Alder Hey Children's NHS Foundation Trust

On this page

• 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

At our last inspection, we rated this key question as good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

Staff assessed and managed risk. However, we found that risk information was not always easily accessible on the care records system. Following our inspection, the Trust took immediate action to address this. Staff followed good practice with respect to safeguarding and worked with other agencies to ensure vulnerable children and young people were safeguarded.

The service had enough staff to deliver care and keep people safe from avoidable harm. Staff received the training required to carry out their roles.

People were cared for in environments which were clean and fit for purpose. Staff followed Infection Prevention and Control procedures.

The service managed patient safety incidents well. There was a positive learning culture within teams and evidence that learning had been implemented.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The Trust and service had implemented the Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

Staff had access to an electronic incident reporting system. Staff knew what incidents to report and how to report them. Staff told us they reported all incidents and near misses in line with the Trust policy and were encouraged to do so by their managers. Staff reported serious incidents clearly and in line with Trust policy.

In the 12 months prior to our inspection (1 March 2024 until 28 February 2025) the service reported 511 adverse incidents. Incidents covered a range of incident categories including incidents related to data quality, infection control, medication and access, admission, transfer and discharge.

Adverse incidents were reviewed by senior managers and clinicians within each team. Staff received feedback where appropriate. There was a divisional governance team that supported processes to monitor incident reporting, identify trends and share learning. Senior managers and clinicians attended monthly meetings where incidents, trends and themes were reviewed and where learning was shared across the service. At team level managers shared learning from incidents in team meetings and supervision. Teams had display boards within staff spaces detailing incident reporting and lessons learnt.

Staff we spoke with were aware of incidents and associated learning from other teams within the service. We saw evidence that learning had led to changes including the updating of Standard Operating Procedures, the development of a monthly relationship meeting between the crisis team and the acute hospital Emergency Department service and changes to doors and magnetic locks in community team buildings following an incident of violence and aggression.

Managers and clinicians completed initial reviews, incident investigations and Situation, Background, Assessment, Recommendation and Decision (SBARD) reports where required. Relevant staff had received and completed training to enable them to complete these processes and were supported by the divisional governance team.

Managers ensured that staff received debriefs and support following any serious incident. Debriefs were facilitated by psychologists within each team. Staff told us they had felt supported following incidents and gave examples of individual, and group debriefs and reflective practice sessions that had taken place.

Staff understood the duty of candour. They were open and transparent and gave service users and families a full explanation if and when things went wrong. There was a duty of candour policy to guide staff. The incident reporting system included a flag to indicate where duty of candour was applicable.

The service worked well with other teams, services and organisations both within and external to the Trust in order to establish and maintain safe systems and care pathways and to support transition between services. There were effective pathways between teams and cross-team working within the service to support children and young people whilst they were receiving treatment. Services worked with external providers and voluntary sector organisations to support this.

The referral and triage processes for the service ensured that all essential information about the child or young person was received in order to determine if their needs could be safely met. Referral information was checked upon receipt of the referral and reviewed in triage. There were processes in place to ensure that staff could chase up and obtain the information they needed to effectively triage and assess referrals. ADHD and ASD services had implemented an electronic referral platform that allowed referrers to see an update on their referral and that ensured that only referrals that met the service’s criteria were submitted. Referral and triage teams meet daily to review this information, complete triage assessments and identify appropriate pathways.

CAMHS, ADHD and ASD services had good links with local GPs and schools to support referral and information gathering. Mental Health Support teams worked within schools and provided a referral pathway as well as a conduit to schools to support communication, liaison and service delivery.

There were pathways and referral processes to ensure that where children or young people did not meet the criteria for CAMHS services but still required support it was provided. For example, within CAMHS the Sefton team had worked with the Primary Care Network to develop a pathway for children and young people who needed more support than the Mental Health Support Team provided but who did not meet the criteria for formal CAMHS services. The Additional Roles Reimbursement Scheme (ARRS), which was also known as the Primary Care Pathway provided up to 8 sessions of low level structured psychosocial interventions with the opportunity to provide some time limited higher intensity sessions if required.

