During our last inspection of the trust between 13 June and 7 July 2022, we carried out an unannounced inspection of three mental health core services provided by this trust because we received information giving us concerns about the safety and quality of the services. We also carried out an announced inspection of the well-led key question for the trust overall.
As a result of significant patient safety concerns related to fire safety and the management of ligature risks we found during the inspection of the acute wards for adults of working age and psychiatric intensive care units, we issued the trust with a Section 29A Warning Notice on the 6 July 2022. We told the trust it was required to make significant improvements by 31 July 2022.
We also issued a further Section 29A Warning Notice to the trust at provider level on 23 September 2022 following the well-led inspection in relation to Regulation 17 (Good governance) and Regulation 18 (Staffing). We told the trust it was required to make significant improvements to staffing on the acute wards for adults of working age, psychiatric intensive care units and forensic wards by 31 December 2022 and significant improvements in relation to governance by the 31 March 2023.
The Commission served the Section 29A Warning Notices because the quality of health care provided required significant improvement in some areas identified during the inspection. The Warning Notices set out a legally set timescale for the provider to become compliant.
Prior to the publication of the inspection report, we suspended all the forensic core service ratings for the trust on 23 September 2022 and the well-led rating for the trust on 22 October 2022. We took this action because of concerns that came to light after we completed our well led inspection.
During a focused inspection at HMP Wymott on 10 and 11 August 2022, we found that the management of medicines was unsafe, resulting in unnecessary risk of harm to patients. We issued the trust with a Section 29A Warning Notice in relation to Regulation 12 (Safe care and treatment). We undertook a follow up inspection at HMP Wymott in November 2022 to follow up on the Warning Notice. Improvements had been made in relation to the Warning Notice however, two breaches of regulation were identified of Regulation 17 (Good governance) and Regulation 18 (Staffing).
Between 4 and 6 October 2022, we carried out a focused inspection at three of the trusts’ community mental health teams for adults of working age to follow up on a Section 29A Warning Notice we had issued to the trust in April 2022 following a focused inspection of two Community Mental Health teams in Manchester. This inspection focused on specific key lines of enquiry in the safe and responsive key questions. We issued a further Section 29A Warning Notice on 4 November 2022 in relation to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). We told the trust it was required to make significant improvements by 4 January 2023.
We undertook a focused inspection of the trusts’ three mental health wards for older people at Woodlands between 16 and 17 November 2022 following whistleblowing concerns we received about the unit. The inspection was focused on the safe key question. We subsequently issued to the trust a Section 29A Warning Notice in relation to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). We told the trust it was required to make significant improvements by 30 March 2023.
Following our last inspection, the trust has faced significant, unprecedented challenges, especially in relation to the external scrutiny the trust has experienced since then. This scrutiny followed a number of serious safeguarding concerns and allegations which have come to light since our last inspection in relation to the Edenfield Centre which are subject to an on-going police investigation and further inspection activity we have undertaken which resulted in the above section 29A Warning Notices being issued to the trust.
At the end of November 2022, the trust were placed into Segment 4 of the NHS Oversight Framework which meant it entered the national Recovery Support Programme and was in receipt of mandated intensive support. A NHSE System Improvement Board was set up to support the delivery of the programme which was chaired by the Regional Director for Strategy and Transformation for NHS North West, with representatives from the trust, Greater Manchester Integrated Care Partnership, Care Quality Commission, Health Education England, Bury Local Authority (as safeguarding lead), General Medical Council and the Nursing and Midwifery Council.
The trust had declared a critical incident following the incidents at the Edenfield Centre and put in place a number of immediate actions to ensure the safety of patients and address the most urgent quality and safety issues. It had also developed a draft Improvement Plan which included a set of longer-term ambitions. The draft Improvement Plan was approved by the trust’s board on 31 October 2022 and System Improvement Board on 1 November 2022. The trust obtained public views on the plan during February and March 2023. Following final approval, the Improvement Plan will be monitored through the System Improvement Board.
On 22 November 2022, NHS England North West wrote to Greater Manchester Mental Health NHS Foundation Trust, to inform the trust it would be commissioning an Independent Review.
On the 6 February 2023, NHSE announced they had appointed a chair to undertake this independent review. It will focus primarily on the Edenfield Centre, as well as the trust’s other services, and will include a review of ward to board escalation, and oversight of patient safety and culture. The review is scheduled to conclude by 30 September 2023.
