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 rated safe as inadequate. We assessed eight quality statements. Staff did not always provide safe care and treatment. The environment was not always c safe or well maintained and risks were not always safely managed. Staff were not always trained, and competent and new staff did not always have the right experience and skills or induction to safely meet people's needs. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. ,

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.

We spoke with 30 patients across the nine wards visited during the assessment. Patients told us that they were aware of the complaints procedure and how to use it. However, the service was not always willing to learn from their feedback. Two patients told us that they did not receive feedback from their complaint. Community meetings took place regularly and improvements were made because of patient feedback. Nine out of 30 patients we spoke with told us that they felt safe on the wards .

Staff knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with trust policy. Staff reported serious incidents clearly and in line with trust policy. Staff understood the duty of candour. They were generally open and transparent and gave patients and families a full explanation if and when things went wrong. Managers debriefed and supported staff after any serious incidents. Staff received feedback from the investigation of incidents, both internal and external to the service. Staff met to discuss the feedback and look at improvements to patient care. There was evidence that changes had been made as a result of feedback. This included improved staffing levels. Staff were aware of the complaints processes and supported patients with this.

The provider had systems and processes in place to manage risk. These included incident logs, risk assessments, care plans, observation records and physical health monitoring. There was a monthly safety and security meeting and a review of incidents was part of this. Safety alerts with information about lessons learned from incidents within the service and elsewhere in the trust were routinely sent out to all staff. However, not all patient risk assessments were regularly reviewed and updated after incidents. Care plans were not person-centred and did not include clear therapeutic goals for people. It was not clear that care plans were being reviewed and updated to reflect changes in needs. On multiple sets of records reviews were being documented but there were no changes being made to the plans. Five out of 10 patients who were prescribed clozapine did not have a clozapine care plan in place.

People had mixed views about the support they received with their transition and discharge from the wards. Seven patients said that they were being supported towards their eventual discharge from the ward. However two patients said they had concerns about the forthcoming relocation of their ward and two patients said that they felt unsafe on their ward.

Safety and continuity of care was a priority throughout people’s care journey. This happened through a collaborative, joined-up approach to safety that involved patients along with staff and other partners in their care. This included referrals, admissions and discharge, and where people were moving between services. There was an awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. The effectiveness of these processes is monitored and managed to keep people safe. Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity.

Partners told us that ward rounds, CPA’s and discharge meetings were routinely held for patients. The provider invited external partners to these meetings and worked in partnership with external organisations in order to support and facilitate safe transitions to and from the service.

We saw evidence of effective partnership working with other hospitals in planning for patients’ discharge. The service used HONOS (Health of the Nation Outcome Scores) to measure risk and this was routinely updated at multidisciplinary team meetings. However we found a number of gaps in the handover records on one ward in relation to patient risk.

12 patients said that they felt safe on the ward and nine patients said that staff spoke to them with kindness dignity and respect. However, seven patients had some concerns including two patients who said that they did not feel safe on the ward, two patients said that staff did things to deliberately provoke them and two patients said staff did not respect their privacy. One patient said that staff used excessive force when restraining them and one patient said that they had been assaulted on the ward . This meant that the service did not always protect people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We spoke with a number of leaders who told us that there was an improved culture regarding safeguarding reporting and better relationships with local safeguarding structures. Ward managers and staff described appropriate processes for dealing with safeguarding concerns. They also described the measures in place to support patients' protected characteristics on the ward.

Staff routinely identified and raised safeguarding issues. Staff knew their patients, were aware of their protected characteristics and cared for them in line with this.

There was a safeguarding policy in place and staff knew how to access this to make appropriate referrals to the local safeguarding authority. Training compliance for safeguarding adults level 1 and 2 was at 97% and level 3 was 83%. Safeguarding children levels 1 and 2 was at 95% and level 3 was 81%. However, safeguarding adults was low at 67% and safeguarding children was low at 44% on Keswick ward, The freedom to speak up guardians routinely visited the ward which ensured that staff were able to speak out about any concerning practice they identified.

Most patients told us that they had been involved in their risk assessment and knew what their risks were. Some patients said they had been restrained or placed in seclusion for a period of time.

