Greater Manchester Mental Health NHS Foundation Trust

We suspended all the forensic core service ratings on 23 September and all the well-led ratings for the trust on 22 October. We are continuing to suspend the well-led rating at trust level and the overall rating for the trust.

We carried out an unannounced inspection of 3 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 part of our continual checks on the safety and quality of healthcare services at our last inspection we rated the trust overall as good. Since our last inspection of the trust, we have carried out 4 focused responsive inspections in 3 of the trust’s core services. We inspected acute wards for adults of working age and psychiatric intensive care units twice, but we did not re-rate any of the key questions with safe remaining requires improvement. We inspected and rated child and adolescent mental health wards as good overall and rated community mental health services for adults of working age as inadequate in the safe key question.

During this inspection, we inspected 3 mental health core services including:

• acute wards for adults of working age and psychiatric intensive care units
• forensic inpatients/secure wards
• mental health crisis services and health-based places of safety.

We did not inspect the following 7 core services at this inspection:

• wards for older people with mental health problems
• community-based mental health services for adults of working age
• 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 provider with a Section 29A Warning Notice and served a further Section 29A Warning Notice at provider level following the well led inspection. We served 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. A further inspection will be carried out to ensure action has been taken to comply with the Warning Notices. We will continue to monitor the progress of other areas of improvement to these services and will re-inspect them as appropriate.

• We rated 2 of the trust’s 10 core services as inadequate and 2 as requires improvement. We rated 5 of the trust’s services as good and 1 as outstanding. In rating the trust, we took into account the current ratings of the 7 services not inspected this time.
• We rated safe as inadequate, effective as requires improvement, caring as good and responsive as requires improvement. We suspended the rating for well-led.
• The trust governance systems and processes did not ensure that all services provided safe and good quality care. Information and data being received by board did not provide sufficient detail to enable the board to have full oversight of the risks which were present within clinical areas and their impact on patient care. This meant that effective action to address and mitigate risks was not taken by the trust.
• The trust did not provide safe care. The ward environments were not all safe, clean, maintained or well presented. We had significant concerns about fire safety in the acute wards. Ligature audits were poor because they did not identify all risks or effectively mitigate these. The environment was dated, and maintenance were slow to react to requests.
• The service did not have enough registered nurses and healthcare assistants to ensure that patients got the care and treatment they needed. Staff frequently worked under the minimum staffing establishment levels, wards had unfilled shifts and there was not always a registered nurse present.
• Dormitory accommodation remained in place in some services and this did not protect the dignity, privacy and safety of patients. We had significant concerns about the sexual safety of patients on mixed sex wards.
• Managers had not identified that the mandatory training program did not meet the needs of all patients and staff. Training figures were poor in some areas and the trust had not ensured that enough staff were adequately trained in fundamentals when providing patient care, including fire safety, safeguarding, basic and immediate life support, the Mental Health Act and Mental Capacity Act.
• Clinic rooms were not all fully equipped, and staff did not check, maintain, and clean equipment consistently. Clinic room temperatures and medicines fridge temperatures were not always checked, and staff did not consistently act when issues were identified.
• Systems were not effective for the proper and safe management of medicines. Physical health observations to review the effects of medicines were not continuously completed and documentation was not always available.
• The trust did not always provide effective care in all services. Paperwork for consenting to, or not consenting to medicines, was not always accurate or available. Staff in the acute wards did not always ensure that informal patients were aware of their rights.
• Services were not always caring, some patients told us that wards were noisy and chaotic, and that they did not always feel safe.
• The trust did not provide responsive care in all services. Bed occupancy often exceeded 100% and patients did not always have a bed when they returned from leave. The acute wards regularly used rooms designed for other purposes as patient bedrooms.
• Patients told us about a lack of therapeutic activity.
• Not all staff were receiving effective, regular supervision and appraisal.
• We found that the quality of services at the point of delivery was not reflected in the executive teams understanding of the services.
• Services were not well led, and the governance processes did not ensure that wards were safe. Ward based audits were undertaken by managers and matrons, but the results were not always acted on. Named nurse audits highlighted areas for improvement, but actions were not taken to make sustained improvement, this was exacerbated by ward acuity and staffing. Managers noted a lack of information coming back to ward and service level, for example, managers relayed information about restrictive interventions to the trust, but no results were fed back down.
• Services in Wigan and Leigh used a different electronic records system to services in the rest of the trust. The Wigan and Leigh services were due to migrate to the trust system in October 2022.
• Leaders had not ensured that where concerns and risks were present, swift action was taken to monitor, mitigate and remove risks.

However:

• We rated 5 of the trust’s services as good and 1 as outstanding. In rating the trust, we took into account the current ratings of the 7 services not inspected this time.
• Staff working for the mental health crisis teams developed holistic, recovery-oriented 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.
• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Overall, patients told us that staff treated patients with compassion, kindness and they understood their individual needs.
• The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
• Staff felt supported and respected by their immediate line managers.

How we carried out the inspection

During this inspection we;

• talked with 112 patients, service users and their carers about their experience of using these services
• toured 9 of the 17 environments on the forensic inpatient / secure wards and all the acute wards and psychiatric intensive care units
• visited 7 crisis teams and 5 health-based places of safety
• spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, advocates, managers, executive directors, non-executive directors and governors
• 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 external partners and staff side
• reviewed a variety of information we already held about the trust
• sought feedback from a number of the trust’s stakeholders such as NHS England and clinical commissioning groups.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

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

We spoke to 62 patients during this inspection and collected 48 comment cards.

Patients said staff mostly treated them well and behaved kindly. Most patients spoke positively about staff who they worked with. Staff were described as supportive, kind, respectful and caring. Patients were also positive about support they received from volunteers and peer support workers across the services.

However, patients were concerned about staffing levels in the service. They told us that the high use of temporary staff meant that there was a lack of consistency and that there was less interaction with them. Patients at Bolton, Trafford and Park House spoke specifically about night staffing issues, noting night staff as being unapproachable, rude and dismissive at times.

