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.
- 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.