Quality Account 2020/2021 - NHS

1Quality Account 2019/20

Quality Account2020/2021Greater Manchester Mental Health NHS Foundation Trust

Improving Lives

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Contents

1 PART 1 – Our Commitment to Quality .......................................................................... 41.1 Chief Executive’s Welcome ......................................................................................... 41.2 Quality Assurance at GMMH ...................................................................................... 61.3 Quality Improvement at GMMH (QI Strategy) .............................................................. 71.4 Accolades and Developments ................................................................................... 11

2 PART 2 - Statements of Assurance from the Board for 2020/21 ............................... 152.1 Review of Services .................................................................................................... 152.2 Participation in Clinical Audits and National Confidential Enquiries ........................... 152.3 Participation in Clinical Research ............................................................................... 182.4 Commissioning for Quality and Innovation (CQUIN) .................................................. 212.5 Registration with the Care Quality Commission (CQC) .............................................. 212.6 CQC Mental Health Act Monitoring .......................................................................... 212.7 Data Quality ............................................................................................................. 222.8 Information Governance ........................................................................................... 232.9 Clinical Coding ......................................................................................................... 232.10 Department of Health Mandatory Quality Indicators ................................................. 232.12 Freedom to Speak Up ............................................................................................... 342.13 Increasing Community Mental Health Services Capacity ............................................ 35

3 PART 3 – Review of Quality Performance in 2019/20 ................................................ 373.1 Delivery of Quality Improvement Priorities in 2020/2021 ........................................... 373.2 Performance against Quality Indicators Selected ....................................................... 483.3 Performance against Key National Priorities .............................................................. 49

4 PART 4 –Priorities for Quality Improvement in 2021/22 ............................................ 524.1 Improvement Priorities for 2021/2021 ...................................................................... 524.2 Monitoring our Quality Improvement Priorities .......................................................... 52

5 Annex ............................................................................................................................ 535.1 ANNEX 1 – Feedback from Key Stakeholders ............................................................ 535.2 ANNEX 2 - Statement of Directors’ Responsibilities in Respect of the Quality Account 575.3 ANNEX 3 - Equality Impact Assessment ..................................................................... 58

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5.4 ANNEX 4 - Local Clinical Audits Reviewed in 2020/21 ............................................... 605.5 ANNEX 5 - Glossary of Terms .................................................................................... 66

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1 PART 1 – Our Commitment to Quality

1.1 Chief Executive’s Welcome On behalf of the Trust Board, I am proud to present our Quality Account for 2020/21. This describes the steps taken during what have been extraordinary times to continually improve the quality of care.

2020/21 has been yet another challenging year, not just for GMMH, but for all Trusts, public services, and our colleagues in the voluntary sector. Covid-19 has continued to affect how we work on a day-to-day basis, and at times, and this has often felt uncomfortable and challenging for us all.

However, I continue to be truly humbled by the way our staff, across GMMH, in our clinical, operational, and corporate services have responded to the biggest challenge that the NHS has ever faced. I would like to acknowledge and thank our workforce, and our volunteers for everything they have been doing at this incredibly demanding time.

On 23rd March 2021, like many other NHS organisations we joined in on a national day of reflection, which marked a full year since we went into lockdown. I took this opportunity to express my deep and sincere thanks to each and every member of staff across GMMH, for their continued compassion, courage, and commitment to our service users and their families.

It was hard for us all to imagine that 12 months ago, we would be in this position– still coping with national restrictions, and the number of lives lost to COVID-19 is hard to bear. So many of us have been affected by this terrible virus. I am proud how we have continued to stick together, and support eachother over this past year.

As well as taking time to reflect on another difficult year, we should also look forward with some optimism to the future as the vaccine is rolled out. I would like to take this opportunity to express my gratitude to our vaccination team for a tremendous effort in vaccinating so many of our staff and service users.

In July 2020 we were pleased to announce that responsibility for the future provision of mental health services in the Wigan Borough would transfer from North West Boroughs Healthcare NHS Foundation Trust (NWBH) to GMMH on 1 April 2021. By welcoming Wigan Borough services, we will benefit from the sharing of expertise, experience and local knowledge and the opportunity to offer more integrated care pathways and achieve economies of scale. Our new colleagues and service users will join a high-performing specialist trust with a key voice in shaping and improving mental health services across Greater Manchester.

During this busiest and most demanding of times, we responded by bringing forward and developing a wide range of plans and projects to ensure that our service users could continue to receive high quality, safe and effective care. By May 2020, we were proud to have introduced a suite of changes, that complemented our services across GMMH. These included:

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• The introduction of a 24/7 helpline for all our service users and their families, and an increase in our support for homeless people.

• Expansion of our physical health provision, including the development of physical health training videos.

• Transforming our emergency pathways, including the introduction of mental health urgent care centres at each acute hospital site.

• Introducing a new, robust support package for all GMMH staff which included supporting our staff to be redeployed to assist our essential services.

• Enhancing our substance misuse services, including the development and introduction of online resources.

• Embracing digital technology through the use of surface pro’s, mobile devices and Microsoft Teams, to support remote working.

Further detail on the changes we have made to our services throughout the year can be found on page 12 of the Quality Account.

Despite the challenges bought about by the Covid 19 pandemic, our staff across GMMH took the time to fill out the annual Staff Survey. We were pleased to see improvements across the Trust in areas such as health and wellbeing, team working, support from managers and staff engagement. It is a real testament to our staff to see how they have continued to support each other in such challenging circumstances.

The results from this important survey will be shared across all of our directorates to consider local actions for improvement. I particularly want to highlight the results from our Health and Justice colleagues who have received extremely positive feedback, specifically in relation to staff experience. The challenge of keeping people safe while in a secure setting has been significant and we know there has been high levels of infection amongst prison populations.

Throughout 2021/22, we will continue our effort to ensure that we do everything we can to improve outcomes, deliver the safest care and integrate our services around our service users. We will do this within a culture of continuous improvement.

Looking ahead, 2021/22 promises to be just as challenging. But I hope that 12 months from today, the world looks very different again and we are back to enjoying our freedoms with confidence and happiness.

Finally, I am pleased to inform you that the Board of Directors has reviewed this 2020/21 Quality Account and confirm that this is an accurate and fair reflection of our quality and performance. I hope that this report provides you with a clear picture of our robust approach to quality at GMMH.

As Chief Executive of Greater Manchester Mental Health NHS Foundation Trust (GMMH), I can confirm that, to the best of my knowledge, the information contained in this report is accurate. The ‘Statement of Directors’ Responsibilities’ at Annex 2 summarises the steps we have taken to develop this Quality Account and external assurance is provided in the form of statements from our commissioners, local HealthWatch organisations and Scrutiny Committees in Annex 1.

Neil Thwaite, Chief Executive 10 June 2021

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1.2 Quality Assurance at GMMH As an organisation that seeks to continually improve, we take steps to quality check our current activities to provide the best possible care to our service users. Our Board of Directors hold ultimate accountability for the quality of the services that we provide. To ensure robust quality assurance and a culture of continuous improvement, the Board has established a committee with delegated authority to set the strategy for quality and to ensure delivery against it.

The Quality Improvement Committee (QIC) is chaired by a non-executive director and has representation from the Trust Board, lead clinicians from all clinical services and from corporate leads with responsibility for quality improvement. The structure and business of the QIC has been informed by an assessment against the national Quality Governance Framework.

QIC provides leadership and oversight for the Trust’s quality and integrated governance framework. It maintains a strategic overview of the Trust’s approach to quality improvement and ensures that it encompasses a robust range of improvement programmes that reflect our local and regulatory requirements. QIC develops the Trust’s quality strategy on behalf of the Board and identifies key quality priorities, goals, and standards for GMMH. This is set out both in our Quality Governance Framework and in our Quality Improvement Strategy for phase one.

Trust Board and QIC members are visible within clinical services. This provides members with opportunities to triangulate evidence, speak to service users and staff about their experience and ensure that there is an open and transparent culture across GMMH. Throughout the year, we have continued to embed our quality improvement approach, within a strategic framework offering ward to Board level assurance that our services are safe, positive, and effective.

GMMH’s Executive Management Team and Board review intelligence gathered from a wide range of sources. These include:

• Service specific performance monitoring frameworks. • Quality improvement project reports, and our Lean A3 single page plans. • Quarterly quality reports, using statistical process control charts to drive and monitor our

improvement programmes. • Commissioning for Quality and Innovation (CQUIN) activity. • Contractual Performance Key Performance Indicators. • Care Quality Commission Insight and Intelligence reports. • Staff and patient surveys, including feedback from our service users and carers. • Clinical governance reports (including incidents, compliments, and complaints). • Corporate governance reports (Compliance with the NHS Improvement Oversight

Framework and Monitor ‘Code of Governance’). • Board performance reports and presentations at Board meetings. • Quality Board performance reports, which have been adapted to become more

improvement orientated. • NHS Benchmarking Network reports. • Our Quality-of-Care Programme. • Additional activities including deep dives and external reviews, as commissioned by the

QIC.

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1.3 Quality Improvement at GMMH (QI Strategy) Our Quality Improvement strategy was launched in May 2019 and has been delivered throughout 2020/21. Our QI strategy incorporates three key enablers which have driven our approach to continuous improvement, supported the delivery of our quality improvement priorities and our wider vision for QI. These were as follows:

1. Supporting staff to deliver QI - building capacity and capability. 2. Identifying improvement methodology to complement workflow. 3. The development of improvement orientated data throughout the organisation, from

Board to team/ward.

Supporting staff to deliver QI – building capacity and capability.

To continue to achieve this, we have focussed on the provision of high-quality training, to support our staff to have the capability, enthusiasm, and motivation to make, sustain and spread QI across GMMH. Building capability in this way will enable us to create a culture, where staff members are trained and empowered to focus on where they can make improvements to the work, they do, whether that is in clinical care, governance, financial systems, estates and facilities or human resources. To date, around 300 members of GMMH staff have participated in QI training, across a wide range of areas ranging from our beginner’s guide and measurement, Lean in healthcare and appreciative enquiry training, through to human factors, improvement practitioner and measurement masterclass training.

Throughout 2021/22, we will continue to focus on the development and delivery of our accredited in-house programme. This will be available to all staff including our service users across GMMH, at different levels to complement the current Advancing Quality Alliance (AQuA) offer. This training is currently available at bronze and silver levels. Our aim for 2021/22 is to introduce a gold level training package, which will be aimed at improving Leaders involved in complex change programmes.

Throughout 2021/22, we have continued at assess our QI capability using the organisational strategy for improvement matrix (OSIM). An OSIM is a capability measurement process that can be used to determine how supportive of improvement or change friendly an organisation is at a point in time. An OSIM is specifically designed to help organisations determine where their services currently stand in their improvement journey by:

• Prompting discussion about organisational strengths and areas of development. • Reflecting on ways to improve capability. • Informing strategic goals.

Completing the OSIM helps GMMH to assess our current progress and to set maturity goals that can close the gap between where the Trust is and where we want it to be. An OSIM is structured around four key areas, or 'domains'. These are as follows:

Domain 1. Organisational systems and structures

The processes and management of processes and its demonstrated ability to drive improvement.

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Domain 2. Workforce capability and development

The knowledge skills and abilities of the workforce related to improving work processes and systems and the availability of training to build capability.

Domain 3. Results and system impact

The means by which results are measured and tracked and the emerging benefits communicated.

Domain 4. Culture and behaviour

The mechanisms to support and embed a continuous improvement environment, including leaders’ awareness of their role in driving improvement.

Each domain comprises a set of criteria - the levers in an organisation that impact on or promote improvement capability. Organisations self-assess against each criterion. This involves asking the question, 'How well does our health service meet this criterion?' and then assigning a maturity level, from Level 1 Foundational, to Level 5 Advanced. Once a service has completed an OSIM it receives a score for its overall maturity level and improvement capability. This helps trusts to gain an understanding of organisational strengths and areas for development. In our second assessment, GMMH improved in all four areas, as follows:

Phase Organisational systems and structures

Workforce capability and development

Results and system impact

Culture and behaviors

OSIM 1 January 2020 2.6 2.2 2.3 2.6

OSIM 2 January 2021 2.9 2.8 3.0 3.0

Our rating continues to outline a high potential for improvement, along with evidence of improvement and capability in some areas across the Trust. Our overall score of 2.9 (building) reflects our current position, and a target maturity score and level has been set for 3.0 (refining). The current maturity level and improvement capability for GMMH is as follows:

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The QI team will continue to repeat the OSIM assessment on an annual basis, to develop a detailed understanding of improvement capability across GMMH, and to build capacity and support to progress this.

Identifying improvement methodology to complement workflow

Within the 2019/20 Quality Accounts, we provided details on the commitment that GMMH had made to identifying an improvement methodology that reflected the vision, values, and principles of our Trust. We developed an options appraisal that described our strategic context, current approaches, capability and programmes, a consideration of the criteria that our chosen methodology should fulfil, and an appraisal of the key improvement methodologies promoted resourced and adopted in front line services throughout the NHS.

The options appraisal highlighted the IHI-QI Model for Improvement as the single methodology that best met each of the individual criteria set that we set out. Throughout 2020/21, we have continued to use the Model for Improvement to drive, structure and evaluate our range of improvement programmes. In addition, we also continue to blend this approach with other QI methods and methodologies when this might be necessary, for example, the Lean approach. We will continue to adopt and adapt our chosen methodology throughout 2020/21 and will maintain our efforts to train our staff in its consistent application to our improvement effort.

