Greater Manchester Mental Health NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

However, we found that the service was in breach of regulation for governance (Regulation 17). This was due to gaps in some of the quality monitoring documentation we reviewed.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The managers and staff we spoke with were all aware of the trust’s vision and the trust values of being caring and compassionate, inspiring hope, being open and honest, working together and valuing and respecting others. Staff received training on the trust’s vision and values as part of their induction and staff appraisals included a section where the individual’s performance and behaviour at work was reviewed in terms of the trust values.

The trust had written information available for staff about their 2025-2028 strategy which included strategic priorities of delivering care that matters, working together and being fit for the future. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Since our last assessment, the trust had continued to deliver a culture development programme to make improvements to the culture on the wards following previous serious concerns which were raised. This included the engagement and involvement of staff at listening events. A behaviours framework had also been developed, this also included input from staff and service users. The trust’s assurance and monitoring frameworks in relation to the culture of care across all their services had also been strengthened.

Staff could explain how they were working to deliver high quality care within the budgets available. Most of the staff we spoke with said they felt their ward had a positive, open and caring culture and many leaders and frontline staff spoke about the positive changes they had experienced in this respect in recent years.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Staff in ward manager, matron and senior management roles were appropriately qualified and experienced and they told us that they had access to sufficient training and development opportunities to support their role as leaders within the organisation.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. All the wards but one had a ward manager in post at the time we inspected, and staff told us that ward managers led the teams well and were supportive of and accessible to staff and patients. However, all but one of the ward managers we spoke with raised concerns about the amount of meetings they were expected to attend, which significantly reduced their capacity to be present on the ward with their teams and patients and led to them being less visible on the ward than they would have liked. Eskdale ward did not have a manager in post at the time of our assessment, this was because the previous ward manager had recently left and their replacement had not yet commenced in post. Cover was being provided by the quality matron for the ward.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The trust prepared monthly reports on patient and carer experience which included an overview of data from the NHS Friends and Family survey, issues raised by patients in community meetings and complaints, and other concerns and compliments received from patients and carers. The report was presented to the patient and carer experience group monthly and any themes or trends arising from the preceding month’s feedback were identified at this meeting. In the 6 months preceding our assessment the trust received 22 completed feedback surveys, 17 of these were positive, 3 were neutral and 2 were negative.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Minutes of the patient and carer experience group meetings showed action being taken to address negative findings and lessons learned from patient and carer feedback.

The trust also had effective systems in place for staff to raise concerns, this included confidential avenues for reporting concerns through a Freedom to Speak Up process. Freedom to Speak Up feedback was analysed by the trust on a monthly basis, and also an annual report was prepared for the trust board to highlight any themes or trends arising from this data. The most recent annual report prior to our assessment was in October 2025 and this included a summary of staff feedback about accessibility and effectiveness of the FTSU process, data on the numbers and types of concerns raised and some narrative about themes of concern. The findings from this period showed high awareness among staff about the FTSU process but also showed that the time taken to resolve concerns had increased since the preceding reporting period.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust reported annually on its compliance with the NHS Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES) and the most recent report at the time of our assessment was published in September 2025. The report included an action plan to address areas for improvement identified from the data.

The trust was undertaking equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. In the most recent WRES and WDES report the trust reported that the proportion of trust staff from a Black or minority ethnic group and the proportion of staff reporting one or more disabilities had increased since the previous reporting period, The trust also analysed equality, diversity and inclusion themes from the NHS staff survey. In the most recent report prior to our assessment (2024) the trust’s score was slightly below the national average for mental health trusts for diversity and equality (7.9 compared to 8.2) and for inclusion (6.9 compared to 7.2).

Managers put reasonable adjustments in place for staff members to help them carry out their role. The staff we spoke with told us they felt well supported in relation to any their protected characteristics, for example disability and race, as an employee of the trust. Examples we were given included effective support following experiencing racism from a patient and measures put in place to support return to work following illness and injury. Staff had the opportunity to join equality, diversity and inclusion networks in relation to race, disability and LGBTQ+ identity. During our assessment period the race equality network for the forensic service presented some feedback to the leadership team which included concerns raised about staff experiencing racist discrimination, equality, diversity and inclusion initiatives not yet resulting in changed practice and a perception that global majority voices were not being heard or valued, which informed the ongoing plans to improve the working conditions of staff from racialised communities. These included the roll out of equality, diversity and inclusion champions across the forensic staff teams and the implementation of a hate response framework for additional support to staff who are subjected to racist abuse at work.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability or good governance. They did not consistently act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although governance processes had significantly improved since our last inspection, our findings from the other key questions still demonstrated that governance processes did not consistently operate effectively at ward level to provide the trust with the necessary assurances about the safety and quality of patient care.

