Greater Manchester Mental Health NHS Foundation Trust

Updated 7 February 2024

During our last inspection of the trust between 13 June and 7 July 2022, we carried out an unannounced inspection of three mental health core services provided by this trust because we received information giving us concerns about the safety and quality of the services. We also carried out an announced inspection of the well-led key question for the trust overall.

As a result of significant patient safety concerns related to fire safety and the management of ligature risks we found during the inspection of the acute wards for adults of working age and psychiatric intensive care units, we issued the trust with a Section 29A Warning Notice on the 6 July 2022. We told the trust it was required to make significant improvements by 31 July 2022.

We also issued a further Section 29A Warning Notice to the trust at provider level on 23 September 2022 following the well-led inspection in relation to Regulation 17 (Good governance) and Regulation 18 (Staffing). We told the trust it was required to make significant improvements to staffing on the acute wards for adults of working age, psychiatric intensive care units and forensic wards by 31 December 2022 and significant improvements in relation to governance by the 31 March 2023.

The Commission served the Section 29A Warning Notices because the quality of health care provided required significant improvement in some areas identified during the inspection. The Warning Notices set out a legally set timescale for the provider to become compliant.

Prior to the publication of the inspection report, we suspended all the forensic core service ratings for the trust on 23 September 2022 and the well-led rating for the trust on 22 October 2022. We took this action because of concerns that came to light after we completed our well led inspection.

During a focused inspection at HMP Wymott on 10 and 11 August 2022, we found that the management of medicines was unsafe, resulting in unnecessary risk of harm to patients. We issued the trust with a Section 29A Warning Notice in relation to Regulation 12 (Safe care and treatment). We undertook a follow up inspection at HMP Wymott in November 2022 to follow up on the Warning Notice. Improvements had been made in relation to the Warning Notice however, two breaches of regulation were identified of Regulation 17 (Good governance) and Regulation 18 (Staffing).

Between 4 and 6 October 2022, we carried out a focused inspection at three of the trusts’ community mental health teams for adults of working age to follow up on a Section 29A Warning Notice we had issued to the trust in April 2022 following a focused inspection of two Community Mental Health teams in Manchester. This inspection focused on specific key lines of enquiry in the safe and responsive key questions. We issued a further Section 29A Warning Notice on 4 November 2022 in relation to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). We told the trust it was required to make significant improvements by 4 January 2023.

We undertook a focused inspection of the trusts’ three mental health wards for older people at Woodlands between 16 and 17 November 2022 following whistleblowing concerns we received about the unit. The inspection was focused on the safe key question. We subsequently issued to the trust a Section 29A Warning Notice in relation to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). We told the trust it was required to make significant improvements by 30 March 2023.

Following our last inspection, the trust has faced significant, unprecedented challenges, especially in relation to the external scrutiny the trust has experienced since then. This scrutiny followed a number of serious safeguarding concerns and allegations which have come to light since our last inspection in relation to the Edenfield Centre which are subject to an on-going police investigation and further inspection activity we have undertaken which resulted in the above section 29A Warning Notices being issued to the trust.

At the end of November 2022, the trust were placed into Segment 4 of the NHS Oversight Framework which meant it entered the national Recovery Support Programme and was in receipt of mandated intensive support. A NHSE System Improvement Board was set up to support the delivery of the programme which was chaired by the Regional Director for Strategy and Transformation for NHS North West, with representatives from the trust, Greater Manchester Integrated Care Partnership, Care Quality Commission, Health Education England, Bury Local Authority (as safeguarding lead), General Medical Council and the Nursing and Midwifery Council.

The trust had declared a critical incident following the incidents at the Edenfield Centre and put in place a number of immediate actions to ensure the safety of patients and address the most urgent quality and safety issues. It had also developed a draft Improvement Plan which included a set of longer-term ambitions. The draft Improvement Plan was approved by the trust’s board on 31 October 2022 and System Improvement Board on 1 November 2022. The trust obtained public views on the plan during February and March 2023. Following final approval, the Improvement Plan will be monitored through the System Improvement Board.

