Archived: Manchester Mental Health and Social Care Trust

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We found that the provider was performing at a level which led to a rating of Requires Improvement.

Manchester Mental Health and Social Care NHS Trust provided mental health services and substance misuse services to adults and older people across the city of Manchester. We found that the trust was providing services that required improvements to ensure it better met the needs of the people that it served.

The trust was not always providing a safe service for people across some of the services it provided. This included the older people’s wards, acute wards and PICU, community based services for older people and the crisis services for adults of working age.

Environmental risks on the SAFIRE unit had not been fully assessed or mitigated. Due to several serious untoward incidents, risks were mitigated with an overly restrictive approach with restrictions not reviewed periodically to ensure they were appropriate to individual patients. There were medicine management issues on the community older people’s services and in the rehabilitation service which amounted to regulatory breaches.

The trust was a low reporter of incidents; there were delays in notifications of incidents and delays in investigating incidents through the national incident reporting and learning system. The trust had been escalated to NHS England’s risk summit for a significant number of months due to several issues relating to patient safety including incident reporting, commissioner assurances and safeguarding arrangements. Whilst some recent improvements were noted in some of these areas, for example, in the safeguarding arrangements; NHS England continued to oversee the trust until sustained improvements were seen.

Risks were not always fully assessed or reviewed by staff. We have issued requirement actions in relation to the safety issues and management of risks and have asked for an action plan to receive assurances that these risks would be addressed.

The trust was not always providing an effective service for people across some of the services it provided. This included the older peoples’ wards, acute wards and PICU; community based services for adults, and long stay rehabilitation wards.

Care plans were not always holistic and person centred especially on the acute wards. There was limited evidence of coherent and consistent care pathways, outcome measures and performance data in community adult teams. This meant that there was not a strong recovery focus evident in community mental health teams and patients were being retained on the caseload of teams longer than was clinically required.

Staff within certain services had not received recent clinical or management supervision and the take up of appraisals remained an issue in some services despite efforts by the trust to address this issue. We saw limited evidence of best practice, except within perinatal services

There was no or limited psychological input for patients especially within in-patient areas. There was inconsistent medical cover at Anson Road which was impacting on patient care. Roles and responsibilities between the acute and mental health trust staff were not clearly defined to ensure effective care when patients received care jointly, such as within the health based place of safety and psychiatric liaison services.

We found systemic issues with the Mental Health Act (MHA) documentation. MHA documentation was not always completed correctly for patients on some wards to assure us that people were being supported to understand their rights. Patients’ medication for treatment for mental disorder was not always properly authorized. Appropriate checks were not always taking place to ensure that patients’ detention was legally supported by the appropriate documentation, for example medical scrutiny checks were not routinely taking place. Action was not always taken to ensure that renewals of detention occurred within appropriate timescales. The operation of the Act was particularly poor on the older people’s service. We saw that appropriate action had not been taken or embedded following our previous Mental Health Act monitoring visits across the trust as we found the same issues being repeated or not resolved.

Where patients were subject to a deprivation of liberty safeguards (DoLS) authorisations pending agreement from the local authority were not kept under review or updated as needed and decisions about time limitations were not communicated. We weren’t routinely being notified of deprivation of liberty safeguards (DoLS) applications once an outcome was known.

We saw that overall the trust was providing a caring service for people across all core locations. Throughout the inspection we saw examples of staff treating people with kindness, dignity and compassion. The feedback received from people who used services and their visitors was generally positive about their experiences of the care and treatment provided by the trust.

The trust was not always responsive to people’s needs across some of the services it provided, in particular the community based services for adults and the long stay rehabilitation services. There were a number of blocks within the system so that people were not always receiving the right care at the right time, for example crisis teams could not pass people through to community mental health teams (CMHTs), there were delays in receiving CMHT support and there were significant delayed discharge arrangements. There were a number of waits in the psychiatric liaison service and assessing people brought in on a section 136 at the health based place of safety emergency department. Some of these involved waits of beyond 12 hours as they related to patients under 18 or with a learning disability. Whilst some of the waits were beyond the full control of the trust, staff had failed to follow agreed escalation procedures to limit the delays in at least one case. The links between the acute and community adult teams needed strengthening to ensure improved communication and better patient flows. Patient activities were cancelled on the acute wards. There was good management of patient complaints.

Overall the trust was not as well led as it could be. Lines of communication from the board and senior managers to frontline services were not always effective. Staff morale was low. Staff felt well supported by local managers but did not feel that the trust senior managers were proactively addressing the current and future challenges of the trust. We saw some recent examples where board members spent time within services to understand the challenges faced and were aiming to engage with front line staff including through initiatives such as commissioning an external review into culture and initiatives such as ‘listening into action’. However these initiatives had limited reach into front line services.