Within the Crisis Care service when a child or young person required admission to the 136 suite but were from out of area there was a framework and process in place with Local Authorities to contact the individuals home authority to support information gathering and the section 136 process. A 136 suite, also known as a Health Based Place of Safety (HBPoS), is a facility where individuals detained under Section 136 of the Mental Health Act can be taken for assessment.Section 136 allows police to take someone from a public place to a place of safety if they appear to have a mental disorder and action is required to protect their safety and wellbeing. 136 suites provide a safe environment for mental health practitioners to assess and support the individual.

Crisis Care services had a framework in place with local Police services to support the use of the 136 suite. Police contacted the crisis team when they were on their way to the 136 suite in order to discuss the child or young person and possible options other than admission to the 136 suite. Children or young people admitted to the 136 suite were RAG rated which determined the length of time Police stayed with the service user before responsibility was passed to either the crisis team or a third sector organisation who provided security and service user observation.

There were processes and procedures in place to support the transfer of care between teams and services, the transition into adult services and discharge from the service. Where a child or young person transferred between teams or services staff liaised with that team or service and completed a signposting letter.

When young people were transitioning into adult services there were pathways and processes to support this. CAMHS teams remained involved with service users for a limited period past the age of 18 to support this transition. The service was recruiting a psychological wellbeing practitioner who would sit in adult services and case manage individuals making the transition. There was a Transition Lead based within the local mental health trust that provided adult services. The Transition Lead was not routinely involved in every transition of care but was involved in more complex cases and was able to provide advice, guidance and a means to escalate concerns.

There were policies and procedures to support the discharge of children and young people. Services contacted relevant stakeholders as part of this. Liverpool and Sefton CAMHS were piloting different approaches to offer support to children and young people who had been discharged. In Liverpool CAMHS this came in the form of the Next Steps pathway which offered monthly peer support sessions for the child or young person for up to 3 months along with parallel support for parents and carers. Within the Sefton CAMHS a Patient Initiated Follow-Up system had been developed which provided a 3-month period for children, young people, family members or carers to contact the service if they needed support without being re-referred. Any calls received under the system were put on the multidisciplinary team lists for discussion and a follow up could either occur via a phone call or a one-off face to face session.

Within Sefton the ADHD and ASD service operated a post-diagnosis support service. Children or young people who had received a diagnosis could be referred into the service. Initial appointments were either by telephone or face to face and aimed to support the child or young person, and their parents and family to understand the diagnosis and the needs of the child or young person. If the requirement for further support was identified the team supported the child or young person and their families to develop personalised strategies including around areas such as behaviour management. A similar service was not commissioned within Liverpool but if there was a need for a follow up appointment related to an associated difficulty such as children and young people with learning disabilities, they were offered appointments with developmental paediatricians.

Staff completed safeguarding training as part of the mandatory training programme. Across the service compliance with safeguarding children level one training was 93%, compliance with safeguarding children level two training was 87% and compliance with safeguarding children level three training was 80%. Staff also completed safeguarding adults training. Compliance with both safeguarding adults level one and level two training was 96%. The Trust’s minimum target for training compliance was 75%

Staff we spoke with knew how to recognise adults and children at risk of suffering harm and worked with other agencies to protect them. They knew how to make a safeguarding referral and who to inform if they had concerns. Staff could access support from identified safeguarding leads within the service and the Trust-wide safeguarding team. There were safeguarding adult and safeguarding children policies in place and a Standard Operating Procedure for safeguarding to support staff. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff completed Preventing Radicalisation – Basic Prevent Awareness training as part of the mandatory training programme. Compliance with the training was 95%. Staff had access to specialist advice and a Trust policy around the government’s PREVENT strategy. The policy covered potential risk factors and detailed the required actions and processes for staff to follow if they identified any concerns about the potential risk of service users, carers, family members or staff being drawn into extremist activities.

Managers and senior leaders we spoke with described positive relationships with local authorities and safeguarding boards. The service was an active member of local Multi-Agency Safeguarding Hubs (MASH).

The service undertook regular audits against safeguarding standards and the Trust had commissioned an external agency to review systems and processes in relation to safeguarding and compliance with national policy and guidance. The review gave an overall assurance of ‘substantial’ indicating there was a good system of internal control designed to meet safeguarding objectives and controls were being applied consistently.

