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

We assessed a total of 4 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Our rating for this key question is requires improvement. We identified 2 breaches of regulation in relation to safe care and treatment and premises and equipment. There was inconsistent recording within patient risk assessment documentation including the safety plans and risk management plans. Risk assessment records did not always reflect recent incidents or specific issues for patients. There were fire safety policies in place however there were gaps in fire safety checks and ligature risk tools used. We toured the environments of all the wards and identified concerns regarding damaged furniture and environments, along with potential infection prevention and control issues. There were effective systems and processes to protect people from abuse and neglect. However, these were not always applied. Mental Capacity Act assessments were not always completed. Staff had not received sexual safety training. Staff managed mixed sex wards appropriately and in line with guidance.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients reported feeling safe on the wards and that they felt that they could raise any concerns with staff or managers. Patients were mostly aware of how to raise a complaint and described that they would feel confident in doing so. Patients reported that they had mostly not experienced violence or aggression whilst on the wards. Carers and family members felt their relatives were safe and had not experienced direct aggression towards them. Where there were isolated incidents of aggression these were dealt with quickly and appropriately by staff. Staff worked with carers to check and ensure their relatives felt safe. If carers and relatives had concerns about safety, several said they felt able to raise this with any member of staff confident that these would be acted on. Relatives felt listened to when they shared knowledge of risks, however only one relative understood that they had been involved in their relative’s risk assessment plan.

Managers could describe how safeguarding was managed on the wards and how any potential issues were escalated. Managers and staff were aware of who to contact if they needed any guidance or advice in relation to safeguarding. Managers reported that relationships with local safeguarding partners were generally positive. Managers could describe the current open and ongoing safeguarding issues on their wards.

We observed that on some wards, the approach to safeguarding was inconsistent. At Wentworth House, there were issues with how incidents were being managed between patients, in particular that safeguarding concerns were not always documented in care plans and handovers. One of the patients spoken with described feeling targeted within the service and stated that they stayed in their room to manage that. It was identified that there was a cultural approach of sharing things verbally rather than recording these in the records. For another patient, there was a requirement of two staff to be on observations although there was no reference or record of this in their records or handover. In a different patient’s care plan, there was no reference to safeguarding and vulnerability. A safeguarding alert had been raised on 18 March 2024. There was a lack of follow up documented in daily notes by the multidisciplinary team who had agreed to discuss this verbally with the patient.

There were effective systems and processes to protect people from abuse and neglect. However, these were not consistent across the wards. Safeguarding incidents had been identified and referred as needed. Safeguarding policies and processes were detailed, comprehensive and accessible to staff and there were effective systems to share learning and safety updates. There was a visiting policy which ensured people’s rights were upheld whilst safeguarding them from harm. Staff received training in safeguarding adults and children and were also undertaking training on self-neglect. Staff training compliance was 97% for safeguarding adults' level 2 and 93% for safeguarding adults' level 3. Level 2 safeguarding children was 99% compliant and level 3 safeguarding children was 93%. Staff had access to Duty of Candour online and face to face training. However, staff within the rehabilitation wards had not received sexual safety training. A physical intervention policy was in place which included principles of safe, ethical, and legal practices. It also addressed the need to involve patients and or advocate in any care planning or risk assessment relating to the use of physical interventions.

Patients felt safe on the wards and reported that they had mostly not experienced any violence or aggression. Patients stated that they had not been restrained whilst on the wards. Patients generally did not raise any concerns about restrictions being placed on them. Carers and family members spoke about informing staff of previous and current risks and they believed these were considered in planning care, leave from hospital, and discharge. Several family members described staff taking time to involve them as carers in care and safety plans. Carers felt their knowledge of a relative’s mental illness and experiences prior to hospital admission was valued and valuable information was shared. Most carers attended ward meetings regularly in which they felt included and listened to. However, some family members commented that they would have liked greater involvement. Managers reported that they completed blanket restriction registers that considered any potential blanket restrictions on their wards. The trust had recently implemented new risk assessment documentation along with a new handover document across all inpatient services. The wards visited were in the process of implementing these. Managers and staff noted that there had been many significant changes in a relatively short space of time which had increased pressure on staff. Managers were aware of these pressures on staff and had tried to manage this to ensure that staff were not overwhelmed by the changes at once. Managers were aware of these pressures on staff and had tried to manage this to ensure that staff were not overwhelmed by the changes at once. Managers did note that the new risk assessment and handover forms had been designed and implemented and was standard across the trust and not specifically for rehabilitation wards. Managers recognised the reasons for the changes and advised that they felt they could provide feedback to senior management about the new processes.