Staff described how the risks relating to each patient's care were assessed on admission to the service using a nationally recognised assessment tool (HCR-20) and regularly reviewed, including following any relevant incident. Managers and staff told us that there were low levels of physical intervention on their wards and that rapid tranquilisation was rarely used . The rapid tranquilisation audit showed that eight patients had received rapid tranquilisation and documentation of the administration of rapid tranquilisation was good with clear notes stating what was given and reason for administration. Staff used restraint as a last resort and only after all efforts at verbal de-escalation had failed. There was a reducing restrictive practice program with patient involvement along with a patient safety panel. However some staff said that colleagues were not confident in using PMVA techniques. The training compliance was however at 84% at the time of the inspection.

We observed staff supporting patients with escorted leave . However, we did not see sufficient evidence to demonstrate that blanket restrictions were only imposed where necessary to meet the needs of the patients and maintain the safety of patients and staff or that they were being kept under regular review when imposed. For example, not all wards were able to provide a copy of their blanket restrictions register and, where this was available, there was no evidence to show the blanket restrictions were being regularly reviewed and removed where no longer required. We also identified blanket restrictions, for example relating to searches and access to the lounge TV, which were not documented on the relevant ward’s register. We observed staff interactions with patients on each ward and saw that the majority were positive. On a few occasions, staff and patient interactions were neutral and we observed that there was less engagement. The trust used Health of the Nation Outcome Scales in which to manage risk. (HONoS) Rusk assessments were completed on admission and reviewed regularly and after each incident. Staff followed best practice in using restraint only as a last resort after all other interventions had been unsuccessful. There had been 117 episodes of restraint and 40 episodes of seclusion across the wards in the six months prior to the inspection. We saw some patient centred care plans showing patient and carer involvement. Observation of patients was used as a method of managing risk. However there were significant gaps in some observation records.

Most patients said their ward was fairly clean, there was adequate space on the ward and they were happy with the visitors room. A patient on Rydal ward said there was an interactive touch screen device in the seclusion area which was helpful. The wards had a range of rooms available to patients including activities rooms, quiet lounges and interview rooms. However, a patient on Silverdale ward said they had restricted access to activities off the ward due to the external 'rec' area being out of bounds so often and two patients on this ward raised concerns about the proposed relocation of all patients on this ward to the empty Eskdale ward as they feared this situation would worsen. One patient complained that the seclusion area was poorly maintained and others said the ward was dirty and they did not have adequate access to outside space. Another patient said they were not challenged by staff for smoking in communal areas. We heard from four individuals (staff and patients) that there were issues with bank staff sleeping at night (three out of four of the people who raised concerns about this were on Keswick ward).

We spoke with six ward managers and 22 other members of staff. Staff were able to describe a range of security procedures on each ward including regular checks and counts of potentially hazardous items and environmental checks. There was an allocated support worker dedicated to ward security on each ward per shift. However staff also told us that there were mistakes and omissions with security checks and this was not always addressed . This meant that although systems were in place, the security and safety of patients was not always prioritised and this created risks to patient and staff safety. Staff told us that the observation policy was not always followed. Some staff described being expected to undertake observations for up to five hours at a time without a break and being asked to undertake observations without having received any training or competency assessment in relation to this . We heard from four staff that there were issues with bank staff sleeping at night.

We saw evidence of effective partnership working with other hospitals in planning for patients’ discharge. The service used HONOS (Health of the Nation Outcome Scores) to measure risk and this was routinely updated at multidisciplinary team meetings. 20240718 GMMH Forensics Collation Document Feedback from Partners. Wards were accessible for patients with mobility needs and disabled bathrooms were available on the wards. However we found a number of gaps in the handover records on one ward. Ward office doors were left unlocked on Silverdale and Ferndale wards. On Silverdale ward we observed a patient walking into the office. There was inconsistent practice around whether pool cues were locked away immediately following games or left unattended on the pool table on Ferndale ward. There were gaps in patient observation records on some wards (Silverdale, Rydal, Delaney) (including where enhanced observations had been prescribed).We witnessed a member of staff completing observation records in the security office, not within sight of the relevant patients (Keswick ward). We identified ligature risks on Isherwood and Delaney wards which were not included on the ligature audit for these wards, as the outside areas were not included and they contained exercise equipment and benches which posed a fixed ligature risk. Outside areas were not included on the ligature heat maps for any of the wards. There were blind spots on some wards (Delaney, Isherwood, Dovedale, Keswick) which were not adequately mitigated by the use of mirrors – for example on Isherwood ward the ward manager said the risk posed by a blind area was mitigated by the use of CCTV, however there was no live feed from the cameras so this did not reduce the risk in real time. There were blind spots in the Keswick, Ferndale and Borrowdale secure garden. It was not always possible to see how the deployment of staff was adequately mitigating these risks. Cleaning records were incomplete or unavailable.