The trust had a research and academic function with research and teaching clinicians also involved in the operational delivery of clinical services. However we did not see evidence of the research and academic function being fully utilised or fully embedded into the work and practices across the trust to proactively improve services and work towards best practice.

The future of the trust was uncertain at the time of the inspection. A process was underway to determine the longer term position of the trust with support from the trust development authority (TDA). This was continuing to cause difficulties for the front line staff. The trust had utilised a number of engagement methods to try and manage this uncertainty. However a number of staff across services told us that they did not feel that these methods provided meaningful engagement to assure them that this uncertainty was being managed well.

Representatives from the local clinical commissioning groups told us that the trust did not engage positively with them and did not involve the local communities or other organisations in how services were planned or designed. The trust also told us that the relationship between them and the commissioning groups was, at times, a difficult one. Despite the efforts of the trust development authority to improve the professional relations between the trust and the local clinical commissioning groups, there continued to be engagement issues between these organisations. We were concerned that this might adversely affect the provision of high quality patient care but recognised that both parties worked to ensure there was no detriment to quality care.

The trust was in the process of an option appraisal for its future direction and strategic intention following its removal from the foundation trust process and future commissioning decisions. The chair of the trust board acknowledged that there were gaps within the non-executive director experience, including managing complex healthcare organisations and mental health experience capability. On occasions, the board had received reassurances from the executive team rather than seeking full assurances themselves when significant decisions were made, for example when changes to older people’s services were made. Staff understood the vision and values but did not always understand how that related to them at a more local level or in terms of the future challenges the trust faced.

The trust needs to take steps to improve the quality of their services and we found that they were currently in breach of regulations. We have issued requirement notices in relation to several areas and have asked for an action plan to receive assurances that these risks would be addressed. We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

We gave an overall rating for acute wards for working age adults and the psychiatric intensive care unit (PICU) of requires improvement because:

• Elm, Laurel, Mulberry and Redwood wards all had shared single sex bed bays. Due to this environmental limitation patient privacy and dignity was not always respected.
• Elm ward has 4 rooms; an activity room, multi functions room, quiet room and nativity room. If any of these are in use for de-escalation or for any other reason, another room is used as a quiet room or for activities.
• The records relating to the seclusion of patients o n Juniper PICU ward did not provide a clear record of medical and nursing reviews, to ensure that these kept people safe and were carried out in accordance with the Code of Practice: Mental Health Act 1983 (CoP).  There were concerns about the seclusion room admission process.
• Ligature points (places to which patient might tie something to strangle themselves) were identified in the risk register and the plan to reduce these fixtures was set out in the Capital programme. Further measures to address ligature risk on a daily basis were identified via individual risk assessments.
• On some of the wards , staff did not have clear lines of sight to all patients areas.
• There were blanket restrictions in place across the acute and PICU wards that were not based on individual risk. For example, e.g. patients were not allowed to use rooms where there were ligature risks unsupervised, energy drinks were banned and drug detection dogs were routinely used to search all patient rooms.
• Staff and patients reported that escorted leave was often cancelled or reduced due to staff shortages. This was confirmed by the advocacy service.
• Many care plans were not holistic, personalised or recovery-focused. Patients confirmed their lack of involvement in their care and support planning.
• The wards did not provide psychological interventions or family therapies.
• Staff demonstrated a confused understanding of the Mental Capacity Act. We found that staff had assessed the mental capacity of a patient to consent to care yet they had not always acted in the patient’s best interest.
• Staff supervision did not take place on a regular basis.
• Activitiese were cancelled whenever there was a shortage of staff or a ward round took place. There were even fewer activities during the weekend.
• Overall, the activities offered were not meaningful, nor did they take into account the individual needs of the patient. Some patients said they were bored..
• The local governance processes did not always enable identification of where the services needed to improve; where they did, no effective action plan was formulated. A system that ensured care plans and risk assessments were up to date relied on supervision to address quality issues.

With a few exceptions, patients spoke positively about the support they received from permanent staff.  They said staff were respectful, helpful and caring. However, some patients commented that agency staff need to be more professional in their attitude, as some did not appear interested in the patients.

Staff morale was varied across the wards we visited. : s Some staff had a positive view of the organisation. Some staff were unaware of the vision and values of the organisation and felt disconnected from the trust. The staff conduct during the inspection varied, in that some staff were reluctant to enable interviews with service users, their carer and staff. Several acting/deputy ward managers had in been in post less than six months.