We found that staff we spoke with were highly knowledgeable around safeguarding and safeguarding risks for individual service users. Team meetings and care reviews we observed reenforced this. However, we identified that the electronic patient records system did not easily allow staff to put safeguarding ‘flags’ on the system. The flag appeared on the front page of a child or young person’s electronic record to alert staff that the individual had a safeguarding alert or concerns. At the time of our inspection staff had to contact the Trust’s central safeguarding team and request that they put the alert on. However, following our inspection the Trust took immediate steps to change this. Staff were now able to place a temporary safeguarding alert on the system. A daily report was sent to the Trust safeguarding team who could then validate the alert or, it was deemed appropriate remove it.

Staff managed risk well and staff that we spoke with had a good understanding of the risks and risk management plans for the children and young people on their caseload. There were effective processes in place to ensure that risks were captured and regularly discussed and reviewed. However, we found that the care records system did not always support this, and that risk information was not always easy to find.

We reviewed 28 care and treatment records during our inspection. We found that each record had a risk assessment in place and that risks had been regularly reviewed. However, we found that risk information was often presented in narrative form in a summarised letter. The risk information was not clearly RAG rated to enable an easier understanding of the level of each risk.

Full completed risk assessment documentation was saved to the system but was not always easy to find. In addition, the system did not effectively utilise risk flags that quickly identified to a practitioner if particular risks had been identified, for example risk flags to indicate that a child or young person had a safeguarding in place or had been referred to PREVENT.

Following our inspection the Trust made immediate changes to the care records system. They gave us a demonstration of the new system which showed the improvements they had made to ensure that risk information was now much more visible and easily accessible. A Risk and Care plan function had been developed which gave staff easy access to key risk documents and a chronology of risk activity. A Systematic Risk Management Document Tool had been developed for documents received from other organisations and providers which meant that staff had easy access to that information and could add key details directly into the risk assessment. The use of risk flags had been emphasised through the Special Indicators function which meant that staff could now more easily put flags on the system and that flags were more prominently displayed to better highlight key risks. Managers and staff could access service user risk information through a Power BI dashboard that gave an overview of caseloads and risk levels.

Service user risks were initially recorded and considered at the referral and triage stages of the care pathway. Following our inspection the service made changes to the triage form, including the introduction of mandatory text fields for each key risk domain and a requirement to score risks as high, medium, low or not known. The triage form was also updated to incorporate a formulation section that utilised the 5 P’s framework (presenting issues, precipitating factors, perpetuating factors, predisposing factors and protective factors). This supported staff to better gather information about the needs of the child or young person, the level of concern, the impact of the problem and contextual factors informing each risk.

Within CAMHS services a full risk assessment was completed at the first Choice meeting and then reviewed at each Partnership meeting. Risks were reviewed a minimum of every 3 months or in response to a specific incident or change in circumstance. Within the ADHD and ASD services a risk assessment was completed as part of the full assessment of the child or young person and was reviewed at each subsequent appointment. Within the Crisis Care service the process depended on the child or young person’s pathway into the service. Where a child or young person presented at an Emergency Department (ED) there was a Standard Operating Procedure and assessment tool to support ED staff to identify potential mental health concerns and contact the crisis team. Crisis staff then attended the ED and completed a full risk assessment including agreeing a management plan and any required resources to support it with ED staff. Where a child or young person were referred to or contacted the crisis team directly a full risk assessment was completed at the first appointment and then updated regularly in line with need.

Service user risk and risk management was also considered within multidisciplinary team meetings (MDTs). We observed 4 MDTs during our inspection and found that in each one service user risk was reviewed and risk management strategies considered. There was effective multi-professional input into these discussions to help ensure comprehensive review and robust management.