The development of improvement orientated data throughout the organisation, from Board to team/ward

Our final key enabler for phase one was the development of improvement data reporting across GMMH. In delivering this, we made a a commitment to exploring how to make better use of data to drive, monitor and inform our QI activity. A key part of measurement for improvement is established baselines, measurable aims, and a means of tracking progress over time. It also requires organisations to report data in a time series analysis format and to develop knowledge and appreciation of variation.

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At GMMH, we are now routinely using Statistical Process Control (SPC) to support the analysis of all GMMH board level quality and performance metrics. SPC charts are also used at our Quality Improvement Committee, and all QI projects have adopted SPC, which is now a consistently applied tool in each of the measurement plans that are used to drive our improvement programmes. This has enabled the development of knowledge and appreciation of measurement, as well as an understanding of common cause and special cause variation.

The GMMH Quality Improvement Team has worked hard over the year to provide support to corporate services in developing their knowledge of measurement and variation. A series of training sessions have been delivered to our human resources, pharmacy, and finance colleagues to support their awareness of statistical process control, along with common and special cause variation rules. To build on this further, the team will be providing an in-house masterclass on measurement, to KPI leads who have responsibility for supporting the monthly board performance report.

We are pleased to be able to report on the progress we continue to make on our QI journey. We will continue with our efforts to build capacity and capability throughout 2021/22.

1.4 Accolades and Developments A year like no other…

2020/21 was a year never to be forgotten, where the NHS had to rise to the biggest health emergency ever in its history. Working through this, continuing to deliver safe and effective services, and remaining safely staffed has been a huge achievement in itself.

When lockdown began in March 2020, numerous plans and projects were initiated or brought forwards exponentially, so that by May 2020, we had delivered the following which featured a 24/7 mental health helpline set up in a matter of days and the roll out of using MS Teams to deliver online IAPT consultations 12 months early.

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Throughout the summer, we continued to put our staff at the heart of our efforts, to offer them as much support as possible during this unprecedented time. This included supporting frontline staff to access the appropriate PPE, antibody testing, lateral flow testing, health and wellbeing advice and support and supporting over 1,200 staff to work effectively from home. Every member of staff was given a risk assessment which have been regularly reviewed to ensure those who needed to shield were supported to do so, and those in patient-facing roles were working as safely as possibly. All our locations were robustly assessed to and brought up to COVID-safety standards.

It was not just frontline services which adjusted rapidly to the pandemic. GMMH’s Research and Innovations team provided vital support to essential services during the pandemic. Many colleagues were redeployed to frontline services that needed extra support. This included putting some of our nurses back into inpatient wards, helping in the catering department, taking blood in community clinics, and delivering PPE across the Trust.

The team rose to the challenge of continuing to provide research opportunities during lockdown through innovative ways of working; and in doing so, supporting vital research into COVID-19. This included contributing towards a global study looking into the psychological impact of COVID-19. GMMH’s participation was a huge success, with a total of 620 participants recruited, finishing 8th overall in the league table of 107 Trusts. The team also began delivering a telephone survey to see how service users were coping during the pandemic, which also allowed us to inform people of the symptoms of COVID-19 at a time when awareness raising was crucial and identify and signpost people who were struggling with their mental health.

The Trust’s Recovery Academy which supports over 7,000 students changed from face-to-face teaching, to developing new ways of working and products that benefit service users, carers, and staff. Examples include:

• New ways of working including new Learner Management System and live webinars. • New products including online self-help materials, videos, e-learning, and radio podcasts. • Supporting Continuous Professional Development across Greater Manchester including

MPs, Foster Carers, Metrolink, Manchester City College, North Manchester Crisis Response Team, Housing Sector and Manchester Local Care Organisation.

• New Level 2 Trauma Informed Peer Mentorship Award mapped to the National Peer Support Competency Framework.

• Working in partnership nationally as part of the new Peer Support Worker Apprenticeship trailblazer group.

• Launching and managing the new Volunteer Responder Scheme. • Developing our brand.

Throughout the pandemic, recovery remained a focus despite the ever-changing backdrop and workstreams were set up across the Trust to assess the impact of COVID-19 and shape future services, always ensuring we were enhancing the support and wellbeing offer for our service users as much as possible.

When the COVID-19 vaccine became available in January 2021, our teams mobilised to begin offering the vaccine to our staff and at the time of writing, over 70% of GMMH have had the first dose. The vaccine is also being offered to our inpatients.

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Notwithstanding COVID-19, the last 12 months have seen further achievements, made even more significant that they occurred during a pandemic. Other research and innovation successes included: the creation of three new Research Units; delivering a number of successful grant applications; adapting our dementia study portfolio to ensure continued, safe involvement; successfully delivering the EXPO trial in our substance misuse services; the launch of the consent to approach database to further enhance research recruitment opportunities for staff; and the implementation of Otsuka Health Solutions’ Management and Supervision Tool (MaST) within GMMH to support the evaluation of risk of crisis and complexity to a sophisticated degree We also launched our new Mental Health Nurse Research Unit (MHNRU) which supports the development of research skills and knowledge amongst mental health nurses.

In July 2020, we were pleased to announce that responsibility for the future provision of mental health services in the Wigan Borough would transfer from North West Boroughs Healthcare NHS Foundation Trust (NWBH) to GMMH on 1 April 2021. Though part of NWBH’s current portfolio, commissioners from Wigan Borough identified clear benefits to separating Wigan Borough’s mental health services from the Mersey Care acquisition and transferring them to a provider within the Greater Manchester region. As the largest provider of specialist inpatient and community mental health services across Greater Manchester, with services already provided in or bordering Wigan, the case for transferring Wigan Borough services to GMMH was strong and supported by all parties to the transaction. This move is in line with the Greater Manchester Mental Health and Wellbeing Strategy, the Wigan Borough Locality Plan and Mental Health Strategy and our own strategic priorities.

By welcoming Wigan Borough services, we will benefit from the sharing of expertise, experience and local knowledge and the opportunity to offer more integrated care pathways and achieve economies of scale. Our new colleagues and service users will join a high-performing specialist trust with a key voice in shaping and improving mental health services across Greater Manchester.

Also, in July 2020, we launched a campaign promoting our Substance Misuse Services. Achieve and Unity worked tirelessly with our partners to make sure that the challenges presented by COVID-19 did not result in losing contact with or reduced the quality of care for those receiving our support, including the most vulnerable.

The pandemic impacted on referrals into the services, and we noted a decrease compared the previous year’s figures. The social media campaign - “You matter, we’re here” - ran for two weeks, detailing information about how our services adapted to continue to provide a high level of support during the pandemic. The campaign successfully raised awareness of our services and reminded and informed communities that we were still open, and they could still access recovery treatment and support.

In August 2020, our CAMHS services at Junction 17 and the Gardener Unit passed the accreditation process awarded by the Royal College of Psychiatrists Quality Networks which promotes the highest level of care for service users. It is a tough and rigorous process involving

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253 standards across seven areas such as Care and Treatment, Staff and Training and Environment and Facilities. It is a prestigious award and is valid until March 2023.

During National Hate Crime Awareness Week in October 2020, GMMH launched its first Hate Crime Protocol. It is a key priority of our organisation to raise awareness and enhance society's perception and understanding of what constitutes a hate crime, to challenge inequality and to celebrate the diverse make up of our society. The Trust will not tolerate any form of hate crime or incident.  We encourage our staff to report any hate incidents or crimes at the earliest opportunity and to promote a zero-tolerance culture.

In December 2020, we delivered an inspiring GMMH Staff Awards online ceremony all our amazing staff.

The pre-recorded awards ceremony, hosted by Neil Thwaite and Rupert Nichols, involving members of the Executive Team, celebrated the winners and highly commended winners. Within the digital ceremony, we also included highlights from our GMMH Superstars and celebrated our teams across the footprint of the Trust for their hard work during the year.

2020 awards winners and highly commended teams or individuals were sent a sweet treat hamper the week after the awards ceremony, which were well received by all on social media.

In January 2021, GMMH received planning permission for the transformation of our adult inpatient unit in North Manchester. This is a £105million investment to overhaul our adult mental health unit (Park House) on the North Manchester General Hospital site. Under the plans, our patients and carers will benefit from a new, purpose-built inpatient unit which will greatly improve the quality of specialist care for adults and older people severely affected by mental health problems including schizophrenia, psychosis, depression, and dementia.

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2 PART 2 - Statements of Assurance from the Board for 2020/21

This section of our Quality Account includes mandated information that is common across all organisations’ Quality Accounts. This information demonstrates that we are performing to essential standards; measuring clinical processes and performance; and are involved in national projects and initiatives aimed at improving quality.

2.1 Review of Services During 2020/2021 Greater Manchester Mental Health NHS Foundation Trust provided and/or sub-contracted a wide range of relevant health services. Services provided include:

• Community and inpatient mental health services. • Adult forensic mental health services. • Adolescent forensic mental health services. • Inpatient Child and Adolescent mental health services. • Mental health and deafness services. • Community and inpatient alcohol and drug services. • Prison healthcare and in-reach services. • IAPT– primary care psychology. • Rehabilitation services. • Perinatal services. • Community Child and Adolescent Mental Health Services. • Public Health Improvement Services.

More detail on the services provided by us can be found on our website – www.gmmh.nhs.uk

GMMH has reviewed all the data available on the quality of care in all of these services.

The income generated by the relevant health services reviewed in 2020/21 represents 100% of the total income generated from the provision of relevant health services by GMMH for 2020/21.

2.2 Participation in Clinical Audits and National Confidential Enquiries

During 2020/21, There were 2 national clinical audits and 1 national confidential enquiry covering relevant health services that GMMH provides.

During that period, GMMH participated in 100% of the national clinical audits and 100% of the national confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquiries that GMMH was eligible to participate in during 2020/21 are as follows:

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• Prescribing Observatory for Mental Health: Prescribing Valproate. • National Audit of Early Intervention in Psychosis re-audit. • National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness

(NCI/NCISH).

The national clinical audits and national confidential enquiries that GMMH participated in and for which data collection was completed during 2020/21, are listed below alongside the number of cases submitted to each audit or inquiry as a percentage of registered cases required of that audit or enquiry (list and percentages are in the table below).

National Clinical Audits:

Audit Title Participation % of cases Submitted

Prescribing Observatory for Mental Health: Prescribing Valproate Yes 100%

National Audit of Early Intervention in Psychosis re-audit

Yes 100%

Information about the Audits

Prescribing Observatory for Mental Health: Prescribing Valproate.

The practice standards for the audit are derived from NICE Guidelines (CG185) Bipolar Disorder: Assessment and management, September 2014. The aim of the audit is to examine prescribing practice to establish if patients prescribed valproate are given written information about its use and that body weight and/or BMI, blood pressure, plasma, glucose, and plasma lipids are measured prior to initiating treatment and at least annually during continuing valproate treatment.

The criteria for the audit also covers prescribing valproate for women of child-bearing age to ascertain that if valproate is prescribed for a woman of child-bearing age, there should be documented evidence that the woman is aware of the need to use adequate contraception and has been informed about the risks that valproate would pose to an unborn baby.

National Audit of Early Intervention in Psychosis (re-audit)

The Early intervention in psychosis (EIP) audit will help to establish the extent to which services comply with a framework of NICE standards of care, NICE quality standard for psychosis and schizophrenia in adults (QS80), which put particular emphasis on early access, physical health, family intervention and supported employment programmes and will enable participating services to identify their strengths as well as the areas of improvement.

The aim is to achieve compliance and provide evidence to NHS England that patients have been screened for all seven cardio metabolic parameters (as per the ‘Lester tool’) which are:

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• Smoking status. • Alcohol. • Drugs. • Blood lipids. • Body Mass Index.

• Blood pressure. • Glucose regulation (HbA1C or fasting

glucose or random glucose as appropriate).

Where clinically indicated they were directly provided with or referred onwards to other services for interventions for each identified problem.

National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH).

National confidential inquiry

Questionnaires received from NCI 2020/2021

Questionnaires completed and returned back to NCI

%

Suicide 25 20 80%

The National Confidential Inquiry examines suicides and homicides by people who have been in contact with secondary and specialist mental health services in the preceding 12 months. Previous findings of the Inquiry have informed recommendations and guidelines produced by the National Institute for Clinical Excellence (NICE), the National reporting and learning system (NRLS) and the Inquiry itself aimed at improving outcomes and reducing suicides rates for individuals with mental illness.

Please note that data collection was postponed by the National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness due to the Covid 19 pandemic and reinstated in January 2021. As a result, it was not possible to clinically assess all outstanding questionnaires by 31st March 2021.

The reports of 2 national clinical audits were reviewed by GMMH in 2020/21 and GMMH intends to take the following actions to improve the quality of healthcare provided as per the table below:

Audit Title Key Actions

Prescribing Observatory for Mental Health:

Antipsychotic Prescribing in People with a Learning Disability under the care of Mental Health Services. Report issued August 2020.

• Improve documentation around side-effect monitoring in the past year of people with a learning disability prescribed antipsychotic medication for more than a year.

• Ensure that written behavioural support plans are developed at initiation of antipsychotic medication.

• To clearly document when a review to consider reducing the dose or stopping has been completed.

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National Audit of Early Intervention in Psychosis Re-audit.

Individual team reports issued September 2020.

• Individual team action plans to date has included: • In Trafford, new monies have allowed us to employ a

dedicated family intervention worker and devote a significant proportion of time of a senior clinical psychologist to training more care coordinators in Behavioural Family Therapy and delivering BFT to more families.

• In Salford, a family intervention lead has been recruited within EIT whose role is to promote family intervention and support care coordinators to provide family intervention.

