Greater Manchester Mental Health NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Patients were not always receiving care from sufficient numbers of appropriate skilled and qualified staff. We found that staffing shortfalls, particularly in relation to registered mental health nurses, were negatively impacting on patient care, reducing access to leave from the hospital and affecting staff wellbeing. We also found that staff were not always up to date with their mandatory training for some modules on some wards, and temporary staff did not always have an induction documented when they first started working on the ward. We also found some shortfalls in the systems for managing medicines and mitigating clinical and environmental risks.

However, the wards were safe and clean and patients and carers told us that this was usually the case. We saw that security and safeguarding procedures were followed, and patients were protected from abuse and improper treatment. The processes for reporting and investigating incidents were followed and lessons learned from incidents were shared with staff. Information relevant to people’s care was shared between teams to ensure safe continuity of care, for example at shift handovers. Patients were receiving the level of therapeutic observations they had been prescribed and records showed that this was happening consistently. The patients we spoke with told us that they felt safe on the ward and reported low levels of restrictive interventions such as physical restraint. Records also confirmed that restrictive interventions were not frequently used and, when they were, safeguards were in place to ensure that restrictive practice was minimised as much as possible.

The service was in breach of Regulation for safe care and treatment (Regulation 12) and staffing (Regulation 18).

This service scored 59 (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 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were 4 serious incidents which occurred on the forensic and secure wards in the 12 months preceding our assessment. This included a serious incident which occurred while we were on site (out of office hours) and we observed a timely and effective response to this including senior management support for the ward staff and prompt liaison with Greater Manchester Police.

The staff we spoke with knew what should be reported as incidents and how to use the reporting system. We reviewed incident records and saw that a range of concerns were being reported as incidents, including staffing pressures and shortfalls in care identified from audits as well as incidents occurring between patients. Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigations of incidents, both internal and external to the service, at team meetings and through regular email bulletins and newsletters. This included a safety alert about the incident which occurred while we were on site, which demonstrated this happening promptly following significant incidents. The staff we spoke with confirmed that they received this information.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Managers described how the assessment of patients started at the point of referral, prior to the patient’s admission to the ward. We saw detailed assessments of risks and care needs on the records we reviewed. Some of the wards had only recently recommenced admitting new patients and the managers and staff we spoke with told us how staff had been prepared for this change.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Patients had access to a range of multi-disciplinary healthcare professionals within the service and we also saw evidence on records that referrals were made to other specialisms where needed, for example dieticians or speech and language therapists. Patients’ community care coordinators were able to dial in to patients’ ward rounds where appropriate. We also saw evidence on the care records of effective information sharing with criminal justice services where patients had been transferred from prison.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Safeguarding children and adults training at levels 1, 2 and 3 as appropriate to job role was part of the mandatory training for all staff. Compliance rates for staff being up to date with this annual training were above 80% on all wards with the exception of Ferndale ward for level 3 safeguarding adults (77%) and level 3 safeguarding children on Rydal ward (78%) and Ferndale ward (69%). Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The staff we spoke with were aware of the procedures for reporting safeguarding concerns and could give relevant examples of things they would report as a safeguarding issue, for example unidentified bruising and concerns about financial abuse. The recent safeguarding referrals from each ward demonstrated a range of relevant issues being reported.

Managers and commissioners described effective working relationships with local safeguarding stakeholders. Senior managers described the overarching systems the forensic service had in place for oversight and quality assurance of the safeguarding systems. We saw evidence on people’s records of action being taken in relation to concerns about abuse or neglect. Most of the patients and carers we spoke with told us that they or their relative felt safe on the ward. Staff followed safe procedures for children visiting the service. There were family visiting rooms available off the ward for children to visit their relatives where appropriate. However, the commissioners for the service told us that there were some delays to safeguarding concerns being recognised as such by ward staff and in concerns being reported externally. The commissioners were aware that work was ongoing within the trust to address this.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 22 sets of care records from all 9 wards and all of these contained a risk assessment which had been commenced on or shortly after the individual’s admission to the ward. Ward managers told us, and the provider’s written policy confirmed, that risk assessments should be reviewed and updated monthly. However, 10 of the 22 risk assessments we reviewed had not been reviewed within the month preceding our assessment. Patients usually had a more detailed forensic risk assessment completed using the nationally recognised HCR-20 tool but 1 patient had not had their HCR-20 updated since 2021, although they did have a more recent risk assessment on the trust’s internal tool. This patient also did not have the safety plan, risk formulation or current risk management plan sections of their records completed, although they had been on the ward for 2 weeks. Another patient did not have a full completed risk assessment although they had been on the ward for 3 weeks. Another patient only had a very brief risk management plan which did not include detailed information on how staff should respond if their mental state deteriorated. Information contained in risk assessments was often undated which made it difficult to identify if the document was being updated each time it was reviewed. Risk assessments were also not always updated following relevant incidents involving the patient. For example, a patient had been involved in recent incidents leading to an increase of their observation level and some sections of their risk assessment and risk management plan had not been amended to reflect this. Another patient had been involved in incidents and these were not referenced in their risk assessment or risk management plan, so it was not clear whether the most recent review of the risk assessment had taken these into account.

