Greater Manchester Mental Health NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There were sufficient staff to support patients, however staff did not always have the required skills, and training to support people's care. Staff had not always received an induction before working on a ward and training and supervision levels were low on some wards. The training compliance levels for some courses were low. Wards were not always clean or well maintained and fire risks were not managed well. Fire emergency procedures were not up to date and staff had not completed actions to reduce the identified fire risks. Patients were smoking on the wards, there had been several fires on the premises and regular fire drills had not taken place. Staff had not always followed systems and processes to prescribe and administer medicines safely. Patients taking high-risk medicines were not always monitored in line with their care plans. Medicines administration was not always recorded accurately and we found 1 patient who was taking an incorrect dose of medication. However, staff administered medicines in a person-centered manner and supported patients to understand the medicines they were taking. Staff understood how to protect patients from abuse and had received appropriate training, however patients did not always feel safe on the wards. Risk assessments were not always completed within established timescales and patient involvement in risk management was poor. Staff did not always have time to read risk assessments. During our assessment of this key question, we found the following concerns which led to breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014: the management of staffing resulting in a breach of regulation 18; the management of medicines resulting in a breach of regulation 12; the management of risk resulting in a breach of regulation 12 and the management of the environment which resulted in a breach of regulation 15. You can find more details of our concerns in the evidence category findings below.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all patients felt they could raise concerns and some patients felt they were not always listened to. We reviewed patients’ meetings and saw evidence of patients raising concerns. However, several of these concerns had been raised repeatedly and there was not always evidence of action being taken in response to the concerns raised.

Wards lacked a culture of safety, for example not all staff had received an induction, fire drills had not taken place regularly and staff told us they found it difficult to manage smoking on wards. Staff told us they received debriefs and most staff felt they were able to raise concerns. Some staff told us they received reflective practice.

There was a standard operating procedure in place for managing patient safety incidents which was in date and contained relevant guidance for staff. Managers investigated incidents and there was some evidence they disseminated learning amongst staff via learning events, briefings, and newsletters. However, not all incidents were investigated thoroughly. We reviewed several incident reports which lacked detail and did not contain actions to help prevent recurrence of the incident. We also reviewed a learning document which had been shared with staff following an incident we witnessed whilst on inspection and found that it was not fully accurate and lacked key details relevant to the incident.

Carers did not always receive information about how to support their loved ones whilst on home leave, when they needed it. Patients were being discharged on a Friday; this was causing challenges regarding them obtaining financial support to help them pay for basic necessities. This was raised at patient’s meetings and raised some concerns about the discharge process. Some patients felt they were not supported consistently due to high numbers of bank and agency staff who did not know them well.

There were daily meetings to identify barriers to discharge. However, some of the actions required to facilitate safe discharge did not always take place in a timely way and key referrals sometimes took place following patient discharge. Staff mostly worked with other agencies to facilitate discharge including housing providers, occupational therapy staff and community teams. Staff told us that thorough handovers and debriefs took place to ensure information was shared about patients. However, staff told us they did not always have time to read patients risk assessments and care plans.

Feedback received from partners, concerned the safety of the ward and challenges with communication, particularly in relation to safeguarding activity. Partners also shared concerns about policies and standard operating procedures not being followed and concerns about treatment decisions not being followed or initiated. There were also concerns about evidencing a trauma informed approach and concerns around risk management.

Discharge meetings took place to identify barriers to patients discharge, however the reasons for discharge were not always clear and staff had not fully completed all discharge records. Audits showed there was sometimes a lack of detail in discharge planning, discharge plans sometimes lacked patient’s views and were not always shared with the patient. Systems to monitor patient transitions were not consistent and varied between wards and locations.

Not all patients felt safe on the wards. Patients told us about assaults that took place on the wards and told us staff did not always intervene during incidents of aggression.

Staff understood how to safeguard patients and knew who to go to, to raise a safeguarding concern. There was evidence of staff raising safeguarding concerns in patient files, and staff shared safeguarding concerns in handover meetings.