• In Bolton, the team have been exploring new models of provision of family intervention over the Covid pandemic which they will continue to offer.

• In Manchester, a family intervention lead is now in place and digital solutions to increasing the availability of family intervention are being used.

We also undertook and reviewed the reports of 101 local trust clinical audits in 2020/21. A full list of these local audits is included in Annex 5. Recommendations and action plans for each local audit has been agreed and shared with relevant people/services in line with our Clinical Audit Policy. If you are interested in learning more about the actions, we are taking to improve the quality of healthcare provided based on the outcomes of these audits, please contact:

Patrick Cahoon, Head of Quality Improvement

Tel: 0161 357 1793

E-mail: [email protected]

All national and local clinical audit reports, and resulting action plans, are reviewed by our Quality Improvement in Clinical Care Group (QICC) (Formally the NICE Implementation and Audit Group (NIAG), which meets on a bi-monthly basis and is chaired by the Trust’s Medical Director, QICC aims to ensure that actions agreed following audit reports are supported and completed. The outcomes of discussion at QICC are reported up to, and considered at, the Trust’s Quality Governance Committee.

2.3 Participation in Clinical Research The NHS Constitution for England requires us to inform service users of any research opportunities that are available to them through which they may be able to improve potential outcomes for themselves and others. The level of research activity within GMMH sets us apart from the majority of mental health Trusts nationally and this is illustrated by the continued success in obtaining external funding from the National Institute of Health Research (NIHR) to carry out ground-breaking research led by Manchester researchers.

Our total NIHR grant income for 2020/21 for all active NIHR grants was £4,172,403 which is over £1million more than 2019/20. We have also received notification of 9 more successful NIHR grant awards since April 2020 which will run over the next 3-5 years. These include:

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A Feasibility Study to Define and Embed a Common Mental Health Dataset in Physical Health Clinical Trials, Kathryn Abel, NIHR Research for Patient Benefit, £240,162, started on 1st July 2020.

The Resilience Hubs: A multi-site, mixed-methods evaluation of an NHS Outreach, Screening and Support Navigation service model to address the mental health needs of key workers affected by the COVID-19 pandemic, Filippo Varese, NIHR Health Services and Delivery Research (COVID response mode), £474,370, started on 1 October 2020.

Motiv8: A randomized feasibility trial of a weight management intervention for adults on secure forensic mental health inpatient units, Rebekah Carney, NIHR Research for Patient Benefit, £248,352, planned start date March 2021.

Evaluation of the feasibility of Empowered Conversations: a training package to enhance relationships and communication between family carers and people living with dementia, Lydia Morris, NIHR Research for Patient Benefit, £246,836, planned start date April 2021.

Cell-Soothe: The feasibility and acceptability of a digital app for women who self-harm in prison, Kathryn Abel, NIHR Research for Patient Benefit, £249.966, planned start date January 2022.

Youth Metacognitive Therapy (YoMeta): A Single Blind Parallel Randomised Feasibility Trial, Adrian Wells, NIHR Research for Patient Benefit, £249,454, start date tbc.

i-Minds: A digital intervention to improve mental health and interpersonal resilience for young people who have experienced online sexual abuse - a non-randomised feasibility study with a mixed-methods design, Sandra Bucci, NIHR Health Services & Delivery Research, £846,667, start date tbc.

Provisional award: A digital tool to reduce inappropriate CAMHS referrals, Kathryn Abel, NIHR Health Services & Delivery Research, final award value and start date tbc (approx. £700k).

Provisional award: Models of social care provision in prison – mixed methods study, Andrew Shepherd, NIHR Programme Development Grant, final award value and start date tbc (approx. £250k).

NIHR grant income also generates Research Capability Funding (RCF) from the NIHR which enables us to support research growth across the Trust. In 2020/21 the Trust received £1,031,706 which is an increase of over 20% compared to the previous financial year. This has enabled us to support many internal research initiatives including the establishment of 4 new Research Units which will increase research activity in specialist perinatal mental health, mental health nursing, psychological therapies for anxiety and depression and equality, diversity, and inclusion in mental health research.

These new Units complement our existing established Research Units in psychosis, digital, dementia, complex trauma and resilience, youth mental health and patient safety. In order to ensure continued access to this funding stream, each unit needs to demonstrate clear service user involvement, integration with clinical services, applications for external research funding, opportunities for service users to participate in research and a commitment to ensuring equal access to research across the communities we serve.

Research Delivery

During 2020/21, over 2,500 service users, staff, relatives, and carers participated in research projects approved by the Health Research Authority in GMMH. Throughout the year, we have

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been able to offer our communities the opportunity to participate in over 50 research studies despite the restrictions that have been imposed as a result of the COVID-19 pandemic and many studies have been adapted to allow full or partial delivery of the research remotely to keep participants and staff safe.

Our study portfolio includes 22 interventional trials including 5 Clinical Trials of Investigational Medicinal Products and 9 studies sponsored by GMMH. Our highest recruiting studies this year include a study looking at cases of avoidable harm in prison settings and a study looking at a peer-delivered intervention in psychosis which are both led by Manchester researchers.

Bringing research to our service users

Research in GMMH is not just about study participation but involvement in every aspect of the research process. Service user involvement is central to our 2021-24 R&I strategy and is a key.

deliverable for all Research Units. This allows our service users to contribute to the development of research questions and the design, conduct and dissemination of all research studies including clinical trials. We have been reviewing all opportunities to increase the number of user-led research projects and service user researchers.

A recent internal funding call has resulted in 2 new awards for user-led projects involving a commitment to submitting training fellowship applications to the NIHR for further funding. We also now have 7 service user posts within R&I supporting Research Units and the R&I Office.

Impact of research and innovation

The Complex Trauma and Resilience Research Unit and the Psychosis Research Unit continue to support the Trust-wide quality improvement programme, specifically in relation to implementation of trauma informed care and access to psychological therapies for service users with serious mental health conditions (psychosis, bipolar, personality disorder).

The Youth Mental Health Research Unit is also supporting quality improvement particularly in relation to physical health initiatives in J17 including the recent grant success to continue the motiv8 work. R&I staff and research units have also been extensively involved in the evaluation of service changes and digital developments that resulted from the COVID-19 pandemic (such as IAPT moving to remote delivery, and changes in inpatient and community services including adult, older adults, CAMHS, substance misuse services and perinatal services).

The Anxiety, Depression and Psychological Therapies Research Unit is involved in wider evaluation of the impact of COVID-19 on outcomes in IAPT service users and the Mental Health Nursing Research Unit is involved in evaluation of inpatient care.

For further information about our Research and Innovation work streams please contact:

Sarah Leo, Head of Research & Innovation Office (0161 271 0076 or [email protected]).

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2.4 Commissioning for Quality and Innovation (CQUIN)

For 2020/2021, GMMH can confirm that the CQUIN scheme was suspended, owing to the national response to the Covid19 pandemic. Therefore, no data on any of the national CCG or NHS England indicators is available for publication within the Quality Account.

Further details and information in relation to the CQUIN schemes that relate to GMMH services can be provided using the contact details below:

Miranda Washington, Deputy Director of Performance and Business Development

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, The Curve, Bury New Road, Prestwich, Manchester M25 3BL

Tel: 0161 358 1366


2.5 Registration with the Care Quality Commission (CQC) GMMH is required to register with the CQC. The CQC has not taken any enforcement action against GMMH during 2020/21, and GMMH has not participated in any special reviews or investigations by the CQC.

The table below provides a summary of the ratings received from the CQC from our last inspection, within their report, which was received on the 9th of January 2020. We are pleased to have retained our CQC inspection overall rating ‘Good’ and for the recognition received by the CQC in relation to outstanding practices introduced across the organisation. We are however aware that further improvements are required to bring all our services in line with the CQC requirements.

Domain Rating CQC Domain GMMH rating Safe Requires Improvement Effective Good Caring Good Responsive Good Well Led Good Overall rating for GMMH Good

2.6 CQC Mental Health Act Monitoring Due to the Coronavirus pandemic, on the 8 April 2020 the CQC introduced an Interim Methodology for Mental Health Act monitoring visits. This meant that new remote methods of monitoring care and treatment provision for those detained under the Mental Health Act would take place using a range of remote data collection methods including phone, email and video communications with ward staff, patients, carers and IMHAs. Where there were significant

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concerns around service provision, the CQC would also undertake additional reviews which may also include a site visit.

Between 1 April 2020 and 31 March 2021, the CQC undertook remote Mental Health Act monitoring visits to the following GMMH wards:

• Bolton – Oak ward. • Rehabilitation wards – Copeland ward, Honeysuckle Lodge. • Salford – Chaucer, Eagleton, Keats, and Hazelwood wards. • Specialist Services Network – Griffin, Buttermere, Silverdale, Dovedale, Delaney, Gardener

Unit, Newlands, Phoenix, Hayeswater, Coniston and Borrowdale wards. • Trafford – Brook, and Bollin and Greenway wards.

2.7 Data Quality The Trust recognises that accurate, complete, and timely information is vital to support both the delivery of safe and efficient patient care and the management, planning, and monitoring of its services.

GMMH submitted records during 2020/2021 to the Secondary Uses Service (SUS) via the MHSDS for inclusion in the Hospital Episodes Statistics, which are included in the latest published data (November 2020). The percentage of records in the published data:

• which included the patients valid NHS Number was: 100%

• which included the patient’s valid General Medical Practice Code was: 100%

During 2020/21 GMMH has continued to build on the improvements of previous years, to ensure that the importance of accurate quality data and ensuring effective collection processes are fully embedded across the organisation, this is achieved by:

• All Information Quality Assurance policies and procedures are reviewed annually as part of our assurance processes for the Data Security and Protection Toolkit.

• Providing constructive and supportive feedback to colleagues when data quality errors are identified.

• A proactive programme of audits undertaken throughout the year, the findings of which inform the Trust on areas of strengths and weaknesses and ultimately guide ongoing developments.

• Continuing to communicate key messages regarding accurate recording of clinical activity.

• The development of a new SAR (Subject Access Request) reporting system to assist in the monitoring and delivery of personal information in line with nationally mandated requirements and legislation.

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2.8 Information Governance We aim to deliver excellence in Information Governance by ensuring that information is collated, stored, used, transferred, and disposed of, securely, efficiently, and effectively and that all our processes adhere to national mandates and legal requirements.

This ensures that information is accessible when needed, to support the delivery of the best possible care to our service users. All our Information Governance polices are reviewed annually and the Trust is fully compliant with the Data Security and Protection (DS&P) toolkit which outlines the management requirements of all service user, staff, and organisational information in terms of the Data Protection Act (2018), GDPR and all other relevant legislation. The DS&P toolkit sets national standards for achievement to ensure that organisations maintain high levels of security and confidentiality of information at all times.

GMMH achieved full compliance with the DS&P toolkit in 2020/21.

2.9 Clinical Coding GMMH outsources its clinical coding processes. This arrangement is audited for accuracy annually by an external expert as part of the Data Security and Protection toolkit submission.

During 2020/2021 the audit report confirmed an accuracy level of 100% for primary diagnosis and 98.53% for secondary diagnosis against a sample of 50 randomly selected patient records.

This has reaffirmed Trusts confidence in the existing system. GMMH will continue to work with clinicians to maintain the high levels of clinical coding accuracy.

2.10 Department of Health Mandatory Quality Indicators We have reviewed the required core set of quality indicators which Trusts are required to report against in their Quality Accounts and are pleased to provide you with our position against all indicators relevant to our services for the last two reporting periods (years).

2.10.1 Preventing People from Dying Prematurely - 7 Day Follow-Up

Please note that due to the COVID-19 pandemic, collection of this indicator was suspended as from Quarter 4 of 19/20. GMMH have continued to report locally on this indicator at Board and team level. The below statement and comparison use local figures for level of achievement.

The national published figures for comparison purposes are not available due to the suspension of national reporting.

GMMH achieved the Oversight Framework (OF) target of >95% of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric inpatient care.

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The latest available local figures are as at the end of Q3 and are set out as follows:

Performance CPA 7 Day Follow-Up YTD Q3 2019-2020* YTD Q3 2020-2021

GMMH 96.0% 97.2%** National Average 95.0% Not Available Lowest Trust 85.9% Not Available Highest Trust 100.0% Not Available

**As of December 2020. Source: PARIS *As at December 2019 Source: https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/ 2019/20 figures are YTD Q1-Q3 2020/21 figures are YTD Q1-Q3

This demonstrates that GMMH achieved the target in Q3. All our staff understand the clinical evidence underpinning this target and are committed to improving clinical outcomes for patients. GMMH has also embedded new requirements for follow up within 72 hours as from April 2020 within clinical teams, building on the 19/20 CQUIN targets. GMMH continue to take the following actions to consolidate this performance, and so the quality of our services:

• Review individual breaches to ensure best practice can be shared and identify learning opportunities to minimise breaches wherever possible.

• Identify any potential training issues as they arise, and provide training to address these issues, particularly for new staff.

• Ensure our operational and data quality policies and procedures remain up to date and reflect new requirements providing clear guidance for staff.

2.10.2 Enhancing Quality of Life for People with Long-term Conditions – Gatekeeping

Please note that due to the COVID-19 pandemic, collection of this indicator was suspended as from Quarter 4 of 19/20. GMMH have continued to report locally on this indicator at Board and team level. The below statement and comparison use local figures to give level of achievement.

The national published figures for comparison purposes are not available due to the suspension of national reporting.

