Greater Manchester Mental Health NHS Foundation Trust

We rated child and adolescent mental health wards as requires improvement because:

• the wards did not always provide a safe environment, there were often insufficient numbers of staff to provide the care required. These staff had not always been trained in the specific needs of children and young people. When individuals had been assessed as requiring increased levels of support the documentation for the monitoring of this support was not always being completed. This included after patients had been administered additional medication following a period of disturbed behaviour

• staff were not trained in the Mental Health Act (MHA) and Mental Capacity Act (MCA). This meant that recent changes to the MHA code of practice were not understood or brought into practice and staff were not able to demonstrate how they considered the MCA when planning and delivering care

• on Junction 17, two patients told us that staff did not provide emotional support when needed. Three patients said that sometimes certain staff told them to ‘grow up’ and rolled their eyes at them

• staff did not keep a record of complaints resolved locally at ward level. There was limited accessible information available to patients

• monitoring systems in place did not identify when care was not being delivered safely nor did they identify when there was not enough staff and a lack of suitably qualified staff.

However:

• the wards were clean and tidy. Where there were risks of ligature points, action had been taken to reduce the risk. Regular risk assessments were carried out and staff knew when and how to report incidents. Staff had received training in safeguarding, but not at level 3, and knew how to protect patients from abuse

• patients could access psychological therapies. Staff received managerial and clinical supervision and were regularly appraised. Staff regularly communicated with local services and external agencies when planning and delivering care

• staff planned for discharge when patients were first admitted and communicated these plans with other services to ensure adequate support was available for patients. There was a range of food choices to meet patients’ dietary requirements and a range of activities available including at weekends

• most staff were respectful and engaged positively with patients. We observed staff being encouraging and supportive and meaningfully engaging with patients. Patients were involved in the planning of their care and staff held regular meetings to encourage patient feedback

• staff knew who the senior management team were by name and told us that they visited the wards. On Junction 17 staff had implemented the ‘safe wards’ initiative and had participated in the Royal College of Psychiatrists accreditation for in-patient child and adolescent services.

We rated mental health crisis services and health-based places of safety as good because:

• Staffing levels within the crisis teams helped ensure people in crisis received safe, appropriate and timely care. Teams had safe working practices and staff held manageable caseloads. Patients' individual risks were assessed and reviewed. Staff acted on adult and children's safeguarding matters. The three health based places of safety provided safe environments to assess patients . S taff learnt lessons following incidents to try and prevent further incidents happening.
• There was very effective multidisciplinary working in the crisis teams and good interagency working with acute hospital staff and the police. There were very good systems in place for ensuring the hospitals’ duties under section 136 were met and very good clinical leadership into the health based place of safety. There was an alcohol worker working at the Trafford RAID service to support intoxicated patients. Nurses worked in police stations to provide professional and intensive support people who regularly presented to the police.
• Patients were treated with dignity and respect. Patients were involved in identifying their crisis support needs and in developing the assessment and intervention tools used in the home based treatment teams.
• Patients were usually seen quickly. Patients’ individual needs were considered and met. There were good complaints processes.
• There were effective local, inter agency and crisis concordat meetings to improve services and patients' crisis experience. Staff were committed to providing high quality care and treatment and teams were managed by experienced and competent clinical leaders. There was a commitment to quality improvement such as improved health based places of safety environments, and improved staffing levels in crisis services.

However

• The rationale for changes in levels of support relating to patients under the Bolton home based treatment teams were not always explicitly recorded.
• It was not always clearly recorded that patients were informed of their rights verbally and in writing whilst in the health based place of safety and patients did not have access to a printed copy of the MHA Code of Practice.
• There were problems across the trust with getting ambulances to take patients to the health based place of safety and there were delays in assessing patients when subject to section 136 including the response of approved mental health professionals at night but where these occurred, delays were beyond the full control of the trust.
• In the home treatment teams, it was not always clearly recorded whether patients were given copies of their crisis care plans.
• There were differing crisis care pathways in each locality and information about each service did not fully inform patients and carers on the services available to them.
• Information on CQC’s role in complaints literature was not up-to-date.

We rated community-based mental health services for adults of working age as good because:

• Staff prioritised keeping people who use the service safe; records we reviewed had comprehensive risk assessments in place.

• Staff had a good understanding of people’s needs and relapse triggers and increased support when needed.

• The trust kept staff safe, staff were aware of and followed the lone worker policy and provided support in pairs where risks necessitated.

• If there was a serious incident, people were supported and offered debriefs. Managers shared learning from incidents amongst teams to reduce the likelihood of reoccurrence.

• Staff received supervision, appraisals and attended regular team meetings; managers disseminated information from senior managers to teams.

• Staff were aware of best practice and guidance and followed this, including offering friends and family groups within the early intervention service to raise awareness of psychosis.

