24 - 27 March 2015
During a routine inspection
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 found that the provider was performing at a level which led to a rating of Requires Improvement.
Manchester Mental Health and Social Care NHS Trust provided mental health services and substance misuse services to adults and older people across the city of Manchester. We found that the trust was providing services that required improvements to ensure it better met the needs of the people that it served.
The trust was not always providing a safe service for people across some of the services it provided. This included the older people’s wards, acute wards and PICU, community based services for older people and the crisis services for adults of working age.
Environmental risks on the SAFIRE unit had not been fully assessed or mitigated. Due to several serious untoward incidents, risks were mitigated with an overly restrictive approach with restrictions not reviewed periodically to ensure they were appropriate to individual patients. There were medicine management issues on the community older people’s services and in the rehabilitation service which amounted to regulatory breaches.
The trust was a low reporter of incidents; there were delays in notifications of incidents and delays in investigating incidents through the national incident reporting and learning system. The trust had been escalated to NHS England’s risk summit for a significant number of months due to several issues relating to patient safety including incident reporting, commissioner assurances and safeguarding arrangements. Whilst some recent improvements were noted in some of these areas, for example, in the safeguarding arrangements; NHS England continued to oversee the trust until sustained improvements were seen.
Risks were not always fully assessed or reviewed by staff. We have issued requirement actions in relation to the safety issues and management of risks and have asked for an action plan to receive assurances that these risks would be addressed.
The trust was not always providing an effective service for people across some of the services it provided. This included the older peoples’ wards, acute wards and PICU; community based services for adults, and long stay rehabilitation wards.
Care plans were not always holistic and person centred especially on the acute wards. There was limited evidence of coherent and consistent care pathways, outcome measures and performance data in community adult teams. This meant that there was not a strong recovery focus evident in community mental health teams and patients were being retained on the caseload of teams longer than was clinically required.
Staff within certain services had not received recent clinical or management supervision and the take up of appraisals remained an issue in some services despite efforts by the trust to address this issue. We saw limited evidence of best practice, except within perinatal services
There was no or limited psychological input for patients especially within in-patient areas. There was inconsistent medical cover at Anson Road which was impacting on patient care. Roles and responsibilities between the acute and mental health trust staff were not clearly defined to ensure effective care when patients received care jointly, such as within the health based place of safety and psychiatric liaison services.
We found systemic issues with the Mental Health Act (MHA) documentation. MHA documentation was not always completed correctly for patients on some wards to assure us that people were being supported to understand their rights. Patients’ medication for treatment for mental disorder was not always properly authorized. Appropriate checks were not always taking place to ensure that patients’ detention was legally supported by the appropriate documentation, for example medical scrutiny checks were not routinely taking place. Action was not always taken to ensure that renewals of detention occurred within appropriate timescales. The operation of the Act was particularly poor on the older people’s service. We saw that appropriate action had not been taken or embedded following our previous Mental Health Act monitoring visits across the trust as we found the same issues being repeated or not resolved.
Where patients were subject to a deprivation of liberty safeguards (DoLS) authorisations pending agreement from the local authority were not kept under review or updated as needed and decisions about time limitations were not communicated. We weren’t routinely being notified of deprivation of liberty safeguards (DoLS) applications once an outcome was known.
We saw that overall the trust was providing a caring service for people across all core locations. Throughout the inspection we saw examples of staff treating people with kindness, dignity and compassion. The feedback received from people who used services and their visitors was generally positive about their experiences of the care and treatment provided by the trust.
The trust was not always responsive to people’s needs across some of the services it provided, in particular the community based services for adults and the long stay rehabilitation services. There were a number of blocks within the system so that people were not always receiving the right care at the right time, for example crisis teams could not pass people through to community mental health teams (CMHTs), there were delays in receiving CMHT support and there were significant delayed discharge arrangements. There were a number of waits in the psychiatric liaison service and assessing people brought in on a section 136 at the health based place of safety emergency department. Some of these involved waits of beyond 12 hours as they related to patients under 18 or with a learning disability. Whilst some of the waits were beyond the full control of the trust, staff had failed to follow agreed escalation procedures to limit the delays in at least one case. The links between the acute and community adult teams needed strengthening to ensure improved communication and better patient flows. Patient activities were cancelled on the acute wards. There was good management of patient complaints.
Overall the trust was not as well led as it could be. Lines of communication from the board and senior managers to frontline services were not always effective. Staff morale was low. Staff felt well supported by local managers but did not feel that the trust senior managers were proactively addressing the current and future challenges of the trust. We saw some recent examples where board members spent time within services to understand the challenges faced and were aiming to engage with front line staff including through initiatives such as commissioning an external review into culture and initiatives such as ‘listening into action’. However these initiatives had limited reach into front line services.
The trust had a research and academic function with research and teaching clinicians also involved in the operational delivery of clinical services. However we did not see evidence of the research and academic function being fully utilised or fully embedded into the work and practices across the trust to proactively improve services and work towards best practice.
The future of the trust was uncertain at the time of the inspection. A process was underway to determine the longer term position of the trust with support from the trust development authority (TDA). This was continuing to cause difficulties for the front line staff. The trust had utilised a number of engagement methods to try and manage this uncertainty. However a number of staff across services told us that they did not feel that these methods provided meaningful engagement to assure them that this uncertainty was being managed well.
Representatives from the local clinical commissioning groups told us that the trust did not engage positively with them and did not involve the local communities or other organisations in how services were planned or designed. The trust also told us that the relationship between them and the commissioning groups was, at times, a difficult one. Despite the efforts of the trust development authority to improve the professional relations between the trust and the local clinical commissioning groups, there continued to be engagement issues between these organisations. We were concerned that this might adversely affect the provision of high quality patient care but recognised that both parties worked to ensure there was no detriment to quality care.
The trust was in the process of an option appraisal for its future direction and strategic intention following its removal from the foundation trust process and future commissioning decisions. The chair of the trust board acknowledged that there were gaps within the non-executive director experience, including managing complex healthcare organisations and mental health experience capability. On occasions, the board had received reassurances from the executive team rather than seeking full assurances themselves when significant decisions were made, for example when changes to older people’s services were made. Staff understood the vision and values but did not always understand how that related to them at a more local level or in terms of the future challenges the trust faced.
The trust needs to take steps to improve the quality of their services and we found that they were currently in breach of regulations. We have issued requirement notices in relation to several areas and have asked for an action plan to receive assurances that these risks would be addressed. We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.