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Provider: Greater Manchester Mental Health NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 23 February 2018

Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Our rating of the trust stayed the same. We rated it as good because:

  • We rated eight of the nine core services as good, with one service rated as requires improvement. This takes account of the ratings of the four core services that we did not inspect this time
  • We rated safe as requires improvement, effective, caring, responsive as good.
  • We rated well-led at trust level as outstanding. The leadership team had effective oversight of the risks and challenges for the trust. They had overseen a very quick acquisition of a failing trust and were managing to maintain a strong clinical and financial performance. The trust was working in partnership with other organisations, including the housing and voluntary sector to promote well-being and good mental health. The trust carried out thorough investigations into serious incidents and had well established systems for learning lessons. The trust apologised when things went wrong. There were established systems for involving carers and service users with the transformation plans in Manchester demonstrated true co-production.
  • Staff generally managed risks well, with risk assessments well completed and reviewed. Staff recognised and reported safeguarding concerns and incidents. Staff understood the duty of candour. Although there were vacancies and sickness, systems ensured there were sufficient staff. Although some training courses were below trust target, the trust had taken steps to ensure there were enough skilled staff to provide care. Medicines were managed safely. Risks related to the two electronic management systems were being managed.
  • In four of the five core services we visited, care plans were holisitic and patient centred. This was not always the case in acute wards for working age adults and psychiatric intensive care units where care plans were not always personalised. There was a comprehensive audit programme and effective systems to monitor action plans. Although people’s rights who were detained under the MHA act were protected, we found that in wards for older people, there were issues with forms of authorisation and requests for second opinion doctors.
  • Feedback from people using the service was positive, with patients and carers telling us that staff were supportive and kind. Patients and carers gave us examples where staff had gone the extra mile to support them. People were generally involved in planning their care although this was not always the case in acute wards for adults of working age and psychiatric intensive care units. Feedback from substance misuse services was universally positive during the inspection and received the highest proportion of compliments by the trust.
  • Services were responsive to the needs of the population they served. Following the acquisition of Manchester out of area placements were high; the trust had plans in place to address and effective systems to monitor this. The transformation plans in Manchester were reviewing care pathways to improve access to services. Staff, patients and carers were involved in developing services. Complaints were well handled locally and at trust level.
Inspection areas

Safe

Requires improvement

Updated 23 February 2018

Our rating of safe stayed the same. We rated it as requires improvement because:

  • We rated three of the nine core services as requires improvement and six as good. We took into account the ratings of services not inspected this time.
  • In acute wards for working age adults and psychiatric intensive care units, staff had not always identified environmental risks and staff were not aware of them. There were blind spots and staff had not mitigated these in Eagleton, MacColl and Chaucer wards.There were environmental concerns in acute wards for working age adults and psychiatric intensive care units, Eagleton and Keats wards had challenges with their plumbing and drainage systems. There were stains on the ceiling of Eagleton and Blake wards. The outdoor space at Maple House and Elm ward contained cigarette ends and rubbish at Maple House. Anti-barricade doors did not open both ways for three of the rooms on Brook and Medlock wards.
  • In acute wards for working age adults and psychiatric intensive care units, staff were not following the trust’s policy in relation to rapid tranquilisation. The monitoring forms for physical observations were not always available within records.
  • In child and adolescent mental health wards, checks to ensure that equipment was safe to use had not always been carried out.

However:

  • Staff assessed and managed risks. Staff completed risk assessments with patients which were reviewed as necessary. There were no blanket restrictions.
  • Staff recognised abuse and reported safeguarding and incidents effectively. Staff and patients received a debrief following incidents.
  • Staff understood the duty of candour and followed trust processes. There were supportive systems in place to help share learning after things went wrong.
  • Medicines were managed well, with a good level of support from the pharmacy team. Although, staff were not always using the trust monitoring form after using rapid tranquilisation, staff were usually recording observations to monitor people’s health.
  • All wards complied with the guidance on same sex accommodation.
  • Although there were high vacancy rates, agency, bank and locum staff were used to keep people safe.
  • There were challenges with two electronic management systems in place which were being managed.
  • There were established systems for sharing learning. Staff described learning events as positive and supportive.