We completed 17 Short Observational Framework for Inspection Observations (SOFIs) and observed that staff did not always intervene when patients became aggressive or behaved in a way that could make others uncomfortable, such as presenting with disinhibited behaviour.

Safeguarding policies for children and adults were in place and up to date and staff had received adult and children safeguarding training at a level appropriate to the needs of the service. Minutes from meetings contained evidence that managers had considered safeguarding concerns during governance meetings. However, during our inspection, we found that staff did not always adhere to safeguarding policies and procedures.

Patients were not always involved in the development of their care plan and risk assessment and a number of patients told us they were unaware they had a care plan. Patients told us they had not always had access to 1-1 sessions. Most carers told us they were not involved in the development of their loved one’s care plans and risk assessments and although some patients did not provide consent to share information, carers were unaware of why they were not involved in their loved one’s care plan.

Staff told us that they did not always have time to read patient’s risk assessment and that they identified risks by reading the handovers and patient’s observation notes. Handovers varied between wards and did not always contain all the relevant information to support patients effectively. For example, handover records were not completed in full on Juniper ward or Poplar ward.

We reviewed 61 care records. Staff completed risk assessments for patients. These were meant to be updated weekly but this was not always the case. Risk assessments varied in quality; some were comprehensive, whilst other lacked detail about how to manage identified risks. We found incidents that were not considered within risk assessments. Clinical audits of staff records showed that patient involvement in their care plans was limited. Patients were also not always involved in developing their risk assessments. This reflected our reviews of care records.

Some patients had concerns about the environment, such as the management of fire risks which made them feel unsafe. Patients told us repairs sometimes took a long time and we saw that patients on one ward had repeatedly raised broken items such as a television which had been broken for a number of weeks. Patients told us there was an unpleasant smell on one of the wards and raised concerns about their being a lack of quiet space and privacy on some of the wards.

Patients were smoking on the premises which put others at risk due to health-related problems and fires. Staff told us fire drills were not conducted regularly. Some wards were in a poor state of repair and staff told us that damage to the environment was not always fixed in a timely manner. During incidents of drug use on the wards, staff occasionally stored illicit substances they had removed from patients, in the controlled drugs cabinet which was an inappropriate place to store these.

Some wards were poorly maintained, for example there was a boarded up window on Medlock ward, unpainted plaster on parts of the walls on Oak ward and cracked paint and chipped frames on Irwell ward. There were fire hazards relating to storage on some wards and the oxygen cylinders were not safely attached to the wall on several wards. Patients were smoking on wards and some wards had had fire incidents. We observed paper towel pushed into a smoke detector on one of the wards. Not all staff were aware of fire evacuation procedures. During our inspection, the fire alarm was activated on one of the wards. The response was uncoordinated and confused, staff did not appear to know how to respond to the alarm and no-one took a lead in managing the situation. Staff had not always checked equipment according to the schedules set, this included gaps in clinic room temperature checks and emergency equipment. Staff had not always recorded the temperatures for the medicine’s fridges and the temperature for the fridge on Medlock ward exceeded 8 degrees which had not been escalated. Staff were not always aware of the process for calibrating equipment. Wards were not always clean. There were several dirty bathrooms and there was blood on the wall on Chaucer ward. There were dirty dormitory curtains in one location and no clear process was in place for washing these. The sharps bin was overfull on one ward. There was an unpleasant smell on some of the wards. We also saw blue tack, which was a restricted item, in use on some of the wards.

Staff had not always completed health and safety documentation. Over half of the health and safety inspections for the premises were a least 3 years out of date. Those that were in date identified a range of concerns similar to those we identified during our inspection, including damaged flooring and trip hazards. Fire risk assessments had been completed, however actions from fire risk assessments had not been actioned and had been identified as issues on subsequent assessments. This was particularly concerning due to a number of fire incidents on wards and due to patients still smoking on the premises. Fire emergency procedures were out of date at several locations. Wards had up-to-date ligature risk assessments, although these were not always present on the wards and they did not always include how risks could be mitigated. Maintenance jobs relating to ligature risks had not always been completed in a timely manner. Not all staff were aware of ligature risks, for example we found a shower curtain that was a fixed ligature point which staff were unaware of.

