (CQC) report on Bristol community services following their unannounced visit on 7 and 8th December last year. This visit followed a number of concerns raised, sometimes anonymously, from service users, carers and staff. The conclusions, which wholly reinforce what UNISON and others have been actively warning about since the New Model of Working was first commissioned, are quite damming.

Under the headings of ‘Lack of safe care and treatment’ and ‘lack of safe staffing, skill mix and competence’, the report points to how a failure to deliver on the original proposals regarding the Recovery Navigator role and caseload size for registered staff, have resulted in services characteris-ed by very high staff turnover, inconsistent care and unsafe working. Such problems are made worse by the estates issue, with both Brookland Hall and Greenway coming in for criticism.

The richness of the evidence provided in the report largely reflects the enthusiastic input from staff at all levels, answering CQC inspectors’ questions and sharing their own practical experiences. It is clear that the AWP have effectively been set up to fail as a result of this model being commissioned by the Bristol Clinical Commissioning Group (CCG) on a reduced real terms budget. Consequently the pressure should now be publicly put on the CCG to account for why patients, their loved ones, and staff have had to face a marked deterioration in working conditions and safety and quality of care.

The CQC report is a significant indictment of the commissioners’ attempt to reorganise Bristol Mental Health services on the cheap in line with the wider Government assault on the NHS.

The local Protect Our NHS campaign group will be submitting a public letter to the CCG to this effect and publicising the date (see below) for a planning meeting to discuss next steps in terms of highlighting the failure of the CCG-supported race to the bottom, involving softening up services for privatisation and market competition.

Secondly, it is not acceptable for staff now to be further squeezed by management in order to make the improvements de-manded by CQC. In addition to the issues raised by the report, there are significant concerns about the new practice of expecting assessors to undertake three thirty minute assessments per day, including associated admin. There are also concerns that medical cover, already too low, is being further reduced, such as with departing staff grade medics not being replaced. In terms of the unions being fully involved in decisions around key changes within the AWP, it is notable that the report mentions the introduction of weekend working and criticises the absence of ‘a genuine attempt [by management] to engage and negotiate with staff about significant change to their working hours’.

Campaign for Mental Health in Bristol – Stop the cuts! Decent care for all!

 **Public Organising meeting***

 7-8pm, Tuesday 2nd February

@ Halo Bar, 141 Gloucester Rd, BS7 8BA


All Welcome.

Supported by: Wiltshire and Avon Health Unison Branch, Protect Our NHS, and Social Work Action Network (SWAN)


Strike at Avon and Wiltshire Mental Health Partnership?

Earlier this year UNISON entered (jointly with the Royal College of Nurses) in good faith into the AWP’s internal grievance process, and a collective grievance was formally heard on 27th March 2015. At the heart of this grievance were concerns around the safety of service users and staff well-being. Such concerns hinged on problems with the New Model of Working in Bristol Mental Health, especially regarding caseload sizes for registered staff, and the role of Recovery Navigators who were being inappropriately allocated complex and risky patients. Despite key concerns being ‘partially upheld’ by the hearing Chair, and having continually raised members’ concerns, UNISON believes that these issues have not been resolved and that the internal grievance process has markedly failed thus far to deliver any significant improvements on the ground for our members. Consequently, management has left us with no choice other than to enter into a vote of no confidence.

UNISON has now conducted an Indicative Ballot (administered by UNISON South West region) among its members working for Bristol Mental Health partnership in the three Assessment and Recovery Teams, Early Intervention, and Bristol Crisis Service. This includes both AWP employees and staff working for voluntary and community sector partners.

The ballot was framed around a series of promises which have not been kept. In particular, that:

  • Recovery Navigators would only be allocated non-complex and low risk clients
  • Caseloads for registered staff would be markedly reduced
  • Bristol Crisis Service would be adequately staffed

The ballot results were that on a turnout of 63% there was a 95% vote for strike action representing 60% of the total membership.

This is a significant body of staff saying they would take strike action over issues which have at their heart concerns around quality of care, the safety of service users and staff well-being.

It is a clear mandate to start moving towards a ballot for strike action. We await your response. In the meantime we will be involved in on-going meetings and discussion with affected staff around the next steps.

 Signed: UNISON members working in Bristol community mental health services (three Assessment and Recovery Teams, Early Intervention, and Bristol Crisis Service)


A Statement from Wiltshire and Avon Health Branch Unison

June 2015

The exciting promise…

We are fast approaching one year since the transition to the New Model of Working associated with the Bristol Mental Health partnership.