The provider’s processes did not always ensure that the ward environment was safe for patients. Staff used observations of patients to mitigate risks. However, staff were unclear on how these should be completed. Some staff told us they completed observations records on the hour or half hour rather than at randomly selected times within the relevant period. Ligature risk assessments were not always dated and it was not possible to see from the documents when these had last been reviewed, the assessment templates included sections for ‘matron’s monthly checks’ but these were mostly blank. Where the action to resolve the risk was a maintenance (MICAD) request it was generally not documented whether this work had been done. The templates in place for staff to record general observations did not prompt staff to document the time at which the observation check was made. Staff undertook a variety of checks to ensure the safety of the ward, this included 15 minute security checks. On Silverdale and Borrowdale wards there were gaps and missing signatures in the 15 minute security check records. The wards did not follow the fire safety processes outlined by the trust’s policy. The records of fire safety checks were in poor condition, weekly fire safety checks were not always recorded, not all staff had undertaken fire induction to the wards, there was no evidence that fire drills had taken place. Audit information was unclear and fire folders which contained instructions on fire wardens and daily checks were missing or incomplete. We found that the fire evacuation instructions panel on the ward was not completed with local information on Rydal and Borrowdale wards Staff had not followed the process stated in trust policy for patients self- medicating. On all of the wards weekly random checks had not been completed. We found that medication was not stored securely in a patient’s bedroom. The patient was storing their self-medication on a shelf in their room.

Patients gave mixed views about the staff that were caring for them . Nine patients spoke positively about the staff on their wards saying that they treated them with kindness and were caring and helpful. Six patients said that staffing levels on the wards were good. However, four patients said that leave and activities were sometimes cancelled due to staffing levels, and two people said that there was not always a staff member in the communal areas. Five patients described a language barrier due to English not being the staff members’ first language.

Staff and leaders generally gave positive views on safe and effective staffing. Most staff told us that they received the right support to deliver safe care. Staff that we spoke told us that they received mandatory training which was relevant to their role. Staff received supervision and appraisal and there an induction for new staff. The new duty manager system had taken pressure off the ward managers and provided extra leadership on the wards. Twelve members of staff said team meetings took place regularly. Managers described a comprehensive handover process covering observation levels, mental state and presentation, safeguarding and physical health for each patient and the skill mix of the team. However, five members of staff said they were asked to work on acute wards too often or had to respond to incidents on the 'top site', both of which caused staffing issues on their own ward. Some managers and staff told us that they were not up to date with some classroom based training. Other staff told us that there continued to be issues with staff sleeping during night shifts and that a number of new staff had no experience in secure services.

We saw that staffing levels across the wards were good. We completed an out of hours evening visit at the beginning of the inspection There were staff in communal areas and one to one sessions between patients and their named nurse routinely took place. Most staff that we spoke with were qualified and experienced. We saw that staff responded promptly to call bells when required. However the Induction records were missing for all five of the NHSP staff working on the wards

The provider had processes in place to ensure safe staffing. Permanent staffing levels for each ward were between five and 10 registered nurses and six and 19 HCA’s. Each ward was supported by an MDT which included a psychiatrist, occupational therapist, psychologist and the named nurse. Each ward had a leadership team consisting of a ward manager, duty manager and matron. Staff used a proforma during the daily safety huddle to consider safe staffing numbers and ensure that inductions for temporary staff took place. Staff would be moved from other wards to the forensic wards if there was a staff shortage. The number of safe staffing incidents reported had steadily reduced from 163 in October 2023 to 71 in March 2024. There was a local induction and assurance pack for observations for new starters ; staff did not deliver observations of patients until sign off of their competency level by senior staff. The mandatory training courses in place for staff were appropriate and thorough. Staff were compliant in most courses other than patient syllabus level 2 was below compliance at 68% and inpatient moving and handling was below compliance at 48 %. Staff received regular supervision and appraisal in line with trust policy. Supervision compliance was at 82% at the time of the assessment and appraisal compliance was at 86% at the time of the assessment.