Services had processes in place to monitor the risk of children and young people who were on waiting lists. Referrals were triaged as urgent or routine based on the level of risk. Urgent referrals were seen within 2 weeks. There were patient tracker lists for those waiting an appointment and a weekly division-wide meeting that reviewed waiting lists and the level of risk for children and young people who were on them. Managers and staff could access a Power BI dashboard that provided an overview of children and young people on the waiting lists and the risk information, scoring and 5 P formulation gathered through the triage process. These were RAG rated for easier visualisation. Children or young people could be prioritised depending on their risk level and related factors. There was a ‘harm review process’ for any child or young person who had been waiting for 18 weeks when a practitioner contacted them and their families and completed a risk and treatment review.

All premises where clients received care were safe, clean, well equipped, well furnished, well maintained and fit for purpose. We saw examples where children and young people had been involved in the design of reception areas and had helped to choose furniture and décor. This included producing artwork that was displayed on walls. Reception areas included information on the Trust, the service and partner agencies as well as information on relevant mental and physical health conditions and guidance on how to provide feedback or complain.

Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. Staff completed appropriate daily, weekly and monthly environmental checks. All premises had completed annual health and safety, and fire safety risk assessments. Community locations had identified fire wardens.

Staff made sure equipment was well maintained, clean and in working order. There were records of regular checks, maintenance and cleaning of equipment. Relevant equipment had been PAT tested and was labelled with date stickers to confirm when they had been tested and when they were due for retesting.

Staff had access to interview rooms, including rooms designed for family use. Staff had access to alarms when using interview rooms and there were established protocols for staff to respond if required.

Within the Crisis Care service staff had access to a 136 suite for children or young people brought in by the Police under s136 of the Mental Health Act. The facility was purpose built and had separate access routes to ensure that the child or young person did not have to come through the main Emergency Department to access it. The physical environment of the room met the requirements of the Mental Health Act Code of Practice. Staff were able to observe a child or young person who was in the room and there was an intercom, air conditioning and appropriate furniture.

The service had enough staff, they knew the patients and received basic training to keep them safe from avoidable harm. Services had seen investment in staffing and staffing structures. The community CAMHS services within Liverpool and Sefton were split into multi-disciplinary teams each with a clinical lead. There were four MDTs within the Liverpool service and three within the Sefton service. Teams consisted of a range of staff including clinical and assistant psychologists, nurses, children’s well-being practitioners and youth workers. In addition, there were roles that worked across the MDTs including peer support workers and art therapists. Consultant psychiatrists were embedded within each service. Each service was supported by an administrative and clerical support team. Vacancies were low and reducing. Across all staff groups the Liverpool CAMHS service was carrying 8.36 wholetime equivalent vacancies against a planned establishment of 86.73 wholetime equivalent posts (a vacancy rate of 7%). The Sefton CAMHS service was not carrying vacancies and had 63.45 wholetime equivalent staff in post against a planned establishment of 55.71 wholetime equivalent posts.

ADHD and ASD teams included a range of disciplines including nurses, health visitors, learning disability nurses, occupational therapists, speech and language therapists, psychologists and ASD specialist teachers. The Alder Hey ASD service also included peer support workers. The Alder Hey ADHD service had no vacancies. There were 27 wholetime equivalent staff against a planned establishment of 25.40 whole time equivalent staff. The Alder Hey ASD service had 49.27 wholetime equivalent staff in post against a planned establishment of 56.10 (a vacancy rate of 12%). Within the combined Sefton ADHD and ASD post diagnostic service there were 5.13 wholetime equivalent staff against a planned establishment of 3.55 wholetime equivalent staff.

The Crisis Care Service was a multidisciplinary team which included psychiatry, psychology, nursing, social workers and mental health engagement practitioners. The Crisis Care Service had a 13% vacancy rate. There were 32.89 wholetime equivalent staff against a planned establishment of 40.18 wholetime equivalent staff. The service was recruiting to vacancies.

Staff shortages were covered by existing staff and where required some overtime. The service had previously used agency but had stopped this as staff numbers improved. Some of the vacancies had been caused by staff being promoted within the service and they continued to support their old roles if required. None of the staff we spoke with in any of the services raised staffing levels as a concern and several commented how much it had improved.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the people using the service. The mandatory training programme included courses covering basic life support, medication safety, positive behavioural support and health and safety. Staff also completed the Oliver McGowan Mandatory Training on Learning Disability and Autism. All the teams we visited had a compliance rate above 80%. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Training needs were identified through supervision, from learning following an incident or audit or in line with service development programmes. Staff were positive about the training opportunities available to them. Staff we spoke with had completed a range of additional training including psychosocial interventions, eye movement desensitisation and reprocessing, non-violent resistance, ticks and turrets and learning disabilities.

