Manchester University NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. The service was in breach of regulation 9A Visiting and accompanying in care homes, hospitals and hospices and 15 Premises and equipment.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There had been no severe physical or psychological harm incidents in the last 12 months at the service.

All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report. We saw incidents recorded on the electronic incident reporting system.

Staff understood the duty of candour. However, there were no incidents that met the threshold of the duty of candour in the 12 months prior to the assessment.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw staff meeting minutes where learning was shared, an example was a young person that received the wrong feed. Staff met to discuss the feedback and reflect on the incident. Changes were made as a result of learning, this included the same member of staff preparing and administering a feed.

Staff followed the requirements of the Patient Safety Incident Response Framework (PSIRF) by completing the appropriate reviews of incidents, including after action reviews. Learning was shared with the team and the wider collaborative of services, which included via young people stories.

Staff were debriefed and received support after a serious incident. Staff also had access to reflective practice where they could discuss their role and any challenges or difficulties with an external facilitator.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the young people was received to determine if the young people’s needs could safely be met. Referrals were made via NHS England and there was a weekly referrals and bed management meeting where new referrals were discussed. Staff completed an assessment of young people prior to admission to ensure that the service could meet their needs.

Staff involved all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge. Reviews of young people’s care involved the full multidisciplinary team which included hospital education, school, the community team and parents, who contributed to the discharge planning process.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. However they did concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff attended training in Safeguarding Children and Safeguarding Adults at levels 1 to 3. Safeguarding training compliance was 100%, except Safeguarding Children Level 3 with 96% and Safeguarding Adults level 2 with 97%.

Staff could give examples of how to protect young people from harassment and discrimination, including those with protected characteristics under the Equality Act. Records showed referrals to children’s services and liaison with them.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

The service restricted visiting on the ward. There was no visiting on Monday and Thursday evenings. This was displayed on the ward and in the welcome booklet. The service reviewed the visiting policy in 2025 and involved young people and their families in this process. The service received responses from 11 family members, 4 of whom said they would like to be able to visit their family member on an additional day. There were no individual assessments in place regarding visiting arrangements.

At the time of the assessment, bathrooms, toilets and communal areas were locked due to clinical reasons of young people vomiting. However, this meant young people could not access the areas without staff unlocking them. Alternative interventions had not been considered to mitigate the risk.

Mental Capacity Act

The Mental Capacity Act only applies to young people over the age of 16. Staff completed training in the Mental Capacity Act as part of their mandatory safeguarding level 3 training, with 100% compliance. Staff had a good understanding of the Mental Capacity Act.

Staff knew where to get advice from regarding the Mental Capacity Act, this included the Mental Health Act Administrator and Mental Health Act and Mental Capacity Act manager.

Staff took all practical steps to enable young people to make their own decisions. We saw accessible documentation in place for young people, with the use of symbols.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to young people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 8 risk assessments during the assessment. These were detailed, comprehensive, individualised and regularly reviewed.

There had been 219 incidences of physical restraint in the 12 months prior to the assessment. Three were prone (face down) whilst the young person was lowered and then turned over, 173 were in a supine (face up) position and 43 were in a seated position. The majority of these physical interventions were to facilitate nasogastric (NG) feeds.

There had been no use of rapid tranquilisation in the 12 months prior to the assessment.

The ward staff had regard to Mental Health Unit (Use of Force) Act 2018 and its guidance and complied with requirements.

Staff mostly involved young people in care planning and risk assessment, shown by evidence in care plans, participation in multidisciplinary team reviews and individualised risk assessments. However, young people told us that restrictions within their care plans were not always reviewed, for example a historical risk resulting in the removal of an NG tube and not been reviewed and this practice continued.

Staff communicated with young people so that they understood their care and treatment, including finding effective ways to communicate with young people with communication difficulties. We saw examples of care plans and plans for activities that were pictorial and accessible for young people.

Staff enabled young people to give feedback on the service they received. Community meetings took place most weeks. The minutes from these meetings were displayed in the communal lounge area. There was also a “you said, we did” board with the progress against issues raised. The majority of the topics raised were in relation to the environment of the ward, food and expectations.

Staff ensured that young people could access advocacy. Details were on display in the ward and the advocate attended the young person’s review.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Staff did not always complete regular fire risk assessments of the care environment. We reviewed the fire safety records and found the fire risk assessment was last completed in 2021 and was due for review in 2022. This had not been reviewed at the time of the assessment. The fire policy stated that psychiatric wards fire risk assessments should be reviewed annually. This was not happening. We raised this with the service and there was a reassessment shortly after our visit. Weekly fire safety checks were generally completed, however there had not been one completed since 3 January 2026.

The ligature audit action plan included risks that had been reported to the building owner for maintenance and had been chased but not completed, for example anti ligature sealant around items. This meant there were several environmental actions outstanding.

However, there was a ligature map which was clear and included high risk areas, medium risk areas and managed risk areas. This also included the location of the emergency equipment such as ligature cutters. The map included how staff mitigated the risks.

The ward layout did not allow staff to observe all parts of ward. There were doors on the main corridor that had blind spots behind them.