This model, involving notable reductions in the numbers of registered staff in each of the Recovery teams, was sold by AWP management as offering a more dynamic and advanced approach whereby an influx of Recovery Navigators would open up opportunities for more recovery-focused working whilst also enabling the caseloads of registered staff to be markedly reduced (to 15-18) in order to free up time for providing supervision to RNs and to provide more effective, psychologically informed, therapeutic interventions.

Likewise, the change in the team bases was presented as driven not by financial savings but because it brought various advantages, such as less stigmatising settings, and greater integration into the community via the ‘liberating’ potential of greater mobile working.

 …and the dangerous reality

Meanwhile things continue to get worse, not better. Caseloads for most registered staff are not coming down (although in response to the on-going joint-Union Collective Grievance process some exceptionally large caseloads in the high 30s have come down). Serious understaffing, including in the Bristol Crisis Service (BCS) which is continually working below its minimum numbers and hence only providing a skeletal service, means huge strain on nurses and high sickness rates.

The resulting significant safety concerns and increased likelihood of preventable fatalities is made worse by the completely inadequate work spaces. We’re aware here of a number of letters from a large group of AWP consultants protesting serious safety issues, including how more hit-and-miss opportunities for inter-professional communication works against ensuring responsible risk management strategies. The crude daily scramble and unpredictability of trying to find a desk top computer eats further into practitioners’ work time.

Recent Root Cause Analysis (RCA) meetings (triggered by the death of a service user) have highlighted the chronic under-resourcing. Senior Practitioners talk about the impossibility of providing quality service. In the light of shortage of assessors North Bristol Recovery was last week considering going into ‘emergency mode’ where the team will ‘only react and only carry out assessments’. Due to the general atmosphere of chaos mistakes are more likely to be made.

Yet it is individual stressed-out staff, who routinely go above and beyond, who are being targeted for blame. A major symptom of the problems and safety issues is the high numbers of staff leaving their jobs in Bristol services or actively seeking alternative employment. Just in Central Recovery for example 7 RNs have already departed or are about to since the new model was introduced. Across all teams many experienced registered staff have either moved on or are seriously seeking alternative employment. RNs feel unsupported, burdened down with work which originally had been defined (in terms of complexity and risk) as needing care co-ordination by more highly paid registered staff. Meanwhile hundreds of unallocated patients float around with no care or support, such that further catastrophe looms. What remains is an even more basic, medically-driven service, further minimising opportunities for therapeutic person-centred care.This corresponds to the cutting of the AWP training budget (from which RNs have been excluded) and the effective de-skilling of staff, with negative consequences for job satisfaction and service quality.

Refusing accountability

Despite these problems there is a continuing management refusal of accountability. Hence their reluctance to provide any milestones for the original promised improvements (which now more clearly appear as mere sweeteners to help crowbar in the New Model). There is simply the repeated mantra that we first have to demonstrate to the commissioners that we have had a good go at making the New Model work, even whilst management unburdens itself of any responsibility to provide a deadline by which improvements have to be evident.

In an earlier management document from last Autumn entitled somewhat laughably ‘modernising Mental Health in Bristol’, and claiming to be an agreed statement between Bristol management and the Joint Union Committee (JUC), there was reference to ‘a need to look at a trend line of data (starting from an unacceptable status quo) which will only begin to be clear after about 4 to 5 months’. The previous ‘status quo’ remains a distant dream compared to the present and we’re way beyond 4-5 months, yet management’s instinct for face-saving trumps honest reflection, sticking to promises and putting patients first.

What next?

A Collective Grievance procedure related to the above problems was initiated by union reps in March. Although key union concerns were ‘partially upheld’ at a hearing on 27th March, no concrete improvements are visible on the ground for most staff. We have stated that we expect change by the time of the review on 17th June but staff understandably worry that we are once again simply being strung along.

UNISON will be holding meetings to listen to staff views and for staff to consider their options. It is simply unacceptable for this reckless gamble with patient safety (as AWP trade unions described it during last summer’s consultation) be allowed to continue in its current form.

 We cannot sit back wondering how many more life-threatening incidents have to happen, not to mention staff break downs, until the Trust finally communicates to the Clinical Commissioning Group (CCG) that the new model is not working.

Protect our NHS in Bristol.

Dear Friends

Protect Our NHS would like to invite you to an organising meeting of service users, their families/carers, and other interested individuals and health activists at 7pm, Tuesday 14th October at Easton Community Centre, Kilburn Street, Easton, BS5 6AW.  The purpose of the meeting is to share concerns and  / or questions about the new service model for mental health services in Bristol. Please pass this on to others who might be interested.

