Quality Account 2020/2021 - Improving Lives - NHS

Quality Account 2020/2021 - Improving Lives - NHS
Quality Account 2019/20   1

Quality Account
Greater Manchester Mental Health
NHS Foundation Trust

             Improving Lives
Quality Account 2020/2021 - Improving Lives - NHS
1     PART 1 – Our Commitment to Quality .......................................................................... 4
    1.1     Chief Executive’s Welcome ......................................................................................... 4
    1.2     Quality Assurance at GMMH ...................................................................................... 6
    1.3     Quality Improvement at GMMH (QI Strategy).............................................................. 7
    1.4     Accolades and Developments ................................................................................... 11

2     PART 2 - Statements of Assurance from the Board for 2020/21 ............................... 15
    2.1     Review of Services .................................................................................................... 15
    2.2     Participation in Clinical Audits and National Confidential Enquiries ........................... 15
    2.3     Participation in Clinical Research ............................................................................... 18
    2.4     Commissioning for Quality and Innovation (CQUIN) .................................................. 21
    2.5     Registration with the Care Quality Commission (CQC) .............................................. 21
    2.6     CQC Mental Health Act Monitoring.......................................................................... 21
    2.7     Data Quality ............................................................................................................. 22
    2.8     Information Governance ........................................................................................... 23
    2.9     Clinical Coding ......................................................................................................... 23
    2.10    Department of Health Mandatory Quality Indicators ................................................. 23
    2.12    Freedom to Speak Up ............................................................................................... 34
    2.13    Increasing Community Mental Health Services Capacity ............................................ 35

3     PART 3 – Review of Quality Performance in 2019/20 ................................................ 37
    3.1     Delivery of Quality Improvement Priorities in 2020/2021 ........................................... 37
    3.2     Performance against Quality Indicators Selected ....................................................... 48
    3.3     Performance against Key National Priorities .............................................................. 49

4     PART 4 –Priorities for Quality Improvement in 2021/22 ............................................ 52
    4.1     Improvement Priorities for 2021/2021 ...................................................................... 52
    4.2     Monitoring our Quality Improvement Priorities.......................................................... 52

5     Annex ............................................................................................................................ 53
    5.1     ANNEX 1 – Feedback from Key Stakeholders ............................................................ 53
    5.2     ANNEX 2 - Statement of Directors’ Responsibilities in Respect of the Quality Account 57
    5.3     ANNEX 3 - Equality Impact Assessment..................................................................... 58

Quality Account 2020/2021 - Improving Lives - NHS
5.4   ANNEX 4 - Local Clinical Audits Reviewed in 2020/21 ............................................... 60
5.5   ANNEX 5 - Glossary of Terms.................................................................................... 66

Quality Account 2020/2021 - Improving Lives - NHS
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:

Quality Account 2020/2021 - Improving Lives - NHS
•   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

Quality Account 2020/2021 - Improving Lives - NHS
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

Quality Account 2020/2021 - Improving Lives - NHS
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

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.

Quality Account 2020/2021 - Improving Lives - NHS
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        Workforce            Results and     Culture and
                          systems and           capability and       system          behaviors
                          structures            development          impact

 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:

Quality Account 2020/2021 - Improving Lives - NHS
Quality Account 2020/2021 - Improving Lives - NHS
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.

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

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.

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

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.

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

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

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.

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

2.2 Participation in Clinical Audits and National Confidential
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:

•   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

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-
                                                              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

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:

•     Smoking status.                               •    Blood pressure.
     •     Alcohol.                                      •    Glucose regulation (HbA1C or fasting
     •     Drugs.                                             glucose or random glucose as
     •     Blood lipids.                                      appropriate).
     •     Body Mass Index.

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

 National confidential        Questionnaires received        Questionnaires            %
 inquiry                      from NCI 2020/2021             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

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           •   Improve documentation around side-effect monitoring in
 for Mental Health:                    the past year of people with a learning disability prescribed
                                       antipsychotic medication for more than a year.
 Antipsychotic Prescribing in      •   Ensure that written behavioural support plans are developed
 People with a Learning                at initiation of antipsychotic medication.
 Disability under the care of      •   To clearly document when a review to consider reducing the
 Mental Health Services.               dose or stopping has been completed.
 Report issued August 2020.

National Audit of Early         •   Individual team action plans to date has included:
 Intervention in Psychosis       •   In Trafford, new monies have allowed us to employ a
 Re-audit.                           dedicated family intervention worker and devote a
                                     significant proportion of time of a senior clinical psychologist
 Individual team reports             to training more care coordinators in Behavioural Family
 issued September 2020.              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: Patrick.cahoon@gmmh.nhs.uk

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:

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.

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

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

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 sarah.leo@gmmh.nhs.uk).

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

E-mail: Miranda.washington@gmmh.nhs.uk

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

 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

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

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

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

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.

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-
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

**As of December 2020. Source: PARIS
*As at December 2019 Source: https://www.england.nhs.uk/statistics/statistical-work-areas/mental-
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).               •   Safety Culture (6.7 to 6.8).
    •    Immediate Managers (7.2 to 7.4).               •   Staff Engagement (6.9 to 7.0).
    •    Morale (6.1 to 6.3).                           •   Team Working (6.7 to 6.8).
    •    Bullying and Harassment (7.9 to 8.1).

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

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

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