North by North West: Doing the right thing

Those involved in the fallout from the Edenfield care scandal in Greater Manchester have delivered an effective comms operation in the last six months - acknowledging the horror of what happened, and explaining the actions being taken in response.

In September last year, an undercover BBC Panorama investigation found a “toxic culture of humiliation, verbal abuse and bullying” at the Edenfield Centre, a secure facility within the forensic division of Greater Manchester Mental Health Foundation Trust.

Numerous staff members have since been sacked, while chair Rupert Nichols resigned in November. Deborah Partington, the chief operating officer, has also departed.

But most of the board remain in place, including chief executive Neil Thwaite, who has been at the trust for 16 years, four as CEO.

They’ve reacted with shock and dismay to what was aired in the programme, essentially saying they had no idea of the behaviours at Edenfield. They admit they should have looked harder, beyond the green flags and “assurances” they were being given at board and executive level.

No idea?

A review by the Good Governance Institute, commissioned by the trust in the immediate aftermath and published last week, does support the case of a governance breakdown.

The review is sympathetic in tone, saying the Panorama revelations were “totally unexpected” for the board, and the fallout has been “deeply felt” by the leadership and staff.

It highlights issues commonly cited in reviews of this kind, such as problem areas being hidden by aggregated data, assurances taken too easily, directors rarely visiting the wards, and an organisation overly focussed on its positive image.

Positive assurances were received from commissioners and regulators, being encouraged to expand into new areas (the takeover of mental health services in Manchester and Wigan), and boasting “good” ratings from the Care Quality Commission (more on this below).

Yet, there does appear to be evidence the executive team had been made aware of significant problems at Edenfield. Not to the degree of the problems shown in the documentary, but certainly to the extent that more questions should have been asked, and actions taken.

In a section about executive oversight, the GGI authors write: “Some of the issues and concerns relating to adult forensic services had been escalated and were known at higher levels within the trust, including high levels of disciplinary action and formal investigations, allegations of a lack of open and fair recruitment, and sickness levels.”

No further detail is given on that, but then in a separate section on culture, the authors note a staff survey in June 2019 which flagged “overwork”, “disempowerment”, and safety fears as prevalent themes among staff Edenfield, with forensic services consistently scoring worse than other services. A presentation of the findings of that survey was made to executive directors, the GGI said.

Perhaps the separate NHS England-commissioned review will scrutinise the apparent lack of action on those concerns.

Governance frameworks can be as tight as you like, but what’s more important is a basic desire and effort to do the right thing, and act on concerns when they become apparent.

Staffing ‘within available resources’

What’s clear is Edenfield was woefully understaffed, with the services being run in poorly maintained buildings that were well past their sell-by date.

The GGI review suggests some wards were being run with one, or even no registered nurses on certain shifts, when the trust’s safer staffing document said there should be two.

This would be seriously concerning on any NHS ward, but especially so in forensic services, where staff can often feel unsafe and at physically at risk, especially when they lack support.

Just as importantly, adequate staffing also allow for patients to be escorted on leave to see family and friends, which is a crucial release from the pressure that can build in secure environments.

There’s no excuse for the disrespect and abuse of patients that was exposed in the documentary. But low staffing levels, a workforce that fears for its safety, and patients feeling trapped in a poor physical environment, will all make it more likely.

The worrying thing is these conditions are unlikely to be unique to Edenfield, partly due to a lack of focus from NHSE. The GGI authors note, for example, the lack of national targets and benchmarking data available for forensic services.

They also point to a staffing model at Edenfield that was “built against available resources using the existing budgeted establishments, rather than on need”, which sounds rather like the problem faced by mental health chiefs everywhere.

CQC had no major concerns

As well as the trust and it’s commissioners, the Edenfield scandal raises serious questions over the CQC’s ability to accurately judge the quality of services.

The GGI review notes how the forensic services (largely Edenfield) were rated “good” in 2019, along with the trust as a whole. And the report from a subsequent inspection, in the summer of 2022, a couple of months before the Panorama documentary, was only published after it was aired, with service ratings suspended.

The CQC and trust have so far refused to reveal what the “draft” rating was from that inspection, which NxNW is challenging through the freedom of information process.

But having seen a copy of the post-inspection letter, the CQC appears to have had a largely positive view of the trust.

There were inevitably some areas of difficulty, around governance and staffing levels, but it noted the efforts being made to address these. It certainly doesn’t appear there were serious concerns or the prospect of a significant downgrade in the organisation’s rating.

Omission

The CQC made its own attempt last week to close the book on a difficult story, which was the effective sacking of one of its inspection advisors after he raised concerns about the quality of their inspection teams, as well as issues at University Hospitals of Morecambe Bay, his primary employer.

As previously reported, Shyham Kumar won an employment tribunal against the regulator last year, which found he was unfairly dismissed for making whistleblowing disclosures.

In a statement last week, accompanying an 87-page report on the CQC’s handling of those disclosures, chief executive Ian Trenholm apologised for the “unacceptably poor treatment Mr Kumar received from us both prior to and during the employment tribunal”, the findings of which were accepted in full.

The glaring omission in this was any mention of the CQC officers that were responsible for effectively dismissing Mr Kumar – named in the tribunal as local manager Kim Wood, and the national advisor for surgery, Mike Zeiderman.

The CQC declined to talk about individuals when asked if they had been subject to any internal action.