Report: observing local mental health wards

As a local Healthwatch, we are able to visit health and social care services (such as hospitals and GP surgeries) and see them in action. This is called 'Enter and View'.

We spoke to thirty-seven service users and approximately fourteen staff across the six Avon and Wiltshire Mental Health Partnership (AWP) inpatient mental health wards we visited.

Wards we visited

• Wellow Ward, a secure ward at Fromeside
• Three wards at Callington Road Hospital:
  • Lime Ward
  • Silver Birch Ward
  • Cherry Ward
• Oakwood Ward at Southmead Hospital
• Juniper Ward, Longfox Unit, at Weston General Hospital

What did people tell us?

• Less than ten percent of service users had access to a written care plan.
• Forty-three percent of service users we spoke to were unaware of the existence of a plan for their care.
• Service users were concerned and frightened by new arrivals and noise at night.
• Physical attacks and violence from other patients led to some service users reporting they felt unsafe.
• Female residents complained about males being allowed to remain in female only spaces on the mixed sex wards.
• Residents preferred creative group therapy and wanted better access to the gym and physical activity.
• Service users reported feeling that quieter residents received less attention, and that staff/patient communication was often limited.
• Although faith was respected, less mainstream beliefs were not supported in the same way.
• Service users requested a healthier nutritional offer with more dietary options and a better variety of fresh fruit and vegetables.
• Some service users' discharge from the wards was delayed due to a lack of onward accommodation and community support.

During the visit, the Healthwatch Team identified safeguarding issues within the ward which they felt compromised the safety of service users. These were mentioned immediately to the duty staff at the time and escalated to North Somerset Adult Safeguarding and AWP senior management.

The primary concerns were: 

1. The staff’s clinic room, containing medications and sharps, was wedged open into the patient area. A charge nurse said that the door was open to keep the room temperature down. (The AWP response is available in our Healthwatch BNSSG Inpatient Summary Report). 
2.  A service user is allowed to sleep in the outside area at night which may not be safe for them. We were told that staff checked frequently on the patient throughout the night, however our team observed things which suggested that this checking process wasn’t robust enough. We found a care plan but no risk assessment had been completed. Escalation to North Somerset Council (NSC) initiated a safeguarding investigation. AWP have provided a risk assessment. 
3. A hole in the fence is a safety concern and service users were not allowed alone in this area. (AWP response as above). 

On-the-day explanations from staff were limited, but we received a reply the following day from AWP safeguarding leads and action has been taken. Item 2 was escalated to North Somerset Safeguarding. AWP fully supported the investigation. In February 2025, six months after the incidence was observed, the Safeguarding team ruled that “evidence gathered did not support the allegations raised in this safeguarding concern and therefore the safeguarding enquiry has now been closed now with the outcome unsubstantiated.“