Independent review – Greater Manchester Mental Health NHS Foundation Trust (31 January 2024)

Summary

This report sets out the findings of an Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust. The review was commissioned following reports of failings within the Trust’s services at the Edenfield Centre and the failure within the organisation to escalate concerns and mitigate patient harm.

Content

The Edenfield Centre is a mental health medium and low secure service, supporting patients with a range of complex needs in Greater Manchester. In September 2022, the BBC broadcast an episode of their current affairs programme Panorama which showed evidence of shocking abuse and poor care of patients at the Edenfield Centre.

In November 2022, NHS England commissioned an Independent Review of the Trust, led by Professor Oliver Shanley. The review raised a number concerns, including:

• Missed opportunities to act on concerning findings relating to National Staff Survey results, information relating to levels of restrictive practice, a cultural audit in 2019 which raised concerns, staff vacancies, the instability of ward management and high consultant turnover.
• Poor leadership visibility in the service, as well as weak governance processes and a practice of suppressing ‘bad news’ in the organisation.
• The hallmarks of a closed culture, including an absence of psychological safety, incivility between staff, poor leadership, and a lack of teamworking.
• That the expansion of the Trust services had not seen a corresponding investment in quality oversight.
• That healthy debate and challenge had been discouraged, and that information provided to the Board was often poor and provided insufficient or inaccurate information to underpin Board assurance.
• Repeated stories of senior managers treating staff poorly and fostering a culture of fear and intimidation in order to maintain performance standards.
• Greater Manchester Mental Health NHS Foundation Trust has had higher vacancies than the national average in some professional groups, notably nursing and medicine. The workforce information the Board received was insufficient and there was not a clear strategy to address either the recruitment or retention of staff.

The report makes several improvement recommendations for implementation over the next year. After 12 months, the review team will undertake an assurance visit to determine what progress has been made.