There were several potential ligature anchor points which were identified on the ligature audit action plan, however actions were not imminent and included “when replaced will look at anti ligature options”.

In the clinic supplies storage room, there was one box of Z Gel Clot Activator blood collection tubes which had expired on 31/12/2025. The system in place to monitor clinic items expiry date and the safe disposal of these was not effective to ensure there were no out of date items.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The environment needed repair and redecoration. There were marked grab rails in the shower in bedroom 11. There was a stained floor in bedroom 12.

The bedroom door windows did not have vistomatic windows and were frosted film with a small viewing hole in the middle, this meant vision was limited for staff to observe the young people and the young people could not have privacy. There had been a maintenance request submitted in May 2025 for replacement doors which had not been completed at the time of the assessment.

In the bedroom corridor there was paper stuck to the ceiling with masking tape covering a light. Staff told us this was due to a young person not being able to sleep due to the light and not being able to block out the light due to the windows in the doors.

In the dining room, there was paint peeling off the windowsills and there were holes in the wall where a notice board had been removed but these had not been filled. We reviewed the maintenance request log, and this job had been logged in October 2025 and not yet completed.

In the sensory room, there was paint peeling off the wall.

Bedroom 7 was cold in temperature; staff could not adjust this. Community meeting minutes noted that concerns about room temperatures had been raised since October 2025.

Bedroom 12 had a marked mirror with stickers from a previous young person which had not been removed.

There were only 2 bedrooms that were ensuite which were not in use at the time of the assessment as they were accessible rooms, mainly used for young people with additional physical health needs. The 2 toilets and bathrooms were directly off the corridor and young people had foot in the door observations which did not protect their privacy and dignity.

Staff had easy access to alarms and young people had easy access to nurse call systems in all rooms.

There had recently been new bedroom furniture installed, including beds and storage which was brightly coloured and smooth, this was safe furniture that was appropriate for young people and was vibrant in appearance.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There was a multidisciplinary team of staff working in the service. However, there were vacancies for a part time band 6 nursing role, 2 band 5 nurses, 4 band 4 posts, a full time and part time nursing assistant role, an occupational therapist role, a part time psychotherapist and psychologist role and a full-time social worker. The average turnover rate was 1.2% for 2025. The average sickness absence was 7.9% for 2025. The average bank staff use was 13% from April to December 2025, with no agency use in that time.

Managers had calculated the number and grade of nurses and healthcare assistants required. There were 7 staff working on the shift at the time of the assessment, due to the number of young people on the ward. There were 7 young people on the ward at the time of the assessment.

The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed bank nursing staff to maintain safe staffing levels. There had been an increase in bank use in July to September 2025 due to the increased observations levels of the young people. There had also been an increase in funding to increase staffing numbers and additional nursing staff had been recruited, which reduced the use of bank staff.

When bank nursing staff were used, those staff did not always receive a documented induction to the ward. We review the rota and found 2 bank staff were working the week prior to the assessment. We reviewed the induction checklists and found only one of them had a completed induction checklist in place. The induction checklist did not include the location of the ligature cutters. This meant that we could not be assured that all staff were familiar with the ward and could respond in an emergency.

A qualified nurse was not present in communal areas of the ward at all times. There were occasions where young people were in the lounge without a member of staff present.

Staffing levels allowed young people to have regular one-to-one time with their named nurse. Young people confirmed this took place.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There were 2 occasions in 2025 when the walking group was cancelled due to staffing levels, however young people had access to the outside space.

There were enough staff to carry out physical interventions safely and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There were 2 consultant psychiatrists, 2 senior trainees and 2 core trainees. The ward was part of the Children’s hospital and there was additional support and response from the hospital if required.

Staff had received and were up to date with most mandatory training. A review of the training data provided by the Trust showed that these courses were under 70% compliance: Oliver McGowan training in learning disability and autism, tier 2 was 53% compliance. Oliver McGowan training in learning disability and autism tier 1 was 60% compliance. Following the assessment, the training compliance level had increased to 77% for both Tier 1 and 2.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. There was a room with equipment for use with young people with physical health needs and mobility needs, including hoists and wheelchairs, which were well maintained, clean and labelled to advise they had been cleaned.

Most of the ward areas were clean, had good furnishings and were well-maintained. However, there was toilet roll on the floor of one of the toilets.

Cleaning records were up to date and demonstrated that the ward areas were cleaned and inspected regularly.

Staff adhered to infection control principles, including handwashing. We saw nursing staff were bare below the elbow.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. We reviewed the medicines cards for the young people and found where young people were having regular PRN (as and when required) medicines, this was being regularly reviewed by their consultant and there was a reason for this use, for example they were moving onto a new medicine and the PRN medicine helped with this transition.

Staff reviewed the effects of medicines on young peoples’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when young people were prescribed a high dose of antipsychotic medicine. Records showed that regular physical health monitoring took place.

Staff carried out and documented weekly medicines stock checks which included the expiry date of the medicines.

The pharmacy team completed safe and secure storage of medicine and controlled drugs audits. The most recent audits were completed in December 2025 with over 90% compliance.