We are sending to supporters as well as other individuals who have shown an interest in current mental health issues, including those who attended the ‘Radical Perspectives in Mental Health’ mini-conference in May this year.

ProNHS 14 October meeting on mental health issues

With best wishes on behalf of Protect Our NHS

Mike and Charlotte
The NHS – For People NOT for Profit

Are the Avon and Wiltshire Partnership honestly ‘Putting Patients First’?

A recent  consultation paper, follows on from a compulsory competitive tendering (CCT) process initiated by the local Clinical Commissioning Group overseeing mental health services in Bristol against a background of budget reductions . The Avon and Wiltshire Mental Health Partnership (AWP) has produced its paper – Modernising Mental Health in Bristol Consultation Paper (1) and has initiated a series of team-by-team HR briefings which have outlined a plan whereby in each of the three Recovery teams (to be renamed ‘Assessment and Recovery Service’) and the Early Intervention team there will be significant reductions in qualified staff. In particular a cut of around 50% in the amount of band 6 staff in each team, and some reduction in band 5 staff is proposed. There is still much vagueness here in that management are claiming that the exact details and amounts are not yet fully confirmed, and calculations incorporating factors such as agency staff who haven’t been replaced, and numbers of people on long-term sick, still need careful attention. The concerns raised thus include Assessment and Recovery; Early Intervention and Crisis Recovery, and are listed below.

First, it is proposed that introducing 25 unqualified band 4 Recovery Navigators (RNs) (envisaged as eventually being employed wholly by Voluntary/Third Sector partners) into each Assessment and Recovery team will make up for this loss. It is supposed that each RN will have caseloads of up to 30 service users (thus taking on effective care co-ordination responsibilities) made up, it is claimed, of the less complex/non-CPA service users. Each qualified staff member will have supervisory responsibilities for three Recovery Navigators in addition to their own caseload which we are told will consist of up to 18 people.

Trade unions in AWP have produced a response[ TUresponse] and are rightly concerned on the effects of these cuts on the quality of care for patients. In particular, they are arguing the case that:

  • It goes against professional standards of safety and duty of care to expect each qualified staff member to carry significant responsibility for the well-being and risk management of around 90 service users in addition to their own caseload.
  • The time and effort alone required for this additional supervisory work, which is likely to require regular guidance and advice, will add much to already high workload pressures. Furthermore, it is being proposed that qualified staff will have to shoulder the major burden of completing risk assessments for service users under the care of RNs, including for service users whom they may lack a full picture for and thus will risk their professional registration. In any case, there are still many unanswered questions about the nature of the training to be given to the RNs.
  • Currently Band 5’s do not have supervisory responsibilities and thus this is a marked change of role. It is not evident that this change of role been properly evaluated. This also applies to the potential for band 5s to be given a new role to help fill gaps in the assessment teams.
  • There is a strong case for not trusting the promises that caseloads for qualified staff will be limited to 18 service users. Previously promised limits have been ignored. Thus Recovery caseloads were supposed to be pegged at 25 at the last re-design in 2012, before rising to around 30+ (in addition to assessment and duty roles), and management itself has recognised that a number of band 4s have struggled following a change of their role to include managing a caseload of clients in the 20s, partly manifesting in a high turnover of staff. Yet it is band 4s who are billed as having a central role in the new model.
  • With regard to the claim that RNs will have less complex/non-CPA clients, it is should be noted that already much work was supposed to have been done in the last year, 2013, involving two band 8 staff specifically employed to scrutinise team caseloads identifying less complex cases to be stepped to band(s) 5/4 or for discharge back to the care of their GP’s. At the end of the process it was found that only about 10% of Recovery caseloads in Bristol were ‘less complex cases’. Many of these were not appropriate for discharge and band 4 and 5 caseloads were already at full capacity. This exercise ended with caseloads for Bristol Recovery teams remaining at levels in excess of 30.
  • This puts into question claims that avoiding risky clients being allocated to RNs will be a straightforward exercise. Currently in Central Recovery around 67% of caseload are considered complex enough to be requiring CPA. With reference specifically to the EI caseload, non-CPA clients presently form only a small part of it hence begging the question of where the less complex clients will come from.
  • Further cause for concern regarding capacity under the new model is the complex clients – requiring intensive multi-agency working – under Ministry of Justice sections, CTOs, Safeguarding, MARAC, Child Protection and MAPPA. Again, we are faced with the prospect of more of such clients being pushed down to band 5s and even band 4s. On top of this there will be additional clients with RNs who may still require depots from qualified staff.
  • Halving the number of band 6 posts in Recovery teams to just eight staff on this grade creates a high likelihood that a number of qualified staff – especially, but not exclusively, band 5 – will lose their jobs.