Monitoring of incidents, complaints and safeguarding incidents were used to make improvements to the service. Staff received debrief and feedback by means of team meetings and emails.

We have judged the service as requires improvement because:-

Acacia had dormitories, which contained four beds, and despite curtains partitioning the beds; the dormitories did not offer full privacy.

On Anson ward, the records and patient comments did not always demonstrate how the patient had been involved in their care and treatment.

Only half of the staff had completed their annual appraisals on Acacia ward.

There were some identified points that a patient could use to fix a ligature point. There was an environmental risk assessment in place that identified these and the staff had taken action to mitigate these areas of risks to protect patients.

Clear processes were in place to safeguard patients and staff knew about these. Incident recording and reporting had taken place. Teams discussed actions from incidents and patient alerts to ensure that staff learnt lessons.

Staff assessed, monitored, and managed risks to patients on a day-to-day basis. Staff assessed the needs of the patient and from this planned their care. Staff involved patients on Acacia ward in the development of their care plans. .

For both wards, we had positive feedback from patients in relation to the care and treatment they received from staff. Patients had the opportunity to be involved in all aspects of their care including regular reviews.

The wards had clear processes in place for managing referrals. Staff planned for patients discharge from admission. This meant that patients were discharged from hospital as soon as possible.

Patients knew how to complain and the staff responded to complaints and made changes as needed.

The formation of the rehabilitation group, the close working relationships between Acacia and Anson ward, and the service audit, demonstrated a commitment to quality improvement.

Compliance with mandatory training and line management supervision was good across both wards. However, the trust’s systems did not enable the ward managers to monitor the nursing staff’s compliance with the trust clinical supervision protocol.

The ward environments were clean and provided appropriate facilities to support patients recovery. The staff helped to ensure that the wards provided patients with privacy.

We gave an overall rating for wards for older people with mental health problems of requires improvement because:

• We identified regulatory breaches around the suitability of fridges on Cedar and Maple wards and testing of their operational temperatures to ensure they were safe.
• Progress had not been made in the use of the Mental Health Act and Mental Capacity Act. Mental Health Act documentation was not completed correctly for patients on Cedar, Cavendish and Maple wards so they were not always supported to understand their rights, their medication was authorized, their leave was approved and their detention was legally supported by the appropriate documentation being in place.

• Where applications to deprive patients of liberty had been made to the local authority by means of an urgent or standard application. The local authority had agreed with the trust that where it had been unable to process and authorise applications, the trust could deprive patients of their liberty without time limits until the authorisation was agreed. This agreement was subject to the trust making urgent and standard authorisation applications together for individual patients and the local authority had confirmed this agreements with senior managers within the trust. The agreement had not been communicated to the relevant service or ward managers so urgent applications to deprive patients of their liberty were not consistently made with standard ones and patients were deprived of their liberty without local authority approval.

• Patients were not always involved in their care planning across the wards nor did they have a copy of their care plans where appropriate.

The ward environments should reflect a recovery focused approach and aid patients living with dementia to be more independent through appropriate signage and low stimulus areas for patients to relax.

The trust had recognised there were performance issues around the management of Cedar and Maple wards and had made remedial changes to the management of the wards as a result. There were also issues about recruitment of staff to later life services effecting Cedar ward. As a result the trust decided to close Cedar ward because of concerns about risk arising from patient case mix and difficulties in recruitment of nursing staff. This also aligned with the trust later life strategy to increase community services and care close to home. It was also good to see that Cedar ward was maintaining safe standards of care during the closure period.

The staff we spoke to across all wards felt connected to the later life service and the trust. Staff were not aware of the trust vision and values. They were well led by their immediate line managers.

Wards were operating the trust wide audit schedule which was used to quality assure services.

The commitment and care displayed by many of the staff was observed throughout the inspection. Wards were well led and on Maple and Cedar wards alternative management arrangements had been implemented. Risks were being well managed.

Relatives and carers were positive about being informed and involved in care decisions, which we observed during multi-disciplinary meeting which they were involved in.

We observed a number of caring and respectful interactions between staff and patients. Staff members were very respectful, for example knocking on doors before entering bedrooms. We observed staff laughing and joking appropriately with patients in a manner which suggested familiarity and mutual respect. Patients we spoke to were positive about their ward and the care they received.

There were many examples of good multi-disciplinary working and work between agencies to facilitate people being discharged.

We saw patients, relatives and carers were involved in MDT meetings and discharge planning. We saw examples of good relationships between community mental health teams and inpatients services, which meant patients, were referred at the appropriate time to community mental health teams.

Patient’s cultural and religious needs were met. Information was available in different languages/formats and a varied choice of meals meeting peoples differing dietary needs was available. Patients were well informed on how to complain and concerns were addressed as needed.