Effective

Good

Updated 23 February 2018

Our rating of effective stayed the same. We rated it as good because:

  • We rated seven of the nine core services as good and two as requires improvement. We took into account the ratings of services not inspected this time.
  • The trust provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs. The service made adjustments for patients’ religious, cultural and other preferences.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Although the trust was using two electronic management systems since acquiring Manchester services, the trust had taken steps to reduce the risks associated with this. There were plans in place to align the systems once remedial work had been completed
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

However:

  • In wards for older people, authorisation was not always in place for giving medicines to people who were detained under the Mental Health Act.
  • In acute wards for working age adults and psychiatric intensive care units staff were not always receiving regular supervision.
  • Care plans were not always person centred in acute wards for working age adults and psychiatric intensive care units. 
  • Not all patients with a learning disability who were being cared for on acute wards had care plans in an accessible format.

Caring

Good

Updated 23 February 2018

Our rating of caring stayed the same. We rated it as good because:

  • We rated eight of the nine core services as good and one as outstanding. We took into account the ratings of services not inspected this time.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.

However:

  • In acute wards for working age adults and psychiatric intensive care units, staff did not always give patients a copy of their care plans.

Responsive

Good

Updated 23 February 2018

Our rating of responsive stayed the same. We rated it as good because:

  • We rated eight of the nine core services as good and one as outstanding. We took into account the ratings of services not inspected this time.
  • The trust planned and provided services in a way that met the needs of local people. The trust was transforming the delivery of care in Manchester and working to reduce the number of out of area placements. Patients, carers and staff were involved in the plans and listened to.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • There was a strong focus on recovery with the use of the recovery model and a vibrant recovery college which was highly valued by staff, patients and carers.

Well-led

Outstanding

Updated 23 February 2018

Our rating of well-led improved. We rated it as outstanding because:

  • The entire inspection team were struck by how well the leadership team had brought the Manchester services into the trust and improved them. The relationships with stakeholders for Manchester services, including staff, unions and commissioners had improved. There was a strong commitment to provide the best care for all patients across the service.
  • Leadership, governance and culture promoted the delivery of high quality care. Leaders were visible and approachable. Leaders understood the challenges to the service and took actions to address them. Staff across services spoke highly of the leadership shown during the acquisition of Manchester services.
  • Leaders understood the challenges for the trust and worked together to ensure delivery of services.
  • Strategies and plans in place were challenging and innovative and fully aligned with the wider health economy. There was a systematic and integrated approach in place to monitor the progress against plans. Plans were consistently implemented and had a positive impact on the quality of services. This was seen in the transformation plans for Manchester.
  • There was an open and transparent approach when things went wrong. Staff were proud to work for the organisation and spoke highly of the culture. Although staff were encouraged to speak up and there were systems in place to support this, the freedom to speak up network needed further embedding throughout the trust.
  • The trust had reviewed their governance arrangements to reflect best practice. Structures and processes were clearly set out and staff understood their responsibilities.
  • The trust identified, monitored and responded to current and future risks. There were effective audit processes in place and actions were taken when issues were identified. Service developments and cost improvement plans were developed with clinicians so that their impact on quality of care was understood.
  • The trust engaged constructively with staff and people who use services and developed services with their full participation. The trust showed that there was a commitment to act on feedback and co-production was evident in service development and training.
  • The trust gathered information to monitor and improve performance where necessary. Plans were in place to align the electronic information system across the trust following acquisition and plans in place to manage the risks whilst this was happening.
  • The trust worked proactively to gather people’s views about services. The trust had mature, open relationships with stakeholders about performance.
  • There were systems in place to support improvement and innovation. The trust were committed to implementing more sustainable models of care and worked collaboratively with others to share learning and make improvements.

However:

  • Although the trust has made great progress, there was still work to do to bring all services to a consistent level.

