An Assurance Review of the Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust: Published May 2026

The Trust must ensure that patient, family and carer voices are heard at every level of the organisation. The Trust must respond quickly when people experience difficulties with the services they receive and make lived experience voices central to the design, delivery and governance of its services. They have developed a strategy in this area, which now needs to be implemented and evaluated to understand its impact.
The Trust must continue to work on these areas in the first year:
• Carry out a full appraisal of the Service User Engagement Strategy with all relevant stakeholders to ensure that its aims are being delivered and that it meets the needs of the Trust’s communities. This evaluation must assess the degree of cultural sensitivity and responsiveness enabled by the strategy.
• Systems to represent and respond to patients’ expertise at every level of the organisation.
• Systems to represent and respond to family and carers’ voices at every level of the organisation.

A strong clinical voice must be developed and then heard and championed from Board to floor, and in wider system meetings.
The Trust must continue to work on these areas in the first year
• Systems for developing robust clinical leadership, which includes a clear understanding of roles and responsibilities and expectations.
• System of high-quality supervision, mentoring and coaching to support clinicians undertaking clinical leadership roles.
• Evaluate the effectiveness of the care group triumvirate model.

The Board must develop and lead a culture that places quality of care as its utmost priority, which is underpinned by compassionate leadership from Board to floor. This culture must ensure that no staff experience discrimination.
The Trust must continue to work on these areas in the first year:
• The Board must reflect on the findings of this report and what happened at Edenfield in order to develop a clear set of expectations about the values and behaviours expected from all staff working within the organisation.
• Develop systems that deliver and measure key aspects of culture so that staff and leaders can be held to account for demonstrating values and behaviours that support the development of a new and healthy organisational culture which encourages and listens to people.
• The organisation must work with staff to develop systems which supports a culture of inclusion and engagement that addresses concerns in relation to equality and racism.
• Review the current leadership programme and ensure that its content covers these key areas. Prioritise this programme’s delivery.

The Trust must work with its current and future workforce levels to recognise, adapt to and manage the safety challenges that a staffing shortfall may pose, including ensuring the stability of nursing staff. The Trust must develop a representative, competent and culturally sensitive workforce which is supported to provide services that meet the needs of its communities.
Within the first year:
• Develop a strategy for the recruitment and retention of staff and an associated delivery plan; with systems to support the Trust to understand the potential impact that unstable staffing (particularly among nurses) has on the quality of their care and to adapt to these challenges.
• The systems to ensure that staff are encouraged to speak freely and that they are listened to when they raise areas of concern or areas for improvement.
• The systems to ensure that staff have the right knowledge, skills, supervision and mentoring to perform their roles.
• The systems to ensure that staff health and wellbeing is supported.

The Trust needs to have a better understanding of the quality of its estate and the impact of this on the delivery of high-quality care, including providing a safe environment. It must ensure that essential maintenance is identified and carried out in a timely manner and that the cleanliness of units is maintained.
Within the first year:
• The Trust Board must assure itself about the quality of its estate and safety within it.

The Trust must ensure that its governance structure (and the culture that this is applied within) supports timely escalation and that the right information can be used at the right level, by the right staff. There must be much greater focus on the validation and triangulation of information to ensure that quality issues can be resolved quickly and learning can take place.
Within the first year:
• Ensure that governance functions (including, but not limited to, safeguarding and complaints) are adequately resourced to meet the needs of the size of the Trust.
• Ensure that the governance framework supports the necessary information flows for staff at all levels to manage and improve quality (from Board to floor).
• Develop systems that proactively scan for safety concerns across its services, using and triangulating a range of information and intelligence sources: including, but not limited to, safeguarding referrals, complaints, staff and patient surveys, staffing levels, FTSU cases, and incidents.
• Design a quality management system to enable the systematic planning for, maintaining and improving quality.