GMMH achieved the UNIFY target of >95% of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period

The latest available local figures are as at the end of Q3 and are set out as follows:

Performance Gatekeeping YTD Q3 2019-2020* YTD Q3 2020-2021

GMMH 99.5% 99.7%** National Average 97.9% Not Available Lowest Trust 91.9% Not Available Highest Trust 100.0% Not Available

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**As of December 2020. Source: PARIS *As at December 2019 Source: https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/ 2019/20 figures are YTD Q1-Q3 2020/21 figures are YTD Q1-Q3 This position demonstrates that GMMH achieved the national target in Q3. All our staff understand the clinical evidence underpinning this target and are committed to improving clinical outcomes for patients. Individual breaches are reviewed to ensure best practice can be shared and learning opportunities identified.

2.10.3 Ensuring that People have a Positive Experience of Care – Staff Survey

Results from the 2020 National Staff Survey are broken down into themes, as outlined in the narrative below. The Trust received a response rate of 48% against a national average for peer Trusts of 49%. Whilst this is a 1% reduction response rate for GMMH as a Trust, nationally the response rate of peer trusts dropped by 5% since 2019.

There have been 7 improvements across themes which are classed as a statistically significant change and overall, the Trust has improved or stayed the same in all areas. Nationally only 3 key themes were highlighted as improvements made, which were of statistical significance.

Theme areas where the Trust reported improvements, of which the Survey Coordination Centre confirmed were statistically significant were:

• Health & Wellbeing (5.7 to 6.2). • Immediate Managers (7.2 to 7.4). • Morale (6.1 to 6.3). • Bullying and Harassment (7.9 to 8.1).

• Safety Culture (6.7 to 6.8). • Staff Engagement (6.9 to 7.0). • Team Working (6.7 to 6.8).

Theme areas where the Trust reported improvements, although not highlighted as statistically significant were:

• Equality, Diversity & Inclusion (8.9 to 9.0). • Quality of care (7.1 to 7.3).

Theme areas where the Trust remained the same in performance were:

• Violence (remained at 9.2).

A full communication and engagement plan will be agreed to thank staff for taking the time to complete the survey and provide information on some of the high-level results, including a “you said, we did” campaign drawing attention to the work that is being done.

Following engagement with key stakeholders’, for example JCNC and Staff Networks, relevant actions will be referenced within the GMMH People Plan to ensure priority actions are delivered across 2021/22.

GMMH results for specific indicators relating to bullying and equal opportunities are set out below:

Indicator KF 26 - % of staff experiencing harassment, bullying or abuse from colleagues was 14.4% (national average 15.5%).

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Indicator KF21 - % of staff believing that the Trust provides equal opportunities for career progression or promotion was 85.6% (national average 86.6%).

2.11 Ensuring People have a Positive Experience of Care – Community Mental Health Patient Survey

The 2020 survey of people who use community mental health services involved 55 providers of NHS mental health services in England. People aged 18 and over were eligible for the survey if they (1) had received specialist care or treatment for a mental health condition, (2) had at least one face to face contact between 1 September and 30 November 2019, as well as at least one other contact either before, during or after the sampling period, and (3) were not a current inpatient.

The peak of the Covid19 pandemic in England and the subsequent lockdown on the 23 March occurred approximately midway through the fieldwork period for the survey. Whilst the Community Mental Health survey primarily asked people to reflect on their experience of care over the previous 12 months, and therefore prior to the pandemic, the analysis has shown that the national lockdown likely impacted the way service users responded to the survey.

When comparing with equivalent time periods from previous surveys, responses received after the lockdown was introduced differ significantly across the majority of questions this year. The 2020 Community Mental Health survey is classed as not directly comparable with previous iterations. Therefore, comparisons with the 2019 Community Mental Health survey were not shown in the CQC reports for this year.

For most trusts, results are based on a combination of responses completed before lockdown and those completed during lockdown, and the proportions of each may differ between trusts. While the CQC analysis shows that there is not a link between the proportion of responses received after lockdown and trust level survey results, because people’s experiences of care may have been affected by lockdown, trusts are advised to consider this when reflecting on the results for individual questions.

For 2020, 247 responses were provided to the 850 questionnaires, which is an increase on the 165 responses from 2019. This represents a response rate of 20.2%, which is similar to the response rate for the 2019 survey programme. The response rate will be discussed at the Service User and Carer Experience Operational Meeting, where members will be asked to provide suggestions for improving on this rate for next year.

The following table provides a summary of thematic scores highlighting the results for the 2020 community mental health survey. For each question in the survey, the individual (standardised) responses are converted into scores on a scale from zero to 10.

A score of 10 represents the best possible response and a score of zero the worst. The higher the score for each question, the better the trust is performing. Thematic scoring takes into account the scores for each individual question, and then averages these to provide a single overall score. The table also highlights the 2020 scores for GMMH, in comparison to the 55 providers of NHS mental health services in England, who participated in this year’s programme.

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Thematic section 2020 score Score in comparison to other trusts

1. Health and Social care workers 7.2 About the same 2. Organising Care 8.7 About the same 3. Planning Care 6.9 About the same 4. Reviewing Care 7.7 About the same 5. Crisis Care 7.0 About the same 6. Medicines 7.1 About the same 7. NHS Therapies 7.7 About the same 8. Support and Wellbeing 5.4 About the same 9. Feedback 2.4 About the same 10. Overall Views of Care and Services 7.6 About the same 11. Overall Experience 7.3 About the same

As the above table highlights, GMMH scored highest in relation to Organising care, and lowest in relation to Feedback.

In relation to banding, for 2020, there were 27 out of 28 questions, where GMMH scores are about the same as other mental health services nationally.

There were 0 areas where GMMH scores were worse than other mental health services.

There was one area, where GMMH scores were higher than those reported across England. This was in relation to:

GMMH will take the following actions to improve our scores, and so the quality of our services. A further, more detailed benchmarking report will be generated, and will include the identification of a small number of areas for improvement. These improvement actions will be delivered across the Trust during the 2021/22 and monitored by the Trust’s service user and carer engagement leads.

2.11.1 Ensuring that People have a Positive Experience of Care – Friends and Family Test

Friends and Family Test (FFT) reporting was suspended from March 2020 through to December 2020, as part of the measures that were introduced to reduce the burden on NHS organisations as a result of the Covid19 pandemic.

Feedback systems at GMMH were being reorganised at this time to upgrade some of the supporting IT systems, however, this was also temporarily put on hold in order to prioritise the Trust’s IT support to enable remote working.

Category: Organising Care

Question

2020 score

National comparison

Do you know how to contact this person if you have a concern about your care?

9.9 Better

Table one: Thematic scores for 2020, in comparison with other mental health services in England.

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Despite the official suspension of national reporting, some FFT data continued to be collected, and the overall feedback remained very high. Feedback was also collected as part of an appreciative enquiry which was undertaken within our older adult inpatient services. The feedback that was gathered as a result of this process from our service users and their carers was very positive in relation to the care and treatment provided.

In December 2020, the GMMH service user and carer engagement team participated in a process mapping workshop, which was specifically focussed on our feedback systems and mechanisms. Whilst it identified very strong local systems for feedback it also highlighted the need to improve trust wide feedback systems, and in particular, a need to reduce the time that it currently takes to provide valuable service user and carer feedback back into our services.

A task and finish group has been established in order to address these issues. Its purpose is to ensure that there is an overall increase in the volume of feedback, and that services can receive timely feedback to support their ongoing quality improvement efforts.

2.11.2 Treating and Caring for People in a Safe Environment and Protecting them from Avoidable Harm – Patient Safety Incidents:

Information within this section of the Quality Account highlights the number and, where available, rate of patient safety incidents reported by GMMH to NHS Improvement via the National Reporting and Learning System (NRLS). The data below includes the number and percentage of patient safety incidents that resulted in severe harm or death and compares this data against the national average along with the highest and lowest incidents reported by other mental health organisations.

Patient Safety

GMMH continues to maintain an open, honest, and timely reporting culture when incidents occur. Timeliness for the reporting and reviewing of incidents is critical in enabling us to respond quickly to concerns that are identified to ensure the care we deliver is safe and of a high standard. The National Patient Safety Strategy published in July 2019 which sits alongside the NHS Long Term Plan and Implementation Framework highlights that ‘those organisations who identify, contain and recover from errors as quickly as possible will be alert to the possibilities of learning and continuous improvement’. Although there has been some delay in implementing the Strategy nationally, GMMH has identified Patient Safety Specialists who are registered with the National Patient Safety Team and who directly lead and support patient safety activity across the Trust. These identified specialists are part of a national and regional network who link together to share learning and good practice and later this year will undertake training in the national patient safety syllabus. The Trust Patient Safety Practitioners, introduced in 2019, are linked into network Senior Leadership Team meetings and work closely with operational staff so that information and learning in relation to the patient safety agenda can be shared. The Patient Safety Practitioners continue to work collaboratively with all our commissioners in relation to further strengthening the Trust Incident management and review processes. Improving our in-patient environments has always been a key priority for GMMH. The Trust has a comprehensive environmental risk improvement and audit programme that takes place on an annual basis in partnership with our Risk and Safety Team, Facilities team, Ward Managers and Matrons to continually ensure our in-patient environments are safe. Any environmental risks

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identified during the annual audit programme are then escalated to senior managers and the board through the Trusts risk register and Board Assurance Framework for consideration of further action. The Trust SharePoint system has been adapted to enable our ward teams quick and easy access to their local environmental risk audits and action plans. Every ward induction checklist has been strengthened to include the location of identified environmental risks which will assist new staff and agency staff who work across our in-patient areas in maintaining the safety of service users.

In November 2019, GMMH published its refreshed Self-harm Toolkit to be accessed by front line teams. To date, 500 copies of the Toolkit have been printed and distributed to all service managers for sharing across their teams. The Toolkit was developed in collaboration with our colleagues from the Manchester Self Harm Project and Patient Safety Research Unit at the University of Manchester for which we are extremely grateful for their assistance expertise and support.

The Toolkit was relaunched in November 2020 by our communications team through the Trust website and social media sites. Sitting alongside the Self-Harm Toolkit and Trust Self-harm Policy the Trust Positive and Safe Team have developed a self-harm care plan and staff management plan to assist teams in their care and treatment of service users. During 2020 the Self-Harm Toolkit and Trust Self-Harm Policy that were relaunched last year have been reviewed and strengthened to reflect Trauma Informed Care approach and updated with reference to Trauma Informed Care and ligature care plans.

To equip our staff with the skills to assess the risks of our service users to self and others the Trust clinical risk training package was reviewed and updated to include some of the learning from serious incident reviews and make it deliverable via Teams. Some of the changes included involving carers in risk assessment and management plans and when to breach confidentiality, the use of professional curiosity when assessing risk and the use of protective factors, the things that may reduce someone’s risk level and ensuring these are individualised and put into context. The Trust Clinical Risk Policy has been updated to reflect these changes and each Division has clinical risk training leads and a programme of training in place. The data below indicates that the number of patient safety incidents resulting in severe harm or death is low in comparison to the number of patient safety incidents reported. This has been a consistent picture for the Trust year on year and demonstrates a culture of reporting and learning from incidents.

Data Source: National Reporting and Learning System (NRLS). The data reported only includes data released by the NRLS in October 2020. This data includes the period of April 2018 - March 2020.

Reporting period

No of incidents occurring

Rate per 1000 bed days

No of incidents reported as severe harm

% of incidents reported as severe harm

No of incidents reported as death

% of incidents reported as death

Greater Manchester Mental

Oct 2019 -March 2020

6985 Data not available

11 0.2 22 0.3

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Health NHS Foundation Trust

April 2019-Sept 2019

6989 Data Not Available

19 0.3 29 0.4



3 0.05 27 0.5

April 2018 -Sept 2018


10 0.2 18 0.3

Total number of incidents for mental health organisations



770 n/a 1213 n/a



679 n/a 1256 n/a



556 n/a 1312 n/a



548 n/a 1286 n/a

Highest value reported from any mental health organisation


9509 145.5 110 2.7 51 2.4


6105 130.8 97 2.3 62 2.0


9058 118.9 118 1.8 77 2.8


9204 114.29 129 2.0 110 0.4

Lowest value reported from any mental health organisation


4 18.1 0 0 0 0


13 17.2 0 0 0 0


1173 14.92 0 0 0 0


16 24.86 0 0 0 0

*Benchmarking data reports from the NRLS continue to highlight that there is a positive and consistent incident reporting culture within the organisation. In accordance with the NRLS

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reporting criteria only deaths of current service users where the death is suspected to be as a result of an accident or suspected suicide are reported to the NRLS.

In the latest reporting period, October 2019 – March 2020, there was a similar number of incidents reported as the previous reporting period, the vast majority if these incidents reported were low harm or no harm and therefore required no further review. There was decrease of eight incidents reported as severe harm and a decrease of seven incidents reported as deaths from the previous reporting period.

Incident reporting and reviewing processes.

In January 2020, the Trust signed up to take part in the Royal College of Psychiatrists College Centre for Quality Improvement (CCQI) Serious Incident Review Accreditation Network. A self-review was completed in September 2020 and a peer review was undertaken in November 2020. Following the review, the Trust met many of the standards and the Head of Patient Safety is working with other providers to share best practice approaches in order to strengthen the quality of our serious incident reviews to ensure that all standards will be met, and accreditation achieved at the CCQI review in June 2021. To achieve this the Trust Incident Accident and Near Miss Policy and Procedure will be reviewed and updated including staff in the services, service users and carers and our commissioners.

