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.

This is the first assessment for this service. This key question has been rated Requires Improvement.

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.

The service was in breach of regulation for Regulations 12 Safe Care and Treatment and 18 Staffing.

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service had 5 incidents of severe physical or psychological harm in the last 12 months. These included incidents of self harm and access to leave.

All staff knew what incidents to report and how to report them. Staff reported incidents via the electronic incident reporting system.

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. There had been 3 incidents which met the threshold for duty of candour in the 12 months prior to the assessment.

Staff received feedback from investigation of incidents, both internal and external to the service. Monthly “Spotlight on Patient Safety” newsletters were shared with staff. These included learning from incidents across the Trust and the promotion of learning events across the Trust. Safety alerts were also shared with staff to show learning from incidents including from other organisations and action that staff should take. The Trust had also developed “Patient Safety Weekly Messages Bulletin” with actions for staff to take following incidents that had occurred within the Trust.

Staff met to discuss the feedback via team meetings and the opportunity to attend learning events. Minutes showed patient safety alerts were shared in team meetings. However, this was not a standard agenda item and was not discussed at every meeting.

There was evidence that changes had been made as a result of feedback and learning from incidents. This included refresh of policies, visual identifier for babies to ensure the correct baby was receiving the correct care, including feeding requirements and medicines.

However, one of the areas for learning was the induction of staff, especially bank staff on the ward. We identified 3 bank staff regularly working on the ward and only one of them had a completed induction record and observations competency completed.

Staff and patients were debriefed and received support after incidents resulting in severe harm.

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. There was a standard referral form that was used for all mother and baby units in England and included reason for referral, mental health needs, physical health needs, children and any support that maybe required.

There was an electronic system which showed all the mother and baby units in England and whether there were any vacancies; this system was used for referral and bed management purposes, we observed the perinatal huddle where discharges were discussed and referrals, including women who were being supported in the community and may require an inpatient admission.

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. We observed a ward round and the community teams were involved in the meetings.

Perinatal patient safety meetings took place with the community and inpatient perinatal services to discuss incident reviews, coronial investigations, trends, risk register and learning from incidents.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Safeguarding training levels for Adults Level 2 was 94% compliance, Adults Level 3 was 82% compliance.

Safeguarding Children training levels were Level 2 100% compliance and Level 3 79% compliance.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of how the team were safeguarding patients and their children, this included liaison with Children’s Services. Records showed this liaison was happening.

Safeguarding was a standard agenda item at team meetings, discussions included how to escalate concerns and visitors process. However no specific safeguarding concerns were discussed in the minutes we reviewed. The handover included a safeguarding section, however we reviewed handover records for 4 dates in November 2025, safeguarding was not completed for 8 out of 9 women on 3 November 2025, 8 out of 9 women on 5 November 2025, 7 out of 8 women on 9 November 2025 and 10 out of 10 on 24 November 2025. This meant safeguarding issues specific to patients on the ward were not being shared routinely with staff in the team that were providing the care.

Staff did not always follow safe procedures for visitors to the service. There was a “Protocol for Overnight Guest Accommodation on Andersen Ward” in place regarding family, usually fathers staying in the flat on the ward to enable them to be involved in the care of their child. The protocol did not include safeguarding considerations. However, the protocol did include guest responsibilities about when they could enter the main ward area, there was an expectation that they should complete a checklist and sign to agree to the requirements however this was not routinely in use. Staff were not aware of the protocol, and the checklist had not been completed by the father that was staying in the flat at the time of the assessment.

The service worked in a least restrictive approach, there had been 20 episodes of restraint in the 12 months prior to the assessment. Restrictions were appropriate to the service, for example infants not being allowed in the milk kitchen due to risk items in there.

Mental Capacity Act

Staff received training in the Mental Capacity Act with 94% compliance.

Staff had a good understanding of the Mental Capacity Act,

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw a capacity assessment in relation to labour and how the patient was going to deliver the baby.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Minutes showed that best interest discussions took place with appropriate professionals, we saw minutes of a best interest discussion with colleagues in midwifery and obstetrician roles.

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.

Perinatal assessments including risk to baby were not completed in full and were not current for 9 of the 10 women on the ward. Five were blank or not opened on the system. Two were partially completed but did not include risk to baby. Two were completed in 2023 and 2024 and were not current for the current admission. One was completed and in date. This meant risks specific to this service were not considered for the women who were accessing the service at the time of the assessment.

There had been 20 incidences of restraint in the 12 months prior to the assessment, 3 of these were in the prone position. There had been 13 uses of rapid tranquilisation in the 12 months prior to the assessment.

Staff involved patients in care planning, patients told us this happened, and we saw patients were involved in their multidisciplinary team reviews, had access to a copy of their care plan and patients told us they were able to comment on their care plan and suggest changes for staff to consider.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Patients told us that staff listened to them if they were overwhelmed, and adjustments were made, for example reducing the number of people in their ward.

Staff enabled patients to give feedback on the service they received. Community meetings were expected to take place weekly, however due to staffing challenges, these were not taking place weekly. There had been 4 meetings in the 3 months prior to the assessment.

Staff ensured that patients could access advocacy. Contact details were displayed on the ward and access to advocacy was discussed at every community meeting.

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.

Staff did regular risk assessments of the care environment. There was a high risk ligature audit which included helpful images of risks but not how to mitigate them. There was a Heat Map in place, however, it was difficult to differentiate between the different risk areas due to the colours used and did not include how to mitigate risks.

There was one ligature cutter on the ward. Staff told us the other one had been returned for sharpening. The procedure for ligature cutter sharpening shows that a replacement should be sent to the service to ensure the number of cutters do not fall below agreed level. We asked the service to action this to ensure the correct number of cutters were on the ward.

