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.

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

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

This service scored 64 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The Trust had introduced a new strategy, vision and priorities in June 2025. These were: “Our purpose: Working in partnership to improve the quality of life for all we serve

Our vision: ‘Great places for care and great places to work’

Our Strategic Priorities for the next three years are: Delivering Care that Matters, Working Together and Being Fit for the Future.”

The provider’s senior leadership team had communicated the provider’s vision and values to the frontline staff in this service. These were easily available on the public website.

However, staff did not know and understand the provider’s vision and values and how they were applied in the work of their team.

Staff did not have the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. However, minutes showed discussions had taken place about staff morale and information had been shared about the service closing temporarily for the installation of air conditioning and that the time would be used for staff training, development and team building.

Staff could explain how they were working to deliver high quality care within the budgets available. Perinatal oversight meetings included discussions and updates on finance and performance.

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. They were knowledgeable about perinatal services and understood the needs of the women and their babies on the ward. They were able to access training and attend events in perinatal topics to ensure their knowledge was current.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders understood where there had been challenges in the past and where they were focusing their efforts, for example with staff supervisions, culture of the service and documentation.

Leaders were visible in the service and approachable for patients and staff. We saw patients asking leaders for updates on their child’s health needs and the ward manager was aware of the situation and could provide an update to the patient and offer reassurance.

Leadership development opportunities were available, including opportunities for staff. There were a variety of training opportunities for leaders to attend including inspiring leaders, leading with compassion, role model, coach, care, and Freedom to Speak up training.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that 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. Staff survey results showed the service scored lower than the rest of the organisation in 63 out of 99 questions. There has been no patient and carer feedback about the service in the 6 months prior to the assessment.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. The freedom to speak up guardian had attended team meetings to discuss the culture of the ward and explain the increased presence of senior leaders was part of the reorganisation of the service, to align the inpatient perinatal service with the community perinatal service and that they were trying to be supportive and provide more oversight of the service.

Patients and carers were not involved in decision-making about changes to the service. Community meetings were supposed to take place weekly, however there had only been 4 meetings in the 3 months prior to the assessment. There had been no discussion about changes to the service as part of these meetings. However, the environment and activities were discussed.

Patients and staff could meet with members of the provider’s senior leadership team and to give feedback. Senior leaders were visible on the ward.

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 had a BAME staff network, disability staff network and LGBT+ staff network to promote equality and diversity within the service.

Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. The agenda for team meetings included staffing, PDP reviews and supervision, service development, infection control, safeguarding and training and development. Staff received feedback from investigation of incidents via the monthly “Spotlight on Patient Safety” newsletters. 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. However, Staff did not routinely receive feedback on the outcome of investigation of complaints, these were not standard agenda items for the team meetings.

Perinatal oversight meetings took place, at least monthly. These meetings had standard agenda items of finance and performance, quality and risks, patient safety, strategic development and transformation. These meetings discussed complaints and compliments too.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. This included the re-introduction of the role of the security nurse.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. There had been nursery nurse documentation audits and the introduction of a specialist health visitor role on the ward who acted on the findings of the audits to improve the documentation regarding the baby, we saw completed admission and care plan documentation for the babies in the service at the time of the assessment.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Meetings observed and records showed joint working with external services, in relation to safeguarding, health matters and discharge planning.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. There were 5 risks for the service on the risk register, these included room temperatures, staff being moved to support other wards in the building and staffing challenges.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Data was extracted from the electronic care records.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Paper based records were in the process of being added to the computer-based systems, we saw induction checklists and handover documentation that was stored electronically reducing the reliance on paper based records.

Information governance systems included confidentiality of patient records. Care records were electronic and staff could only access these records if they had a secure log in to the system.

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 saw that managers could access data in relation to training compliance, appraisal compliance, use of bank and agency staff.

Information was in an accessible format, and was timely, accurate and identified areas for improvement. The use of colours showed where there were areas for improvement.

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. There were meetings between the community perinatal teams and the ward to discuss care of women in the community and anyone that may require a hospital admission, also the planning of discharges.

There was an electronic dashboard and central database used by all mother and baby units in England to show availability in the services, the service used this when sourcing a bed for a women, with the aim of keeping the women as close to home as possible.

The service worked alongside other mother and baby units when planning for the temporary closure of the ward to enable the air conditioning to be fitted and the availability of beds in neighbouring services if women needed to transfer to another service.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. Senior leaders visited the ward and were present at times on the day of the assessment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff were given the time and support for improvements and innovation and this led to changes. Staff attended perinatal training annually, baby safe sleep and physical health in infants training and infant feeding training.

Staff did not have opportunities to participate in research.

Innovations were taking place in the service. The service had entered an arts competition facilitated by the Royal College of Psychiatrists Perinatal Quality Network (PQN) and artwork created by women in the service had won.

Staff did not use quality improvement methods, staff did not participated in national audits relevant to the service and learned from them.

The service participated in accreditation schemes relevant to the service and learned from them. The service were a member of the Perinatal Quality Network (PQN), they were going to apply for accreditation with the Royal College of Psychiatrists PQN once air conditioning had been installed as currently they could not meet the temperature environmental standard.