On 22 November 2022, NHS England North West wrote to Greater Manchester Mental Health NHS Foundation Trust, to inform the trust it would be commissioning an Independent Review.

On the 6 February 2023, NHSE announced they had appointed a chair to undertake this independent review. It will focus primarily on the Edenfield Centre, as well as the trust’s other services, and will include a review of ward to board escalation, and oversight of patient safety and culture. The review is scheduled to conclude by 30 September 2023.

During this inspection, we inspected the following three mental health core services:

• acute wards for adults of working age and psychiatric intensive care units
• forensic inpatients/secure wards
• community mental health services for adults of working age.

The inspections were focused on checking the trust's progress in relation to the two Section 29A Warning Notices we had issued as a result of our inspection of the trust between 13 June and 7 July 2022 and the Section 29A Warning Notice issued on the 4 November 2022 regarding the community-based mental health services for adults of working age.

We also carried out an announced inspection of the well-led key question for the trust overall.

We did not inspect the following seven other core services at this inspection:

• wards for older people with mental health problems
• mental health crisis services and health-based places of safety
• specialist community mental health services for children and young people
• long stay/rehabilitation mental health wards for working age adults
• child and adolescent mental health wards
• community-based mental health services for older people
• substance misuse services.

Following the inspection, we took enforcement action against the trust. We served the trust with a Section 29A Warning Notice at provider level following the well led inspection. The Commission served a Section 29A Warning Notice because the quality of health care provided required significant improvement in some areas identified during the inspection. The Warning Notice set out a legally set timescale for the provider to become compliant. A further inspection will be carried out to ensure action has been taken to comply with the Warning Notice. We will continue to monitor the progress of other areas of improvement to these services and will re-inspect them as appropriate.

Our rating of services went down. We rated them as inadequate because:

• We rated the trust well led (leadership) as inadequate.
• One of the trust’s ten core services was rated as inadequate and three were rated as requires improvement. In rating the trust, we took into account the current ratings of the seven services not inspected this time.
• We rated the trust’s core services as inadequate overall for safe. The assessment of well led gave us some significant concerns about the assurance of the quality and safety of the trusts’ provision of services across the board.
• We rated the trust’s core services as requires improvement for caring, effective, responsive and well led overall.
• We rated caring as requires improvement as we found quite profound concerns in relation to poor governance and lack of oversight across the board.
• The trust had experienced significant changes at board level which had de-stabilised the board. These changes meant we were not assured that all senior leaders had the necessary experience, knowledge, and capacity to lead effectively.
• Although there was some recognition of individual strengths in different leaders, there were significant concerns about leadership capacity and capability at board level, and the ability of the board to respond at pace to key areas of risk and effectively implement and embed the improvement plan.
• From board to ward, the trust had been operationally led and dominated to the detriment of the quality agenda.
• Leaders did not have sufficient oversight of services at point of delivery, and they did not respond effectively when staff raised concerns about safety and quality issues which impacted on patient care and service delivery.
• Risks issues were not always managed and acted upon by leaders in an effective or timely manner.
• We had significant concerns about fire safety in the acute, psychiatric intensive care and forensic wards. Leaders had not supported front-line staff to implement the trusts’ no smoking policy and there was significant evidence of patients smoking across most of the wards. Some doors on the acute wards were not fit for purpose to prevent the spread of a fire as they had gaps in the top. This was an issue we raised during our last inspection.
• Ligature audits were poor in the acute, psychiatric intensive care wards because they did not identify all risks or effectively mitigate these. This was an issue we raised during our last inspection.
• Audits were not owned locally and were not effectively used to drive improvement.
• Leaders did not always identify and manage priorities in an effective and timely way.
• The trust did not always collect reliable data. IT systems were not always integrated to ensure provision of timely data and information and there was a reliance on manual data collection. The incident reporting system was out of date. This meant data could not be easily analysed accurately to identify themes or trends to improve performance. The board and leaders had lacked curiosity and had accepted reassurance from data rather than the assurance needed.
• The trust governance systems and processes did not ensure that all services provided safe and good quality care. The trust had recently reviewed the governance arrangements and implemented a new structure however; this was embryonic, and it was too early to determine if this would operate effectively.
• Dormitory accommodation remained in place in some services, and this did not protect the dignity and privacy of patients.
• Whilst the trust had systems in place to identify learning from incidents, deaths and complaints; these were not always effective or delivered in a timely way, which delayed any required improvements to patient care.