The Trust must ensure that Edenfield provides compassionate, high-quality care and that all staff, permanent or temporary, have the skills, knowledge, and support to achieve this.
Within the first year:
• The clinical model to deliver best forensic practice.
• The systems that deliver and measure key aspects of culture with particular emphasis on compassionate, high-quality care and a positive patient safety culture.
• The systems to ensure that the lived experience and expertise of patients and families are central to the work of the service.
• The use of data and intelligence that gives leaders meaningful oversight of restrictive practices, complaints, concerns, safeguarding and incidents.
• The systems that encourage staff to report quality concerns and improvement ideas.
• A review of advocacy services in Edenfield to ensure that they are delivering the intended benefits for patients there which includes how leaders value advocacy.
• The systems that support all staff, including those who are temporary, to work effectively in multi-professional teams. This should include consideration of training, supervision, mentoring, coaching, reflective practice and wellbeing.
• The systems that ensure that the internal environment is clean, safe and fit for purpose.

The Trust should review the improvement plan again following receipt of this report’s findings to develop further clarity about the problems that they are trying to solve and the actions that need to be taken to achieve better outcomes. It needs to be clear on how all actions will be evaluated so that it can be assured about whether changes being made are having the desired impact. The plan should be prioritised to ensure that actions are sequenced, build on each other, and prioritise the quality of care people receive from GMMH. This includes ensuring a balanced approach between the scale of the improvements required and setting out a realistic timescale for implementing identified actions with the support of their system partners.
Within the first year:
• Articulate clearly the problems the Trust is trying to resolve. This process needs to involve clinicians and service users.
• Ensure that impact measures are clearly defined and that the Trust knows how it will measure them.
• Ensure the plan is prioritised, sequenced, and the first 18 months of work are described clearly.

We identified some common concerns across services we visited at the Trust, which were also prevalent within Edenfield. The Trust and the wider system must consider how they understand issues identified in these services (and others) in more detail, including through the actions described below.
Within the first year:
• The Trust should urgently review how it identifies safety concerns and initiates sustainable learning when people die unexpectedly while using their inpatient services.
• The GMMH Board needs to immediately ensure that it has an up-to-date and accurate view of the current levels of safety within each of the services referenced, and controls in place to address any immediate risks. This should include a re-assessment of the effectiveness of their ligature reduction plan.
• NHS England should consider whether they, and GMMH, require a more detailed review of deaths across both inpatient and community services to ensure that safe care is being provided and to maximise every opportunity to learn, in line with contemporary practice.
• As a second stage review, the Trust and its partners should identify together where and in which services further independent assurance is needed. We recommend that Community Mental Health Services are independently reviewed.

The organisations with responsibility for regulation, oversight and support to GMMH must review their current systems of quality assurance. They must also review how they work together collectively to identify concerns in a provider at an early stage to prevent tragedies like those seen at Edenfield from reoccurring. Where learning is identified that applies nationally, this must be cascaded by the relevant organisation.
Within the first year:
• Within each organisation discussed in this report, review the assurance architecture for the oversight of GMMH and consider why this failed to identify workforce, culture, and quality concerns at an earlier stage.
• The ICB should review the level of mental health expertise it has in its oversight of mental health organisations, ensuring that its staff have the relevant experience and seniority to be able to identify leading quality concerns in providers.
• The CQC must define why their oversight of the Adult Forensic Service did not identify a closed culture or that the service was at risk of developing one, as per their definition.
• Redesign systems to support better partnership-working between external agencies, so that information is shared and understood in a timely way to identify potential services in distress.
• Review how the system supports the Trust to ensure that their approach is focused on enabling the Trust to identify priorities, make the improvements needed, and model, at a system level, the compassionate leadership that is required to achieve sustainable change.

NHS England must review and clarify the role of the GM Adult Secure (Northwest) provider collaborative and the governance structures needed to oversee this role. The responsibilities of the collaborative need to be discharged by staff with the right experience and expertise. In light of the concerns identified in this report in relation to Adult Forensic Services (and wider issues in the Trust’s Specialist Services), the role of GMMH as lead provider needs to be reviewed by NHS England. If this arrangement is to continue, support should be provided to GMMH to stabilise the current situation and to develop it to deliver the role effectively in the future.
Within the first year:
• NHS England must review and clarify the role of the Greater Manchester Adult Secure (Northwest) provider collaborative and the governance structures needed to oversee this role.
• Review GMMH’s position as lead provider in the provider collaborative.
• NHS England should develop a Standard Operating Procedure within six months to provide clarity around the thresholds for information sharing and escalation of concerns (e.g., relating to IC(E)TRs, and include Contract Performance Notices and other sources) when issued in relation to patient care.