Patients also raised concerns about the ward environments, particularly about feeling unsafe in some wards and in dormitory accommodation.

Feedback about activities was mixed. At Bolton and Park House some patients mentioned there was limited choice and no activities at weekend. Most patients noted some activities taking place during the week and there was positive feedback for psychology led groups where these were running.

Forensic inpatient or secure wards

We spoke with 18 patients, 6 carers, families or relatives and 2 advocates that worked into the service.

Most patients felt safe and listened to on the wards. Patients said staff looked after them well and they described staff as polite, respectful and caring. Most families and carers felt informed and involved but told us that making telephone contact with wards was difficult. They described regular staff as amazing. Advocacy said that the service took a patient-centred approach and that patients were given opportunities to participate in their own care, treatment and recovery.

Patients and their carers or relatives raised concerns with us about staffing. Advocates also raised staffing as a concern. Patients told us that staffing levels made them feel unsafe at times and that their leave or activities had to be cancelled due to staffing levels.

Patients said there were not a lot of activities on the wards other than television. Patients said food portions were small and that the food was unpleasant.

Mental health crisis services and health-based places of safety

We spoke with 12 patients who used the service. Patient feedback about staff was positive. Patients viewed staff as kind, caring and considerate. They felt that staff were responsive and interested in the patients’ health and well-being. However, we spoke with 4 patients who were on the Safire Unit. They raised concerns over the dormitory facilities on the unit and the impact upon their privacy and dignity.

We last inspected child and adolescent mental health wards at the trust in 2018. At this inspection we rated the service as good overall, with requires improvement in safe.

We visited Junction 17 and Gardener Unit.

The inspection was unannounced (the service did not know we were coming).

During the inspection the inspection team:

• Toured the wards
• Interviewed the ward managers and the senior leaders within the service
• Spoke with Children and Young People who were using the service
• Spoke with carers of Children and Young People using the service
• Spoke with other staff members including, nurses, doctors, junior doctors, psychologists, family therapist, art therapist, music therapist, domestic staff, support workers, occupational therapy staff, the headteacher of the school and the wellbeing lead
• Attended and observed a multidisciplinary meeting
• Looked at the care and treatment records of Children and Young People on the wards
• Carried out a check of medication management
• Reviewed prescription charts
• Looked at a range of policies, procedures and other documents relating to the running of the service.
• Attended and observed ward based activities.

Our rating of this service stayed the same. We rated it as good because:

• Patient feedback about the staff was universally positive. Children and Young People told us that the staff had changed their lives and that the level of support they received had gone above and beyond what was expected of them. Children and Young People felt that staff genuinely cared about their wellbeing, and took the extra time needed to get to know them individually. Children and Young People and their families/carers were involved in all decisions about their care and treatment, and the multi-disciplinary team spent time explaining different options available to Children and Young People.
• The service provided safe care. The environment was clean, safe, well maintained and fit for purpose. The environment was in keeping with the needs of young people and was decorated and furnished to suit their needs. Risks were well managed, and staff had a good understanding of the risks the patient group posed. Risk assessments were thorough and individualised. The wards had enough staff to safely manage the patient group and staff were well trained. Medicines were managed safely, and staff had a good understanding of safeguarding procedures.
• Comprehensive assessments were made for each patient, most started prior to the patient’s arrival. There was a range of treatments available for Children and Young People which were in line with best practice guidance. There was a vast multi-disciplinary team available to young people in the service. This included a full therapy team with access to a family therapist immediately. Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
• Staff planned discharge well and involved outside agencies that were relevant to the Children and Young People care. This meant that discharge was only ever delayed if there was a clinical need, or due to the time some more specialised placements took to secure. The involvement of Children and Young People in the local community was important. Children and Young People were involved in local groups, attended local attractions with staff and even attended local colleges on public transport. Children and Young People were actively encouraged to be part of the local community and staff supported them to do this.
• The service was well led. All staff and even Children and Young People told us that the senior team were visible and frequently spent time on the wards, not only for meetings but to meet Children and Young People and get to know them and support the staff team. The senior team were experienced in CAMHS and had worked in them for some time. The systems in place to support staff enabled them to do their work much more easily. The team had a clear vision about the future for the service and were working hard to ensure this materialised. The passion for the service shown by the senior leaders within the service was clear for all to see and staff remarked on how this leadership and support had impacted positively on the morale of the team. All staff we spoke to were extremely proud to work within CAMHS services and wanted to ensure that they did their best for the Children and Young People who were in their care. Both wards were accredited with the quality network for inpatient child and adolescent mental health services and were involved in research to improve the service.

We carried out this unannounced focused inspection because we had concerns about the quality of services across the acute wards for adults of working age and psychiatric intensive care units. Our inspection was carried out to consider the safety of the wards and the care and treatment being provided to patients.

This inspection was not rated as it was a focused inspection regarding the safety of the wards.

Since our last inspection of the acute wards for adults of working age and psychiatric intensive care units, the trust had acquired the Wigan Mental Health services from North West Boroughs NHS Foundation Trust in April 2021. At the time of this inspection, these services were still being integrated into Greater Manchester Mental Health NHS Foundation Trust.

We visited eight wards across five of the seven locations where the trust’s acute wards for adults of working age and psychiatric intensive care units (PICU) were located. These were:

• Griffin ward, an eight bedded female acute ward at Junction 17, Prestwich
• Oak ward, a 20 bedded female acute ward at Rivington Unit, Bolton
• Priestner’s Unit, an eight bedded mixed PICU at Atherleigh Park, Wigan
• Medlock ward, a 21 bedded female acute ward at Moorside Unit, Trafford
• Brook ward, a 22 bedded male acute ward at Moorside Unit, Trafford
• Poplar ward, a 20 bedded female acute ward at Park House, Manchester
• Juniper ward, a 10 bedded male PICU at Park House, Manchester
• Laurel ward, a 23 bedded male acute ward at Park House, Manchester.