• Teams prioritised physical health, with a physical health lead in each team. Staff facilitated activities to improve health and wellbeing including badminton groups and recovery groups.

• People using the service reported staff were respectful, caring and supportive. Staff had a good knowledge of individual needs and preferences. Interactions observed were positive and respectful of individuals.

• People who use the services had access to advocacy, both independent Mental Health Act advocates (IMHA) and independent Mental Capacity Act advocates (IMCA).

• The community teams provided support in an early evening and at a weekend.

• Staff processed referrals quickly and had a clear eligibility criteria and prioritisation of referrals for assessments.

• Managers had embedded learning from feedback in practice, including informing people who use the services if their worker is temporary.

• Information in relation to mental health conditions and therapies was available in a variety of languages. Joint working took place with community organisations to engage with people from different cultural backgrounds.

• There was a nurse led clinic in Salford to provide a gradual discharge from the community mental health team. People who accessed the clinic talked positively about the support offered.

• Staff reported being valued and feeling supported in their role, by their team and managers. Morale was high within teams and staff enjoyed working for the trust and making a difference in the lives of people they supported.

We rated long stay/rehabilitation mental health wards for working age adults as GOOD because:

• The wards provided a safe environment. The layout across the service allowed for monitoring of patients, with good use of mirrors for blind spots on Ash and Dove wards. All wards complied with the requirements of same sex accommodation guidance.There were sufficient staff deployed to meet the needs of the patients, with on-going recruitment in place to meet shortfalls in staffing numbers. There was access to personal alarms and call buttons in rooms across the service. Risk assessments were completed and up to date.

• Thirty nine care records were reviewed across the service, all of a high standard, patient focussed, and comprehensive.Physical examinations were undertaken and effectively monitored. Multi disciplinary team meetings were well attended with the patient being central to all discussion. Mental Health Act records were in place and in order.

• We saw interaction between staff and patients that was respectful, thoughtful, considerate, timely, and professional.  We attended a care programme approach meeting in which a patient had a list of considerations for approval to allow acceptance of a job offer, and the team gave full consideration and agreement to the request.  There was evidence of family and carer involvement in the care of patients.  Patients stated they were happy with the service.

• In the six months prior to inspection there had been no delayed discharges, referral to assessment / referral to treatment delays or readmissions for this core service. Facilities such as specific telephone rooms were available for private telephone calls.  There was access to well-maintained outside areas.  Patients were actively encouraged to find voluntary or paid work. Activities were available across the service, including weekend activities.  There was access to information about services, with consideration for culture and language. Complaints were dealt with and results fed back to both patients and staff.

• Staff knew the values of the trust.  Senior management visited the service regularly.  Key performance indicators were used across the service to monitor and improve the service.  Staff could raise issues confidently and could give input into service development.  The service had actively embraced duty of candour, with the use of staff questionnaires to enhance understanding.

However:

• mandatory training for the service was not being monitored or audited effectively, leading to confusion over figures.  The mandatory training figures for Recovery First were well monitored and showed a compliance rate of 83%, with the other service locations averaging compliance at 78%.

• Mental Health Act and Mental Capacity Act training access was not very effective, but the trust had identified this and was working towards a solution.

• Immediate Life Support training was not given enough prominence in training schedules, and needed to be addressed.

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 have rated services provided by Greater Manchester West NHS Foundation Trust overall as good.

This was because we rated six of the eight services as good. We rated two service as requires improvement. These services were; child and adolescent mental health ward and wards for older people.

The trust did many things well and we saw good practice across most services.

The main areas which were positive were as follows:

• Staff were caring, professional and worked to support the patients using the services.
• The trust was supporting patients with their physical health well. People had their health assessed in a comprehensive manner and were being supported to have any health care needs addressed.
• Staff, patients and carers had access to a wide range of opportunities for learning and development, which was helping improve care.
• Patients and carers had the opportunity to be involved in how services were provided and their input was leading to changes.
• The trust was aware of best practice and was using guidance and research to inform their work. Access to psychological therapies was good in the child and adolescent mental health wards and acute wards.
• Patients could access care in their local service when they needed it. Services were designed to be accessible for all patient groups and the trust worked hard to ensure that hard to reach groups were engaged.
• The trust had excellent working relationships with external agencies and stakeholders. An example was the work of the community team for older people working to reduce admissions into the acute trust.
• Patients were cared for in the least restrictive way in the forensic service with patients self-medicating and positive risk management.
• There was strong, effective and visible leadership. Staff knew the trust values and vision and their importance in the work of the trust. There was an effective governance system in place at board level so that the trust knew where action was needed.