Managers and staff reported low usage of physical restraint across the locations. Managers were confident that staff would only use restraint where necessary and that staff could de-escalate incidents before requiring the use of restraint. We reviewed 31 patient records including the patient risk assessments and plans. It was not always clear if or how patients were involved in managing their own risks within these records. We also observed inconsistent recording of patient involvement in managing their risks. In some of the records, we saw that staff had ticked boxes on the patient record to state that the patient had been involved however there was no detail or information about how staff had involved the patient. Managers noted that patients did not always wish to be involved in their risk assessments, but that staff would be expected to have discussions about risks in patient one-to-one sessions. The wards had blanket restrictions registers where staff and managers had considered and reviewed any blanket restrictions that may be in place on the wards. It was not clear how patients were involved in this process although they could attend community meetings where they were given the opportunity to raise any concerns or complaints. When reviewing the blanket restrictions register at Honeysuckle Lodge, we identified that the blanket restriction of access to the outside space at night was not recorded as a current blanket restriction. At the time of the visit to the ward, the outside space was locked at handover on an evening although patients could access this space under supervision of staff . The blanket restrictions register did not reflect this restriction. The restriction was in place to manage an ongoing risk however it was not clear if patients understood the reasoning and rationale behind this restriction.

We identified inconsistent recording and quality within risk assessment documentation including the safety plans and risk management plans. Governance processes on the wards had not ensured these issues were identified and addressed to ensure that records supported staff in providing safe and effective care and treatment. On Copeland and Acacia wards we saw records which had no information recorded on the formulation or safety / risk management plan tabs within the risk assessment tab. There were further omissions in other patient records on certain tabs reviewed, including a patient at Honeysuckle Lodge which did not have the safeguarding tab completed and the risk formulation tab was only partially completed. We did not see evidence that risk management plans were consistently written on an individual basis, for example, we saw two patients who had identical risk management plans. We observed examples in 10 patient records of risk assessments not reflecting recent incidents or specific issues for patients, including areas such as smoking on the wards and illicit drug use; with the potential risks from these not being reflected in the risk assessments or the relevant management plans to support staff to manage these risks effectively. There was a therapeutic engagement and observation policy. This addressed the need for therapeutic intervention with patients and person-centred care and individualised patient needs. Staff received prevention and management of violence and aggression including breakaway training, compliance was 83%. There was a reducing restrictive practice driver diagram alongside a quality improvement project. This was to reduce restraint, rapid tranquilisation, seclusion, violence and aggression and the use of substances as well as patients being absent without leave. The quality improvement project was co-produced involving patients. The trust logged reported incidents and provided information of actions taken in response to the incidents.

Patients gave mixed feedback about their experiences across the locations visited. On Acacia ward at Park House, patients raised an issue about lack of privacy due to dormitory accommodation still being in place along with issues regarding the level of noise on the ward. The trust was in the process of completing a new build which would replace the dormitory accommodation that was to open later in the year. At Anson Road, patients raised an issue regarding the bedrooms being dated and that the toilets could sometimes be blocked, although they noted that when this occurred, and it was escalated to staff that they would report and address this issue promptly. Patients did not generally raise any concerns in relation to the safety of the environment.

Managers had oversight of the environments and could escalate issues as appropriate within the trust. Managers and staff spoken to did not generally raise any issues regarding the environments. Managers at Acacia ward at Park House described the challenges related to managing the environment and were positive about the pending move to the new building. At the point of publication, the dormitory accommodation had been replaced by a new building with individual rooms. We toured the environments of all the wards and identified concerns regarding damaged furniture and environments, along with potential infection, prevention, and control issues. On Acacia ward at Park House, we observed a damaged chair, cluttered activity room, evidence of cigarette burns on the floor and furniture along with general damage to the rooms through the ward. At Anson Road there were areas where there was damage to the ward environment and staining in places. At Braeburn House, there were cracked privacy screens on some of the windows, stained flooring in places and damage to the architraves around doors in some of the patient bedrooms. Braeburn House also had a fault on the fire alarm panel. The system needed replacing in full. It was confirmed that the system was working and being tested pending it being replaced. At Bramley Street there were some issues with the environment in the shower room and the outside space was in a poor condition. Copeland ward at Meadowbrook also had some internal and external environmental issues. Copeland ward at Meadowbrook was a mixed sex ward. Staff managed this appropriately and in line with guidance. The remaining wards visited were all single gender wards.