We did not visit a ward at either Laureate House in Wythenshawe or the Meadowbrook Unit in Salford.

We did not rate this service at this inspection. The previous rating of requires improvement in safe remains. We found:

• The wards did not all have up to date and recently reviewed ligature risk assessments. Staff on two wards could not locate the ligature risk assessments at the time of the inspection.
• The service did not always have enough nursing staff, who knew the patients or received basic and essential training to keep patients safe from avoidable harm.
• The environment on Poplar ward was not clean on the first day of inspection and space on the ward was limited for patients.
• It was not clear that immediate concerns or learning from incidents was shared across the locations, although local learning and reviews were taking place.

However:

• Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• Staff had easy access to clinical information and it was easy for them to maintain clinical records – whether paper-based or electronic.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about the location. During the inspection visit, the inspection team:

• Toured the ward environment and reviewed environmental risk documentation
• Spoke with the ward manager, matron or a senior member of staff on each ward
• Spoke with 17 other staff members including registered mental health nurses and healthcare assistants
• Reviewed 51 care and treatment records
• Reviewed documentation and data for each ward.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We did not speak directly to patients on the wards during this inspection due to the focus of our inspection being on specific areas. However, we did observe 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.

We carried out an unannounced focused inspection of Elm Ward at Park House. This was because we had concerns regarding the safety of patients and leadership on the Ward.

This was a focused inspection looking at the safe and well led key questions. We did not rate key questions at this inspection. However, due to a regulatory breach in safe, this domain has been limited to requires improvement.

We had carried out a Mental Health Act Review visit in August 2019 which raised concerns about the acuity on the ward, the environment, lack of space for patients to lock away their possessions and staffing levels. At this time we asked the trust for assurances that improvements would be made and a robust action plan was put in place to support the ward to make these improvements. Despite this, information we received about the ward from patients, relatives and from notifications from the trust continued to contain similar themes. We therefore, decided to carry out a focused unannounced inspection to look into these concerns in more detail.

Elm Ward is a 24 bedded female acute ward at Park House. This is a mental health unit based on the site of the North Manchester General Hospital. The acute wards for adults of working age and psychiatric intensive care units at the trust are currently rated as Good.

Summary

• The design, layout, and furnishings of the ward did not supported patients’ treatment, privacy and dignity.
• The patients had no lockable space to store their belongings, this meant that patients did not feel safe leaving valuables in their bedrooms
• The action plan for improving the ward environment was not up to date. There should have been monthly walkarounds and the last one completed was in July 2020. From this walkaround, there was a long list of maintenance issues that needed addressing but the action plan did not detail what had been done to address this or an expected completion date.

However,

• The service provided safe care. The wards had enough nurses and doctors. They followed good practice with respect to safeguarding.
• With the exception of the action plan mentioned above, our findings from the other key questions demonstrated that governance processes operated effectively at ward level and that performance and risk were managed well.

Following on from our inspection, we had significant concerns about the environment on Elm Ward. We raised our concerns with the trust and they provided a response including assurance on the immediate actions being taken.

The trust responded in the agreed time frame and told us that they had immediately reduced the number of beds on the ward from 24 to 20. They had used the dormitory that was closed to provide a quiet lounge for patients away from the main dining room. They had also provided a lockable space for each patient. All lighting was fixed and obscene language removed with blackboards installed for patients to write on. Smoking at the top of the stairs was stopped with immediate effect.

Following on from this response we decided that it was no longer necessary to take urgent action against the trust. We will monitor the progress of these actions during our routine engagement with the trust.

How we carried out the inspection.

We visited Elm Ward. We toured the ward, spoke to four staff, the ward manager and the inpatient service manager. We spoke to six patients and one carer. We also reviewed the ward rota, the observation shift planner and the action plan relating to Elm Ward that the Trust had been working on.

What people who use the service said.

We spoke to six patients on Elm Ward. All apart from one told us they felt safe on the ward. All six patients told us that there was no lockable space for their personnel possessions, one patient slept with their purse under their mattress. All patients told us that the ward was extremely busy and that there was no space for them to go to relax and have some quiet time. All patients we spoke to were unhappy with having to share a bedroom with other patients and felt this along with the level of noise and lack of private space on the ward had a negative impact on their mental health.

Our rating of the trust stayed the same. We rated it as good because:

• We rated effective, caring and well-led as good, and safe as requires improvement. We rated seven of the trust’s ten core services as good, two as requires improvement and one as outstanding. In rating the trust, we considered the current ratings of the six services not inspected this time.
• Patients received a range of care and treatment based on national guidance and best practice from staff who had the range of skills needed to provide high quality care. Teams included or had access to the full range of specialists to meet the needs of patients.
• Staff understood their responsibilities under the Mental Health Act 1983 and Mental Health Act Code of Practice.
• Staff treated patients with compassion and kindness. Staff respected the privacy and dignity of patients and in most services involved patients in their care planning.
• Services did not have referral criteria which excluded patients who may benefit from care and met the needs of patients, including those with a protected characteristic.
• The trust investigated incidents and treated complaints seriously. The trust learned from the outcome of investigations and complaints, sharing learning across the organisation to improve services.
• The trust had an experienced and senior leadership team who provided leadership to create a culture which supported high quality care. The trust engaged with patients, staff and communities to develop services which met the needs of local people and sought feedback to allow services to be improved.
• Senior leaders understood the current and future risks to the trust and acted to mitigate these. Strategies were in place which supported the vision of the trust and its role within the wider health and social care system within the Greater Manchester area.

However:

• The trust did not have effective processes in place to monitor the provision and compliance with supervision across its services.
• Dormitory accommodation was being provided for patients admitted to acute wards for people of working age.
• Not all patients within community services for working age adults had current risk assessments in place.
• Patients waited too long for to access treatment in specialist community mental health teams for children and young people and community mental health services for working age adults.
• Processes were not in place to ensure emergency equipment was safe to use in specialist community mental health teams for children and young people.

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.