During this inspection, we inspected the following three mental health core services:
- acute wards for adults of working age and psychiatric intensive care units
- forensic inpatients/secure wards
- community mental health services for adults of working age.
The inspections were focused on checking the trust's progress in relation to the two Section 29A Warning Notices we had issued as a result of our inspection of the trust between 13 June and 7 July 2022 and the Section 29A Warning Notice issued on the 4 November 2022 regarding the community-based mental health services for adults of working age.
We also carried out an announced inspection of the well-led key question for the trust overall.
We did not inspect the following seven other core services at this inspection:
- wards for older people with mental health problems
- mental health crisis services and health-based places of safety
- specialist community mental health services for children and young people
- long stay/rehabilitation mental health wards for working age adults
- child and adolescent mental health wards
- community-based mental health services for older people
- substance misuse services.
Following the inspection, we took enforcement action against the trust. We served the trust with a Section 29A Warning Notice at provider level following the well led inspection. The Commission served a Section 29A Warning Notice because the quality of health care provided required significant improvement in some areas identified during the inspection. The Warning Notice set out a legally set timescale for the provider to become compliant. A further inspection will be carried out to ensure action has been taken to comply with the Warning Notice. We will continue to monitor the progress of other areas of improvement to these services and will re-inspect them as appropriate.
Our rating of services went down. We rated them as inadequate because:
- We rated the trust well led (leadership) as inadequate.
- One of the trust’s ten core services was rated as inadequate and three were rated as requires improvement. In rating the trust, we took into account the current ratings of the seven services not inspected this time.
- We rated the trust’s core services as inadequate overall for safe. The assessment of well led gave us some significant concerns about the assurance of the quality and safety of the trusts’ provision of services across the board.
- We rated the trust’s core services as requires improvement for caring, effective, responsive and well led overall.
- We rated caring as requires improvement as we found quite profound concerns in relation to poor governance and lack of oversight across the board.
- The trust had experienced significant changes at board level which had de-stabilised the board. These changes meant we were not assured that all senior leaders had the necessary experience, knowledge, and capacity to lead effectively.
- Although there was some recognition of individual strengths in different leaders, there were significant concerns about leadership capacity and capability at board level, and the ability of the board to respond at pace to key areas of risk and effectively implement and embed the improvement plan.
- From board to ward, the trust had been operationally led and dominated to the detriment of the quality agenda.
- Leaders did not have sufficient oversight of services at point of delivery, and they did not respond effectively when staff raised concerns about safety and quality issues which impacted on patient care and service delivery.
- Risks issues were not always managed and acted upon by leaders in an effective or timely manner.
- We had significant concerns about fire safety in the acute, psychiatric intensive care and forensic wards. Leaders had not supported front-line staff to implement the trusts’ no smoking policy and there was significant evidence of patients smoking across most of the wards. Some doors on the acute wards were not fit for purpose to prevent the spread of a fire as they had gaps in the top. This was an issue we raised during our last inspection.
- Ligature audits were poor in the acute, psychiatric intensive care wards because they did not identify all risks or effectively mitigate these. This was an issue we raised during our last inspection.
- Audits were not owned locally and were not effectively used to drive improvement.
- Leaders did not always identify and manage priorities in an effective and timely way.
- The trust did not always collect reliable data. IT systems were not always integrated to ensure provision of timely data and information and there was a reliance on manual data collection. The incident reporting system was out of date. This meant data could not be easily analysed accurately to identify themes or trends to improve performance. The board and leaders had lacked curiosity and had accepted reassurance from data rather than the assurance needed.
- The trust governance systems and processes did not ensure that all services provided safe and good quality care. The trust had recently reviewed the governance arrangements and implemented a new structure however; this was embryonic, and it was too early to determine if this would operate effectively.
- Dormitory accommodation remained in place in some services, and this did not protect the dignity and privacy of patients.
- Whilst the trust had systems in place to identify learning from incidents, deaths and complaints; these were not always effective or delivered in a timely way, which delayed any required improvements to patient care.
- Staff at all levels reported the culture had significantly improved over the past few months and they felt able to speak up. Clinical staff felt able to raise concerns and were confident that their voices would be heard. All staff we spoke with knew about the freedom to speak up guardian.
- Staff felt supported by their immediate managers however, the trust still had work to do.