Some patients were not receiving physical health monitoring as required, for example 2 patients with diabetes should have been having daily blood glucose checks, according to their care plans, but these were not being completed daily.Patients did not always have physical health care plans on their records, for example a patient had a diagnosis of asthma and was also subject to additional physical health monitoring due to the medications they had been prescribed (clozapine and lithium) but they had no care plans for these aspects of their care. Another patient should have been receiving additional physical health checks but they had no care plan for this. Patients on high dose antipsychotic treatment were not always receiving physical health monitoring in line with best practice, either because this was delayed or because they had incorrectly not been identified as requiring this. Some patients who had been prescribed clozapine (which can cause a side effect of serious constipation) had care plans which stated that they should have been having daily bowel monitoring charts completed, but this was not happening consistently.Some patients prescribed lithium and/or clozapine were not having regular blood tests to check their levels of these medications. Action was taken by the trust to promote the use of the bowel monitoring charts across all wards during our time on site.

However, levels of restraint, rapid tranquilisation and seclusion were low (86 restraints, 14 rapid tranquillisations and 46 episodes of seclusion across all 9 wards in the 6 months preceding our assessment). Patients and carers told us that restrictive interventions rarely happened within the service. The patients we spoke with who had been restrained said they did not have any concerns about how this was managed by staff. The staff we spoke with said they did not often use restraint and they were aware of how to de-escalate potential incidents to reduce the need for hands on interventions. Staff working directly with patients received prevention and management of violence and aggression (PMVA) training as part of their mandatory training. Over 80% of staff on Delaney, Hayeswater, Borrowdale, Ferndale, Rydal and Dovedale wards were up to date with this training. Compliance levels were lower on Keswick (64%), Isherwood (71%) and Eskdale (77%) wards but ward managers on all the wards had systems in place to track staff mandatory training updates to ensure staff who were outstanding were booked on to courses as soon as possible. Written information about restrictive practices was available for patients in compliance with the Mental Health Units (Use of Force) Act. All episodes of seclusion over 7 days duration and long-term segregations were also reviewed by a multidisciplinary clinical panel every week.

Due to the nature of the service, there were blanket restrictions in place on all wards to ensure the safety of patients, staff and visitors. These included hospital wide restrictions and those which were specific to the forensic service as a whole and individual wards. These were all documented on blanket restrictions registers which were reviewed, and updated where appropriate, at monthly reducing restrictive practice meetings. Other standard agenda items at these meetings included reviews of incident data and training compliance, oversight of the seclusion panels and review of the implementation of the trust’s reducing restrictive practice strategy across the forensic and secure wards. We only identified 1 blanket restriction during our assessment which was not correctly documented on the relevant register (the secure garden on Ferndale ward was kept locked at all times, but the register stated it was only locked at night). Staff confirmed the register was incorrect and there were risk-related reasons for the garden to be locked at the time of our assessment. Patients could access the garden by asking staff to open the door if they had no individual risk relating to this. There were security procedures in place on all wards in line with national guidance for low and medium secure services, and the staff we spoke with were aware of these. This included one member of staff undertaking the role of security nurse at all times. The staff we spoke with were aware of the individual risk management plans in place for some patients, for example enhanced observations, and the reasons these were necessary to safeguard the patient and others.