Managers provided new staff with a comprehensive induction and ensured all staff had access to supervision, appraisal and regular team meetings. New staff completed a two week induction programme if they were moving within the Trust or a four week induction if they were joining from an external provider or organisation. Staff were given an induction pack as part of the programme. The induction pack had been reviewed and revamped using an improvement huddle and based on feedback from staff who had completed the process.

Staff received regular supervision. All staff we spoke with told us they felt supported and were able to access advice whenever they needed to. Staff received supervision in formal one to one sessions. Staff involved in the delivery of psychological therapies received clinical supervision from the relevant clinical lead for the discipline. Staff also received general clinical supervision within their MDT and there were supervision trees in place to support this with staff receiving supervision from colleagues the band above them. In addition, staff received managerial supervision from the appropriate individual. Staff also received supervision in group settings, daily huddles, reflective practice sessions and team meetings. Staff we spoke with told us that managers and colleagues were always available during the day, and they were able to access support, advice and informal supervision as required.

Managers ensured staff received an annual appraisal in line with the Trust’s personal development review policy. However, two teams had an appraisal rate below 75%. They were Sefton CAMHS where 34 out of 47 staff had an appraisal in place (72%) and the Alder Hey ADHD team where 17 out of 24 staff had an appraisal in place (68%).

The service managed infection prevention and control well. All services we visited were clean and well maintained. Cleaning records were up to date and demonstrated that all areas were cleaned regularly. Staff adhered to infection control principles, including handwashing. They made sure equipment was well maintained, clean and in working order. There were records of regular checks, maintenance and cleaning of equipment.

Staff completed infection control training as part of the mandatory training programme. Across the service compliance with both level one and level two infection prevention and control training was 98%.

Staff were able to access support and further guidance around infection prevention and control. Each team had an infection prevention and control champion in place. Staff had access to a Trust Infection Control and Prevention policy and the Community and Mental Health Division had developed a Standard Operating Procedure for Infection Prevention and Control Responsibilities. There was a Trust-wide Infection Prevention and Control team that could provide further support if required.

The service had a programme of infection control audits to provide assurance. These included mon thly infection prevention and control and personal protective equipment audits completed by a matron. The results of audits were discussed in team meetings and displayed in staff areas.

Staff followed systems and processes to safely prescribe and monitor the use of medicines. Medicines were not dispensed or administered from the service and there was no medication on-site in the locations we visited. Medication was prescribed by doctors and in line with national guidance. Within the ADHD service staff ensured an electrocardiogram had been conducted where relevant before commencing the prescribing of medication. We observed a Medication Initiation meeting within the ADHD service. The meeting gave a space for children, young people, parents and carers to discuss medications and ask questions. The staff member involved provided information, advice and guidance and worked to assuage any concerns. For example, they spent time explaining to a young person how the blood pressure machine and cuff worked so they were comfortable having their blood pressure taken.

Staff reviewed the effects of medication on children and young people in line with national guidance. The ADHD service was working with schools to introduce physical health clinics to support the required physical health monitoring and to develop better processes for obtaining feedback from teachers and staff. These were already in place at specialist schools and were being rolled out into mainstream schools. There was a Standard Operating Procedure in place to manage and report parents, carers or young people who misused medications.

During a period of national shortage in ADHD medication the service had sent communications and had discussions with service users, parents and carers around the use of alternative brands and medications and provided advice on how to use these and what to do in the event of side effects.

Medication management within the service was overseen by the divisional Medication Sub-group which fed into Trust medication management forums and processes. The divisional sub-group met monthly and considered new guidance, developed and reviewed policies, procedures and standard operating procedures for the service and reviewed any medication related incidents. Staff had access to a suite of policies and procedures to support them including Trust level policies such as the Trust Medicines Management policies and local guidance such as ADHD medication Standard Operating Procedure.