There were gaps in emergency box daily checks and hypoglycaemia box checks used for patients with diabetes at Bramley Street and Honeysuckle lodge. Oxygen cylinders were not always attached to the wall at Copeland ward and there was no expiry date on the one at Honeysuckle Lodge. Blue tack was in use at Honeysuckle lodge which is not in line with trust policy due to the risk this may present to patients. We identified some issues with smoking on some wards where we could smell smoke during our visits along with on Acacia ward at Park House there was some evidence of cigarette burns on furniture and the floor. We also observed patients vaping in communal areas on certain wards with staff not addressing this with the patients at the time. Fire safety policies were in place however there were gaps in fire safety checks being undertaken. Action plans we reviewed associated with the fire risk assessments had many outstanding actions from previous risk assessments. Acacia ward fire officer logbook audit had not been completed since 2020. There were gaps in records of weekly fire checks from January 2024. And there had been no fire drills completed or recorded. Anson road fire alarm weekly test record showed that there was just one completed on 4 June 2024. Weekly and monthly fire checks records for 2024 identified gaps in recordings.

Ligature risk assessment tools were in place, but there were gaps in recording of the monthly matron checks. These checks were to chase and update on any outstanding actions that had been identified on the assessment to reduce the ligature risks. Ligature heat maps showed that on some wards that the outside space was not included on the heat map, albeit ligatures had been identified in the assessments. This could have resulted in staff not being aware of ligature risks in outside areas. There were also issues with checks around ligature cutters such as weekly checks not being completed at Anson Road, Braeburn House, Bramley Street and Copeland ward; whilst the wards at Braeburn House had incorrect guidance for the ligature cutters at the location which referred to a type of ligature cutter that was not present and staff did not understand the process of what they should be doing when undertaking checks. Some ligature audits included reference to an airlock when there was no airlock. Data reviewed showed there were no ligature incidents. There were health and safety security site inspections in place. These identified actions required by the service to rectify any risks in the care environment with recommendations and timescales for completion. Staff received fire safety training during their induction. Health and safety and security audits were in place as well as environmental audits. Capital, estates, and facilities held a monthly quality safety group meeting. The group shared information to identify gaps in service delivery and standards. However, these processes were not effective in improving the environmental safety on the wards.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients spoken to did not raise any significant concerns in relation to the cleanliness of the wards or about infection prevention and control, although patients on Acacia ward at Park House stated that the cleanliness of the communal areas was sometimes lacking. Some patients at Anson Road also raised issues with the cleanliness of the communal areas, in particular the kitchen and bathrooms.

Managers had oversight of the environments and could escalate issues as appropriate within the trust. Managers and staff spoken to did not generally raise any issues regarding the environments. Managers at Acacia ward at Park House described the challenges related to managing the environment and were positive about the pending move to the new building.

Acacia ward (Park House), Anson Road, Braeburn House, Bramley Street and Honeysuckle Lodge (Rivington) had inconsistent practices with the management of food hygiene and storage which meant that roles and responsibilities in respect of this were not always clear and that food was potentially being stored in an unsafe condition. We identified out of date food products at Acacia ward, Anson Road, Braeburn House, Bramley Street and Honeysuckle Lodge that had not been removed and certain items that had not been labelled when they had been opened. There was inconsistent management and checks that staff undertook to manage the safe storage of food and that utensils were clean, where it was not always clear who was responsible for undertaking checks and ensuring that actions were taken to address any issues. This could have resulted in patients using out of date or unsafe food products or equipment. On Acacia ward, the flooring of the patient kitchen was dirty, and the walls were damaged. The kitchen was unclean and in a poor state of repair. Anson road had tiles missing in the kitchen area and the downstairs toilet whilst the accessible toilet had staining on the floor and damaged walls. The upstairs toilet was also dirty and had staining to the floor. We saw damaged and dirty environments at Braeburn house. The extra care area toilet was dirty and not fit for use if needed in an emergency. There were gaps in the kitchen safety and cleaning checklist on Light Oaks ward.

Health and safety audits were completed however these did not indicate if any of the identified areas of action had been completed. An example of this was Bramley Street the assessment was completed September 2023, but no actions documented. More recent assessments had been completed at other sites. Environmental audits were completed prior to our inspection of the wards and these highlighted actions that could have been addressed and actioned immediately. For example, safe food storage and labelling of food. There were gaps in the kitchen safety and cleaning checklists on Light Oaks ward.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.