In sum, these plans are unworkable and a threat to the well-being of already over-burdened staff, but most fundamentally they are extremely reckless in relation to patient safety. Furthermore, it is hard to see how the attendant workload pressures will allow the spaces required to deliver decent therapeutic interventions, or even just to properly listen to clients. 

 The concerns do not stop here.

For example so far as the Early Intervention Service (EI) is concerned The publicly stated plan is for a service which ‘replicates the existing high-performing early intervention in psychosis service presently provided’, one which adheres to the national pattern of reducing suicide rates, improving longer term outcomes and helping reduce the number of service users having extended careers as patients within secondary services. However, even acknowledging that the proposed EI model remains especially poorly defined and fluid, there is good reason to question the viability of this planned continuation of EI given proposals which significantly undermine central EI principles of lower caseloads and structured psycho-social interventions.

  • In the proposed new model there are reductions in the number of staff including medical staff, registered staff including band 7s, band 6s and band 4 staff as well as the re-banding of staff to lower grades.
  • As in the recovery teams it is proposed that band 4 staff care coordinate a caseload of less complex, non-CPA service users. Currently these service users make up a small percentage of the EI caseload and band 4 staff in EI do not care-coordinate. This shift reduces the capacity of the band 4s to facilitate recovery via interventions such as the Recovery Star, practical support, assertive engagement, active life, specialist Individual Placement and Support (IPS) model vocational support, and numerous core group activities.
  • As in the Recovery teams this and the de-banding of half the band 6 staff will add increased supervisory pressures for registered staff reducing capacity to deliver core recovery focused interventions including psychosocial interventions. A reduction in the number of band 7s is a concern. The introduction of band 5s to make up numbers are a further concern given that staff at this grade have less post graduate specialist training to deliver the specialist interventions that this client group require to best aid recovery. Band 5’s will also have less clinical experience at managing clients with complex needs and high levels of risk.
  • It’s proposed that qualified caseloads will expand up to 20 (and likely beyond given current pressures). Current EI caseloads are supposed to be capped at 15, but regularly run above 20.

Serious concerns similar to those above have been expressed surrounding issues of expanding caseloads and resulting issues of patient safety and clinical responsibility.

 Thirdly, there are further concerns over plans for the Crisis Service whereby the consultation paper suggests that ‘the new Crisis Service model will provide an enhanced high quality service to people contacting us in distress’, there remains much confusion about what the staffing levels will be, the effect of the changes in geographical team bases, and the knock-on effects of the wider changes to the Recovery teams.

  • The impact of the band 6 changes proposed for the Assessment and Recovery and Early Intervention teams is likely to increase risks and the team workload. There is concern that many complex service users, who are likely to feel the effects of these changes, will present regularly in crisis.
  • There are concerns by staff about how the team ‘must…(undertake) mental health emergency assessments seen within 60 minutes (p.14). Although staff do acknowledge the importance of responding immediately to service users in distress, there are questions as to how feasible this will be due to the caseload pressures of the team and overall assessment numbers. 60 minutes is potentially setting the team up to fail and placing staff under increased pressure to deliver. This could put other service users at risk.

Frontline assessors have highlighted the importance of taking time to think, talk and reflect on assessments that come in as this promotes good clinical practice.

 Finally, staff have concerns that the fragmentation of the teams is likely to have a detrimental effect on staff decision making. Risk sharing and ‘corridor conversations’ are crucial to the work of the intensive team. To think carefully and have support from colleagues when making complex decisions regarding services users’ care is paramount. Recovery staff have raised similar concerns, acknowledging the significantly reduced office space available in the new sites. There is also a general consensus that mobile working with laptops and using ‘where appropriate public spaces’ (p. 12) is inappropriate and has potential for issues around confidentiality. Non-cycling staff based in at least one of the proposed sites (Well Spring) will be faced with severely limited parking capacity and efforts to circumvent this problem (such as by using public transport or parking greater distances from the base) will eat further into already pressured work hours.

In sum we are extremely worried that the management proposals of AWP will have a serious detrimental effect on the welfare and quality of care of the mentally ill in Bristol.