However;

• Staff at all levels reported the culture had significantly improved over the past few months and they felt able to speak up. Clinical staff felt able to raise concerns and were confident that their voices would be heard. All staff we spoke with knew about the freedom to speak up guardian.
• Staff felt supported by their immediate managers however, the trust still had work to do.
• Leaders were aware of the improvements which needed to be made which were incorporated into the improvement plan and accurately reflected within the board assurance framework.
• Within the community based mental health services for adults, actions had been taken to meet the Warning Notice we had previously issued. There were improvements to medicines management, improved oversight of the waiting lists and safeguarding referrals. A full-time senior pharmacist had been deployed within the Manchester community teams and this new post has been instrumental in the immediate and ongoing improvement of the service.
• All staff were able to register and access the maintenance reporting system to support the self-reporting of ad-hoc repairs and maintenance. The trust reported that recent system changes had made it quicker and easier for staff to report where maintenance repairs were required.
• Within the forensic wards, at our last inspection we identified concerns about the management of ligature risks and clinic rooms which had now improved.
• Leaders continued to work well with stakeholders in continuing to drive forward the community transformation programme, although this was work in progress.
• The trust had an established strategy to engage with carers and service users which was co-produced following extensive engagement with service users, carers, families, staff and external agencies.
• The trust was on track in the delivery of its estate strategy to remove the use of dormitory accommodation with the Park House new build project. Work was also well underway to refurbish the seclusion suites across the trust and several of the forensic wards had been refurnished.
• The trust had implemented electronic care records across all in-patient services.
• The trust had a planned approach to taking part in national audits and research.
• The trust had a track record of strong financial governance, and robust data security and protection with substantial audit opinions from both external and internal auditors.

How we carried out the inspection

During this inspection we;

• talked with 69 patients and nine carers about their experience of using these services
• arranged for a bespoke survey to be sent to all staff within the trust
• visited all 10 forensic inpatient / secure wards
• visited all 22 acute wards and psychiatric intensive care units
• visited three community-based mental health teams for adults of working age
• attended a number of clinical based meetings such as safety huddle meetings, smoking free meeting and handover meetings
• spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, advocates, managers, chief pharmacist, executive directors, non-executive directors and members of the senior leadership team
• reviewed a number of records relating to the care and treatment of patients
• reviewed a variety of documents relating to the management of the trust and the services it delivers
• held focus groups with staff side, governors, medical staff / consultants, non-executive directors, chairs of the staff equality networks and associate directors within the five care groups
• reviewed a variety of information we already held about the trust
• sought feedback from a number of the trust’s stakeholders.

What people who use the service say

Acute wards for adults of working age and psychiatric intensive care units

Patients provided mixed feedback regarding their treatment by staff. A large majority were positive regarding the care they received and their interactions with the staff, stating that they felt safe and well supported. However, some were negative and did not appreciate some of the blanket restrictions in place. They felt unsafe at times and that some night staff were disrespectful in their attitudes or behaviour towards them.

Forensic inpatient or secure wards

Most patients said that staff were respectful and polite. One said that staff were rude but did not give any examples.

Some patients had copies of their care plans, but some told us they didn’t want them. They understood their care plans and had been involved in developing them and making decisions about their care. They said that physical health issues were addressed, by contacting the GP, but one person said staff would do this for them and they preferred to do it themselves due to confidentiality.

Some patients described their care pathway and how they were working towards lower levels of security and discharge.

Patients had access to the advocacy service, and opportunities to give feedback about the service.

Staff encouraged patients to take part in activities on the wards that were relevant to their needs. Patients had access to education at an adult learning centre and local college. They told us that at the recovery academy, they could learn information technology skills, budgeting, languages and develop skills such as reading.

Staff supported them to build and continue their relationships with their families and friends.

