A mental health trust that was found to have a “controlling” leadership culture two years ago has been ordered to make urgent improvements to the safety of its services by the Care Quality Commission.

The regulator found widespread short staffing at Avon and Wiltshire Partnership Trust’s inpatient units and a failure to investigate and learn from patient safety incidents.

Inspectors also highlighted a number of patient safety problems, including potential ligature points in bedrooms and bathrooms, and pressure on bed capacity leading to patients being moved or treated out of area.

The trust was issued with four warning notices and told there were 32 areas in which it must improve.

CQC deputy chief inspector of hospitals Paul Lelliott said it was a “matter of concern” that some of the issues uncovered had been highlighted by the CQC in previous inspections but not addressed.

However, he added: “I recognise that there has been a change in the most senior leadership of the trust, which has now embarked on a programme of service improvement… The onus is on them now to make the urgent improvements we require.”

Iain Tulley took over as chief executive in November 2012, following his predecessor’s departure in the wake of highly critical reports on the trust and its leadership. The entire executive team has since been replaced.

Trust medical director Hayley Richards told HSJ that although the trust leadership was disappointed by the report it had not been surprised by the findings and was already to working to address the issues raised.

The trust was one of the first mental health trusts to be inspected under the CQC’s new methodology, and as a result has not received a formal rating under the regulator’s new four point scale.

A team of 70 people inspected 39 wards and 27 community services, as well as other specialist services, across the six clinical commissioning group areas covered by the trust.

Dr Richards told HSJ the trust had pushed to be part of the pilot because they wanted an independent assessment of progress over two years.

She said it was “extremely difficult” to address issues caused by the trust’s estate, some of which is old, but a programme of refurbishments and staff training was underway.

Following the inspection the trust and its commissioners have set up three system led working groups focusing on the acute care pathway, workforce capacity, and system wide learning from incidents.

Despite the CQC’s concerns about a lack of secure bed capacity, a national problem recently highlighted by a HSJ investigation, Dr Richards said that “no-one was talking about commissioning additional capacity”.

He added: “However, we have secured a commitment from NHS England to help us better manage current capacity in secure services.”