Most patients told us that the wards were generally clean, tidy and well maintained. However some people told us that their ward was visibly dirty with empty hand gel dispensers (Rydal ward), empty hand towel dispensers (Rydal ward) and on some wards these had been removed in bulk. In the Rydal seclusion room there was a smell from the drain, the patient using the room at the time we visited told us they had to put a pillow over the drain to reduce this. There was also an unpleasant smell in the Ferndale seclusion room and the toilet. On Ferndale ward and Silverdale ward there were blood stains on blood monitoring storage boxes in the clinic rooms. Some equipment had clean stickers on but also settled dust on Ferndale ward.

Staff and leaders told us that there we an infection prevention and control policy in place which covered all areas including hand hygiene, personal protective equipment, safe management of equipment and safe disposal of waste. Staff said that there was a dress code and that they were expected to be bare below the elbow and with the absence of jewellery or false nails. One member of staff said they were not usually expected to be bare below the elbows but had been asked to take off their fleece because CQC were on the ward.

On all the wards we visited we witnessed inconsistent compliance with the Trust ‘bare below the elbows’ dress policy - we observed staff with jewelry, false nails and false eyelashes, a member of staff told us they had been told not to wear their long-sleeved fleece because of the CQC inspection. Cleaning records were incomplete on Ferndale, Derwent and Silverdale wards or not available on Borrowdale, Dovedale, Delaney and Keswick wards. No environmental audits were available on the wards. Cleanliness and hygiene across the wards was variable. Some of the wards that we visited were clean and well maintained. However, we observed a lack of access to gloves on Rydal ward in the kitchen clinic room.. We also found that food in the Rydal and Dovedale patient fridges was not marked with date of opening. On Ferndale ward we observed an unpleasant smell in the seclusion room and the toilet was dirty. There was no hand sanitiser in the airlock dispenser on Delaney ward. There was a large stain on the Isherwood clinic room floor and the communal bathroom was not clean. Some staff on Isherwood ward were not bare below the elbows.

There were a number of processes in place to prevent the spread of infection . This included cleaning schedules and audits. However, cleaning records were incomplete (Ferndale, Derwent, Silverdale) or not available (Borrowdale, Dovedale, Delaney, Keswick). There were also gaps in the clinic room cleaning records. No environmental audits were available on the wards. Hand hygiene audits took place every two months and audits showed that there was 100% compliance on three wards on one occasion across the forensic services. Infection prevention training compliance was at 92% at the time of the assessment and the trust had an infection prevention and control policy in place.

People were appropriately involved in decisions about their medicines. Ten patients we spoke with said they were given enough information about their medicines and five patients said they had been supported to self-administer medicines.

Ward managers, staff and the pharmacist described the systems in place on the ward for the safe management of medicines. This included staff monitoring patients who were prescribed high dose antipsychotic medication and lithum and supporting patients to self-administer medication.

There were not appropriate arrangements for the safe management, use and oversight of medication and controlled drugs. On Borrowdale ward we found open stock medicines (liquids/topical creams) with no date of opening documented. On Rydal ward we found gaps in the medicines stock check records and missing signatures in the controlled drugs book. The temperature of two clinic rooms was 26 degrees on a day which was not particularly warm. Staff had tried to mitigate this with fans but this was not effective. Emergency drugs were not available in all clinics as per trust policy (flumazenil, amiodarone, Epipen). There were expired items in the emergency bag on Silverdale and Dovedale wards and the checks of the bags had not resulted in the expired items being identified and removed; also an item in the Silverdale bag which was in date was marked expired on the check record but was still in the bag. The trust pharmacist visited the wards weekly to monitor medicines and controlled drugs compliance. The ward manager conducted weekly medicine card audits and the results were fed into the medicines management group.

The trust had a medication management policy in place along with a rapid tranquillisation policy. A rapid tranquilisation audit showed that rapid tranquilisation was used eight times in the last nine months. Audit processes were in place to ensure that patients were not over prescribed anti-psychotic medication and the trust followed national standards in prescribing practice. Quarterly audits were undertaken by all wards to ensure adherence to the trust and local standards for the management of controlled drugs (CDs) However these were not always effective. we found gaps in the medicines stock check records and missing signatures in the controlled drugs book. Staff obtained consent to treatment and this was recorded in patient records. There was also a self medication procedure for inpatients which allowed patients to medicate safely on the ward and provided guidance for nurses and pharmacy staff. The trust pharmacist visited the wards weekly to monitor medicines and controlled drugs compliance. The ward manager conducted weekly medicines card audits. The results were fed into the medicines management group and stream meeting.