Patients said they felt confident to raise concerns or complaints and told us they knew how to escalate their concerns.

One patient told us that staff had installed a blackout screen to protect against the bright sunlight but, as it went all the way to the floor, patients could not see out. We raised this with managers who agreed to address it.

Prior to the pandemic, patients had access to a bus service, which helped facilitate their leave from the unit. This stopped during the pandemic but had not been reinstated. Patients told us that this meant they had to walk from the unit to leave the site, which was a long distance, or use taxis. We raised this with senior managers, who agreed to investigate with a view to reinstating the service as soon as possible.

Patients told us how the events of 2022 had impacted on them. Some reported that things had improved, but the changes were unsettling.

One patient’s relative told us they had been waiting to meet with a doctor to forward plan and discuss discharge, but no meeting had been arranged yet.

Community-based mental health services for adults of working age

Because of the focused nature of this inspection in following up specific issues, we did not attend any home visits or appointments.

Updated 5 May 2024

We carried out an unannounced inspection of the child and adolescent mental health wards on 2nd 3rd and 18th July 2024. During our inspection we visited all 3 operational wards which are all located on the site of Prestwich Hospital. We gathered information from young people using the service and their loved ones, staff and managers, other stakeholders, carried out observations and looked at a range of documents including care records, policies and procedures. We looked at 9 quality statements. Staff were caring and supportive, responded to patients needs and made sure they were involved in the planning and delivery of their care. There were sufficient staff on the wards, and they had received suitable inductions and training to enable them to carry out their roles. Risks were managed effectively; care plans were clear, and medicines were managed safely. Staff generally felt supported by their managers and felt they could raise concerns. Governance processes were effective and were supporting the service to learn and grow.

Updated 10 May 2024

Dates of assessment: 1 to 2 May 2024 and 10 to 13 June 2024. We carried out an unannounced assessment of the long stay or rehabilitation mental health wards for working age adults as they had not been inspected since 2018. At the last inspection in 2018, the core service was rated good overall. During this assessment we visited 10 wards across 8 locations. We assessed 8 quality statements across the safe, effective, caring, responsive and well led key questions. We have combined the scores for these areas with scores from the last inspection. Our overall rating is requires improvement. We identified 4 breaches of the legal regulations in relation to person-centred care; safe care and treatment; premises and equipment; and good governance. At this assessment, we found inconsistent recording in patient risk assessments, safety plans and risk management plans. There were gaps in fire safety checks and ligature risk tools. We identified concerns with the environments, along with potential infection prevention and control issues. The service was not always effective because patient care plans were not always clear as to how the patient was involved with and kept informed about their care planning. Care plans did not always reflect identified needs for patients and how staff should support them with these. The service did not always ensure that people’s care was delivered in line with best practice and supported their ongoing rehabilitation. We found ineffective governance processes to ensure that the services had appropriate oversight and monitoring of the care and treatment being provided to patients. However, patients and carers reported positive feedback about their care and told us that they were treated with dignity and respect. The service was involved in development programmes to make improvements to the service. We have asked the provider for an action plan in response to the concerns found at the assessment.

Updated 23 February 2024

We carried out an unannounced inspection of the acute wards for adults of a working age and psychiatric intensive care units on 19th – 22nd March 2024. During our inspection we visited all 23 wards across 6 locations. We gathered information from people using the service and their loved ones, staff and managers, other stakeholders and our own observations. We reviewed a range of documents including care records, and policies and procedures. We looked at 22 quality statements. During our inspection we found that patients had mixed views of the service and not all of them felt safe. Some staff were caring and supportive, whilst other staff did not always respond to patients needs or distress. The environment was not maintained safely and there were issues with fire risks which were not being addressed adequately. Although there were sufficient staff, staff had not always received an induction, supervision or appropriate training. We had concerns about the skill mix on some of the wards. The physical health needs of patients were not always managed adequately and medicines were not always administered and managed safely. Staff generally felt supported by their managers and felt they could raise concerns. However, governance processes were inconsistent in quality and format across different locations and were not always effective at ward level.

