• Organisation

Manchester University NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

2nd October - 8th November 2018

During an inspection of Specialist community mental health services for children and young people

We had not previously inspected this service under this provider. We rated the service as outstanding because:

22nd March 2018

During an inspection of Child and adolescent mental health wards

During our inspection we found:

  • Patient risk assessments were brief, not all sections were completed. Risks identified at assessment did not have subsequent guidance for staff in the form of risk management plans.

  • Patient alarms were only located in two bathrooms and patients/visitors did not have access to alarms in other locations of the ward.

  • The service could not always comply with same sex accommodation guidance, this had occurred once in the previous year.

  • Controlled drugs on the premises were not checked in accordance with local procedures.

  • Blanket restrictions were in place, patients could not access their bedrooms or bathrooms during the day without staff assistance. No individual plans or rationale for this were in place

  • Staff did not have guidance on reducing restrictive practice, procedural support was not in place

  • Identified environmental risks on the ligature risk assessment did not have associated action plans and were not included on the services risk register.


  • All ward areas were clean and well maintained and staff followed local infection control procedures.

  • Electronic rostering was used to support staff management and staffing was reviewed regularly to ensure there was enough staff with the relevant skills to deliver safe patient care.

  • All incidents were recorded on the electronic incident recording system; these were reviewed regularly to monitor themes and incident analysis. The trust had an open and transparent culture to reporting incidents and learning from incidents. Lessons learnt from incidents were shared across teams and staff described changes to policy and practice in response to lessons learnt

  • Systems were in place to ensure that child safeguarding was fully integrated into local systems and practices.

  • There was an established governance structure with a defined hierarchy of reporting and decision making within the service.

  • There were clear systems of accountability and senior managers were actively involved in the operational delivery of the service. Processes and systems of accountability were in place and performance management and quality reporting was clearly set out.

  • Performance issues were escalated and discussed at relevant governance forums and action taken to resolve concerns.

  • All staff we spoke with were positive about their roles and were passionate about service development. Staff felt able to raise concerns without fear of victimisation and spoke positively about the organisation. They told us that they felt valued, had input into the service and were consulted and involved in service quality developments.

  • The service was committed to improving the services on offer and continually improving the quality of care provided to patients.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.