The nurse’s office door was regularly open throughout the day, anyone could walk in and out, this was a concern in relation to safety and confidentiality.

Ward layout allowed staff to observe all parts of ward.

There were several ligature anchor points including cupboard door handles and sinks with taps. These were in the ligature assessment, with the mitigation of observations and individual patient assessment. There were always staff in the main communal area.

Staff had easy access to alarms and patients had easy access to nurse call systems, there were call buttons in each room.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Emergency equipment included for babies too.

A staff member should be allocated to security for each shift, however when we reviewed allocation records, in 4 out of 6 records reviewed, staff were not allocated the role of security nurse. The security nurse was required to complete a security checklist to evidence that they had completed their allocated tasks, including management of keys, alarms, fridge temperatures, fire checks, ligature cutters. We reviewed the security checklists and found they were not completed fully, with gaps of tasks not completed, handover not completed, agency and bank induction checklists not completed. The nurse in charge was supposed to be countersigning the completed security records and this only happened on 2 out of the 18 days we reviewed. Staff had noted on the security checklist there was only 1 ligature cutter on the ward, however had not taken action to resolve this.

There were areas within the ward that required maintenance; there was mould on the sealant next to the sink in the milk kitchen. In the nursery there was crumbling of the wall under the window. This is the room where babies are nursed if room temperatures are too high or mums are struggling at night. External health checks took place in this room too. We requested the maintenance log to see if they had been reported and an update on outstanding work. The maintenance log showed that these repairs had not been reported. This meant staff were not reporting repairs as soon as possible.

The viewing pane in the clinic door where medicines were dispensed was clear which meant patients privacy and dignity would not be maintained.

The patient fridge and patient dryer were broken, managers told us that the dryer broke the week before and had maintenance out and the fridge has been ordered. Security records showed that the dryer was not working on 16 November 2025. This meant at the time of the assessment, patients were having difficulty drying their own and their babies clothes as there was only one drier on the ward. The broken fridge was discussed at the community meeting on 25 November 2025, patients were told they could use the one in the flat or staff fridge if food was labelled.

Due to extreme temperatures in the patient bedrooms which could not be individually controlled, there were plans to install air conditioning throughout the ward in 2026, as an interim measure, the security nurse was taking room temperatures hourly.

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. They did not work together well to provide safe care that met people’s individual needs.

The team included nurses, nursery nurses, nursing assistants, doctors, occupational therapist, psychologist, social worker and perinatal mental health, health visitor. There was one band 5 occupational therapist vacancy and a band 5 nurse vacancy at the time of the assessment. There had recently been an increase in nursing staff leaving the service and the rolling turnover rate at October 2025 was 25% and the sickness rolling absence was 9% at October 2025. Bank and agency usage was an average of 35% in the 6 months prior to the assessment.

Feedback from staff was that they were moved to other wards within the hospital when there were staffing challenges. This was being monitored by the ward manager. Daily inpatient huddle meetings took place Monday to Friday to review staffing levels and ensure there were staff on shift trained in Immediate Life Support and Prevention and Management of Violence and Aggression who could respond where needed.

We reviewed 20 days of staffing in November 2025 and found that on one occasion staff were moved to another ward, there were 8 occasions of being one registered nurse below numbers and 5 occasions of being one health care assistant below numbers and one occasion of being 2 health care assistants below numbers. This meant that the number of nurses and healthcare assistants did not always match the required number for all shifts.

There were 2 occasions where there were no fire wardens on the shift. We reviewed 6 allocation records and found they were not completed in full and did not include allocation of safety roles of fire warden, security nurse and physical health checks in 4 out of 6 allocation records reviewed. This meant the service could not be assured that staff were allocated to and undertaking those roles.

When agency and bank nursing staff were used, there were not always records to show if staff had received an induction and had completed their observations competency and were familiar with the ward. We reviewed the staff rota to identify bank staff that had worked in the service. Out of 3 staff reviewed, 2 staff had not had a recent induction into the service and had not had their observation competency reviewed. An action from a rapid review of care was that a bank member of staff required to re-do their induction and observations competency, this was set as an action in March 2025 and was not completed until 30 September 2025. This meant there was a delay in the completion of the induction and observation competency, and the service could not be assured that all staff had the knowledge and skills to conduct observations safely.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so).

However, staffing shortages had an impact on activities and the community meetings taking place. Patients shared in the community meetings that they would like to do more activities and required materials to do this, for example craft and cooking.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had not received and were not up to date with all appropriate mandatory training. A review of the training data provided by the Trust showed that these courses were under 70% compliance:

• Infection Prevention and Control Level 1 – 50% compliance.
• Moving and Handling inpatient level 2 – 55% compliance.
• Therapeutic engagement and observation HCSW – 31%
• Therapeutic engagement and observation for RN – 43%

This meant staff were not up to date with their required training and knowledge and the service could not be assured that staff had the skills and knowledge to conduct observations safely and move objects and people safely.

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.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. We viewed these for the clinic room.

Staff adhered to infection control principles, including handwashing. Staff wore uniforms, which were short sleeved tunics, staff were bare below the elbow.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with the National Institute for Health and Care Excellence (NICE) guidelines, especially when the patient was prescribed a high dose of antipsychotic medication. Records showed that blood tests were taken when required.

Consent to treatment pharmacy audits took place which showed that 7 patients were informal and consented to their treatment.

Patients told us and we observed in a ward round that patients were involved in discussions about their medicines and any side effects and staff listened to their views and experiences.