However;

The main areas for improvement were:

• Patients were not always having physical observations recorded when they had received medicines for rapid tranquilisation.
• Patients were sometimes being secluded without the checks and safeguards of the MHA code of practice being applied.
• In wards for older people, accommodation was not always being provided in line with same sex guidance.
• Staff were not always recording decisions, and how they had been made in patients’ best interests on older people’s wards.
• Not all staff were able to use the new electronic record system confidently and staff struggled to find records at times.
• Not all staff had completed mandatory training and there were low numbers of staff who were up to date with their basic life support, immediate life support training, MHA and MCA training.
• Not all staff were receiving regular supervision.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

We rated community based mental health services for older adults as good because:

• Safe

Teams had sufficient staff to meet patients’ needs. Staff vacancies were being recruited into quickly. Staff reported that complexity of caseloads were reviewed in supervision to ensure equity. Team caseloads were at a manageable level. There were good lone working practices in the team and trust policy was followed. Staff knew about duty of candour. Patients had a crisis contingency plan in place in their care plan and staff knew how to respond to deterioration in a patients’ physical or mental health. Staff had a good understanding of safeguarding processes and knew their responsibilities to protect patients from possible risk of abuse and harm. Staff showed a good understanding of incident reporting and there was good reporting of incidents.

• Effective

Staff attended a multidisciplinary group to review and problem solve complex cases, provide plans and anticipate care needs for those using health and social care services. There was a psychology team who provided input to patients, carers and staff. Care plans were holistic and person-centred. There was a staff development group who had protected time to meet on a monthly basis to undertake internal training. There were developments around the emphasis on physical health with some staff receiving specific training to support this. There was evidence of good inter-agency and multidisciplinary working.

• Caring

Staff treated patients who used the service with kindness, dignity and respect. Staff demonstrated warmth and compassion in their interactions with patients and their carers. Staff involved patients and their carers in decisions about their care.

• Responsive

There were five clinical pathways which gave clear and consistent support to patients. Patients reported that staff were flexible in their approach and quick to return phone calls. The service opened at weekends with reduced staffing in order to ensure flexibility and continuity of care. There was a duty system in place that ensured any urgent issues were dealt with in a timely manner. There were low numbers of complaints.

• Well-led

Staff were aware of trust values. Staff told us that managers listened and they felt valued and supported. Supervision and appraisal were comprehensive and up to date. Clinical audits were regularly undertaken. Staff morale had improved since managers had become established in their role.

However

• Mandatory training in basic life support was significantly below the trust target of 85% and below 75% for infection control.
• Compliance with mandatory training across all teams was lower than the trusts’ target of 85%.
• Training levels in the Mental Capacity Act and Mental Health Act were both significantly low.
• The rights of patients subject to community treatment orders were not always being met. Patients were not referred to an independent mental health advocate after being placed on a community treatment order and their capacity to consent was not always recorded.
• Carers were not always offered a carers assessment to ensure their needs were being met.
• Patients were not always offered a copy of their care plan or given the opportunity to develop advanced statements about their care with staff.

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

• There was effective and timely discharge planning at Meadowbrook and Moorside units. This meant that patients did not have to stay in hospital longer than necessary.

• Physical health checks were in place for all patients. This was achieved by using a physical health intervention tool. Staff were specifically trained in delivering this aspect of care. This meant that patients being admitted to the service had their physical health needs met.

• Risks assessments were in place for all patients. These were regularly reviewed and updated when necessary. This meant that staff were aware of risks and that patients and staff safety was managed well.

• There was effective multidisciplinary team working. A range of professionals had input into patient reviews and other ward meetings. This meant that patient care was holistic and barriers to recovery and discharge were challenged and overcome.

• The psychology provision at the Rivington unit was embedded in the ward culture and was well resourced. There were daily patient sessions available that focussed on relapse prevention and staying well.

• The service had an efficient system in place regarding bed management. Patient admissions were not unnecessarily prolonged and patients were rarely placed out of area. This enabled new patients being admitted to stay in their local area.

• All wards had access to occupational therapy. This meant that patients needing support with independent living skills or other needs could have this support whilst an inpatient.

• The food provided to patients was of good quality and variety. Patients had a choice of healthy meals and dietary or religious requirements were catered for.

• The senior management team were a visible presence on all wards. This meant that patients and staff were aware of whom the managers were and that they were accessible.

However:

• Environmental difficulties in observation/clear lines of view and ligature risks were evident in each ward area. Staff described mitigating environmental risks with increased observation of patients.

• There were inconsistencies in application of the environmental assessment tool used on wards with similar risks and patient populations, particularly the window design which was identified on the trust’s risk register but not in the environmental assessment of risk.Six wards had environmental assessments with action planning in place and three had none. Patients may be exposed to unidentified risks if these tools are not applied consistently over all areas.

• Not all staff had the opportunity to access supervision or appraisal.