We identified shortfalls in the systems for documenting patient care. Patients’ risk assessments were not being consistently updated in line with the trust’s policy. Staff on several wards reported challenges in recording seclusion reviews due to these records being paper based and needing to be manually added to the trust’s electronic system at a later date, which could lead to delays and gaps in the electronic records. The seclusion records we reviewed did have gaps and so did not fully demonstrate that reviews were taking place as required by the Mental Health Act Code of Practice. Mental capacity assessments and best interests meetings were not always clearly documented in people’s records. We also found gaps in some of the care plan documents we reviewed.

We also identified shortfalls in the ward management documentation we reviewed. The indices of the controlled drug register contained errors on 3 out of 9 wards. We found instances of medicines fridge temperatures outside the recommended range which had not been escalated in accordance with the trust’s policy. The blanket restrictions register on Ferndale ward said the garden was only locked at night but staff said this was locked at all times as patients could only have supervised access. There were induction records missing for bank staff who had recently worked on the wards. We also found that compliance levels for several mandatory training modules were below the expected level on some wards.

However, there was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Governance and ward level meetings were minuted and the minutes all had standing agenda items which enabled important information about the safety and quality of care to be shared and monitored. There was a clear process for information about the safety and quality of care to be reported to the trust board through a range of sub-committees and the commissioners of the forensic service fed back that the effectiveness and transparency of this process had improved since our last assessment.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. We saw evidence that lessons learned were shared with staff through a variety of means including safety bulletins and team meetings and that action was taken to make improvements to the standard of care following reviews of complaints and untoward incidents.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. The trust had a calendar of audits in place which included reviews of care records, monitoring of the care environment and medicines safety checks. The ward managers on each ward were aware of the findings from recent audits and described how they ensured action was taken when audits identified any shortfalls. However, some of the staff we spoke with shared that they felt excessive audits were carried out and said that some of these were not effective, as the same issue was being picked up over repeated audits with no action being taken to address the concern. At the time of our assessment an improvement plan was in place on Eskdale ward due to concerns identified through the trust’s internal processes with the quality of care on this ward.

Staff maintained and had access to the risk register at directorate level. Staff at ward level could escalate concerns when required. The risk register was regularly reviewed and included the areas of potential risk raised by the staff we spoke with, for example the impact of opening the wards to new admissions. The service had plans for emergencies – for example, adverse weather or a flu outbreak. These were documented in business continuity plans which were regularly reviewed.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure worked well and helped to improve the quality of care. Information governance systems enabled the confidentiality of patient records to be maintained. Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders – such as commissioners and NHS England. We received feedback from commissioners that the trust were more open and transparent with them than previously, with commissioning case managers being supported to visit the wards and have open conversations with staff, patients and independent advocates. This included the facility for case managers to make unannounced visits to the wards to review the quality of care being provided to their patients. Commissioners also reported that formal reporting of incidents from the wards had improved since our last assessment, although there could still be a delay in some serious incidents being reported to the national Strategic Executive Information System (StEIS). Commissioners told us that links between the trust and local safeguarding systems were good, with a monthly safeguarding meeting taking place which was attended by trust representatives, the commissioning provider collaborative’s head of quality and the safeguarding lead for the Greater Manchester Integrated Care Board.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Innovations were taking place in the service. Quality improvement projects taking place in the 6 months prior to our assessment included work to improve unplanned staff absence rates, a project to enhance communication between family carers and ward staff, a time management improvement programme and work to improve the trust’s response to staff experiencing racist abuse at work.

Staff used quality improvement methods and knew how to apply them. The trust offered Bronze and Silver Quality Improvement training and monitored the uptake of this across the adult forensic service. The trust was a member of the Royal College of Psychiatrists’ Quality Network for Forensic Mental Health Services and we saw an ongoing action plan which was being implemented across all the forensic wards to improve compliance with the Network’s standards. In January 2025 the trust launched a new forensic research unit in partnership with the University of Manchester.