Staff usually involved patients in care planning and risk assessment – 20 out of 22 care plans and 19 out of 22 risk assessments showed evidence of this. Patients told us they were happy with the level of involvement they had in their care. Each patient had their care reviewed at a weekly multidisciplinary team ward round meeting which they, and their advocate if required, were able to attend. Managers and staff also described how patients were supported to be involved in their care through one-to-one meetings with their named nurse before and in between ward rounds. Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Managers described the systems in place for accessing interpreters for patients if their first language was not English, or they had communication or sensory impairments, and we saw an example in the records of an interpreter being regularly arranged for a patient who spoke limited English. Staff enabled patients to give feedback on the service they received (for example, via surveys and community meetings). We observed 2 community meetings taking place during our assessment. Staff and patients confirmed these took place monthly and we also saw minutes of previous meetings which confirmed this. However, 4 of the 12 carers we spoke with said they did not feel adequately involved in their relative’s care planning or had only been involved because of their own persistence.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment on all 9 wards was safe and the trusts had systems in place for the assessment and mitigation of ligature, fire and other environmental risks. Most of the patients and carers we spoke with said they were happy with the cleanliness and maintenance of the care environment. However, although most of the ligature risk assessments included all internal and external areas of the ward, some still excluded the external areas which did include items, such as gym equipment, which posed a potential ligature risk. Also, some of the ligature heat maps were blurry and therefore difficult to read. The external areas had been included on the heat maps by handwritten amendments rather than the maps being formally amended since our last assessment. The records of the matrons’ monthly checks were also not always up to date on the ligature risk assessments we reviewed. On 4 out of 9 wards there were maintenance jobs identified on the ligature risk assessment as the action to be taken to resolve the risk and neither the main risk assessment document nor the records of the monthly checks stated whether this work had been completed.

However, an audit of blind spots on the wards had been completed and additional mirrors installed to improve visibility since our last assessment. Also, the management and mitigation of fire risks was much improved since our last assessment, with annual risk assessments and monthly and weekly checks taking place and being consistently recorded. We did not identify any concerns about patients smoking on the wards or in the secure gardens, and the use of electronic cigarettes in areas not allowed by the trust’s smoke free policy had also reduced since our last assessment, although some of the staff and patients we spoke with said this was still happening and we did witness it happening at times while we were on the wards. There were also audits of the maintenance request system and annual health and safety inspections taking place on all wards. The recent reports of these were reviewed and showed a high level of compliance with environmental safety requirements and maintenance requests being resolved in a timely manner.

The ward complied with guidance on eliminating mixed-sex accommodation. All the wards were single sex. The care environment was comfortable and adequately equipped on all wards and, with the exception of a damaged chair covering on Ferndale ward, furniture and equipment was in a good state of repair. Staff had easy access to alarms and patients had easy access to nurse call systems. Where there was a seclusion room on the ward, this allowed clear observation and two-way communication, and it had toilet facilities and a clock. However, the sink in the Ferndale seclusion room was not working at the time of our visit.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, there were gaps in the room temperature records for Rydal ward’s treatment room and we noted 2 occasions of the room being an excessive temperature for the safe storage of medicines in July and August 2025. We explored this with staff and we were told this had not been escalated to the estates team (as required by the trust policy). We saw records which confirmed that equipment was regularly maintained and calibrated as required and that annual Portable Appliance Testing was carried out on electrical equipment.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs.

The trust’s safer staffing data showed that the forensic service as a whole met their safer staffing criteria in August and September 2025. All wards were at or over 100% for all months other than Keswick ward in September 2025 (98%). However, the skill mix did not always comply with the trust’s policy, particularly in relation to qualified nurses (less than 100% for 3 wards for day shifts and 6 wards for night shifts in August 2025 and for 5 wards in September 2025 for day and night shifts). Following our inspection the trust told us that there was a temporary agreement in place at the time of our inspection for a baseline level of one registered nurse on Newlands ward, due to there being a reduced number of patients on this ward.Staffing data on bank use in the 6 months preceding our assessment showed an average of 8% bank for qualified staff and 16% for unqualified staff. The incident data for the month prior to our assessment showed multiple incidents being reported in relation to staffing shortages impacting staff’s ability to care adequately for patients. Staffing boards displayed on the wards showed that some wards had less than their safer staffing baseline numbers on the days we visited. Most of the ward managers (7 out of 9) said that there were vacancies on their ward teams which had increased their use of bank staff and/or were leading to shifts not meeting their baseline establishment levels at times. The trust’s staffing data confirmed that there were vacancies in the staff teams for 7 out of 9 of the forensic wards at the time we inspected. Most of the ward managers (6 out of 9) reported high bank staff use on their ward at the time we inspected, caused by a combination of vacancies, long term absences and high patient acuity.