Our rating of this service improved. We rated it as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• 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 service managed beds well so that a bed was usually available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• The design, layout, and furnishings of the wards did not always support patients’ treatment, privacy and dignity. Each patient did not have their own bedroom, as five of the wards at Park House had dormitories.
• The trust did not have a robust mechanism for assuring itself that all staff received appropriate supervision. This was identified as a breach of regulation at the last inspection in 2017 and has been addressed as a trustwide issue at this inspection.

Our rating of this service went down. We rated it as requires improvement because:

• In four out of six care records reviewed at the Central Manchester community mental health team, patients allocated a care coordinator in April 2019 had not been risk assessed, a situation confirmed with team management at the time of the inspection
• Data provided about referral to initial assessment and referral to treatment times indicated very long waiting times within the service
• Mandatory training data for safeguarding children level three was well below the trust target.

However,

• environmental risk assessments had been completed, including ligature assessments, and actions taken to remove or reduce risks. Staff monitored patients waiting for assessment, with a duty officer system that allowed patients to contact the service during and after assessment
• patient notes were recorded electronically and were found to be comprehensive and entered onto the system in a timely manner
• Assessments of patients were comprehensive and holistic, and physical health monitoring was taking place, where required
• Staff provided a range of treatments and access to treatment across the service, and care was delivered in line with national guidance
• Staff were taking part in clinical audits and using results to drive improvement. Staff employed in the service had the right skills and experience to ensure informed treatment for patients
• Staff were seen to be responsive and respectful when dealing with patients. Patients were involved in decisions about the service, where appropriate
• There was a strategy to maintain and renew engagement with patients in the service, ensuring patients had every opportunity to receive the treatment they were prescribed.
• The service used key performance indicators to take the service forward.

• Our rating of this service stayed the same. We rated it as good because:
• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• 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.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

However:

• Staff did not always make requests for cover through the on-call management system.
• Staff did not always review the prescription of high dose antipsychotic medicine.
• Medicines were not always administered safely.  Staff oversight of the administration of medicine was inconsistent and patients were at risk because drug interactions were not recognised, or medicine administration reviewed, so medicine was not administered appropriately.
• Staff did not always record information about patients’ care and treatment in a way that was comprehensive and easy to find.
• Not all care plans were person centred and did not reflect the patient voice. Care plans used a medical language rather than the patient’s own words.
• Recording of physical healthcare following rapid tranquilisation was recorded in patients’ electronic records but not all in the same place. Staff were recording monitoring either in daily notes or on medical early warning scores.
• Patients’ one to one sessions with their named nurse were taking place, but not as two to three times a week as per the trust policy. One to one sessions were recorded but did not reflect the details of what was discussed and if this related to patients’ care, treatment and recovery.
• Patients were offered a copy of their care plan, but this was not consistently recorded as to whether the patient had accepted or declined the offer.

Our rating of this service stayed the same. We rated it as good because:

• The locations inspected were clean and equipped appropriately.
• Staffing levels showed that very few vacancies existed within the service, and that shifts were adequately covered.
• Care plans and risk assessments were completed in a holistic and comprehensive manner, taking into account the opinions of patients in the service.
• Staff mandatory training compliance averaged above 80% for the service.
• Activities for patients were meaningful, designed with an aim to not only keep patients engaged but to give skills for use in the community, including access to a recovery academy for both patients and staff.
• Patients were positive in their comments regarding care in the service, and we saw evidence of positive interaction between staff and patients at each location inspected.
• The Mental Health Act and Mental Capacity Act were observed and noted to be applied correctly.
• There were very few complaints across the service, and we saw evidence of shared learning from complaints that had been investigated.
• Key performance indicators were used to guide and improve practice across the service.
• The service was due for Accreditation for Inpatient Mental Health Services under the Royal College of Psychiatrists.

However:

• Acacia ward was in need of refurbishment and consideration for a total environment change: the trust had plans in place for implementation of such a change.
• We saw a table used to inform staff of mandatory training figures was not importing the correct data in relation to immediate life support training, giving an incorrect data set in regards to said training; this was dealt with immediately on identification of the problem.
• The sickness rate for staff was at 9%, but was only at 5% for the year to date.

Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Our rating of the trust stayed the same. We rated it as good because:

• We rated eight of the nine core services as good, with one service rated as requires improvement. This takes account of the ratings of the four core services that we did not inspect this time
• We rated safe as requires improvement, effective, caring, responsive as good.
• We rated well-led at trust level as outstanding. The leadership team had effective oversight of the risks and challenges for the trust. They had overseen a very quick acquisition of a failing trust and were managing to maintain a strong clinical and financial performance. The trust was working in partnership with other organisations, including the housing and voluntary sector to promote well-being and good mental health. The trust carried out thorough investigations into serious incidents and had well established systems for learning lessons. The trust apologised when things went wrong. There were established systems for involving carers and service users with the transformation plans in Manchester demonstrated true co-production.
• Staff generally managed risks well, with risk assessments well completed and reviewed. Staff recognised and reported safeguarding concerns and incidents. Staff understood the duty of candour. Although there were vacancies and sickness, systems ensured there were sufficient staff. Although some training courses were below trust target, the trust had taken steps to ensure there were enough skilled staff to provide care. Medicines were managed safely. Risks related to the two electronic management systems were being managed.
• In four of the five core services we visited, care plans were holisitic and patient centred. This was not always the case in acute wards for working age adults and psychiatric intensive care units where care plans were not always personalised. There was a comprehensive audit programme and effective systems to monitor action plans. Although people’s rights who were detained under the MHA act were protected, we found that in wards for older people, there were issues with forms of authorisation and requests for second opinion doctors.
• Feedback from people using the service was positive, with patients and carers telling us that staff were supportive and kind. Patients and carers gave us examples where staff had gone the extra mile to support them. People were generally involved in planning their care although this was not always the case in acute wards for adults of working age and psychiatric intensive care units. Feedback from substance misuse services was universally positive during the inspection and received the highest proportion of compliments by the trust.
• Services were responsive to the needs of the population they served. Following the acquisition of Manchester out of area placements were high; the trust had plans in place to address and effective systems to monitor this. The transformation plans in Manchester were reviewing care pathways to improve access to services. Staff, patients and carers were involved in developing services. Complaints were well handled locally and at trust level.

