Greater Manchester Mental Health NHS Foundation Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people’s needs were usually met, through good organisation and delivery. Staff managed beds well. A bed was available when a patient needed one. Patients were not moved between wards except for their benefit. Patients did not usually have to stay in hospital when they were well enough to leave. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships. Staff helped patients with communication and advocacy. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Some patients with protected characteristics, for example relating to race or disability, did not have care plans or additional assessments on their records relating to these needs or aspects of their identity. Some of the patients we spoke with (4 out of 55) said they were not able to access food which met their individual needs, this was also fed back to us by 2 of the 12 family carers we spoke with. A patient also told us that they had not been able to access spiritual support as the chaplain had stopped visiting their ward, although all the ward managers we spoke with said there were systems in place for all patients to access the trust’s multi-faith chaplaincy service.

Most of the patients we spoke with said that staff did their best to meet their needs as an individual, however 22 out of the 55 patients we spoke with told us that staffing pressures on the ward, leading to the increased use of bank staff, impacted staff’s ability to meet their individual needs at times. Some examples of this the patients gave us included patients having to wait for leave or having leave cancelled, not being able to make phone calls, family visits not being facilitated as often as they would like, not having 1:1 sessions with staff, delays to substance misuse interventions and a lack of varied activities that met their needs. This was also raised by patients in 1 of the 2 community meetings we observed.

However, most of the records we reviewed did include care plans which reflected a person-centred approach to the patient’s care and treatment. Patients had sections of their care plans relating to individual needs where needed, such as the management of a specific physical health condition during their admission. We saw evidence in care records, and during our observations on the wards, that patients had access to a range of activities and educational opportunities to meet their needs. Minutes of the weekly community meetings showed that people were asked at these meetings if there were any additional activities they would like to request. We saw during the shift handovers we observed, and from handover records, that each individual’s current needs were discussed at each handover to ensure the incoming staff were enabled to deliver person-centred care to each patient.

Patients received support to make their own decisions about their care and treatment as much as possible. There was evidence of patient involvement in 20 out of 22 care plans and 19 out of 22 risk assessments we reviewed. In 18 out of 22 sets of records we found the care plans were written in accessible language to support patients’ understanding of their care. The ward rounds we observed were attended by the patient and they were included in the discussions about their ongoing care, with their views and preferences taken into account. Patients and staff told us that patients had access to independent advocates on all the wards to support them in communicating their needs and preferences and we saw advocacy reports which confirmed this. However, we identified some gaps in the records in relation to whether the safeguards required by the Mental Capacity Act were fully in place for people who may have lacked the capacity to make some decisions about their care.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

When appropriate, staff ensured that patients had access to education and training opportunities. We saw in the care records, and some patients confirmed, that patients had access to a range of educational opportunities through the Recovery Academy which was on site at the Riverside Centre.

Staff supported patients to maintain contact with their families and carers. All patients had access to a mobile phone on the ward. Where smart phones were not allowed, for example on the medium secure male wards, patients had access to the internet under staff supervision at the Recovery Academy. However, some patients, who did not have leave from their ward, said they would have liked to have internet access on the ward as well. People’s capacity to access section 17 leave from the ward was regularly reviewed at their ward rounds and, where they did not have access to leave, they were able to meet with visitors at the hospital.

We saw evidence on the care records, and during the ward rounds we observed, that patients received continuity of care as they moved between services. For example, where patients were ready to move from a medium secure to a low secure ward, or from an admissions ward to a less acute ward, this was facilitated without undue delay and staff on the new ward were able to immediately access the patient’s care and medication records through the electronic systems.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. All the incidents we reviewed which should have been notified to CQC, for example absences without leave, had been notified without delay, this included incidents which took place while we were on site for the assessment. The ward managers we spoke with described the systems they had in place for ensuring that incident notifications were made to CQC, local authority adult safeguarding teams and NHS England as required. Commissioners told us that the trust was open with them and usually shared relevant information without delay, although also said there could be some delays in the trust reporting serious incidents to NHS England’s Strategic Executive Information System (StEIS).

There were information governance systems to ensure the confidentiality of patient records. Records were stored on a password protected electronic system and staff received information governance training as part of their mandatory training. On all the wards, with the exception of Eskdale (82%), over 90% of staff were up to date with this training at the time of our assessment. We did not observe any concerns in relation to the confidentiality and security of patients’ personal information during our time on the wards.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights and how to complain. Patients on all wards received a pack of written information on admission which included information about the ward, activities available, their rights under the Mental Health Act as a detained patient and how to access an independent advocate and raise concerns about their care. Ward managers told us that this could be translated into other languages if required by an individual. Information was also displayed for patients, staff and visitors on noticeboards on all the wards we visited. The trust told us that family carers were supported to access relevant information by a carers support worker who worked across the whole of the forensic inpatient service. However, the feedback we received from carers about their access to information was mixed, with some saying they were happy with the information provided and others saying they did not receive information about the care their relative was receiving or other relevant information such as how to access a carer’s assessment.

