Greater Manchester Mental Health NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We rated well led as inadequate. We assessed eight quality statements. There had been some improvements in the culture, leadership and support offered to staff within the service. However, new staff were not always appropriately inducted and generally staff did not always have the skills, experience or training to safely meet the needs of the people in their care. Leaders had not ensured that there was effective oversight of audit and risk management systems and processes to ensure that people received safe care and treatment. Some ward managers were not engaged with or aware of the drivers for improvement at the trust, for example previous CQC findings or the recommendations from the Shanley review. Staff were not always aware of policies and procedures for example, smoking and and did not act consistently to ensure that policies were followed and wards and patients were kept safe.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Three managers and 13 members of staff said they felt the trust's culture had improved. A safety culture questionnaire had been completed by staff evidencing a more supportive rather than punitive HR culture. The new team of five duty managers and the quality matrons worked well together and had driven improvements on the wards. Sleeping on nights had improved along with the use of CCTV. Allied health professionals said there had been a shift in power balance and that they had more of a voice and their expertise were actively sought. They felt they were working well with the medical team and were seen as clinically integral. Staff told us that the level of MDT working was good and handover and liaison on the ward were helpful. However some staff said there was a lack of forensic/mental health experience due to the influx of a large number of new staff and/or senior managers and a ward manager said they felt there was a cultural split on their ward between the old and new staff. Ward managers and one member of staff said improvements needed to be made to the clinical teams, for example further streamlining and being based closer to the wards. Some ward managers said they had not felt engaged in the changes made and it felt like these things were done to rather than with ward staff. There was some variation in how ward managers dealt with staff sickness and late shift cancellations. There could be excessive demands on duty managers, an example was given of holding five sets of keys and three alarms on one shift. Staff said there had been a lack of consultation with the nursing team about the new care plan format. Concerns were raised by ward staff and managers across multiple wards about the challenges of managing the mix of experienced and new staff due to the large influx of new staff. We were told this had led to a cultural divide on some wards, with some isolated complaints of bullying/discrimination being raised by individual staff members.

Senior leaders described the clinical model development and workforce and financial plans to support this were in progress. Managers had visited other forensic services to inform this and worked with an external team. There were co-produced improvement workstreams involving clinical and ward staff and patients, embedding ward to board governance structure. Cultural improvements included visible leadership and role modelling. Staff and patients knew who the senior leadership team were. There was evidence of embedding learning culture with a patient safety panel and learning from safeguarding referrals. The duty managers who were not ward-specific had evolved to support staffing and incident management. They offered feedback to the SLT and this meant that ward managers could stay on their own ward.

Ward managers and one member of staff said they felt well supported by senior leaders and that they were more visible on the wards. Staff said they felt well supported by their immediate managers The advocates attended the MDT and SLT meetings. However, a ward manager and two members of staff said they did not feel well supported by senior leaders and that they did not visit the wards and that the requirements from the SLT were not always realistic. The duty managers said there were concerns at times about the understanding of the new management team about how the wards operated on the ground.

We saw evidence of leadership competency, support and development. Senior leaders said that staff in management roles had received training on quality improvement methodology and that they were delivering away days for staff to improve visibility to the workforce . There was safe recruitment of leaders in relation to fit and proper person requirements. There were structures in place for reporting and evidence of succession planning. However not all ward managers and staff were aware of the plans for improvement arising from previous concerns and systems and processes had not been effective in ensuring that this information had been cascaded to staff. There was Inconsistent compliance and levels of staff understanding relating to the smoke-free policy – patients openly vaping on most wards without being challenged by staff, some staff were aware of the policy for patients to vape outside or in their rooms but not in communal areas but elected not to follow it to reduce the risk of incidents from challenging patients who were persistently vaping, Some staff were not aware of the policy at all.

A Freedom to Speak Up Guardian regularly visited the wards and ward managers and staff said they were aware of the process for raising concerns. Leaders said the wards had a more open culture now, with staff feeling safe to speak out. However, two members of staff said they did not feel safe to raise concerns, one member of staff was not confident that action would be taken in response to concerns raised and another felt that concerns were swept under the carpet. Other staff told us that there had been some isolated complaints made alleging bullying and discrimination.