  • Although, there were networks and actions to promote opportunities for all staff, there was poor representation of staff from all backgrounds at management level.
  • The trust held figures for training did not reflect locally held figures in the services which were higher.
  • The freedom to speak up guardian role needed further embedding.
Checks on specific services

Acute wards for adults of working age and psychiatric intensive care units

Requires improvement

Updated 23 February 2018

Our rating of this service went down. We rated it as requires improvement because:

  • Ligature audits did not include all ligature risks. Staff were not advised of ligature risks within the wards and how to mitigate these.
  • There were environmental concerns with drainage difficulties on Keats and Eagleton wards at Meadowbrook Hospital and stains on ceilings at Blake and Eagleton wards. Anti-barricade doors did not open both ways for three of the rooms on Brook and Medlock wards. We found there were blind spots on Maple House, Eagleton, MacColl and Chaucer wards not mitigated.
  • There were concerns with medicine storage, staff were not recording the minimum and maximum temperatures of medicine fridges. Staff were not following the trusts policy in relation to rapid tranquillisation, in relation to the timeliness of completing physical observations and the availability of these records.
  • Lessons learnt were not shared across different parts of the trust. Team meetings and supervisions did not have standard agenda items to discuss learning.
  • The service did not provide training for staff in how to support people who have a learning disability.
  • Care plans were not always person centred and staff did not always make them accessible for people with a learning disability except on Juniper ward. Care plans were nursing led and did not include the involvement of other members of the multidisciplinary team. Less than half of the patients we spoke with had received a copy of their care plan and felt involved in the process.
  • Staff did not receive regular supervision. Team meetings, handovers and supervisions varied in content across the wards.
  • The consent to treatment policy, time out, seclusion policy and standard operating procedure and Mental Health Act 1983: information policy did not comply with the current Mental Health Act code of practice.
  • There was limited access to psychology for patients. Patients had limited access to the gym at Meadowbrook hospital as only one member of staff was trained to enable patients to safely use the equipment.
  • We could not find evidence in records that staff were always explaining section 132 rights to patients. Staff were not supporting patients to create advanced statements and decisions regarding their care and treatment.
  • Seven patients told us that the agency staff who usually worked at night did not treat them well. They were dismissive, unresponsive and not approachable.
  • There were dormitory sleeping arrangements at Poplar, Mulberry, Redwood, Elm and Laurel wards. There was no examination couch in the clinic at Poplar and Mulberry wards, patients would not have their privacy and dignity protected if they required an examination.
  • Information advising patients how to contact the Care Quality Commission was not displayed on all wards.

However:

  • Staff had received training in and had a good understanding of safeguarding. Staff liaised with professionals and attended strategy meetings for patients.
  • Although staff training in immediate life support was low at 55%, the trust had systems in place to ensure that there was always a member of staff available who was trained in immediate life support.
  • Patients had detailed, individualised risk assessments in place. Staff and patients received a de brief following incidents.
  • The service managed medicines well, with daily visits from the pharmacy department to the wards. All clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines that were in date.
  • Staff received an induction to the ward and had an appraisal.
  • The majority of patients told us that staff were caring, supportive and responsive. We observed staff interacting with patients in a friendly, supportive and calm manner.
  • Staff gave welcome booklets to patients to assist with their orientation to the ward and leaflets were available for carers and contact details of the carers support services.
  • Staff responded to patients’ needs. Morning meetings took place with the ward managers, service managers and community mental health teams to discuss patient’s progress, discharge plans and support needs post discharge. Staff supported patients when admitted to acute hospitals, to provide consistency and mental health support. Staff booked interpreters to enable family members to be involved in the planning of care for their relatives. Patients had access to a variety of food and chaplaincy services.
  • Ward managers and deputy ward managers we spoke with were knowledgeable, motivated and skilled when interacting with both staff and patients. They could locate required information, and were able to give clear guidance and advice to staff. Patients and staff told us that ward managers were supportive and approachable.
  • The service implemented the recovery model of care, with patients being involved in staff training and recruitment and as peer mentors. Wards were recovery orientated with MacColl ward opening to meet the needs of Manchester patients. Recovery boards were in use to provide encouragement to patients.