• Mandatory training levels were low for basic life support and immediate life support, with three wards with no staff trained in immediate life support. Checks on life support equipment had failed to identify out of date oxygen on two wards. Lack of training in life support and faulty equipment could compromise the safety of patients.

• De-stimulation rooms were used to calm patients on some wards. However, patients were prevented from leaving due to behavioural disturbance. Staff were also not following the checks and safeguards of the MHA Code of Practice.

• Staff were not adequately trained in the MHA or Mental Capacity Act. This meant that patients’ rights could be compromised.

We rated forensic inpatient/secure wards as good because:

• Care and treatment was provided by a multidisciplinary team of staff, which included doctors, nurses and healthcare assistants, occupational therapists, psychologists, social workers and pharmacy.

• Patients were assessed and care plans were developed. Staff understood patients’ needs.

• The findings of the friends and family test showed that people were generally satisfied, except for the availability of activities. Patients were mostly positive about the staff. Patients felt involved in their care plans, but there was limited evidence of this in the records.

• Patients were involved in decisions about the service, which included the recruitment process and the recovery academy. There were regular community meetings where patients could give their views of problems or developments in the service.

• The service routinely reviewed its use of restrictions on patients. This was balanced against the need for security procedures to keep patients and others safe.

• The service provided 25 hours of activity to patients per week, and monitored this target. Patients had access to the Patterdale Centre, which provided activities such as a gym and bike riding. The Edenfield Centre had a branch of the recovery academy, which provided therapy and activity groups, some of which were co-produced with patients. Work opportunities were provided for patient, which included painting and decorating, and car valeting.

• The service used the trust-wide governance structures for monitoring the quality of care and of the service. This included reporting incidents, feedback about complaints, safeguarding and staffing. Ward managers monitored and took action on key performance indicators. These included staffing levels, training, supervision, if recovery care plans were in place, and activities.

• The trust had initiatives where managers could apply for one-off funding to improve their service. This had been used to install a Zen garden, and a new patients’ kitchen.

• The wards had environmental risks, but staff managed these and there was an ongoing programme of refurbishment to remove them. The wards were clean and maintained.

• Staffing levels were monitored, and recruitment was ongoing. There was pressure on staff, but leave and activities were rarely cancelled because there was not enough staff. Staff received regular supervision, training and appraisal.

• Medication was stored correctly.

However:

• Not all the care plans were patient-centred or recovery focused. There was a new electronic records system, and many staff found it difficult to use or find information in it.

• Training in the Mental Health Act and the Mental Capacity Act was limited. There were errors on consent to treatment forms under the Mental Health Act.

• Although staff explained patients’ rights under the Mental Health Act and requested support from independent mental health advocates appropriately, staff did not consistently record this information in individual patient care records.

• Not all eligible staff across the wards we visited had completed mandatory training in basic life support and intensive life support.

• When staff administered rapid tranquilisation, physical health checks were not always completed consistently afterwards which may put patients at risk.

• Staff had not always completed medication records correctly, and there were gaps in charts. There was a process for reporting and learning from medication errors, and nurses worked through a competency process to ensure they were safe to practice.

We rated wards for older people with mental health problems as requires improvement because:

• Bollin and Greenway wards did not comply with Department of Health’s guidance on eliminating mixed sex accommodation.

• The layout of the wards did not allow staff clear lines of sight. This risk was not mitigated on any of the wards by the use of mirrors, risk assessments or staff observations. Staff had identified ligature points (places where someone intent on self-harm might tie something to strangle themselves) and took action to remove or minimise risks.

• On all of wards National Institute for Health and Care Excellence (NICE) guidance was not being followed in relation to rapid tranquilisation. On Bollin and Greenway wards staff we spoke to were not aware of the trust policy in relation to physical health monitoring following rapid tranquilisation. On Holly ward one episode rapid tranquilisation had not been logged as an incident as required by the trust policy.

• The staff did not always follow best practice with respect to recording of capacity assessments and best interest decisions. There were issues on all five wards with the recording and reviewing of patients’ rights when detained under the Mental Health Act (MHA). There was a lack of evidence that leave was routinely risk assessed prior to authorisation or that the outcome of any specific period of leave was reviewed consistently. The leaflets provided to patients detailing their rights under the MHA did not include the most up to date contact details for the Care Quality Commission.

• Training levels were poor for the MHA and Mental Capacity Act. This was at 21% at the time of our inspection. Only 60% of staff across the older adult wards had received an annual performance appraisal.

However:

• The wards were clean and tidy and maintained to a high standard.

• There was a sufficient number of staff on the wards to provide people with the care and treatment they required.

• There was good multidisciplinary team working and staff engaged well with community teams as well as external organisations.

• The clinical leadership on the ward was clear and all staff said that they felt supported and listened to. Staff were aware of the trust vision and values and were committed to providing good care in line with this.