2.11.3 Learning from Deaths

Supporting Carers and Families

The Trust introduced a Bereavement Liaison Practitioner in 2018 to provide timely support to families and staff following an unexpected service user’s death. The role has provided direct support to families throughout the Trust internal review process and supported families during the coroner’s inquest process. The Bereavement Practitioner has delivered Grief awareness workshops to staff across the Trust on how to support families following a death including bespoke sessions for student nurses and staff working in perinatal services, further training workshops have been planned over 2021.

The Trust is hoping to further develop the Bereavement Practitioner support as we recognise how critical this role is in supporting families and staff who are affected or bereaved in the event of all service user deaths and not only deaths by suicide.

During 1 April 2020 to 3 March 2021 a total of 1112 GMMH patients died. This is shown as number of deaths, which occurred in each quarter of that reporting period:

There has been an increase of 308 deaths from 804 total deaths reported in 2019/20, of these deaths 271 can be attributed to cases of confirmed COVID-19.

There is an increase across all categories:

• unexpected outpatient deaths show an increase of 120 (94 COVID related) • unexpected inpatient deaths show an increase of 19 (2 COVID related) • expected Outpatient’s deaths show an increase of 151 (157 COVID related) • expected inpatient deaths show an increase of 18 (15 COVID related) • 369 deaths in the first quarter • 219 deaths in the second quarter • 283 deaths in the third quarter • 241 deaths in the fourth quarter

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Quarter Unexpected Outpatient

Unexpected Inpatient

Expected Outpatient

Expected Inpatient

Total

1 158 7 190 14 369 2 128 4 82 5 219 3 168 12 99 4 283 4 141 5 87 8 241 Total 595 28 458 31 1112

*Inpatient deaths refer to those service users who are inpatient or former inpatients who died within 6 months of discharge in accordance with the current National Serious Incident Framework 2015.

During 1 April 2020 to 31 March 2021 (so far) 103 RCA’s have been commissioned in response to the deaths reported. The data highlights a comparable amount to the previous year of 101 RCA’s commissioned for 2019/2020.

The Trust ‘Learning from Deaths’ policy highlights to staff that all deaths should be reported through the GMMH Incident Risk Management System. All deaths including deaths of service users with an identified learning disability are reported and are then reviewed by the Trust Patient Safety Team. A 3-day review is requested by the service for all unexpected deaths and also for those expected deaths where care concerns have been identified by the service during the service users end of life pathway.

Where a completed 3 Day review has indicated significant care delivery concerns and areas for learning a Root Cause Analysis Investigation or Structured Judgement Review will be commissioned. Data relating to service user deaths is reviewed by the Trust Mortality Review Group and presented to the Trust Board of Directors meeting through the Trust Quarterly Mortality Dashboard in accordance with the National Learning from Deaths Framework.

• 35 serious incident root cause analysis investigations, 17 case record reviews* in the first quarter

• 28 serious incident root cause analysis investigations, 1 case record reviews* in the second quarter

• 25 serious incident root cause analysis Investigations, 1 case record reviews* in the third quarter

• 10 (to date) serious incident root cause analysis Investigations, tbc case note reviews* in the fourth quarter.

*Structured Judgement Reviews are referred to as ‘case record reviews.

Zero representing 0% of the patient deaths during the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient.

As mandated, this is broken down by quarter as follows:

• Zero representing 0% in the first quarter. • Zero representing 0% in the second quarter.

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• Zero representing 0% in the third quarter. • Zero representing 0% in the fourth quarter.

The national Quality Board Learning from Deaths Guidance published in March 2017 set out the key requirements ensuring organisations have mechanisms in place to effectively respond to, learn from and review all patient deaths. GMMH currently uses Root Cause Analysis as its primary investigatory methodology, in line with the requirements of the National Serious Incident Framework 2015 to review unexpected deaths. The Learning from Deaths Guidance also highlights the use by Trusts of the Structured Judgement Review (SJR) process as another method of reviewing deaths.

The SJR approach requires reviewers to make safety and quality judgements over 6 elements and phases of care accessed by a service user. In 2018 training for approximately 40 staff was delivered by the Yorkshire and Humber improvement academy who adapted the SJR Tool for mental health Trusts. Although the majority of deaths that occur in the Trust are reviewed using the comprehensive RCA methodology the trust will use the SJR process where a 3-day review has identified problems in care that may relate to treatment and management plans for those incidents relating to for example pressure ulcers, falls, some medication errors and also VTEs. The SJR process helps to understand the reasons for poor care and define further action or learning for the organisation.

The SJR process was used to review all the expected inpatient deaths of people from COVID-19 to ensure the care they received was of good quality and adhered to guidelines in place at that time.

All reviews completed into a service user death are presented and reviewed by the Trust Serious Incident Review (SIR) panel or Post Incident Review (PIR)Panel. One of the significant functions of both the SIR and PIR panels is to review the findings from all reviews and ensure recommendations made within the serious Incident report address the overall root causes and key areas for action by the Trust to reduce the likelihood for further similar incidents to occur.

Learning from serious incidents

The Trust continues to explore new methods of how learning from serious Incidents is effectively shared across the organisation. The Patient Safety Team has developed a ‘Lessons Learned’ newsletter that shares learning from incidents and reviews of incidents. The newsletter was launched in February 2021, is available on the intranet as well as being shared in the weekly Trust staff bulletin and will be produced quarterly. In addition, 7-minute briefings continue to be used to provide a short briefing to staff regarding a particular subject. The briefings provide a mixture of new information such as learning from serious incidents or a reminder of information for teams to think about the application to practice within their teams such as Duty of Candour, self-harm, and red flags.

The Trust has adopted the principles of a ‘Just Culture’, a term that acknowledges that we are human and refers to a culture that demonstrates the fair treatment of staff who make errors and supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. The serious incident investigation training now incorporates how to use the just culture guide and a 7-minute briefing has been produced to explain the process to staff.

Niche Health and Social Care Consulting (Niche) were commissioned to undertake a review of key themes, patterns and factors in some high-profile serious incidents which have occurred since

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2016 when the Trust was formed. The Trust Executive Team wanted to ensure that any wider learning from these incidents could be captured and used to make services as safe as possible. This review started in July 2020 and was completed in November 2020.

The review used both internal and external serious incident reports to examine the clinical practices of the teams involved. The review also considered clinical records, policies, procedures, and training materials relevant to the services and systems included in this review and had discussions with staff. The findings and recommendations identified during the review are being taken forward by the Trust in workstreams. One of the themes identified in patient safety incidents is staff engagement with carers and families of our service users. To address this a Trust wide learning event was held in March focussing on carer engagement by GMMH staff. 70 senior staff from across the Trust attended the event which was opened by two of our Executive Directors. There were interactive presentations from the Head of Patient Safety and the Trust Carer lead in relation to themes and data around carer involvement. Pat, who is one of our carers told a very powerful story of his experience of being the carer of someone under the care of GMMH and John Mainwaring from Connect Support shared his experience.

Following the presentations, the staff were asked to meet in their own operationaldivisions and discussed the barriers to carer engagement and how they were going to address this in their own division. Each division has developed an action plan to improve carer engagement which will be shared and monitored through the Trust Exec Post Incident Review Panel.

Hate Crime

At GMMH, we have taken a number of steps to help tackle racism and launched our first Hate Crime Protocol in October last year as part of National Hate Crime Awareness Week. We are committed to protecting and safeguarding all our employees, service users and visitors within our Trust from hate crimes. The key priority of the organisation is to raise awareness and enhance society's perception and understanding of what constitutes a hate crime, to challenge inequality and to celebrate the diverse make up of our society. The hate crime group won the award for Creating a Diverse and Inclusive Place to Work at the annual GMMH staff awards in December for the work done on developing the protocol and online training for staff. To support this a hate crime button has been located on the Trust intranet and internet pages to enable people to report a hate crime to the police or to report online hate material.

2.12 Freedom to Speak Up The Trust has adopted the national ‘Freedom to Speak Up’ Policy to promote an open culture across the Trust to ensure staff feel safe to report incidents and raise concerns, this means that staff are encouraged to speak up in a variety of forums, whether that be directly to their line manager, a more senior manager or to the Trust’s Freedom to Speak Up Guardian.

The Trust has a nationally registered Freedom to Speak up Guardian and Deputy Freedom to Speak Up Guardian whose roles are to support and enable staff to raise concerns, in addition to both an Executive Lead and a Non-Executive Lead for Freedom to Speak Up. The more recent appointment of the Deputy Freedom to Speak Up Guardian will ensure the Trust can spend more

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time supporting managers to create supportive environments where staff feel supported to raise concerns at a local level where possible.

In line with the national policy, staff are encouraged to raise concerns with line managers and line managers are encouraged to listen and act on staff’s concerns. It is appreciated that, at times, staff may not feel able to do this and the role of the Freedom to Speak Up Team is widely promoted through a variety of methods including through the Corporate Welcome Day, as a continual feature on the Intranet Site and wide coverage within operational meetings held throughout the organisation. The Trust reports quarterly to the National Guardian’s Office on the number of speaking up cases, and in addition reports twice a year directly to the Trust Board. This report contains information in relation to the number of cases, but also themes of cases and organisational learning.

The Freedom to Speak Up Guardian (our Senior Independent Director) reports directly to the Chief Executive, and meets on a quarterly basis with them, the Chair and the Executive and Nonexecutive Leads for Freedom to Speak Up. The Freedom to Speak Up Team work closely with Trade Union Representatives and others in trusted roles who are “Freedom to Speak Up Ambassadors” and they act as advocates for the Freedom to Speak Up route and guide staff accordingly when concerns may arise.

The Trust is committed to ensuring that staff do not suffer any detriment as a result of speaking up. Trust wide this is achieved through ensuring that all messages relating to speaking up are delivered by a member of the Executive Team to outline the highest level of support for wanting staff to feel able to speak up. More locally the Freedom to Speak Up Team remain in close regular contact with those who raise concerns through the speaking up route, any such indicator that identifies that a staff member feels they are suffering a detriment will be dealt with immediately. Both the Freedom to Speak Up Guardian and Deputy Guardian, together with the Chief Executive, also regularly promotes the role through visits to Wards and other areas within the organisation to ensure that staff know that if they are raising concerns locally and these concerns are being dealt with and managed effectively, there is still a route for them to take should anything change within that process.

Feedback in relation to concerns raised is achieved in a variety of methods, depending on the level or size of the concern. Staff may either be met with or may receive a more formal letter, the Freedom to Speak Up Team will then maintain contact with the member of staff until the feel their concern has been heard and they no longer need support.

Given the restrictions in face-to-face meetings and visits the Communications and Engagement Team have supported the Freedom to Speak Up Team to have increased presence through other methods such as the splash screen and staff newsletters.

2.13 Increasing Community Mental Health Services Capacity Within this section, GMMH is asked to include a statement on progress made in bolstering staffing in adult and older adult community mental health services, following additional investment from local CCGs’ baseline funding.

During the pandemic CMHTs in GMMH continued to offer face to face appointments with those service users assessed as requiring this level of intervention. Systems were also in place to ensure all caseloads were contacted on a regular basis by their team. As a result of the increase in demand for mental health services due to the impact of the pandemic work has been delivered on a

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proposal to bolster the CMHT offer in 2021/22. This will be delivered through the next 12 months with a full review outlined in 2022/23 Quality Account.

New models of working in primary and community mental health services

At GMMH, we are continuing to pilot new approaches to primary care mental health services in each of our localities, working with GPs, VCSE partners and neighbourhood teams to test new approaches to supporting people with mental health needs in primary care. This includes the ongoing model of care delivered under the Living Well national pilot in Salford which will continue into 2021/22. In addition, we have well established Home-based Treatment Teams in each locality which will feature as part of the crisis pathway being reviewed as part of the crisis offer proposed by GMMH for implementation in 2021/22.

Adult Eating Disorders (AED)

Throughout 2020/21 GMMH has continued to work with commissioners to develop and agree an expansion in service provision to better meet demand for our community adult eating disorders services. In addition, a North West Provider Collaborative has been formed for Adult Eating Disorders with Cheshire and Wirral Partnership NHS Foundation Trust as Lead Provider. Initial discussions had taken place to link specialised inpatient and community pathways and these discussions, as well as those with commissioners regarding community services, continued in 2020/21 with the service offer developed to be fully implemented in 2021/22.

Individual Placement Support (IPS)

GMMH employs IPS co-ordinators already embedded in Community Mental Health Teams (CMHTs) and Early Intervention in Psychosis (EIP) Teams. In 2020/21 this was held for a short while due to the impact of Covid-19 on ability to deliver this fully however this is now fully in place in the planned enhanced model, which is led by a new Greater Manchester IPS service. The Greater Manchester service, procured through the Greater Manchester Combined Authority, was awarded to Remploy and new staff are now based with our CMHT and EIP Teams to further develop support and opportunities for people to access IPS. This will continue for 2021/22.

Early Intervention in Psychosis (EIP)

During 2020/21 GMMH has worked with commissioners in each of our localities to invest in services to deliver the 56% access standard. Our Bolton and Salford EIP teams are operating at Level 3 NICE concordance. Our EIP team in Manchester is on track to achieve Level 3 in 2020/21. Our Trafford EIP team has received additional investment from Trafford CCG together with a change in service criteria to focus on under 35-year-olds. Because of this, the Trafford EIP team remained at Level 2 as expected. In February 2020, the NHSE/I Intensive Support Team undertook a two-day visit to the Manchester and Trafford EIP teams with helpful feedback being taken forward through an action plan. The services will continue to deliver the 56% access standard throughout 2021/22.