Patients gave mixed feedback about staff and this varied between wards. They told us that some staff were great, whilst others were not caring and also shared that there were sometimes not enough staff to facilitate leave or one to one sessions. Patients told us some staff did not intervene in incidents or respond when they needed help. Patients also told us that there were a high number of bank staff, particularly at night, who did not know them well and that staff occasionally fell asleep on observations. Some patients told us that staff did not work together well and disagreed over who should be carrying out observations and supporting leave. Most carers provided positive feedback about staff. They told us they were great and felt they really cared about their loved ones.

Staff mostly told us that staffing levels were good, although there were still challenges on some of the wards which meant that staff could not always provide one to one support or support patient’s leave. This supported what patients told us. Staff also told us that the staff team was supportive and that they received debriefs following incidents. Not all wards had a full complement of staff, for example, some lacked activity coordinators, occupational therapists or a psychologist. Staff also told us they conducted back-to-back observations without breaks. We had concerns about the skill mix on some of the wards. There was not always enough staff trained in the accredited approach to management of violence and aggression to respond to incidents safely. Staff felt that agency staff did not always engage with patients. Agency staff had not always received an induction prior to working on the ward.

We noted that staff did not always engage with or respond to patients using the service. We observed staff talking amongst themselves and not intervening when patients needed support. Although there was mostly enough staff, they did not always work together to meet individual needs. Staff did not always carry out observations as prescribed, for example we noted gaps in observations on Redwood ward and Brook ward. We also noted that some staff were carrying out observations at predictable times, which increased the risk of those patients who were at risk of self harming.

There were high levels of non-substantive staff at the trust. For example, the average use of bank staff across all wards in the 6 months prior to our inspection was 84.6% and the average agency use was 10.9%. Not all agency staff had completed an induction prior to working on the wards. We had concerns about the skill mix on some of the wards and the impact this has on overall safety. This appeared to be an issue particularly at night when there were higher numbers of bank and agency staff. Although overall training levels were high, some wards had low levels of training compliance, for example Brook ward was 43% compliant, Medlock ward was 33%, compliant and Irwell ward 56% compliant. Not all staff were trained in the accredited approach to management of violence and aggression and this sometimes impacted on staff carrying out restraints. For example, 59% of staff on Mulberry and 59% of staff on Laurel ward had received this training. In addition, 19% of agency staff had completed the accredited approach to management of violence and aggression training. There were insufficient staff who had completed Immediate Life Support training on some wards. Although some wards were 100% compliant other wards had low compliance levels, for example Brook ward was 42% compliant and Priestners ward was 40% compliant. Managers held meetings to review the skill mix for the wards and moved staff around to try and improve this, however some wards were still left with low levels of staff who had completed this training. Supervision compliance was 73% overall, however some wards had low compliance rates, for example Mulberry had a 27% compliance rate and Irwell had 42% compliance rate. Most staff had received an appraisal however, only 39% of staff on Priestners ward and 62% on redwood ward had received an appraisal.

Some of the patients we spoke with raised concerns about the cleanliness of the wards, particularly in relation to the bathrooms and dormitories. This was corroborated by our observations during the inspection.

Staff told us that they washed their hands to prevent infection and that personal protective equipment was available, however we observed areas on some of the wards where this was not the case. Some staff felt there were insufficient staff to clean the ward.

