Manchester University NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. This was included in the induction handbook.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Minutes showed service development was regularly discussed at the senior leadership team meetings. Away days took place with the staff team where discussions about the service, processes and reasons to be proud were discussed.

Staff could explain how they were working to deliver high quality care within the budgets available. The service had submitted a business case to commissioners to increase the staffing compliment to increase the therapy provision and nursing staffing numbers to respond to the changing needs of the service including the acuity levels of young people accessing the service. This was agreed and increased posts had been recruited to except for a full-time social worker and a team administrator.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had worked in the service for several years and had progressed through the service.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Senior leadership meetings involved senior nursing colleagues as well as senior members of the multidisciplinary team to ensure a joint working approach.

Leaders were visible in the service and approachable for young people and staff. We saw leaders on the ward during the assessment, engaging with both staff and young people. The service lead was based on the ward, alongside the ward manager for ease of access.

Leadership development opportunities were available, including opportunities for staff. We saw staff had access to several recognised NHS leadership programmes. These included a programme for staff exploring leadership and developing leadership skills. The Trust also offered a programme for new or aspiring leaders; this was a 6-month programme designed for leaders in healthcare. The Trust also offered a leadership programme focused on leading transformation and change.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Young people and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This included community meetings for young people and the independent advocate. Parents and families had opportunities to share their experiences with family ambassadors, via the parent and carer group, via questionnaire and the weekly meetings with the lead consultant.

Managers and staff had access to the feedback from young people, carers and staff and used it to make improvements. Minutes were taken from the community meetings, and ‘you said, we did’ information was displayed. Feedback from parents was being reviewed with suggestions of making the parent and carer groups longer and including information sessions about mental health conditions.

Young people and carers were involved in decision-making about changes to the service. This included wall displays and new furniture. There was a quality improvement project underway to improve the care plan documentation and patient participation.

Young people and staff could meet with members of the provider’s senior leadership team to give feedback. The service lead was present on the ward and approachable to staff and young people.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were equality and diversity champions within the service, the importance of these roles was included in the service’s delivery plan.

Staff were able to apply to work flexibly, for example flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role. For example, some staff were not involved in physical interventions due to health needs.

Staff had the opportunity to attend reflective practice which we saw staff valued, being given an opportunity to share experiences and reflect in a safe space which was independently facilitated.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. However they did act on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was not always a clear framework of what must be discussed at a ward level in team meetings to ensure that essential information, such as complaints, was shared and discussed. We reviewed minutes from meetings including team meeting minutes and found they did not have a standard agenda, minutes showed the meeting as an information giving meeting with requests for staff to action. However, incidents was a standard agenda item. Senior meetings including CAMHS Quality Safety meetings had a set agenda and included complaints, learning from incidents. Senior Leadership Team Meetings had a set agenda and included PSIRF, audits, restrictive practices and complaints.

Staff had implemented recommendations from reviews of incidents at the service level. For example, staff were not preparing feeds in advance and leaving them on the side, the same staff member prepared and administered the feed.

Staff undertook or participated in local clinical audits. The audits were not always sufficient to provide assurance and staff acted on the results when needed. The medicines audit did not reflect the current stock list. The item that we found out of date was not included in the stock list. The system in place to monitor clinic items expiry date and the safe disposal of these to ensure staff were not using out of date items was not effective as there was an item out of date.

Care plan audits from November 2025 showed that care plans were not always being reviewed monthly. When we were on site there were care plans that continued not to be reviewed at the required frequency. However there had been an improvement since the November 2025 audit when this was repeated in January 2026.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the young people.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. There were 5 risks on the Trust risk register, which were reviewed by leaders every 6 months via the electronic incident reporting system.

Staff concerns matched those on the risk register. These included the environment and care records being spread across several systems.

The service had plans for emergencies – for example, adverse weather or a flu outbreak. However, staff had not ensured that the fire risk assessment had been completed in line with the organisational policy. We reviewed the fire safety records and found the fire risk assessment was last completed in 2021 and due for review in 2022. This had not been reviewed at the time of the assessment. The fire policy states that psychiatric wards’ fire risk assessment should be reviewed annually. This was not happening. We raised this with the service and there was a reassessment shortly following the assessment.

The service did not use systems to collect data from wards and directorates that were not over-burdensome for frontline staff. Staff had to use 2 electronic care record systems for the recording of information about young people, in addition to the shared drive, which was time consuming and made it difficult to locate information promptly.

Information governance systems included confidentiality of young people records. This included passwords for staff to access the information.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and young people’s care. Leaders could access the electronic care records and details about staffing including rotas and training compliance.

We reviewed the handover documentation and found that the handover did not include risk and observation levels for every young person. This meant new staff joining the ward would not be fully informed of the young people’s needs. We raised this with the service, and they changed the handover process and template following the assessment to a SBAR format (situation, background, assessment, recommendations), to ensure full information, including the specific risk for the young person are included in the handover.

Staff mostly received a role service specific induction. However, when bank nursing staff were used, those staff did not always receive a documented induction to the ward. We reviewed 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. We raised this with the service, and they changed the induction checklist immediately following the assessment. The nursing assistant induction pack was acute hospital focused and not mental health focused, for example “To check bedside suction daily and report any concerns.” This meant that not all new staff would have a documented induction that was relevant to their role and the environment they worked in.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders – such as commissioners and Healthwatch. Regular reviews took place with commissioners and information was provided to commissioners in between the reviews as part of contract compliance.

The service shared their skills and knowledge regarding caring for young people with Pervasive Arousal Withdrawal Syndrome (PAWS) and delivered training to other professionals.

The service worked in partnership with community teams and education when planning young people’s discharge from the service.

Young people and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. When the provider collaborative conducted their quality visits they spoke with young people and staff.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff had opportunities to participate in research. The service were involved in a pilot study examining the potential of smartphones to capture new types of data that can accurately assess the physiological and psychological health status of an individual with an eating disorder. The service received a runner up award from the Royal College of Psychiatrists for “Comparing a novel device (NGPOD®) to standard practice for ascertaining the positioning of nasogastric tubes in paediatric inpatients (NGPOD-P)” at the Faculty of Eating Disorders Spring Online Conference 2024 Poster Competition.

The team had a doctor, who was a research fellow, who was in the process of completing their PhD in eating disorder research.

The education provision was inspected by Ofsted in July 2025 and rated outstanding for the quality of education, behaviour and attitudes, personal development and leadership and management.

Innovations were taking place in the service. There was a teenage lounge for the older young people on the ward with appropriate activities and another lounge for younger children on the ward with appropriate activities. Music therapy was taking place on the ward which resulted in young people having the opportunity to record music and share this with others.

Staff used quality improvement methods and knew how to apply them. There were quality improvement projects underway in the service involving young people to improve the care plans and young people’s participation in the service. Progress was displayed in the communal lounge at the service.

Staff participated in national audits relevant to the service and learned from them. The service were involved in the National Audit of Eating Disorders (NAED).

The service participated in accreditation schemes relevant to the service and learned from them. Galaxy House was accredited by the Quality Network for Inpatient CAMHS (QNIC).