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3 PART 3 – Review of Quality Performance in 2019/20

3.1 Delivery of Quality Improvement Priorities in 2020/2021 We have made significant progress against all our 2020/21 priorities for improvement. Summaries of our key achievements are detailed in this section. Each achievement reflects the immense commitment of our staff, services users, and carers to continually improving quality. We have provided summaries along with evidence of our key achievements, within the section that follows.

Quality Improvement Priority One: To Improve Outcomes Red2Green Days Improving Supervision

The Red to Green Days Project was first introduced during the Multi-Disciplinary Team (MDT _Board Round following the development of Red2Green Operational Guidelines. Each patient has an identified discharge date following an initial MDT review and all barriers are discussed each day with a focus to resolve these before this date, where clinically appropriate, for a safe and effective discharge. All actions are allocated same day with an expected resolution to maintain green days. This project has seen a number of positive outcomes and productivity gains. This has included a 31% increase on yearly discharges noted in April 2020 to March 2021 compared to the previous year. Progressively discharges have caught up and then exceeded admissions in the last financial year supporting inpatient flow and reducing OAP’s (24 % reduction from previous financial year). During the last financial year 136 Bolton patients were admitted to other divisions and 211 patients from other division within the Trust were admitted to Bolton. This demonstrates that Bolton resources were utilised more to support overall bed pressure within the Trust. The Red to Green Days QI Project is now complete and the project team is currently looking at sustainability of improvement.

The supervision project started in January 2020 with an overall aim to increase the compliance rate for supervision to 85% by 31st December 2020. The project achieved 80% of supervision compliance at the end of 2020 and has now moved to Phase 2. The Improving Access and Quality of Supervision project is delivered as a Breakthrough Series Collaborative and has a twofold aim; a) improving quality of supervision based on an appropriate set of standards as developed by the innovation teams and b) achieving 85% compliance of supervision by 31st December 2021. Innovation teams are looking at change ideas focusing on the quality of clinical/ professional and managerial supervision, safeguarding supervision and patient safety considerations, culture around the importance and benefits of supervision and appropriate documentation.

Building an Improvement Culture (Adult Forensic service and North Manchester community services)

This programme includes six wards based at our Adult Forensic Services working alongside three community teams in North Manchester as part of a Breakthrough Series Collaborative. The aim of this programme is to build an improvement culture within the teams.

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An initial questionnaire has been developed in order to provide a baseline assessing the culture within the teams. Two Learning Sessions have taken place and teams are working collaboratively to identify and share change ideas and testing using PDSA cycles. Change ideas include promoting civility, the introduction of daily huddles, star of the week, a re-design of clinical team meetings processes, promoting health and well-being, increasing the uptake of staff taking a break, mood jars, incorporating health & well-being into staff huddles, improving communication between SLT and team, improving zoning meetings and creating a ‘new starters’ group. This is a longer-term project, which will continue across 2021/22.

Quality Improvement Priority One: To Deliver the Safest Care

Reducing Restrictive Practice Falls Reduction

The project aim for this collaborative is to decrease use of restraint by 20% by 30th of November 2021 across innovation wards. The importance of this project and the project aims lie within the context of the Mental Health Units (Use of Force) Act 2018 which have a goal of reducing the use of restrictive interventions and delivering care which has a trauma-informed approach and a focus on human rights. The key areas this Quality Improvement Project is focused on the following areas:

• Robust monitoring systems and processes • Implementation of the evidenced-based

Safewards intervention • Increasing PMVA training compliance to

ensure sufficient numbers of substantive staff are trained.

• Continuous improvement of the PMVA training package with a focus on prevention

The Phase 2 Reducing Restrictive Practice project is being delivered as a Breakthrough Series Collaborative with 7 wards across the Trust (Blake, Phoenix, Holly, Oak, Buttermere, Juniper, and Irwell wards). Since the start of Phase 2 in October 2020, innovation wards have progressed with their change ideas and participated in two Learning Sessions. Following this, future plans will involve more wards participating in a Breakthrough Series Collaborative which will run for a year each. This is expected to be an ongoing project.

Following a temporary pause, owing to Covid 19, plans to re-start the Reducing Falls QI project were initiated in November 2020.

Phase 2 of this programme will be delivered using the Breakthrough Series Collaborative approach. Innovation wards participating in the Breakthrough Series are all later life wards across the Trust as well as our Chapman Barker Unit (CBU) ward. The aim is to reduce the number of inpatient falls by 15% and associated harm across innovation wards by 31st December 2021. So far, innovation wards are focusing on change ideas relating to observations, updating the falls management and prevention training pack, and increased mobility protocols. In addition, the GMMH Trust’s Falls Group is working on reviewing the Falls Policy and establishing an Oversight Falls Protocol. The 1st Learning Session is scheduled for April 2021.

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Priority Three: To Integrate Care Around the Person

Trauma Informed Care Mental Health Optimal Staffing Tool (MHOST)

The Trauma Informed Care (TIC) QI Project group was formed in June 2020. The group has involvement and input from across the MDT and lived experience experts, linking into the positive and safe agenda, and supervision projects.

The project is now guided by standards produced from national examples of good practice and key drivers for change. Key areas of focus include:

• Contributing to the positive and safe agenda • Understanding the prevalence and impact of trauma

on service users and staff • Developing an understanding of TIC for the whole

workforce • Compassionate Leadership

Robust monitoring systems and processes of these priorities are in place using QI methodology and audit.

Phase 1 work has been ongoing across the Trust and we have achieved some positive results, including:

• Development of ‘know each other’ workbooks for inpatient and community areas.

• Development of compassionate leadership training. • Development and delivery of one day TIC training for

clinical teams in Bolton, recovery academy training and TIC adopted as standard into PMVA training.

• TIC is now incorporated into GMMH self-harm policy and toolkit and posters are ready for distribution to inpatient areas.

Phase 2 of the project will be delivered as a Breakthrough Series Collaborative with some ongoing recruitment on order to ensure a blended approach; teams that have already been testing ideas (have experience) and those that are new to testing but represent different areas/services of the Trust.

The overall aim of the project is to demonstrate adherence to 7 standards of TIC by 2024 across GMMH.

MHOST is a data collection tool which is designed to calculate the level of dependency of patients over a 20-day period in order to make assessments about the requirements for staffing.

It also takes into consideration the quality of patient care over this period, so in addition to the dependency level, metrics such as incident numbers, staff wellbeing and activities on the ward are also collected.

The 5 PICU wards at GMMH have been involved in meetings supported by the QI team following the structure of a Clinical Microsystem approach.

The aim of these meetings was to ensure robust, reliable data collection which is consistent between wards.

Data collection for this project was completed in October 2020 and a report was produced.

Key recommendations from this first phase included a review of bed occupancy for PICU wards taking into consideration flow across services, appropriate use of observations and a review of the budgeted establishment for PICU wards.

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In addition to our core, formal Quality Improvement Programmes, Quality Improvement support has also been directed at a number of additional actives including:

Additional QI activities

Substance Misuse Services (SMS) Medical Review Project

• Representatives from community SMS Teams participated in a Process Mapping Workshop focusing on the process and content of Medical Reviews. The project team identified some key areas for improvement and currently working on constructing a driver diagram and change ideas to take forward.

Sexual Safety National Collaborative

• Chaucer ward and Blake ward are participating in the Sexual Safety National Collaborative which re-started in September 2020. National collaborative meetings and workshops are continuing, and the wards also receive support from a designated QI Coach from the Royal College of Psychiatry.

• The collaborative is due to end in September 2021 and during the last three months the wards will work on developing a ‘change package’.

Redwood Ward: AIMS Standards Implementation

• The GMMH Inpatient Recovery Workstream-Demand and Capacity group has reviewed the standards from the Accreditation for Working Age Inpatient Mental Health Services (AIMS-WA) document and selected 11 standards to be implemented at Redwood Ward.

• Following a QI approach and utilising relevant tools the project is aiming at improving patient flow and reducing length of stay. The project started in October 2020 with an aim to reduce Length of Stay or time of reaching DTOC by 30% by end of March 2021.

• The project team has tested change ideas relating to the aim of admission and barriers to discharge but work has been on pause the last two months due to Covid-19 related pressures.

Community Mental Health Team (CMHT) to Home Based Treatment (HBT) Referral Pathway

• Bolton Early Intervention Team and North-East Manchester CMHT are working collaboratively to support patients earlier in their crisis and reduce the likelihood of inpatient admission by increasing referrals to HBT.

• Key drivers for this project include direct referral and acceptance on the assessment pathway, overview of cases and effective use of crisis beds.

• So far, the project team has developed change ideas focusing on removal of requirement for face-to-face gatekeeping, benchmarking referrals against referral principles, reducing threshold for referrals to HBT, crisis plans included on referrals, escalation of concerns to team managers, interface meetings, supportive supervision with staff to improve referrals for teams and weekly audit reviews by operational managers to consider trends.

Increasing Feedback and Patient Experience data

• The GMMH Customer Care Team, service users and service user feedback representatives from across the Trust participated in a number of process and value stream mapping workshops focusing on patient feedback systems across the Trust.

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• The project team worked on a ‘Feedback Cause and Effect Diagram’ looking at current systems and documentation, service users and staff.

• Next steps include the development of a driver diagram and identification of change ideas to drive improvement forward.

Mental Health Act (MHA) Documentation

• The Mental Health Act team in collaboration with the QI Team and Innovation Manager have participated in process mapping activities, focusing on MHA assessment paperwork.

The purpose was to identify challenges and areas for improvement whilst considering a business case for introducing an electronic system to replace current documentation.

Single page Lean A3 plans (SPPs) have been produced for each of the six QIPs that follow the Breakthrough Series Collaborative approach. These SPPs including outcomes, improvement actions and measures, where these have been agreed. The A3 plans also highlight associated high-level quality, patient, staff and productivity gains for each QIP. The SPPs for each of the six QIPs are set out on the following pages.

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3.2 Performance against Quality Indicators Selected This section of our Quality Account provides an overview of quality as demonstrated by a range of indicators. The indicators cover the three domains of quality (experience, effectiveness, and safety).

We have continued to use a number of the same indicators as our previous years’ quality accounts.

Please note that due to the COVID-19 pandemic, national collection of a number of these indicators were suspended as from Quarter 4 of 19/20. GMMH have continued to report locally where possible at Board and team level. The below statement and comparison use local figures were available to indicate level of achievement. Figures reflect the latest available position.

National published figures for comparison purposes are not available where national reporting has been suspended. The latest available local figures are as at the end of Q3 and are set out as follows:

Patient Experience 2019/20 2020/21 Comments PLACE inspections. The assessment evaluates cleanliness, condition/appearance, privacy and dignity and food.

*Scores Cleanliness: 99.4% Food: 86.8% Organisation Food: 88.6% Ward Food: 86.2% Privacy, Dignity, Wellbeing: 93.2% Condition, Appearance, Maintenance: 97.6% Dementia: 85.5% Disability: 85.0%

Not Available

*PLACE inspection published 30/01/2020. Please note PLACE inspections were suspended during 2020 due to the COVID-19 pandemic hence scores not available.

Complaints – total number of complaints received per 10,000 recorded service user contacts

10.1 6.03 Source: PARIS and Datix (2019/20 Apr 2019 - Mar 2020 2020/21 Apr 2020 - Dec 2020)

Compliments – total number of compliments received per 10,000 recorded service user contacts

15.0 13.84 Source: PARIS and Datix (2019/20 Apr 2019 - Mar 2020 2020/21 Apr 2020 - Dec 2020)

Clinical Effectiveness

2019/20

2020/21

Comments

Community Mental Health Survey - % of responses that rated the services received from our Trust as good, very good or excellent

*Score: 64.8% **Score: 69.0%

Source: * CQC Community Survey 2019, Q35, Rank 7-10 as % of Ranks 0-10) ** CQC Community Survey 2020, Q35, Rank 7-10 as % of Ranks 0-10)

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Friends and Family Test – Service Users – % of Service Users who responded as “Extremely Likely” or “Likely”.

79.5% Not Available

Source: Friends and Family Service Users Submission to Unify. (YTD As at Feb 2020) Please note: Due to COVID-19, the Friends and Family Service Users Submission was suspended as from March 2020.

Total staff sickness absence (%) – rolling 12-month position

6.6% 6.2% Source: Board Performance Report (Dec 2020) via Electronic Staff Record (ESR)Average sickness rate for Mental Health / Learning Disability Trusts in the North West is 4.8%* *Source: NHS Sickness Absence Rates - NHS Digital Latest Version: July 2020 – September 2020 Provisional

Safety

2019/20

2020/21

Comments

Degree of harm incurred by service users in incidents reported to the National Patient Safety Agency - % of all incidents reported that resulted in no obvious harm

76.1% 71.23% Source: Datix (As at Dec 2020)

% of all patient safety incidents that resulted in severe harm or death

1.6% 2.19% Further information on this indicator can be found in Section 2.10.7 of this Quality Account. Source: Datix (As at Dec 2020)

Number of under 18s admitted to our adult mental health inpatient wards

35 9

Source: PARIS (Apr 20 – Dec 20)

3.3 Performance against Key National Priorities GMMH work hard to deliver all relevant national priorities and targets. Our performance against the mental health indicators set out by NHS England and by NHS Improvement (NHSI) in the Oversight Framework are summarised here (please note operational Oversight Framework requirements only).

We are registered with NHSI the regulatory body for Foundation Trusts and have consistently achieved all required targets and standards for continued registration. We are currently rated at level 3 (month 11) for the Finance and Use of Resources metric.