Updated 9 January 2020

We have not previously inspected this service under the current provider. We rated it as requires improvement because:

• Children who did not require urgent care waited too long to start treatment.
• Emergency equipment kept on the premises had not been serviced, meaning that it was not safe to use. None of the partner trust’s staff had completed level 3 training in safeguarding children. Between April 2018 and February 2019, staff only reported two safeguarding referrals as incidents.
• Governance structures were not always effective. Routine checks had not identified that emergency equipment was overdue for a service. Managers could not be assured that staff were discharging their responsibilities in relation to safeguarding.

However:

• Clinical premises where patients were seen were safe and clean. Patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
• Managers promoted a positive culture. They worked with partners to meet local needs.

Updated 3 June 2016

We rated community based mental health services for older adults as good because:

• Safe

Teams had sufficient staff to meet patients’ needs. Staff vacancies were being recruited into quickly. Staff reported that complexity of caseloads were reviewed in supervision to ensure equity. Team caseloads were at a manageable level. There were good lone working practices in the team and trust policy was followed. Staff knew about duty of candour. Patients had a crisis contingency plan in place in their care plan and staff knew how to respond to deterioration in a patients’ physical or mental health. Staff had a good understanding of safeguarding processes and knew their responsibilities to protect patients from possible risk of abuse and harm. Staff showed a good understanding of incident reporting and there was good reporting of incidents.

• Effective

Staff attended a multidisciplinary group to review and problem solve complex cases, provide plans and anticipate care needs for those using health and social care services. There was a psychology team who provided input to patients, carers and staff. Care plans were holistic and person-centred. There was a staff development group who had protected time to meet on a monthly basis to undertake internal training. There were developments around the emphasis on physical health with some staff receiving specific training to support this. There was evidence of good inter-agency and multidisciplinary working.

• Caring

Staff treated patients who used the service with kindness, dignity and respect. Staff demonstrated warmth and compassion in their interactions with patients and their carers. Staff involved patients and their carers in decisions about their care.

• Responsive

There were five clinical pathways which gave clear and consistent support to patients. Patients reported that staff were flexible in their approach and quick to return phone calls. The service opened at weekends with reduced staffing in order to ensure flexibility and continuity of care. There was a duty system in place that ensured any urgent issues were dealt with in a timely manner. There were low numbers of complaints.

• Well-led

Staff were aware of trust values. Staff told us that managers listened and they felt valued and supported. Supervision and appraisal were comprehensive and up to date. Clinical audits were regularly undertaken. Staff morale had improved since managers had become established in their role.

However

• Mandatory training in basic life support was significantly below the trust target of 85% and below 75% for infection control.
• Compliance with mandatory training across all teams was lower than the trusts’ target of 85%.
• Training levels in the Mental Capacity Act and Mental Health Act were both significantly low.
• The rights of patients subject to community treatment orders were not always being met. Patients were not referred to an independent mental health advocate after being placed on a community treatment order and their capacity to consent was not always recorded.
• Carers were not always offered a carers assessment to ensure their needs were being met.
• Patients were not always offered a copy of their care plan or given the opportunity to develop advanced statements about their care with staff.

Updated 24 November 2022

Updated 21 July 2023

Updated 21 July 2023

We carried out an unannounced focused inspection because we had concerns about the quality of services at two locations and to follow up actions taken from a warning notice served in November 2022. This inspection was carried out to consider the safety of the wards and the care and treatment being provided to patients at Greenway ward and the three wards at Woodlands hospital.

Greenway ward is a 10-bed older adult mixed gender inpatient ward located at the Moorside Unit in Trafford.

Woodlands hospital is an older adult inpatient facility located in Little Hulton, Salford. There are three wards on the site:

• Delamere Ward, a 15-bed ward for female patients, predominantly those who are living with dementia or a functional mental illness such as bipolar disorder or schizophrenia.

• Hazelwood ward, an 18-bed ward for male and female patients who are living with a functional illness, for example bipolar disorder or schizophrenia.

• Holly ward, a 17-bed ward for male patients living with dementia.