There was a whistleblowing policy in place and staff knew where to find this and how to use it . The Freedom to Speak up Guardian regularly visited the ward and staff could contact them if they had concerns to discuss. There was a freedom to speak up report and improvement plan which was routinely reviewed and updated at the trust board meetings. All actions on the improvement plan had been completed in March 2024. A freedom to speak up network had been developed and there were 43 trained freedom to speak up champions as part of this. However some staff did not feel that their concerns would be listened to or acted upon despite processes being in place.

There had been some cultural improvements made and there was additional support for black and minority ethnic staff. Additionally, there was a wellbeing lead, breastfeeding space and a menopause group.

As part of the mandatory training staff received equality, diversity and human rights training. Compliance was at 98% at the time of inspection. There was an equality and diversity sub-group who supported staff, for example, with experiences of racism from patients.

Ward managers and the pharmacist we spoke with outlined the systems in place on their wards to ensure effective governance in relation to medicines management and ligature risks. Staff said that the record keeping system supported them in their role and that there were systems in place to manage fire safety on the wards. Senior leaders said that there were processes in place to ensure better oversight of incidents, complaints and concerns. Staff were engaged in the roll out of the PSIRF incident management framework. Ward managers showed us the system they had for monitoring mandatory training updates. However, one ward manager acknowledged that the fire safety paperwork did not accurately reflect the fire safety measures which were actually in place on the ward. Leaders said there were no PMVA audits taking place on the wards, there had been recent issues identified with the management of controlled drugs on Silverdale ward and the quality of care plans varied between wards. The new format was being rolled out due to the current format having excessive detail.

Leaders met to review incidents, complaints and concerns and identify themes. Lessons learned were cascaded to staff. However, we identified concerns relating to the governance systems for the management of risks, assurance of staff induction and training and maintaining accurate and up to date clinical records. There was evidence of a lack of consistent governance relating to ligature, fire and security risks. 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. There were gaps in handover records for multiple patients on Isherwood, Silverdale, Ferndale and Rydal wards.

People that we spoke with said that they were able to maintain links with services in the community such as substance misuse support.

The advocates attended the ward and were invited to patient meetings and the senior leadership team meetings. Advocacy information was widely available on the wards and advocates were provided with confidential spaces to meet with people.

Community meetings took place regularly on each ward and there was a patient empowerment group within the service. Advocates regularly attended the ward and senior leaders and ward staff were supportive of the service.

Ward managers, and staff described effective systems for reporting and investigating incidents to ensure debriefs were offered to staff, feedback was shared and safety improvements were made in response to lessons learned. Staff gave us examples of an improvement made due to lessons learned from an incident (improvements to record keeping in relation to depot administration). Another staff member described how improvement actions had led to a reduction of smoking related incidents on their ward. There was engagement with quality improvement projects on the wards and the aim was to embed learning culture on the wards. This was underway, with the safety panel and improvements to safeguarding systems being examples of this process. Senior managers discussed the PSIRF roll out which was focussed on engagement with staff at all levels in after action reviews. There was also a piece of work to involve staff in incident simulations as some new staff had never encountered aggression. However some ward managers were not engaged with or aware of the drivers for improvement at the trust, for example previous CQC findings or the recommendations from external reviews.

There was an up to date incident policy in place which set out the trust's systems and processes for responding to patient safety events and issues. Of the 12 serious incidents reported, all had been investigated in line with trust policy. The highest number of incidents were on Ferndale and Rydal wards. Ward managers and staff described effective systems for reporting and investigating incidents to ensure debriefs were offered to staff, feedback was shared and safety improvements were made in response to lessons learned . Ward managers received safety alerts with information about lessons learned from incidents elsewhere in the trust. QI methodology was being used on the wards to empower staff to take forward improvements, which included safety improvements. However there were many examples of processes not being robust or effective, resulting in insufficient learning and improvement, including lack of a robust system for monitoring the de-burring of ligature cutters; signatures missing on security check records (Silverdale and Borrowdale); 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. There were gaps in handover records for multiple patients on Isherwood, Silverdale, Ferndale and Rydal wards and records were not always available for NHSP staff to demonstrate that they had received an induction to the ward.