The service complied with the Accessible Information Standard, which is a legal requirement for all NHS and adult social care organisations to ensure people with disabilities or sensory loss can easily access information and communicate effectively. The trust monitored implementation of this through their equality, diversity and inclusion oversight group which reported to the people and culture committee, a sub-committee of the trust board.

Staff usually ensured carers, families and commissioners were regularly updated about the patient’s progress. Commissioner feedback confirmed this, however out of the 12 carers we spoke with, 5 told us that they did not get sufficient information about their relative’s progress.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

There were a range of systems in place on the wards for patients and carers to feed back about their experience of the care provided, including weekly community meetings on all wards, surveys, PLACE (patient led assessment of the care environment) assessments, patient and carer experience forums and complaints processes. We observed 2 community meetings taking place during our time on the wards and we saw minutes which showed that these were taking place regularly on all 9 wards. The patients we spoke with were aware of the community meetings taking place and said they were able to attend if they wished to. Information about the community meetings was also displayed on noticeboards on the wards. We saw evidence of action being taken in response to patient feedback in ‘you said, we did’ bulletins for patients. The advocacy service also held a monthly patient empowerment meeting which provided another avenue for patients to raise concerns and have their voices heard. However, the advocacy service told us that patients had raised concerns about these systems not being effective as they were given no feedback about actions taken in response to the concerns raised. The advocacy service had also raised this with the leadership team for the forensic service so action could be taken in response. The advocacy service also told us that a number of patient experience group meetings had been cancelled prior to our assessment, which had increased patients’ concerns about not having avenues for their voices to be heard. Some family carers (2 out of 12) said they were not given any information about how to complain or raise concerns about their relative’s care.

Levels of complaints about the service were low (9 formal complaints across all 9 wards in the 12 months preceding our assessment). The patients we spoke with confirmed they were aware of the process for raising concerns about their care and said they would feel comfortable doing this if needed, for example by speaking to a member of staff on the ward. We saw that information about the complaints process was displayed on noticeboards on the wards and it was included in the written information provided to patients on admission. The service also tracked compliments received from patients (22 received in the 12 months preceding our assessment).

Staff received feedback on the outcome of complaints investigations and acted on the findings. Compliance with complaints timescales and the implementation of actions following complaints was monitored by the trust’s patient safety and patient and carer experience groups. We saw minutes of these groups’ meetings which confirmed this. Managers and staff told us that lessons learned from complaints were shared at team meetings. This was not confirmed by the team meeting minutes we reviewed, but this was likely to be due to the low numbers of complaints received across the service. The advocacy service fed back to us that individual complaints and concerns were acknowledged and resolved promptly, but said that responses to formal complaints could be delayed at times.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service was accessible to people who needed it. There were no delays or barriers to admission for patients who had been assessed as suitable to receive care on the wards. Managers told us that admissions panels and a fortnightly patient flow meeting took place to ensure admissions to and discharges from the ward were kept under review and progressed without undue delays. The wards were gradually re-opening to new admissions in accordance with a plan agreed with the commissioners of the service and other local healthcare partners at the time of our assessment.

Staff ensured the needs of patients with mobility issues were met. All the wards were fully accessible to wheelchair users and others with mobility impairments. Staff made reasonable adjustments for patients, for example providing mobility aids where these were needed.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital. Managers and staff told us, and care records confirmed, that patients had access to medical care at all times when this was needed.

Staff planned for patients’ discharge, including good liaison with community care co-ordinators and social workers. Discharge could be delayed for other than clinical reasons at times, for example due to barriers in arranging suitable ongoing care or support for the individual in the community. In the last 12 months, there was an average of 3 delayed discharges per month on the male forensic wards and an average of 4 per month from the women’s wards. Staff and the manager on Isherwood ward raised concerns about delays with the discharge pathway for some patients. Managers told us that there was ongoing communication between the multi-disciplinary teams, particularly the social workers, and community services to try to mitigate these barriers and facilitate timely and appropriate discharge for patients.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. Most of the staff we spoke with told us that they felt the culture on their ward had improved since our last assessment and was now more open and supportive for both patients and staff. We did not identify any concerns about any patients experiencing discrimination for any reason during our assessment. Some staff with a Black or minority ethnic origin reported experiencing racist abuse from some patients at work but they also said they felt well supported by the trust in relation to this. The response to staff experiencing racist abuse had been the subject of a recent quality improvement project across all the forensic wards.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. This had taken place for all the written policies we reviewed as part of our assessment.

Staff were trained in equality, diversity, inclusion and human rights. This was part of the mandatory training for all staff and over 90% of staff on all wards were up to date with this training at the time of our assessment.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make decisions about their care and treatment and their future. Patients usually had care plans relating to their discharge from the ward from the point of admission and these were kept under regular review at ward round meetings.

Due to the nature of the services provided, patients were not usually in need of end of life care during their time on the wards. The trust confirmed that, in the rare event of a patient needing end of life care during their admission, they would work closely with local acute and community healthcare providers to ensure their holistic needs were met.

Staff ensured that all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. This included liaison with prison and probation services where the patient had been convicted of a criminal offence and/or was subject to Ministry of Justice restrictions in relation to their discharge from detention under the Mental Health Act.