The Care Quality Commission (CQC) has published a report following an inspection of services provided by Greater Manchester Mental Health NHS Foundation Trust. CQC found a deterioration in how well-led the trust was, which was having a significant impact on the standard of care being delivered to people using their services.
Unannounced inspections were carried out at the following services in June after CQC received concerns about the safety and quality of care being provided:
- acute wards for adults of working age and psychiatric intensive care units (PICU)
- forensic inpatient and secure wards
- mental health crisis services and health-based places of safety.
CQC also carried out an announced inspection in July of how well-led the trust is overall. However, due to concerns about services provided by the trust - including community mental health services, prison services and older people’s services - which came to light since this inspection, it was necessary to conduct further inspections, and the overall trust rating including for well-led has been suspended as a result. The rating suspension will remain in place until CQC returns to the trust to carry out a further trust-wide well-led inspection.
Following the June inspection, the overall rating for the acute wards for adults and PICUs has deteriorated from good to inadequate. The safe and well led domains also dropped to inadequate. The ratings for effective, caring and responsive moved from good to requires improvement.
The overall rating for forensic inpatient and secure wards dropped from good to inadequate, as have the safe and well-led ratings. How effective, caring and responsive the service is has declined from good to requires improvement.
However, the mental health crisis services and health-based places of safety remained rated as good overall and for being safe, effective, caring, responsive and well-led.
As a result of these inspections CQC took enforcement action, serving the trust with two Section 29A warning notices - one relating to ligature and fire risks, and another relating to staffing and governance, requiring significant improvements within a set timescale. A further inspection will be carried out to ensure action has been taken to comply with the warning notices. CQC will continue to monitor the progress of the other areas for improvement.
CQC have also recently carried out inspections at other services run by the trust. HMP Wymott and HMP Garth were inspected to follow up on information received regarding concerns around medicines management, and these reports have published on our website.
CQC also inspected community-based mental health services for adults of working age to follow up on previous enforcement action, and an inspection of wards for older people with mental health needs was carried out in response to receiving whistleblowing concerns. These reports will publish in due course.
Following the inspections in June and July, undercover footage showing staff subjecting people to abuse on Buttermere ward in the Edenfield Centre was broadcast. In response CQC worked with the trust, the local authority safeguarding team, NHS England and the police as well as other partners to ensure people were safe. The trust carried out clinical reviews of people affected, and they immediately suspended and subsequently dismissed a number of staff. The trust has since closed Buttermere ward and moved people to alternative services. CQC suspended the trust’s ratings for forensic inpatient and secure wards until this report published, due to concerns about the quality and safety of services.
CQC will continue to work closely with NHS England, as well as other partners to ensure urgent improvements are made and embedded.
Ann Ford, CQC’s director of operations network north, said:
“Our inspections of Greater Manchester Mental Health NHS Foundation Trust in June and July were prompted by information of concern and we took enforcement action as a result. We found that leaders hadn’t taken action to remove risks in order to keep people safe, and that the board didn’t have full oversight of the risks which were present within clinical areas and their impact on people’s care.
“Mandatory training figures were poor, and the trust hadn’t ensured enough staff were adequately prepared in areas such as fire safety, safeguarding, as well as basic and immediate life support which could place people at significant risk of harm.
“Across the services we looked at, there weren’t enough registered nurses and healthcare assistants to ensure people got the care and treatment they needed with staff frequently working under the minimum staffing levels.
“Not all ward environments we saw were safe and clean and we had significant concerns about the fire safety on some wards. It was also very worrying that ligature audits were poor. They didn’t identify all risks or effectively mitigate them to keep people safe.
“However, we did see some really good care and management in the mental health crisis team, with staff and managers displaying the values of the trust and working well together, and with external agencies to provide timely and compassionate care for people. Other leaders at the trust should look to this service to see what learning can be applied to other departments.
“Since our inspections in June and July, we’ve been contacted by whistleblowers and additional serious concerns have emerged. We have carried out further inspections in other services run by the trust in response to those concerns and found further breaches of regulation which the trust must address as a matter of urgency. We expect to see leaders make rapid and widespread improvements and will continue to closely monitor this progress. We will return to carry out further inspections to ensure action has been taken and the quality and safety of services has improved.
“If we’re not satisfied people are receiving safe care, we will not hesitate to take further action in line with our regulatory powers.”
Across the areas inspected CQC found:
- Services were not well-led, and processes did not ensure that wards were safe. Ward based audits were undertaken by managers and matrons, but the results were not always acted on.
- Dormitory accommodation remained in place in some services and this did not protect dignity, privacy and safety. There were significant concerns about the sexual safety of people on mixed sex wards.
- Clinic room temperatures and medicines fridge temperatures were not always checked, and staff did not consistently act when issues were identified.
- Systems were not effective for the proper and safe management of medicines. Physical health observations to review the effects of medicines were not continuously completed and documentation was not always available.
- The trust did not always provide effective care in all services. Paperwork for consenting to, or not consenting to medicines, was not always accurate or available. Staff in the acute wards did not always ensure that people were aware of their rights.
- Services were not always caring, some people told inspectors that wards were noisy and chaotic, and they did not always feel safe.
- The trust did not provide responsive care in all services. Bed occupancy often exceeded 100% and people did not always have a bed when they returned from leave. The acute wards regularly used rooms designed for other purposes as bedrooms.
- People said there was a lack of therapeutic activity.
- Not all staff were receiving effective, regular supervision and appraisal.
However, inspectors also found some areas of good care within the mental health crisis team:
- Staff working for the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to people’s needs.
- The mental health crisis teams included or had access to the full range of specialists required to meet people’s needs. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
- The mental health crisis service and the health-based places of safety were easy to access. Staff assessed people promptly and those who required urgent care were taken onto the caseload of the crisis teams immediately.
- Staff felt supported and respected by their immediate line managers.
- The trust had set up community-based crisis cafes within each locality. Some of these had been developed and were delivered in conjunction with third sector organisations.