Our rating of this service went down. We rated it as requires improvement because:

• Ligature audits did not include all ligature risks. Staff were not advised of ligature risks within the wards and how to mitigate these.
• There were environmental concerns with drainage difficulties on Keats and Eagleton wards at Meadowbrook Hospital and stains on ceilings at Blake and Eagleton wards. Anti-barricade doors did not open both ways for three of the rooms on Brook and Medlock wards. We found there were blind spots on Maple House, Eagleton, MacColl and Chaucer wards not mitigated.
• There were concerns with medicine storage, staff were not recording the minimum and maximum temperatures of medicine fridges. Staff were not following the trusts policy in relation to rapid tranquillisation, in relation to the timeliness of completing physical observations and the availability of these records.
• Lessons learnt were not shared across different parts of the trust. Team meetings and supervisions did not have standard agenda items to discuss learning.
• The service did not provide training for staff in how to support people who have a learning disability.
• Care plans were not always person centred and staff did not always make them accessible for people with a learning disability except on Juniper ward. Care plans were nursing led and did not include the involvement of other members of the multidisciplinary team. Less than half of the patients we spoke with had received a copy of their care plan and felt involved in the process.
• Staff did not receive regular supervision. Team meetings, handovers and supervisions varied in content across the wards.
• The consent to treatment policy, time out, seclusion policy and standard operating procedure and Mental Health Act 1983: information policy did not comply with the current Mental Health Act code of practice.
• There was limited access to psychology for patients. Patients had limited access to the gym at Meadowbrook hospital as only one member of staff was trained to enable patients to safely use the equipment.
• We could not find evidence in records that staff were always explaining section 132 rights to patients. Staff were not supporting patients to create advanced statements and decisions regarding their care and treatment.
• Seven patients told us that the agency staff who usually worked at night did not treat them well. They were dismissive, unresponsive and not approachable.
• There were dormitory sleeping arrangements at Poplar, Mulberry, Redwood, Elm and Laurel wards. There was no examination couch in the clinic at Poplar and Mulberry wards, patients would not have their privacy and dignity protected if they required an examination.
• Information advising patients how to contact the Care Quality Commission was not displayed on all wards.

However:

• Staff had received training in and had a good understanding of safeguarding. Staff liaised with professionals and attended strategy meetings for patients.
• Although staff training in immediate life support was low at 55%, the trust had systems in place to ensure that there was always a member of staff available who was trained in immediate life support.
• Patients had detailed, individualised risk assessments in place. Staff and patients received a de brief following incidents.
• The service managed medicines well, with daily visits from the pharmacy department to the wards. All clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines that were in date.
• Staff received an induction to the ward and had an appraisal.
• The majority of patients told us that staff were caring, supportive and responsive. We observed staff interacting with patients in a friendly, supportive and calm manner.
• Staff gave welcome booklets to patients to assist with their orientation to the ward and leaflets were available for carers and contact details of the carers support services.
• Staff responded to patients’ needs. Morning meetings took place with the ward managers, service managers and community mental health teams to discuss patient’s progress, discharge plans and support needs post discharge. Staff supported patients when admitted to acute hospitals, to provide consistency and mental health support. Staff booked interpreters to enable family members to be involved in the planning of care for their relatives. Patients had access to a variety of food and chaplaincy services.
• Ward managers and deputy ward managers we spoke with were knowledgeable, motivated and skilled when interacting with both staff and patients. They could locate required information, and were able to give clear guidance and advice to staff. Patients and staff told us that ward managers were supportive and approachable.
• The service implemented the recovery model of care, with patients being involved in staff training and recruitment and as peer mentors. Wards were recovery orientated with MacColl ward opening to meet the needs of Manchester patients. Recovery boards were in use to provide encouragement to patients.

Our rating of this service improved. We rated it as good because:

• The service had made improvements following our last inspection. Staff were now completing observations following rapid tranquilisation. The safety of the environment had been improved with better lines of sight and the use of parabolic mirrors and staff observations. The gender segregation on the two wards at Trafford was much improved. Documentation around patients capacity was clear and we saw good evidence of capacity being assessed when necessary and best interest decisions being made appropriately.
• There was adequate staffing levels to ensure patients were well looked after and able to spend one to one time with staff on a regular basis.
• There were good patient risk assessments on each ward. The service provided a safe environment and risks were managed well. Patients told us they felt safe on the wards.
• Staff deescalated aggressive and potentially violent situations well. Staff knew patients well and were able to use distraction and diversion techniques when they saw a patient becoming agitated. For example, the use of activity equipment that focused on patients interests and hobbies.
• There was effective multidisciplinary team working evident on all wards.
• Patients and carers gave universally positive feedback about the care and treatment they received on the wards we visited. Staff involved patients in decisions about their care where possible. They engaged with and supported families and carers where appropriate. Staff contacted them with updates on patient progress, held regular carers meetings, and invited them to ward rounds.
• Recent changes within the service had led to a positive change in staff morale. Staff focused on the needs of the people using their service, providing high quality patient centred care, which reflected the trust’s vision and values. Senior managers were committed to improving the environment at the Manchester wards and had identified that the dormitories on those wards needed to be changed as a priority.
• Two wards at Woodands hospital were AIMS accredited. The two wards at Trafford were going through the AIMS accreditation process with draft reports available at the time of our inspection.