In November 2022 we inspected the wards at Woodlands Hospital. Following this inspection, the trust was served with a Section 29A warning notice as the Care Quality Commission formed the view that the quality of health care provided within this service required significant improvement. The trust was required to take immediate action to make improvements within this service.

We visited Greenway ward on 18 April 2023 and all three wards at Woodlands hospital on 20 April 2023. The team that inspected the service comprised three CQC inspectors.

At Woodlands hospital, we reviewed actions the trust had taken in relation to the warning notice issued in November 2022. In the warning notice, concerns were outlined around environmental risks, including ligature risks; the management of medicines; the completion of risk assessments and care plans alongside poor handover documentation; staff access to record systems and the overall oversight of the service.

We rated the service as inadequate previously. At this inspection, the trust had developed action plans to address all of these areas. We were able to see all the areas of concern had improved and there were ongoing plans to ensure that progress was built on and improvement sustained.

We also saw areas of good practice at Greenway ward including comprehensive care plans, risk assessments which were complete and updated daily and good medicines management.

What people who use the service say

We did not speak directly to all patients on the wards during this inspection due to the focus of our inspection being on specific areas. We saw and spoke to patients on each of the wards. Patients that we spoke to were positive about staff, describing them as “nice”, “kind”, “lovely”, “cannot fault them”. In one ward, we were told of concerns about staffing at night and managers were taking actions to address these.

We observed interactions as we spent time on the wards. Staff responded to patient’s needs and requests. Staff spoke to patients with respect and in a caring manner. Staff were calm in their approach to patients and were patient when assisting them with their needs. We saw staff and patients engaged in group and individual activities on wards we visited.

Updated 23 February 2018

We have not previously inspected substance misuse services. We rated it as outstanding because:

• There was a very strong recovery emphasis throughout the service. Staff worked with clients to help identify their goals and to develop their recovery capital. Staff were knowledgeable about local recovery and support services and they were promoted within teams.
• Services were tailored to meet the needs of individuals and were delivered in a way that offered flexibility and choice. There were different pathways within community teams to address individual need and an innovative rapid access to alcohol detoxification pathway within inpatient services.
• Client and carer feedback on the service was overwhelmingly positive. Clients spoke highly of staff and their supportive nature. Clients and carers were active participants in care and in decisions about treatment. Carers were able to access carer assessments and relevant support.
• There was excellent multi-agency working. Services worked collaboratively with partner agencies within the local treatment network as well as with physical health services. There were clear referral processes into support services and mutual aid groups. Staff were active in facilitating client engagement.
• The service employed volunteers and peer navigators with lived experience of substance misuse and recovery. Clients we spoke with talked positively about staff members and the visual representation of recovery that they provided.
• There was excellent engagement with the community. Clients were encouraged and supported to attend community groups and services. There were community leads within teams to develop effective links and ensure that recovery was embedded within the team. There was a building recovery in the community asset fund that clients and staff could access to support new projects such as community allotments or trainee kitchens.
• Clients and carers were able to give feedback on the service they received in a variety of manners. The service responded to feedback and developed action plans to address concerns.
• Buildings were clean and well maintained. There were regular checks of equipment and maintenance records were in place. There were appropriate health and safety checks.
• Staff actively managed client risk. Staff worked collaboratively with clients to complete risk assessments and develop risk management plans. The service prescribed in line with risk assessments and utilised methods such as supervised consumption to manage the risk of overdose or diversion. There were strong processes and procedures to manage safeguarding concerns and effective links with local authorities.
• Staff had been trained to deliver psychosocial interventions. Services offered a range of one to one and group sessions to meet client need. Clients we spoke with were positive about the psychosocial interventions they received
• There was a good governance structure. Quality of service provision and performance was monitored. Service and team managers were well regarded by staff. The service engaged effectively with stakeholders when introducing change.

However:

• Staff in community services did not use personal alarms in a consistent manner.
• Staff in community services did not always record consideration of mental capacity.
• We found three care records where there was no consent to treatment or confidentiality agreement in place.
• Although information sent by the trust showed six mandatory training courses below 75% compliance, local figures and staff confirmed training rates were higher. We observed skilled staff, competent in their role.

Updated 21 July 2023