- Leaders were aware of the improvements which needed to be made which were incorporated into the improvement plan and accurately reflected within the board assurance framework.
- Within the community based mental health services for adults, actions had been taken to meet the Warning Notice we had previously issued. There were improvements to medicines management, improved oversight of the waiting lists and safeguarding referrals. A full-time senior pharmacist had been deployed within the Manchester community teams and this new post has been instrumental in the immediate and ongoing improvement of the service.
- All staff were able to register and access the maintenance reporting system to support the self-reporting of ad-hoc repairs and maintenance. The trust reported that recent system changes had made it quicker and easier for staff to report where maintenance repairs were required.
- Within the forensic wards, at our last inspection we identified concerns about the management of ligature risks and clinic rooms which had now improved.
- Leaders continued to work well with stakeholders in continuing to drive forward the community transformation programme, although this was work in progress.
- The trust had an established strategy to engage with carers and service users which was co-produced following extensive engagement with service users, carers, families, staff and external agencies.
- The trust was on track in the delivery of its estate strategy to remove the use of dormitory accommodation with the Park House new build project. Work was also well underway to refurbish the seclusion suites across the trust and several of the forensic wards had been refurnished.
- The trust had implemented electronic care records across all in-patient services.
- The trust had a planned approach to taking part in national audits and research.
- The trust had a track record of strong financial governance, and robust data security and protection with substantial audit opinions from both external and internal auditors.
How we carried out the inspection
During this inspection we;
- talked with 69 patients and nine carers about their experience of using these services
- arranged for a bespoke survey to be sent to all staff within the trust
- visited all 10 forensic inpatient / secure wards
- visited all 22 acute wards and psychiatric intensive care units
- visited three community-based mental health teams for adults of working age
- attended a number of clinical based meetings such as safety huddle meetings, smoking free meeting and handover meetings
- spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, advocates, managers, chief pharmacist, executive directors, non-executive directors and members of the senior leadership team
- reviewed a number of records relating to the care and treatment of patients
- reviewed a variety of documents relating to the management of the trust and the services it delivers
- held focus groups with staff side, governors, medical staff / consultants, non-executive directors, chairs of the staff equality networks and associate directors within the five care groups
- reviewed a variety of information we already held about the trust
- sought feedback from a number of the trust’s stakeholders.
What people who use the service say
Acute wards for adults of working age and psychiatric intensive care units
Patients provided mixed feedback regarding their treatment by staff. A large majority were positive regarding the care they received and their interactions with the staff, stating that they felt safe and well supported. However, some were negative and did not appreciate some of the blanket restrictions in place. They felt unsafe at times and that some night staff were disrespectful in their attitudes or behaviour towards them.
Forensic inpatient or secure wards
Most patients said that staff were respectful and polite. One said that staff were rude but did not give any examples.
Some patients had copies of their care plans, but some told us they didn’t want them. They understood their care plans and had been involved in developing them and making decisions about their care. They said that physical health issues were addressed, by contacting the GP, but one person said staff would do this for them and they preferred to do it themselves due to confidentiality.
Some patients described their care pathway and how they were working towards lower levels of security and discharge.
Patients had access to the advocacy service, and opportunities to give feedback about the service.
Staff encouraged patients to take part in activities on the wards that were relevant to their needs. Patients had access to education at an adult learning centre and local college. They told us that at the recovery academy, they could learn information technology skills, budgeting, languages and develop skills such as reading.
Staff supported them to build and continue their relationships with their families and friends.
Patients said they felt confident to raise concerns or complaints and told us they knew how to escalate their concerns.
One patient told us that staff had installed a blackout screen to protect against the bright sunlight but, as it went all the way to the floor, patients could not see out. We raised this with managers who agreed to address it.
Prior to the pandemic, patients had access to a bus service, which helped facilitate their leave from the unit. This stopped during the pandemic but had not been reinstated. Patients told us that this meant they had to walk from the unit to leave the site, which was a long distance, or use taxis. We raised this with senior managers, who agreed to investigate with a view to reinstating the service as soon as possible.
Patients told us how the events of 2022 had impacted on them. Some reported that things had improved, but the changes were unsettling.
One patient’s relative told us they had been waiting to meet with a doctor to forward plan and discuss discharge, but no meeting had been arranged yet.
Community-based mental health services for adults of working age
Because of the focused nature of this inspection in following up specific issues, we did not attend any home visits or appointments.