There were effective systems, processes and practices in place to keep people safe and safeguard them from abuse. There was openness and transparency about safety. Staff understood their roles and responsibilities to raise concerns and report incidents and near misses. However, the community mental health teams did not have appropriate systems in place for the storage and recording of medicines. Systems to ensure risks were reviewed regularly were not robust or effective.

There was evidence of effective multi-disciplinary team working across all the teams. They also made links with organisations external to the trust. The day service team provided a range of activities and therapeutic interventions to support people's recovery in line with best practice guidance. However, the CMHTs did not have the facilities to provide similar services and focused mainly on visiting people who used services, usually at home.

Some of the community mental health team (CMHT) services had experienced significant pressures due to high absence levels. Despite this, waiting times, delays and cancellations were minimal. Access to care and treatment was timely and services were planned and delivered to take into consideration people’s individual needs and circumstances. Reductions in staffing levels were  offset in some teams by use of long term agency staff who were familiar with the team’s work.

Current information was stored on the trust's electronic mental health recording system. Social work staff also had access to the system used by the local authority.

A lot of staff time was taken up travelling, especially as the teams did not have facilities to run clinics or groups for people who used services to attend. We were told about one nurse-led out-patient clinic that patients could attend.

Staff talked about their work in terms of the recovery model. Their focus on supporting people to remain in the community was clear. However, some care plans, while containing elements of a recovery based approach, tended to be mainly generic and whilst they were goal focused, they were not always recovery based. Some staff said they did write full holistic care plans wherever possible but their time was pressured and they prioritised seeing the person above inputting data.

We found some good examples of how teams ensured the physical health care needs of people who used services were being met. The south team included an assistant practitioner who provided support around physical health care. There was a comprehensive tool in use for reviewing physical health needs. Physical health care was well care planned and documented.

Staff had the skills, knowledge and experience to deliver effective care and treatment. They were supported by means of supervision and appraisal processes, to identify additional training requirements and manage performance.

Overall, there was a holistic approach to assessing, planning and delivering care and treatment, using best practice guidance. However, some care plans and risk assessments were out of date although notes reflected more recent discussion and review. This meant people's care needs were not being reflected accurately and may not be being met.

We gathered information from a range of sources to gain feedback from people who used services and their carers. Their feedback was positive, particularly about the way staff treated them. People and their family members were treated with kindness and respect and they were involved in decisions about their care. They told us they felt they were listened to and supported during their care and treatment. Staff were sensitive and respectful of the wishes of people who used services and were committed to providing personalised care based upon their needs.

A single point of access, the Gateway service, had been introduced to manage and prioritise referrals into the service. We found that the Gateway was embedded, effective and responsive in prioritising the needs of people who used services.

Consent was recorded and reviewed to ensure people were involved in making decisions about their care. Consent to care and treatment was sought in line with the Mental Capacity Act 2005. People who were subject to the Mental Health Act (MHA) 1983 were assessed, cared for and treated in line with the Act and the MHA Code of Practice.

At a local level, we found staff were clear about the values and vision of the team they worked in. A divisional plan was in place and had recently been taken forward. Part of the plan was to ensure that with recent bed reductions, community developments would take place quickly. However, staff were less clear about the direction of the trust and there was concern about its future. Some staff thought the trust had been “branded” in a negative way and that this was historic rather than objective. They expressed concern about the nature of the relationship between the trust and commissioners of its services. They thought this may have meant the jobs of senior management were not secure, leading to decisions made not being as objective as they could have been.

The trust had put in place a range of initiatives to improve engagement with staff. These were welcomed but people thought there should be more; for example, of the Chief Executive’s forums where staff could meet her.

The services managed complaints and concerns effectively. They listened to concerns and learning was disseminated to the teams so it could be used to improve the services.

Section 136 of the Mental Health Act 1983 gives power to the police to take someone from a public place to a place of safety if they have a mental illness and are in need of care. The place of safety can be in a police station or health service premises such as a hospital.

The CQC inspected hospital places of safety. These were located at Wythenshawe hospital and at Manchester Royal Infirmary (MRI).

The place of safety at Wythenshawe hospital had a safe and suitable environment. At Manchester Royal Infirmary, in addition to the place of safety in the A&E department, there was a mental health assessment suite behind A&E for patients which opened in January 2015. We identified fixed ligature points in the mental health assessment suite that posed a risk.

The places of safety premises were provided by the acute hospitals but were staffed by Manchester Mental Health and Social Care NHS Trust staff.