However:

• Staff were not always using the trust approved form for physical health monitoring following rapid tranquilisation.
• We found there were delays in requesting second opinion doctors when patients had been detained for three months and administered medication in order to complete a form T2 or T3 (dependent on whether the patient was able to consent to treatment). There were also delays in section 62 being completed (emergency treatment of a detained patient) with medication being administered without the correct legal framework across all of the Wards except Maple Ward. We also found examples of when a section 62 had been completed and medications were not on the list but being administered.
• On Cavendish Ward we found examples where patients had not been read their rights at the correct times or when there was a change in their detention status.
• There was a lack of privacy Bollin Ward where privacy screens on bedroom windows had been left open and there were no privacy curtains in the bathrooms on the main corridor.
• At Trafford the wards were very small with no quiet space for patients to use if they wanted to. Activities had to be done in the main lounge which meant that patients who wanted to sit quietly would either have to go to their rooms or listen to the activities.

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.

Our rating of this service improved. We rated it as good because:

• The service had made improvements in many of the areas which previously were highlighted as concerns.
• There was a shared culture of embracing the organisational values.
• There was a culture of reporting concerns and learning from incidents.
• Use of restrictive practices was carefully monitored and used as a last resort.
• Risk awareness was taken seriously and there was evidence of regular risk assessments being conducted.
• The senior management team met routinely with staff and had a presence within clinical areas.
• There were real attempts to engage patients with every aspect of the service and develop their skills through work and education opportunities.

However:

• Although most equipment was checked so it was safe to be used, not all safety checks had been completed when due.
• The service did not always ensure patients understood interventions including medication.
• Although physical observations were usually carried out, in one case we could not find records to show they had been completed.

We rated long stay/rehabilitation mental health wards for working age adults as GOOD because:

• The wards provided a safe environment. The layout across the service allowed for monitoring of patients, with good use of mirrors for blind spots on Ash and Dove wards. All wards complied with the requirements of same sex accommodation guidance.There were sufficient staff deployed to meet the needs of the patients, with on-going recruitment in place to meet shortfalls in staffing numbers. There was access to personal alarms and call buttons in rooms across the service. Risk assessments were completed and up to date.

• Thirty nine care records were reviewed across the service, all of a high standard, patient focussed, and comprehensive.Physical examinations were undertaken and effectively monitored. Multi disciplinary team meetings were well attended with the patient being central to all discussion. Mental Health Act records were in place and in order.

• We saw interaction between staff and patients that was respectful, thoughtful, considerate, timely, and professional.  We attended a care programme approach meeting in which a patient had a list of considerations for approval to allow acceptance of a job offer, and the team gave full consideration and agreement to the request.  There was evidence of family and carer involvement in the care of patients.  Patients stated they were happy with the service.

• In the six months prior to inspection there had been no delayed discharges, referral to assessment / referral to treatment delays or readmissions for this core service. Facilities such as specific telephone rooms were available for private telephone calls.  There was access to well-maintained outside areas.  Patients were actively encouraged to find voluntary or paid work. Activities were available across the service, including weekend activities.  There was access to information about services, with consideration for culture and language. Complaints were dealt with and results fed back to both patients and staff.

• Staff knew the values of the trust.  Senior management visited the service regularly.  Key performance indicators were used across the service to monitor and improve the service.  Staff could raise issues confidently and could give input into service development.  The service had actively embraced duty of candour, with the use of staff questionnaires to enhance understanding.

However:

• mandatory training for the service was not being monitored or audited effectively, leading to confusion over figures.  The mandatory training figures for Recovery First were well monitored and showed a compliance rate of 83%, with the other service locations averaging compliance at 78%.

• Mental Health Act and Mental Capacity Act training access was not very effective, but the trust had identified this and was working towards a solution.

• Immediate Life Support training was not given enough prominence in training schedules, and needed to be addressed.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We have rated services provided by Greater Manchester West NHS Foundation Trust overall as good.

This was because we rated six of the eight services as good. We rated two service as requires improvement. These services were; child and adolescent mental health ward and wards for older people.

The trust did many things well and we saw good practice across most services.

The main areas which were positive were as follows:

• Staff were caring, professional and worked to support the patients using the services.
• The trust was supporting patients with their physical health well. People had their health assessed in a comprehensive manner and were being supported to have any health care needs addressed.
• Staff, patients and carers had access to a wide range of opportunities for learning and development, which was helping improve care.
• Patients and carers had the opportunity to be involved in how services were provided and their input was leading to changes.
• The trust was aware of best practice and was using guidance and research to inform their work. Access to psychological therapies was good in the child and adolescent mental health wards and acute wards.
• Patients could access care in their local service when they needed it. Services were designed to be accessible for all patient groups and the trust worked hard to ensure that hard to reach groups were engaged.
• The trust had excellent working relationships with external agencies and stakeholders. An example was the work of the community team for older people working to reduce admissions into the acute trust.
• Patients were cared for in the least restrictive way in the forensic service with patients self-medicating and positive risk management.
• There was strong, effective and visible leadership. Staff knew the trust values and vision and their importance in the work of the trust. There was an effective governance system in place at board level so that the trust knew where action was needed.

However;

The main areas for improvement were:

• Patients were not always having physical observations recorded when they had received medicines for rapid tranquilisation.
• Patients were sometimes being secluded without the checks and safeguards of the MHA code of practice being applied.
• In wards for older people, accommodation was not always being provided in line with same sex guidance.
• Staff were not always recording decisions, and how they had been made in patients’ best interests on older people’s wards.
• Not all staff were able to use the new electronic record system confidently and staff struggled to find records at times.
• Not all staff had completed mandatory training and there were low numbers of staff who were up to date with their basic life support, immediate life support training, MHA and MCA training.
• Not all staff were receiving regular supervision.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

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.

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

• There was effective and timely discharge planning at Meadowbrook and Moorside units. This meant that patients did not have to stay in hospital longer than necessary.

• Physical health checks were in place for all patients. This was achieved by using a physical health intervention tool. Staff were specifically trained in delivering this aspect of care. This meant that patients being admitted to the service had their physical health needs met.

• Risks assessments were in place for all patients. These were regularly reviewed and updated when necessary. This meant that staff were aware of risks and that patients and staff safety was managed well.