Wards for older people with mental health problems

Good

Updated 23 February 2018

Our rating of this service improved. We rated it as good because:

  • The service had made improvements following our last inspection. Staff were now completing observations following rapid tranquilisation. The safety of the environment had been improved with better lines of sight and the use of parabolic mirrors and staff observations. The gender segregation on the two wards at Trafford was much improved. Documentation around patients capacity was clear and we saw good evidence of capacity being assessed when necessary and best interest decisions being made appropriately.
  • There was adequate staffing levels to ensure patients were well looked after and able to spend one to one time with staff on a regular basis.
  • There were good patient risk assessments on each ward. The service provided a safe environment and risks were managed well. Patients told us they felt safe on the wards.
  • Staff deescalated aggressive and potentially violent situations well. Staff knew patients well and were able to use distraction and diversion techniques when they saw a patient becoming agitated. For example, the use of activity equipment that focused on patients interests and hobbies.
  • There was effective multidisciplinary team working evident on all wards.
  • Patients and carers gave universally positive feedback about the care and treatment they received on the wards we visited. Staff involved patients in decisions about their care where possible. They engaged with and supported families and carers where appropriate. Staff contacted them with updates on patient progress, held regular carers meetings, and invited them to ward rounds.
  • Recent changes within the service had led to a positive change in staff morale. Staff focused on the needs of the people using their service, providing high quality patient centred care, which reflected the trust’s vision and values. Senior managers were committed to improving the environment at the Manchester wards and had identified that the dormitories on those wards needed to be changed as a priority.
  • Two wards at Woodands hospital were AIMS accredited. The two wards at Trafford were going through the AIMS accreditation process with draft reports available at the time of our inspection.

However:

  • Staff were not always using the trust approved form for physical health monitoring following rapid tranquilisation.
  • We found there were delays in requesting second opinion doctors when patients had been detained for three months and administered medication in order to complete a form T2 or T3 (dependent on whether the patient was able to consent to treatment). There were also delays in section 62 being completed (emergency treatment of a detained patient) with medication being administered without the correct legal framework across all of the Wards except Maple Ward. We also found examples of when a section 62 had been completed and medications were not on the list but being administered.
  • On Cavendish Ward we found examples where patients had not been read their rights at the correct times or when there was a change in their detention status.
  • There was a lack of privacy Bollin Ward where privacy screens on bedroom windows had been left open and there were no privacy curtains in the bathrooms on the main corridor.
  • At Trafford the wards were very small with no quiet space for patients to use if they wanted to. Activities had to be done in the main lounge which meant that patients who wanted to sit quietly would either have to go to their rooms or listen to the activities.

Child and adolescent mental health wards

Good

Updated 23 February 2018

Our rating of this service improved. We rated it as good because:

  • The service had made improvements in many of the areas which previously were highlighted as concerns.
  • There was a shared culture of embracing the organisational values.
  • There was a culture of reporting concerns and learning from incidents.
  • Use of restrictive practices was carefully monitored and used as a last resort.
  • Risk awareness was taken seriously and there was evidence of regular risk assessments being conducted.
  • The senior management team met routinely with staff and had a presence within clinical areas.
  • There were real attempts to engage patients with every aspect of the service and develop their skills through work and education opportunities.

However:

  • Although most equipment was checked so it was safe to be used, not all safety checks had been completed when due.
  • The service did not always ensure patients understood interventions including medication.
  • Although physical observations were usually carried out, in one case we could not find records to show they had been completed.