At both places there were appropriate staffing levels and skill mix, assessment processes, multi-agency involvement and learning from any incidents. At the home treatment team, and the Swift Assessment for the Immediate Resolution of Emergencies (SAFIRE) unit we observed safe environments, staffing levels and skill mix, effective systems in place to assess people’s needs and monitor risks. The teams used an incident reporting system, multidisciplinary staff worked well together and with others outside their teams, and they learned from incidents to improve future practice.

A clear assessment and physical health check was undertaken when patients arrived at both places of safety and on the SAFIRE unit, and any physical health problems were followed up appropriately.

Qualified staff undertook the co-ordination of admissions to the places of safety and clear guidance was available to them.

Throughout the services we visited we found that the care and support received by patients was positive. Patients told us that staff took their time, they didn’t feel rushed when they were carrying out an assessment. Staff told us they were proud of the work they did.

Patients were fully involved in planning their care. Although care plans followed a set format and were not always individual to the person. Advocates were involved as appropriate and according to the person’s wishes.

Patients had access to information in different accessible formats, and to interpreting and advocacy services if necessary.

The home treatment teams visited patients in their own home or met with them at the crisis and access team offices dependent upon their needs and level of risk. Patients were also supported by regular telephone calls or a level of contact agreed by both parties.

The teams had daily contact with the acute wards to identify people who might be appropriate for early discharge with support from the team. This included providing support to people during leave periods from the ward.

Staff told us they sometimes had problems accessing beds within the trust when a person required an inpatient admission. This often meant that out-of-area placements had to be arranged, resulting in delayed transfer from the place of safety.

Patients we spoke with knew how to raise any concerns they may have had.

Some staff were aware of the chief executive and board level leadership in the trust and were able to identify the trust values. Some staff told us they did not identify with senior managers within the trust.

Staff working in community teams did not feel they were valued by the trust and told us they did not think that staff engagement within the trust was meaningful. They cited being asked about the development of new services only to be told how they were going to be run just after the consultation. Staff felt management knew how they wanted to run the service and the staff input had no meaning.

It was not clear how data was used to measure performance improvement. The data provided at trust level about training uptake showed significant gaps in training.

We found that Manchester Mental Health and Social Care Trust provided substance misuse services to people experiencing issues with alcohol that were caring, effective and responsive. This was because:

• Environments were welcoming with kind and respectful staff.
• People were comprehensively assessed in a timely manner.
• Staff attempted to meet the diverse needs of people using the service.
• Staff were encouraged to develop to meet the needs of people using the service.
• Staff were well supported.
• People using the service were involved in decisions about the service.

But we also found:

• Cover arrangements for sickness were ineffective.
• Security arrangements did not protect the safety of people using the service or staff.
• Staff did not periodically review risks of all people using the service.
• Care plans were not always individual or regularly reviewed.
• Staff were unable to track individual prescription numbers from a central record.
• There was a disconnect between the service and the overall trust.

The ward provided a safe clean and welcoming environment which was furnished to meet the needs of the mother and baby.

Risk assessments and management plans were available for patients and a ligature audit risk assessment had highlighted areas that were detailed on the risk register. Interventions had been implemented to ensure the safety of patients.

New staff to the ward received induction training specific to the patient group.

There was is a weekly ward round attended by ward based staff, members of the external care team and patients to discuss on going care and discharge planning.

Patients were mainly positive about the support which they received on the unit.

Clear assessments were in place to ensure that the wards admission criteria was being adhered to.

The unit has been accredited through the Royal College of Psychiatrists Quality network for Perinatal Mental Health Services accreditation scheme. This was is due for renewal in July 2015.

The staff had ve a good understanding of the complaints process and there were are methods in place to ensure that lessons from incidents are shared.

Recent staff shortages have impacted on staff morale due to high workloads and support required to assist bank and agency workers. New staff were are due to join the service in April and staff reported that morale was is now lifting.

But we also found

There was no protocol in place to support fathers remaining on the unit through the night. We raised this issue with the trust during our inspection and we received assurances that this practice would be halted until a protocol was in place and the trust could be assured that patients and their babies were not placed at risk by visitors staying overnight.

Mandatory training in all areas was below the trust standard of 90%. Regular clinical and managerial supervision was not in place to support nursing staff.

Fridge temperatures were not checked and recorded on a daily basis.

There was no provision for levels of observation to be reviewed and reduced as appropriate over the weekend.

Mobile alarms often go went missing as there was no robust system in place to ensure they were logged out and returned each shift.

Medication cards were not always completed correctly. Whilst this had low level impact on patient care due to the nature of the medication omitted, the process for administration, recording and monitoring showed room for improvement.

We currently only rate core services and as perinatal services do not fall within our definition of core services, we have not rated the service.