• There was effective multidisciplinary team working. A range of professionals had input into patient reviews and other ward meetings. This meant that patient care was holistic and barriers to recovery and discharge were challenged and overcome.

• The psychology provision at the Rivington unit was embedded in the ward culture and was well resourced. There were daily patient sessions available that focussed on relapse prevention and staying well.

• The service had an efficient system in place regarding bed management. Patient admissions were not unnecessarily prolonged and patients were rarely placed out of area. This enabled new patients being admitted to stay in their local area.

• All wards had access to occupational therapy. This meant that patients needing support with independent living skills or other needs could have this support whilst an inpatient.

• The food provided to patients was of good quality and variety. Patients had a choice of healthy meals and dietary or religious requirements were catered for.

• The senior management team were a visible presence on all wards. This meant that patients and staff were aware of whom the managers were and that they were accessible.

However:

• Environmental difficulties in observation/clear lines of view and ligature risks were evident in each ward area. Staff described mitigating environmental risks with increased observation of patients.

• There were inconsistencies in application of the environmental assessment tool used on wards with similar risks and patient populations, particularly the window design which was identified on the trust’s risk register but not in the environmental assessment of risk.Six wards had environmental assessments with action planning in place and three had none. Patients may be exposed to unidentified risks if these tools are not applied consistently over all areas.

• Not all staff had the opportunity to access supervision or appraisal.

• Mandatory training levels were low for basic life support and immediate life support, with three wards with no staff trained in immediate life support. Checks on life support equipment had failed to identify out of date oxygen on two wards. Lack of training in life support and faulty equipment could compromise the safety of patients.

• De-stimulation rooms were used to calm patients on some wards. However, patients were prevented from leaving due to behavioural disturbance. Staff were also not following the checks and safeguards of the MHA Code of Practice.

• Staff were not adequately trained in the MHA or Mental Capacity Act. This meant that patients’ rights could be compromised.

We rated forensic inpatient/secure wards as good because:

• Care and treatment was provided by a multidisciplinary team of staff, which included doctors, nurses and healthcare assistants, occupational therapists, psychologists, social workers and pharmacy.

• Patients were assessed and care plans were developed. Staff understood patients’ needs.

• The findings of the friends and family test showed that people were generally satisfied, except for the availability of activities. Patients were mostly positive about the staff. Patients felt involved in their care plans, but there was limited evidence of this in the records.

• Patients were involved in decisions about the service, which included the recruitment process and the recovery academy. There were regular community meetings where patients could give their views of problems or developments in the service.

• The service routinely reviewed its use of restrictions on patients. This was balanced against the need for security procedures to keep patients and others safe.

• The service provided 25 hours of activity to patients per week, and monitored this target. Patients had access to the Patterdale Centre, which provided activities such as a gym and bike riding. The Edenfield Centre had a branch of the recovery academy, which provided therapy and activity groups, some of which were co-produced with patients. Work opportunities were provided for patient, which included painting and decorating, and car valeting.

• The service used the trust-wide governance structures for monitoring the quality of care and of the service. This included reporting incidents, feedback about complaints, safeguarding and staffing. Ward managers monitored and took action on key performance indicators. These included staffing levels, training, supervision, if recovery care plans were in place, and activities.

• The trust had initiatives where managers could apply for one-off funding to improve their service. This had been used to install a Zen garden, and a new patients’ kitchen.

• The wards had environmental risks, but staff managed these and there was an ongoing programme of refurbishment to remove them. The wards were clean and maintained.

• Staffing levels were monitored, and recruitment was ongoing. There was pressure on staff, but leave and activities were rarely cancelled because there was not enough staff. Staff received regular supervision, training and appraisal.

• Medication was stored correctly.

However:

• Not all the care plans were patient-centred or recovery focused. There was a new electronic records system, and many staff found it difficult to use or find information in it.

• Training in the Mental Health Act and the Mental Capacity Act was limited. There were errors on consent to treatment forms under the Mental Health Act.

• Although staff explained patients’ rights under the Mental Health Act and requested support from independent mental health advocates appropriately, staff did not consistently record this information in individual patient care records.

• Not all eligible staff across the wards we visited had completed mandatory training in basic life support and intensive life support.

• When staff administered rapid tranquilisation, physical health checks were not always completed consistently afterwards which may put patients at risk.

• Staff had not always completed medication records correctly, and there were gaps in charts. There was a process for reporting and learning from medication errors, and nurses worked through a competency process to ensure they were safe to practice.

We rated child and adolescent mental health wards as requires improvement because:

• the wards did not always provide a safe environment, there were often insufficient numbers of staff to provide the care required. These staff had not always been trained in the specific needs of children and young people. When individuals had been assessed as requiring increased levels of support the documentation for the monitoring of this support was not always being completed. This included after patients had been administered additional medication following a period of disturbed behaviour

• staff were not trained in the Mental Health Act (MHA) and Mental Capacity Act (MCA). This meant that recent changes to the MHA code of practice were not understood or brought into practice and staff were not able to demonstrate how they considered the MCA when planning and delivering care

• on Junction 17, two patients told us that staff did not provide emotional support when needed. Three patients said that sometimes certain staff told them to ‘grow up’ and rolled their eyes at them

• staff did not keep a record of complaints resolved locally at ward level. There was limited accessible information available to patients

• monitoring systems in place did not identify when care was not being delivered safely nor did they identify when there was not enough staff and a lack of suitably qualified staff.

However:

• the wards were clean and tidy. Where there were risks of ligature points, action had been taken to reduce the risk. Regular risk assessments were carried out and staff knew when and how to report incidents. Staff had received training in safeguarding, but not at level 3, and knew how to protect patients from abuse

• patients could access psychological therapies. Staff received managerial and clinical supervision and were regularly appraised. Staff regularly communicated with local services and external agencies when planning and delivering care

• staff planned for discharge when patients were first admitted and communicated these plans with other services to ensure adequate support was available for patients. There was a range of food choices to meet patients’ dietary requirements and a range of activities available including at weekends

• most staff were respectful and engaged positively with patients. We observed staff being encouraging and supportive and meaningfully engaging with patients. Patients were involved in the planning of their care and staff held regular meetings to encourage patient feedback

• staff knew who the senior management team were by name and told us that they visited the wards. On Junction 17 staff had implemented the ‘safe wards’ initiative and had participated in the Royal College of Psychiatrists accreditation for in-patient child and adolescent services.