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Similarly, we are registered with CQC without conditions, complying with all regulations. We have established robust mechanisms for monitoring compliance against all the outcomes detailed in the CQC Compliance Guidance to provide ongoing registration assurances. We are compliant with the NHS Quality Risk Management Litigation Authority Standards.

Indicator Target 2019/20 2020/21 Comments 1. People with a first episode of psychosis begins. treatment with a NICE recommended package of care within 2 weeks of referral (SDCS and MHSDS)

60% 72.7% 78.8% As of December 2020. Source: Board Performance Report (Dec 2020)

2. Data Quality Maturity Index (DQMI) - MHSDS Dataset Score.

95% 94.9%* 96.5%**

*Position as of March 2020 **Latest Published Figure November 2020

3. Improving Access to Psychological Therapies (IAPT)/talking therapies (from IAPT minimum dataset): 3a. Proportion of people completing treatment who move to recovery (from IAPT minimum dataset)

50% 46.5% 45% As of December 2020. Source: Board Performance Report (Dec 2020)

3b. Waiting time to begin. treatment within 6 weeks of referral


3c. Waiting time to begin. treatment within 18 weeks of referral


4. Inappropriate out of area placements for adult mental health services (Total number of bed days)

0 2117 178 As of December 2020. Source: Board Performance Report (Dec 2020)

Admissions to adult facilities of patients who are under 16 years old

0 0 0 As of December 2020. Source: Board Performance Report (Dec 2020)

Care programme approach (CPA) follow up - proportion of discharges from hospital followed up. within 7 days

95% *96.0% **97.2%

Please note due to the COVID-19 pandemic, collection of the Mental Health Community Teams Activity was suspended by NHS Digital from Q4 2019-20. **As of December 2020 Source: PARIS *As of December 2019

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Indicator Target 2019/20 2020/21 Comments Source: https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/ 2019/20 figures are YTD Q1-Q3

The above reflects good and improved performance in the majority of areas when compared to 19/20. The improvement in delivery of IAPT 6- and 18-week targets should be particularly noted. This reflects ongoing improvement in Manchester services during 20/21 to deliver these targets with the support of commissioners. This has included the development of trajectories to clear historical waiting lists and more effective and timely management of new referrals. The IAPT service has also made significant progress in progressing the digital agenda offering alternatives to face to face clinic appointments for patients via video consultations for example. This has been an important choice to offer during the COVID response.

The IAPT recovery target has not been met however it should be noted that in Salford and Manchester GMMH only provide the Step 3 IAPT services. This impacts on our recovery rates for these services as the recovery target is linked to the delivery of the whole stepped-care IAPT pathway. The Step 2 IAPT services in these areas contribute to the achievement of the target at a CCG pathway level.

During 20/21 a key priority has been improving patient flow and reducing the number of placements out of the local area. This has been particularly challenging to address given the impact of Covid 19 on the wider system. This work includes promoting timely discharges and developing alternatives to admissions in collaboration with the whole system including third sector partners and voluntary agency support.

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4 PART 4 –Priorities for Quality Improvement in 2021/22

This section of the Quality Account sets out our priorities for improvement that we intend to deliver during 2021/2022. As referenced in the Chief Executives introduction, the speed and spread of Covid-19 has affected how we work on a day-to-day basis. As a result of this, we have unfortunately been unable to consult in the usual way with our staff, service users, carers, our Council of Governors, and our other key stakeholders across the GMMH footprint. As a result, we have decided to maintain our existing QIPs, which were agreed and set out in last year’s Quality Account.

This will allow us to continue with the significant progress we have already made, and when we are able to, we will develop and implement further additional improvement programmes that relate to these important areas. Further detail on our quality improvement projects, enablers and programmes will be set out in phase two of our Quality Improvement strategy.

4.1 Improvement Priorities for 2021/2021 The Quality Improvement Priorities for Greater Manchester Mental Health NHS Foundation Trust during 2021/22 include the following:

PRIORITY 1 – Improving outcomes

Quality domain Effectiveness and Service User Experience

PRIORITY 2 – Delivering the safest care

Quality domain Safety and Service User Experience

PRIORITY 3 – Integrating care around the person

Quality domain Effectiveness and Service User Experience

4.2 Monitoring our Quality Improvement Priorities These Quality Improvement Priorities will be subject to robust monitoring during 2021/22. Each priority area has an improvement lead, along with dedicated support from the QI team. Leads are required to produce regular summaries for discussion at expert faculty and project meetings. The QI Team will also produce robust quarterly summaries that will be reported to our Quality Improvement Committee and received at our Trust Board.

This Quality Account provides an overarching picture of some of the work we have done and will do in the future as part of a much wider comprehensive quality agenda. This ensures that our services are provided to the highest possible quality standards and continue to meet changing needs in a person-centred way.

Please feel free to contact us if you would like to know more about any of the priorities for 2021/22 or any other quality improvement activity at the Trust.

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5 Annex 5.1 ANNEX 1 – Feedback from Key Stakeholders

Feedback from NHS Bolton CCG on behalf of Bolton, Manchester, Salford and Trafford Clinical Commissioning Groups

Bolton CCG has coordinated this response on behalf of the CCGs involved in the above contracts. We would like to offer our sincere gratitude to staff across all services for their commitment throughout 2020/21, particular with regard to the unprecedented pandemic.

The Account demonstrates how the Trust has successfully tackled the many challenges posed by COVID while maintaining the majority of services available. Enabling remote working, redeploying staff to support essential services, online IAPT consultations, implementing strict IPC practice to keep staff and service users safe, and the successful vaccine roll-out for staff and patients, to name but a few.

We have once again worked closely with GMMHFT to gain assurance that the Trust has provided safe, effective and patient focused services. Performance and quality continues to be monitored via a collaborative and clinically led process and the content of this account is consistent with the information presented in year.

We’re pleased to see the Trust has maintained its overall CQC rating of ‘Good’ and we note the work that is being undertaken in areas that require improvement. This is emphasised by the development of the QI Committee which provides strategic leadership for the QI strategy and ensures it connects directly with clinical services and positively influences the organisational culture.

The Account again reflects numerous accolades, examples of good practice and shows high levels of staff and service user involvement. It is encouraging to see both good levels of audit compliance, and the practical application of the extensive internal research programme e.g. improvements in Trauma Informed Care, which we recognise as having a positive impact in each of our localities.

It is pleasing to see the Account reflecting on Integrated Care and it would be good to see a continued emphasis on this as localities develop their neighbourhoods and primary care with mental health again very much at the forefront. We acknowledge the impact of COVID on staff but the staff survey results remain under the national average and we look forward to seeing how these issues are addressed in 21/22.

It is noted that the Trust, in view of COVID, has decided to continue last year’s QI Priorities into 21/22. It is good to see clearly measurable goals associated with the priority areas and we look forward to seeing progress against these throughout the coming year. We note the QI methodology and the use of SPPs to reflect progress but it would be preferable in a public facing document to see clearer presentation as to whether these priority outcomes are attained.

The Account again describes an organisation that is able to deliver services to a high standard, is innovative and service user focused. We look forward to working with the Trust in 21/22 to further develop the delivery of mental health services and to ensure smooth transfer of our current system into the GM Integrated Care System.

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Dr Jane Bradford - Clinical Director for Governance and Safety

Michael Robinson - Associate Director for Governance and Safety

Feedback from HealthWatch, one narrative provided on behalf of Healthwatch Bolton, Manchester, Salford, and Trafford

GMMH Quality Account 2020/21

There are five Greater Manchester Healthwatch who relate to GMMH and who are countersigning this Quality Account as representing a true and accurate reflection of the services provided to our resident population.

We do, of course, fully recognise the efforts of our frontline workers during the pandemic and the extraordinary attempts made by the Trust to provide a high quality service to contribute to the health and wellbeing of our population.

We particularly welcome the inclusion of Wigan and also the development at Park House in North Manchester which should significantly improve services in our most populous Borough. We welcome the regular meetings we have with GMMH and the honesty they display in facing up to challenges. These are invariably addressed.

We look forward to the Trust demonstrating how it is going to restore services during the forthcoming year and also to ensure that some of the innovative changes made during the pandemic are taken forward where it is efficient and effective to do so and, importantly, what our service users and their carers would welcome.

We also commend the national clinical audits undertaken during the year under review as well as the additional investments made by individual boroughs in relation to family intervention. This, coming at a time where the Trust is reporting continued significant numbers of deaths is very welcome along with the steps the Trust is taking to minimise such numbers.

There are some areas we would like to draw particular attention to. These are continued support for people with learning disability, best efforts to improve the Niche work in relation to carer engagement, as ensuring positive experience of care needs significant improvement.

We commend the self-harm toolkit for adults - we have serious concerns about the number of young people, including those in transition, who are attending A&E self-harming and sharing experience of this toolkit with other Trusts in Greater Manchester would be a positive way forward as a sign of innovation and integration.

We also commend the appointment of a Bereavement Liaison Practitioner but given the number of deaths and serious incidents, it would be good if the Trust could persuade its commissioners to expand on numbers.

Healthwatch Bolton

Healthwatch Manchester

Healthwatch Salford

Healthwatch Trafford

Healthwatch Wigan

May 2021

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Feedback from Health Scrutiny Committees

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5.2 ANNEX 2 - Statement of Directors’ Responsibilities in Respect of the Quality Account

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to review:

• The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered.

• The performance information reported in the Quality Report is reliable and accurate. • There are proper internal controls over the collection and reporting of the measures of

performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice.

• The data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review.

• The Quality Report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. GreaterManchesterMentalHealthNHSFoundationTrust

By order of the board:

Rupert Nichols – Chairman Neil Thwaite - Chief Executive

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5.3 ANNEX 3 - Equality Impact Assessment

Consideration Yes/No Comments

1. Does the Quality Account affect a group with a protected characteristic less or more favourably than another on the basis of:

Please see comments below

• Age NO N/A

• Disability NO N/A

• Gender Re-assignment

NO N/A

• Marriage and Civil Partnership

NO

NO

NO

N/A

• Pregnancy and Maternity

• Race

N/A

N/A

• Religion or Belief

NO

N/A

• Sex NO

N/A

• Sexual Orientation

NO N/A

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2. Has the Quality Account taken into consideration any privacy and dignity or same sex accommodation requirements that may be relevant?

YES This was taken into account as part of the planning and production of the Quality Account. No specific issues have been identified throughout the production stages of this Quality Account.

3. Is there any evidence that some groups are affected differently?

NO There is no evidence that any groups are adversely affected as a result of the Quality Account. Monitoring and consideration will remain ongoing.

4. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

NOT APPLICABLE

No valid, legal, or justifiable discrimination has been identified throughout the production of this Quality Account.

5. Is the impact of the Quality Account likely to be negative?

NO The impact of the Quality Account is not likely to be negative.

6. If so, can the impact be avoided?

NOT APPLICABLE

This does not apply as no negative impact has been identified

7. What alternatives are there to achieving the Quality Account without impact?

NOT APPLICABLE


8. Can we reduce the impact by taking a different action?

NOT APPLICABLE


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5.4 ANNEX 4 - Local Clinical Audits Reviewed in 2020/21

Audits from the GMMH clinical audit programme

Advancing quality / commission for quality and innovation (CQUIN) /key performance indicator audits

1 CPA Risk Assessment/Risk Management Plans

Patient Experience/Safety Audits, Health and Safety Audits

2 Care Planning in the Community

3 Annual Ligature Audit

4 Audit of under 18’s Admitted to Adult Wards

5 Mattress Audit

6 Infection Prevention Hand Hygiene Audit

7 Transfer of Care

8 Diabetes re-audit

Mental Capacity/Mental Health Act Audits

9 Patient’s Rights

Medicines Management Audits

10 Antibiotic Prescribing

11 Prescribing Valproate

12 Medicines Handling (Duthie Audit)

13 New Prescription Card Audit

AUDITS COMPLETED WITHIN EACH DIVISION

Multi-Site Audits

14 Audit of standards of record keeping – Best Interest Meeting and mental Capacity Act Assessment Form (779)

15 An audit of serious incident reporting on acute inpatient wards against local and national guidelines (848)

Manchester, City Wide and Trafford Division

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Manchester and City-Wide Services

16 HDAT audit at North Mersey CMHT (789)

17 Monitoring Polypharmacy and reducing problematic prescribing in patients with dementia (794)

18 Audit of Initial communication from Medical Teams to GPs for patients in Central Manchester HBT (797)

19 Medication charts and consent to treatment documentation audit in an inpatient psychiatry unit in Bronte Ward (821)

20 An Audit of Medicines Reconciliation on SAFIRE Unit (826)

21 Consent to Treatment Audit All Wards Park House (827)

22 Are the Central and South Manchester EITs meeting standards across three KPIs (833)

23 Assessing and diagnosing patients with dementia waiting time to assessment and diagnosis (842)

24 Assessing compliance with ward round standards – Re-audit (844)

25 15 Democratic Therapeutic Community Service-user understanding of the model of practice (845)

26 Record keeping for alcohol use in Older Age patients and referral to the correct services (846)

27 Physical Health Monitoring for patients on Clozapine (847)

28 Services in Liaison Psychiatry-Response Time and How Adequate (851)

29 Audit of Consent to Treatment on Cavendish Ward (855)

30 Pre-birth planning meeting documentation in a Community Perinatal Mental Health Team (858)

31 Ward round record keeping completion on Redwood and Juniper (861)

32 Referrals to a Central Mental Health Liaison Team (863)

33 Referrals to the South Mersey Community Mental Health Team (864)

34 Audit to examine completeness of PHIT tools on PARIS (867)

35 Implementation of Section 17 of the MHA 1983 in relation to current Covid 19 Government restrictions (870)

36 Psychotropics/Antipsychotic usage in BPSD in a Specialist unit comparing usage at admission to 6 months into admission (872)