Substance misuse services

Outstanding

Updated 23 February 2018

We have not previously inspected substance misuse services. We rated it as outstanding because:

  • There was a very strong recovery emphasis throughout the service. Staff worked with clients to help identify their goals and to develop their recovery capital. Staff were knowledgeable about local recovery and support services and they were promoted within teams.
  • Services were tailored to meet the needs of individuals and were delivered in a way that offered flexibility and choice. There were different pathways within community teams to address individual need and an innovative rapid access to alcohol detoxification pathway within inpatient services.
  • Client and carer feedback on the service was overwhelmingly positive. Clients spoke highly of staff and their supportive nature. Clients and carers were active participants in care and in decisions about treatment. Carers were able to access carer assessments and relevant support.
  • There was excellent multi-agency working. Services worked collaboratively with partner agencies within the local treatment network as well as with physical health services. There were clear referral processes into support services and mutual aid groups. Staff were active in facilitating client engagement.
  • The service employed volunteers and peer navigators with lived experience of substance misuse and recovery. Clients we spoke with talked positively about staff members and the visual representation of recovery that they provided.
  • There was excellent engagement with the community. Clients were encouraged and supported to attend community groups and services. There were community leads within teams to develop effective links and ensure that recovery was embedded within the team. There was a building recovery in the community asset fund that clients and staff could access to support new projects such as community allotments or trainee kitchens.
  • Clients and carers were able to give feedback on the service they received in a variety of manners. The service responded to feedback and developed action plans to address concerns.
  • Buildings were clean and well maintained. There were regular checks of equipment and maintenance records were in place. There were appropriate health and safety checks.
  • Staff actively managed client risk. Staff worked collaboratively with clients to complete risk assessments and develop risk management plans. The service prescribed in line with risk assessments and utilised methods such as supervised consumption to manage the risk of overdose or diversion. There were strong processes and procedures to manage safeguarding concerns and effective links with local authorities.
  • Staff had been trained to deliver psychosocial interventions. Services offered a range of one to one and group sessions to meet client need. Clients we spoke with were positive about the psychosocial interventions they received
  • There was a good governance structure. Quality of service provision and performance was monitored. Service and team managers were well regarded by staff. The service engaged effectively with stakeholders when introducing change.

However:

  • Staff in community services did not use personal alarms in a consistent manner.
  • Staff in community services did not always record consideration of mental capacity.
  • We found three care records where there was no consent to treatment or confidentiality agreement in place.
  • Although information sent by the trust showed six mandatory training courses below 75% compliance, local figures and staff confirmed training rates were higher. We observed skilled staff, competent in their role.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 23 February 2018

Our rating of this service stayed the same. We rated it as good because:

  • The locations inspected were clean and equipped appropriately.
  • Staffing levels showed that very few vacancies existed within the service, and that shifts were adequately covered.
  • Care plans and risk assessments were completed in a holistic and comprehensive manner, taking into account the opinions of patients in the service.
  • Staff mandatory training compliance averaged above 80% for the service.
  • Activities for patients were meaningful, designed with an aim to not only keep patients engaged but to give skills for use in the community, including access to a recovery academy for both patients and staff.
  • Patients were positive in their comments regarding care in the service, and we saw evidence of positive interaction between staff and patients at each location inspected.
  • The Mental Health Act and Mental Capacity Act were observed and noted to be applied correctly.
  • There were very few complaints across the service, and we saw evidence of shared learning from complaints that had been investigated.
  • Key performance indicators were used to guide and improve practice across the service.
  • The service was due for Accreditation for Inpatient Mental Health Services under the Royal College of Psychiatrists.

However:

  • Acacia ward was in need of refurbishment and consideration for a total environment change: the trust had plans in place for implementation of such a change.
  • We saw a table used to inform staff of mandatory training figures was not importing the correct data in relation to immediate life support training, giving an incorrect data set in regards to said training; this was dealt with immediately on identification of the problem.
  • The sickness rate for staff was at 9%, but was only at 5% for the year to date.

Community-based mental health services for adults of working age

Good

Updated 3 June 2016

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.

Community-based mental health services for older people

Good

Updated 3 June 2016

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.

Forensic inpatient or secure wards

Good

Updated 3 June 2016

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.

Mental health crisis services and health-based places of safety

Good

Updated 3 June 2016

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.