We rated wards for older people with mental health problems as requires improvement because:

• Bollin and Greenway wards did not comply with Department of Health’s guidance on eliminating mixed sex accommodation.

• The layout of the wards did not allow staff clear lines of sight. This risk was not mitigated on any of the wards by the use of mirrors, risk assessments or staff observations. Staff had identified ligature points (places where someone intent on self-harm might tie something to strangle themselves) and took action to remove or minimise risks.

• On all of wards National Institute for Health and Care Excellence (NICE) guidance was not being followed in relation to rapid tranquilisation. On Bollin and Greenway wards staff we spoke to were not aware of the trust policy in relation to physical health monitoring following rapid tranquilisation. On Holly ward one episode rapid tranquilisation had not been logged as an incident as required by the trust policy.

• The staff did not always follow best practice with respect to recording of capacity assessments and best interest decisions. There were issues on all five wards with the recording and reviewing of patients’ rights when detained under the Mental Health Act (MHA). There was a lack of evidence that leave was routinely risk assessed prior to authorisation or that the outcome of any specific period of leave was reviewed consistently. The leaflets provided to patients detailing their rights under the MHA did not include the most up to date contact details for the Care Quality Commission.

• Training levels were poor for the MHA and Mental Capacity Act. This was at 21% at the time of our inspection. Only 60% of staff across the older adult wards had received an annual performance appraisal.

However:

• The wards were clean and tidy and maintained to a high standard.

• There was a sufficient number of staff on the wards to provide people with the care and treatment they required.

• There was good multidisciplinary team working and staff engaged well with community teams as well as external organisations.

• The clinical leadership on the ward was clear and all staff said that they felt supported and listened to. Staff were aware of the trust vision and values and were committed to providing good care in line with this.

We rated mental health crisis services and health-based places of safety as good because:

• Staffing levels within the crisis teams helped ensure people in crisis received safe, appropriate and timely care. Teams had safe working practices and staff held manageable caseloads. Patients' individual risks were assessed and reviewed. Staff acted on adult and children's safeguarding matters. The three health based places of safety provided safe environments to assess patients . S taff learnt lessons following incidents to try and prevent further incidents happening.
• There was very effective multidisciplinary working in the crisis teams and good interagency working with acute hospital staff and the police. There were very good systems in place for ensuring the hospitals’ duties under section 136 were met and very good clinical leadership into the health based place of safety. There was an alcohol worker working at the Trafford RAID service to support intoxicated patients. Nurses worked in police stations to provide professional and intensive support people who regularly presented to the police.
• Patients were treated with dignity and respect. Patients were involved in identifying their crisis support needs and in developing the assessment and intervention tools used in the home based treatment teams.
• Patients were usually seen quickly. Patients’ individual needs were considered and met. There were good complaints processes.
• There were effective local, inter agency and crisis concordat meetings to improve services and patients' crisis experience. Staff were committed to providing high quality care and treatment and teams were managed by experienced and competent clinical leaders. There was a commitment to quality improvement such as improved health based places of safety environments, and improved staffing levels in crisis services.

However

• The rationale for changes in levels of support relating to patients under the Bolton home based treatment teams were not always explicitly recorded.
• It was not always clearly recorded that patients were informed of their rights verbally and in writing whilst in the health based place of safety and patients did not have access to a printed copy of the MHA Code of Practice.
• There were problems across the trust with getting ambulances to take patients to the health based place of safety and there were delays in assessing patients when subject to section 136 including the response of approved mental health professionals at night but where these occurred, delays were beyond the full control of the trust.
• In the home treatment teams, it was not always clearly recorded whether patients were given copies of their crisis care plans.
• There were differing crisis care pathways in each locality and information about each service did not fully inform patients and carers on the services available to them.
• Information on CQC’s role in complaints literature was not up-to-date.

We rated community-based mental health services for adults of working age as good because:

• Staff prioritised keeping people who use the service safe; records we reviewed had comprehensive risk assessments in place.

• Staff had a good understanding of people’s needs and relapse triggers and increased support when needed.

• The trust kept staff safe, staff were aware of and followed the lone worker policy and provided support in pairs where risks necessitated.

• If there was a serious incident, people were supported and offered debriefs. Managers shared learning from incidents amongst teams to reduce the likelihood of reoccurrence.

• Staff received supervision, appraisals and attended regular team meetings; managers disseminated information from senior managers to teams.

• Staff were aware of best practice and guidance and followed this, including offering friends and family groups within the early intervention service to raise awareness of psychosis.

• Teams prioritised physical health, with a physical health lead in each team. Staff facilitated activities to improve health and wellbeing including badminton groups and recovery groups.

• People using the service reported staff were respectful, caring and supportive. Staff had a good knowledge of individual needs and preferences. Interactions observed were positive and respectful of individuals.

• People who use the services had access to advocacy, both independent Mental Health Act advocates (IMHA) and independent Mental Capacity Act advocates (IMCA).

• The community teams provided support in an early evening and at a weekend.

• Staff processed referrals quickly and had a clear eligibility criteria and prioritisation of referrals for assessments.

• Managers had embedded learning from feedback in practice, including informing people who use the services if their worker is temporary.

• Information in relation to mental health conditions and therapies was available in a variety of languages. Joint working took place with community organisations to engage with people from different cultural backgrounds.

• There was a nurse led clinic in Salford to provide a gradual discharge from the community mental health team. People who accessed the clinic talked positively about the support offered.

• Staff reported being valued and feeling supported in their role, by their team and managers. Morale was high within teams and staff enjoyed working for the trust and making a difference in the lives of people they supported.