We observed that some wards were not clean. For example, we observed dirty toilets and sinks and poorly maintained bathrooms, on Chaucer ward, Keats ward and Eagleton ward, a staircase leading to the garden on Redwood ward which was dirty and areas of some wards were stained and difficult to clean. We observed gaps in cleaning checklists. We also observed that cleaning records were not always accurate. Staff had not always cleaned medical equipment as regularly as prescribed. The sharps bin on Mulberry ward was overfull and a syringe had not been disposed of properly and was protruding from the bin. Staff were not always using anti-bacterial hand gel and this was not always available. Not all staff were bare below the elbow. On some of the wards, personal protective equipment such as gloves and aprons were not available at the personal protective equipment dispensers.

We noted there were gaps in cleaning records and there was a lack of oversight of these. The Trust had an infection control policy in place although this was not always followed. Staff had completed infection prevention training and compliance levels were high.

Patients understood their medicines and most felt involved in medicines reviews through multi-disciplinary team meetings. When we reviewed patients’ records, we found that they were not always involved when making decisions about their treatment. We saw records of patients who had capacity to consent to treatment but had been prescribed rapid tranquilisation. There was no evidence that these patients had consented to this form of treatment. We saw one patient who was ready for discharge who had not been supported to self-administer their medicines to ensure this was safe.

Staff reviewed patient’s medicines regularly as part of the multidisciplinary meeting and provided specific advice to patients and carers about their medicines. The pharmacy service had pharmacists currently working across all wards. Staff were able to maintain a limited service and they were valued by staff on the wards.

Observations of staff administering medicines to patients showed this was carried out in a person-centred manner whilst treating the patient with dignity. However, we observed issues with some of the clinic rooms. The British National Formulary which provides prescribing guidance to staff was out of date on some of the wards at Park House. Clinic room temperatures, and emergency equipment checks were not always completed and the medicine’s fridge on one ward exceeded the maximum required fridge temperature and there had been no escalation of this. We saw gaps in medicines administration records which had not been identified by ward staff. We were told that some of these gaps were due to agency staff who had no access to the system and were therefore completing paper records. This meant there was a risk that patients did not receive their medicines as prescribed or risk of duplication. Staff did not always follow the trust policy and national guidance when rapid tranquilisation was administered. Physical observations were not always carried out appropriately. This meant that adverse effects to the medicine were not monitored placing patients at increased risk. This had been identified by a trust audit carried out in March 2023, however there were no actions or recommendations following this and no further audits conducted. This demonstrated a lack of oversight of rapid tranquilisation usage and compliance against policy. The trust had an electronic prescribing and medicines administration system in place. We found that staff did not always accurately record what medicine they had administered to patients. For example, the route of administration of a medicine was found to be incorrect on seven occasions, and this had not been identified by the service. We saw that records for 2 patients were incorrectly noted as self-administering their medicines when they were out of the service.

Monitoring for high-risk medicines was not always carried out in line with patient’s care plans. There were several patients who were diabetic who were not monitored in line with their diabetic care plan. One patient was not taking the correct prescribed dose and another patient did not have their ketones monitored in line with their diabetic care plan when their blood glucose was out of range. 6 patients at risk of constipation did not have bowel movements monitored as detailed in their care plan. All medicines were prescribed within national guidance and as required medicines clearly stated indications and maximum doses. However, care plans lacked patient centred information to guide staff when patients were prescribed more than one Pro Re Nata (as required) medicine for the same indication. Controlled drugs were stored and checked in line with the provider’s policy. The Mental Health Act forms were not always available to review and we found that on several occasions the forms did not accurately reflect the medicine being prescribed and administered. This meant that these medicines had not been legally authorised. There were no audit processes in place to ensure medicines were prescribed and administered correctly against the Mental Health Act forms. Staff reviewed the effects of each patient’s medicines on their physical health according to guidance, but regular monitoring was not always in place. The appropriate monitoring sheets for 5 patients receiving High Dose Antipsychotic Treatment (HDAT), had not been completed to ensure correct physical monitoring had taken place. The rationale for continuing with High Dose Antipsychotic Treatment prescribing was not always recorded as part of the multi-disciplinary team review. There were variable rates of medicines training completed within the service, ranging from 45-100%, prescribing and administration training completion rates ranged from 36-100%.