Also, we heard from managers, staff and patients that the staffing on the wards was not sufficient to meet patients’ needs. We were told by 8 out of 35 staff members we spoke with that patients were not always receiving the community leave they had been prescribed, and some of the records we reviewed corroborated this, for example a patient was prescribed a range of leave to the local community, but the records showed them to be mostly just having leave within the hospital grounds. During our observations on the wards, although we observed positive interactions with patients when staff were present, there were periods when there were no staff in communal areas and some patients were having no or minimal staff interaction for the duration of the observation period. During one of these structured observations, on Ferndale ward, we observed a patient requesting support which staff did not have the capacity to provide in a timely manner. We also observed staff having to rush between tasks which at times impacted their ability to complete timely and appropriate records, including documenting the administration of medicines. Some staff told us that they did not always get to take their breaks due to how busy the wards were.

We heard feedback from ward staff and managers that it could be challenging caring for patients in seclusion due to staffing pressures. Staff on Isherwood ward described having to regularly open the seclusion suite with 3 staff when it should have been 4 due to insufficient staff being available. This presented an ongoing risk to patient and staff safety. On 2 occasions when we arrived on this ward, we were told they were short staffed due to the need for staff to leave the ward to undertake seclusion reviews. On the evening of 14 October 2025, we observed staff attempting to seek support from the duty manager for this reason and this support was not provided in a timely manner. A significant proportion (16 out of 25) of the nursing and support staff we spoke with said the wards could be short staffed at times. Some Band 6 nurses said they did not consistently get to take their designated management days as they were being regularly pulled into the clinical staffing numbers and 5 out of 25 staff said that staffing pressures negatively impacted their ability to interact with patients and/or the activities available for patients on the wards.

We also found that staffing pressures were impacting the medical and allied health professional teams. Half the multidisciplinary team (MDT) staff we spoke with (5 out of 10) told us that staffing pressures were a problem at times and/or that they personally were overworked due to vacancies. Some ward managers (2 out of 9) said the structure of the MDTs covering the wards was confusing, but we were told this was being streamlined for the future. Some ward managers (3 out of 9) said there were vacancies in the MDTs which impacted their ward and 2 out of 9 ward managers commented that they had no access to an in-house Speech and Language Therapist, which was a resource they used to have. Some staff described ineffective working relationships between the ward and MDTs and some staff on the Lowry unit said they felt the medium secure services were prioritised and they were expected to offer support to the Riverside Centre but they did not receive a proportionate level of support from the medium secure wards. The commissioners for the service also shared that concerns about a divide between ward teams and the MDTs covering the wards were still coming up at times.

Almost half the patients we spoke with (22 out of 55) described being negatively impacted by staffing levels on the wards. Examples of the impact of this included patients not being able to access the secure garden, 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 one to one sessions with staff, delays to substance misuse interventions, staff frequently changing, a lack of varied activities, too many unfamiliar bank staff and community meetings not taking place regularly. The negative impact of staffing shortfalls was also raised by patients as a concern in a community meeting which we observed. We received feedback from 2 advocates who attended the wards to support patients and they both said that the impact on patients of reduced staffing was a theme of concern from patient feedback and also from their own observations on the wards.

We identified 19 members of NHS Professionals staff who had worked a shift at the hospital recently where there was no completed induction checklist available for them. There were no bank induction records at all available for us to review on Delaney ward. Training figures for therapeutic observations training were low on all wards, managers told us this was because of an issue with the system which meant that staff were not able to book on this training. Staff training data showed rates of less than 80% compliance for multiple other modules across all wards. Rates of clinical and management supervision sessions taking place in line with trust policy were also less than 80% on multiple wards.