37 Referrals to Central Mental Health Liaison Team (876)

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38 CMHT Out-Patient Department Clinical Letters (Re-Audit) (878)

39 Evaluating service user and staff perspectives on remote therapy in a specialist psychotherapy service (882)

40 Smoking Cessation Audit (888)

41 Compliance of South Manchester Home Treatment team with DVLA guidance regarding Fitness to Drive (889)

42 Discharge CPAs in Delayed Discharges from the South Manchester EIS (904)

43 Re-audit Discharge CPAs in Delayed Discharges from the South Manchester EIS (905)

44 Referral Process Audit Gaskell House Psychotherapy Service (907)

45 An evaluation of smoking intervention in community mental health services (914)

46 VTE Risk Assessment on an Acute Later Life Mental Health Ward (918)

47 Carer engagement and Support on Poplar Ward (919)

48 Compliance of Safire with DVLA guidance – Fitness to Drive (940)

Trafford Services

49 Monitoring & Management of Hyperprolactinaemia secondary to Antipsychotic use in Trafford Early Intervention Team (765)

50 Audit of valproate prescription in women of childbearing age (767)

51 Older Adult In-patient Discharges and Emergency Community Assessments (822)

52 Audit to measure the accurate recording of service user’s children on PARIS (830)

53 Compliance with the shared care protocol in Trafford MHHTT (860)

54 Audit of High Dose Antipsychotic Prescribing in the Trafford South CMHT (862)

55 Survey of Healthcare workers perception of COVID-19 outbreak (869)

56 Re-audit on DVLA guidance within the patient population of the Trafford MHHTT (894)

57 The assessment of weekly MDT ward round documentation for inpatients at the Moorside unit (906)

Rehab, IAPT, Bolton And Salford Division

Rehab Services

58 Treatment with Clozapine in Treatment Resistant Schizophrenia for Copeland Ward (Salford Inpatient Rehabilitation) Referrals (853)

59 Consent to Treatment T2/T3 (881)

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Bolton Services

60 Rapid tranquilisation Audit (707)

61 Clinical Audit on the Physical Assessment of Mental Health Patients in ED (798)

62 Audit of compliance with WHO Surgical safety checklist (modified for ECT incl NPSA advise) for ECT (805)

63 Use of Zuclopenthixol acetate (Clopixol acuphase) ascertain if this is being prescribed in accordance with trust policy (806)

64 An audit of Compliance with the Stepped care model of psychology provision within South Bolton CMHT (825)

65 Clinical audit of trauma awareness training across Bolton Mental Health teams (841)

66 Antipsychotic Induced Hyperprolactinemia in the Older Adult CMHT (850)

67 Use of sodium valproate in women with childbearing potential in LD team in Bolton (865)

68 Physical Health Monitoring in severe and enduring mental illness (875)

69 Audit on Assertive Outreach (AO) Pathway for Bolton North and South CMHTs (884)

70 Initial Screening of patient accepted onto the 136 suite in Bolton (891)

71 Audit Bowel Care Management Guidelines for Adults (910)

72 DVLA notification following Dementia Diagnosis (916)

Salford Services

73 Care Planning and Risk Assessment Audit (761)

74 Audit of Alcohol as a potential cause or contributor of cognitive difficulties in a memory clinic (813)

75 Quality of Outpatient Clinic Letters from Cromwell House CMHT to GPs (814)

76 Use of Pregabalin for Anxiety Disorders (838)

77 Performance of urine drug screen for substance misuse in patients admitted with psychotic symptoms on Eagleton ward (852)

78 Timely completion of discharge summaries (859)

79 CMHT Standard Care Contact During Covid 19 Lockdown (874)

80 Re-audit Performance of urine drug screen for substance misuse in patients admitted with psychotic symptoms on Eagleton ward (880)

81 Safe use of atypical antipsychotics medications (885)

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82 Diagnosis and treatment of UTI at Woodlands Inpatient Unit (892)

83 Completion of IPE and Phit Form of new patients admitted to Meadowbrook unit (897)

84 Monitoring of Patients on Cholinesterase Inhibitors and Memantine (913)

IAPT Services

85 The provision of psychological and family interventions for clients with a diagnosis of psychosis or schizophrenia in an adult community mental health setting (811)

86 Clinical Audit of the PIDS Process in GMMH during 2018 (832)

Specialist Network Services

Adult Forensic Service

87 Seclusion Assessment and decision making (787)

88 Audit of Menstruation Documentation within Women’s Service (866)

89 Consent to Treatment (868)

90 Side effects of Antipsychotic medications (893)

CAMHS

91 Quality of Medical Records for MHA Tribunals (854)

92 ‘Use of psychostimulant medication for attention deficit hyperactivity disorder (ADHD) in Bolton Community CAMHS.’ (871)

93 Audit documentation of capacity and consent to treatment for inpatient CAMHS (879)

Substance Misuse Services

94 Pabrinex prescription at Chapman Barker Unit compared to NICE and local guidelines (803)

95 Audit project on compliance to the guideline on prescribing and administering opioid medication to adult patients with a history of opioid misuse (818)

96 Patients with a pharmacological modality in Achieve Bolton were seen by service doctor in last 12 Months (820)

97 Prescribing changes in opioid replacement treatment due to COVID-19 (883)

98 Multi-agency audit tool - Children in need (917)

Health and Justice Service

99 Evaluating medicines reconciliation activity for prisoners within HMP Manchester (755)

100 Psychotropic medication prescribing in a prison personality disorder pathway unit (873)

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101 Benzodiazepine Prescriptions in Prison (899)

Contact for Further Information:

For further details about the information contained in this Quality Account, please contact:

Patrick Cahoon, Head of Quality Improvement

Greater Manchester Mental Health NHS Foundation Trust, The Knowsley Building, Bury New Road Prestwich, Manchester M25 3BL

Telephone: 0161 357 1793


5.5 ANNEX 5 - Glossary of Terms

A&E Accident and Emergency hospital services

AC Accreditation Committee

ACE 111 The Addenbrooke’s Cognitive Examination are neuropsychological tests used to identify cognitive impairment in conditions such as dementia

Achieve Drug and alcohol recovery services

AIMS Accreditation for Inpatient Mental Health Services

ADSM Anxiety Disorder Specific Measures

AMIGOS Former Manchester Mental Health and Social Care Trust current clinical patient record system

AQuA Advancing Quality Alliance

ARMS At Risk Mental State

BAME Black and Minority Ethnic

BD Bipolar Disorder

BMI Body Mass Index

BNF British National Formulary

BP Blood Pressure

BSL British Sign Language

CAARMS Comprehensive Assessment of at-Risk Mental States

CAMHS Child and Adolescent Mental Health Services

Care Co-ordinator

The professional who, irrespective of their ordinary professional role, has responsibility for co-ordinating care, keeping in touch with the service user, and ensuring the care plan is delivered and reviewed as required.

CARE Hub The CARE hub was created in 2014 to support the Trust to develop a coordinated approach to Service User and Carer feedback and engagement. The CARE hub is a virtual network to engage with Service Users, Carers and Volunteers in a number of different ways. CARE stands for Compassionate and Recovery Focussed Every Time.

Carer An individual who provides or intends to provide support to someone with a mental health problem. A carer may be a relative, partner, friend or neighbour, and may or may not live with the person cared for.

CBT Cognitive Behavioural Therapy

CBU Chapman Barker Unit, specialist service for those with substance misuse needs on the Prestwich site

CCGs Clinical Commissioning Groups - groups of GPs are responsible for designing and commissioning local health services

CG Clinical Guideline

CMHT Community Mental Health Team

COASSIST Children with OCD: Identifying Accessible Support Strategies for Parents

CTIMP’s Clinical Trials of Investigational Medicinal Products

CPA Care Programme Approach - a framework for assessing service users’ needs, planning ways to meet needs and checking that needs are being met.

CQC The Care Quality Commission is the independent regulator of all health and adult social care in England and has responsibility for protecting the rights of individuals detained under the Mental Health Act.

CQUIN Commissioning for Quality and Innovation framework, which allows commissioners to link income to the achievement of quality improvement goals

CRN:GM Clinical Research Network: Greater Manchester

CROM Clinician Reported Outcome Measures

DATIX The Trust’s Integrated Risk Management Software

DH Department of Health

DS&P Data Security and Protection

DNAR Do not attempt resuscitation

ECG Electrocardiography

EDIE Early detection and intervention evaluation for people at risk of psychosis

e-GFR Estimated Glomerular Filtration Rate

EI Early Intervention

EIP Early Intervention in Psychosis

EQUIP ‘Enhancing the quality of user involved care planning in mental health services. A collaborative project between the University of Manchester, University of Nottingham, Nottinghamshire Healthcare NHS Trust and Greater Manchester Mental Health NHS Foundation Trust to examine ways to improve user and carer involvement in care planning in mental health services.

FFT Friends and Family Test

GDPR General Data Protection Regulation

GM Greater Manchester

GMMH Greater Manchester Mental Health NHS Foundation Trust

GMP Greater Manchester Police

GMW Greater Manchester West Mental Health NHS Foundation Trust

GM: CRN Greater Manchester Clinical Research Network

GP General Practitioner

HAELO Innovation and Improvement Science Centre in Salford

HBT Home Based Treatment

HealthWatch HealthWatch is an independent consumer champion. It was created to listen and gather the public and patient’s experiences of using local health and social care services. Local Health Watches were set up in every local authority area to help put patients and the public at the heart of service delivery and improvement across the NHS and care services.

HEE Health Education England

HinM Health Innovation Manchester

HMP Her Majesty’s Prison

HoNOS Health of Nation Outcome Scales

HR Human Resources

HSJ Health Service Journal

IAPT Improving Access to Psychological Therapies: National programme aiming to improve access to evidence-based talking therapies in the NHS through an expansion of the psychological therapy workforce and supporting services.

ICO Integrated Care Organisation

iESE Improvement and Efficiency Social Enterprise

IM Intra-muscular

JDR Join Dementia Research

JDU John Denmark Unit - Inpatient unit for deaf mental health services on the Prestwich site

Junction 17 Inpatient unit for child and adolescent mental health services on the Prestwich site

KPI Key Performance Indicator

KPMG Professional Service Company and Auditors

LeDeR Learning Disabilities Mortality Review

Lester Tool Downloadable resource used in a range of healthcare settings to improve screening and to ensure a person’s physical and mental health conditions are

jointly addressed providing a systematic framework for screening and recommendations for treatment and support.

LGBTQI Umbrella term for people who identify as Lesbian, Gay, Bisexual, Transsexual. The “Q” stands for those who are questioning or in a state of flux with their gender and/or sexual identity.

LQAF Library Quality Assurance Framework

MATS Memory Assessment Services

MBU Mother and Baby Unit

MDT Multi-Disciplinary Team

MH Mental Health

MHSDS Mental Health Services Data Set

MIAA Mersey Internal Audit Agency

MMHSCT Manchester Mental Health and Social Care Trust

Monitor The independent regulator of NHS Foundation Trusts

MSK Musculoskeletal

NCI National Confidential Inquiry

NCISH National Confidential Inquiry into Suicide and Homicide

NCSCT National Centre for Smoking Cessation and Training

NG NICE Guidelines

NHS National Health Service

NIAG NICE Implementation and Audit Group

NICE The National Institute for Health and Care Excellence

NIHR National Institute for Health Research: The NIHR commissions and funds a range of NHS and social care research programmes

NRLS National Reporting and Learning System

NWAS North West Ambulance Service

OPS Operations

OCD Obsessive compulsive disorder

OF Oversight Framework

PAM Assist People Asset Management Assistance

PARIS PARIS: GMMH current electronic patient record system.

PbR Payment by Results

PIR Post Incident Review panel

PCFT Pennine Care NHS Foundation Trust

PCMIS Clinical information system used in Manchester

PHIT Physical Health Improvement Tool used in PARIS

PICU Psychiatric Intensive Care Unit

PLACE Patient-Led Assessments of the Care Environment

PLAN Psychiatric Liaison Accreditation Network

PMVA Prevention and Management of Violence and Aggression

PREM Patient Reported Experience Measures

PRN Pro Re Natum (as the need arises)

PROM Patient Reported Outcome Measures

PRU Psychosis Research Unit

PSI’s Psychological Interventions

QIC Quality Improvement Committee (formerly Quality Governance Committee)

QICC Quality Improvement in Clinical Care group

QI Quality Improvement

QIP’s Quality Improvement Priorities

QPR Questionnaire about Process of Recovery

R&D Research and Development

R&I Research and Innovation

RAG Red, Amber Green

RCA Root Cause Analysis investigation

RCF Research Capability Funding

SQI The Sustainability and Quality Improvement Group

SUS Secondary Uses Service

STORM Skills based suicide prevention training in risk assessment and safety planning for frontline staff

SJR Structured Judgement Review

SIR Serious Incident Review

THOMAS Those on the margins of society

WRES Workforce Race Equality Standard

WDES Workforce Disability Equality Standard

© Greater Manchester Mental Health NHS Foundation Trust

This information can be provided in different languages, Braille, large print, interpretations, text only, and audio formats on request, please telephone 0161 358 1644.

Greater Manchester Mental Health NHS Foundation Trust

Bury New Road, Prestwich, Manchester M25 3BL

Telephone: 0161 773 9121Website: www.gmmh.nhs.uk

Quality Account 2020/2021 - NHS

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