However, managers used a nationally recognised tool (the Mental Health Optimal Staffing Tool) to calculate staffing levels and this was regularly reviewed. Ward managers told us that they were able to request additional staff if patients’ needs changed and/or there were unexpected staff absences and this could usually be arranged without undue delay. There were twice weekly staffing oversight meetings taking place so that senior managers could review and respond to any areas of increased need. Additionally, staffing huddles took place to review and respond to any unexpected absences or other issues, for example a shortage of Intermediate Life Support trained staff on a particular shift. Most of the staff we spoke with told us that there were sufficient staff to respond to incidents safely, although there had been 2 recent staff injuries on 1 ward and more concerns were raised by staff on this ward about safety at work, including the impact of staffing shortages on this. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. Substantive staff had received an induction and mandatory training updates were provided although, as noted above, staff were not always up to date with all modules. Staff received annual performance reviews and most staff were up to date with their appraisals (over 80% of staff up to date on all wards except Eskdale where 69% of staff were up to date).

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All the wards were clean and well maintained and we observed cleaning taking place during our time on the wards. Cleaning records were usually complete and up to date and demonstrated that the wards were cleaned daily. Staff maintained equipment well and kept it clean. We observed staff adhering to infection control best practice including handwashing and compliance with the trust’s ‘bare below the elbows’ uniform policy. The patients and carers we spoke with told us that the wards were usually clean. Rates of hospital acquired infections on the wards were low, with only 2 instances of notifiable infections (1 instance of MRSA and 1 instance of COVID-19) occurring in the 12 months prior to our assessment. Infection prevention and control audits were carried out annually on all wards and we saw that action was taken in response to any issues identified by these checks. The kitchens providing food to the wards were all up to date with their Food Standards Agency environmental health inspections and received a 5-star rating at their last inspection. Domestic and clinical waste including sharps was managed and stored safely on all the wards we visited, and we saw records which confirmed the arrangements for regular waste collections. Staff vaccination rates for Hepatitis B were high (90% of staff vaccinated across the whole forensic service). Uptake of seasonal flu vaccination was low (13% of clinical and 26% of administration staff receiving a flu vaccine from the trust in 2025), but our assessment took place relatively early in the flu vaccination season.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe. However, medicines met people’s needs, capacities and preferences and staff involved people in planning.

Medicines were usually stored safely and securely, however daily checks of emergency medicines were not always being completed in accordance with the trust’s policy. On 3 wards we found that the room temperatures where medicines were stored exceeded the maximum recommended temperature on numerous occasions. Staff had not escalated this to the trust’s estates team as required by the trust’s policy, therefore, we could not be fully assured that medicines were always safe to use. Liquid medicines had ‘date opened’ labels on them to ensure they were being used before they expired. Controlled drugs, which have a potential to be misused, had registers in place with two staff signatures to show when administration had taken place. However, the index pages of 3 controlled drugs registers included errors due to not having been accurately updated. Daily stock counts were completed and the levels of medicines we checked on the day of our site visit were correct and accounted for. It was not always clear that there were safe systems in place for the disposal of waste controlled drugs, as there were no denaturing kits (used to reduce the risk of diversion and misuse of waste controlled drugs) on 3 of the 9 wards we visited. However the trust told us following our inspection that there were alternative processes in place for patients' own controlled drugs to be returned to pharmacy and illicit drugs to be sent to the trust's security team for analysis and destruction, if denaturing on the ward was not possible. The trust also confirmed following our inspection that 3 additional denaturing kits would be ordered for the wards which did not have one.

Medicines were prescribed on an electronic prescribing and medicines administration (ePMA) system. Staff told us they found the system difficult to navigate. One patient had items still showing on their electronic drug chart that had been suspended by the prescriber for a significant time. When staff tried to find further information on the care notes around this, there was no documentation, which could lead to confusion about why these medicines were suspended. Some care plans also had out of date information about the medicines people were taking and how often medicines-related physical health checks should be taking place. Staff were able to tell us the requirements of the patients on their ward, but this was not always reflected in the care documentation. The physical health team had good oversight of which patients were prescribed clozapine (an antipsychotic that requires regular blood tests for monitoring). However, side effects were not always monitored consistently, for example bowel monitoring charts were in place for some patients who were taking clozapine but these were not being completed at the required intervals. Of the 12 family carers we spoke with, 2 said their relative had been impacted by a medication error during their time on the ward.

Staff told us monthly medicines audits were completed by pharmacy staff and said the electronic system also showed staff when something was overdue or due that day, for example monthly depot injections. Records confirmed that monthly audits took place and that action was taken in response to issues identified by the audits. This was overseen by the trust’s medicines safety committee, which met monthly, and we saw evidence in the minutes of these meetings of action being taken to address any trends of concern identified from incidents and audits.