Alder Hey Children's 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

At our last inspection we rated this key question as good. At this inspection the rating has improved to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved high-quality, person-centred care.

There was strong and effective leadership at all levels. The service had a shared vision and strategy that was communicated well to staff. Staff were very positive about the service, managers and culture. Managers created a positive culture that encouraged staff feedback and innovation. There were examples of staff being empowered to make change and drive improvements. They fostered a culture where staff felt they could speak up without fear or reprisal. There was evidence of staff feeling safe to raise concerns and of the service responding to them. Managers had an excellent understanding of the service and a clear overview of service performance. They were able to describe risks and challenges the service faced as well as actions to address them. The service focussed on continuous learning, innovation and improvement across the organisation and the local system. Children and young people were active participants in service development projects.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

CAMHS services were linked into the wider vision and values of the Trust. There was a Vision 2030 document and programme in place that was Trust-wide and identified four main goals based on what children and young people had identified. These were ‘get me well’, ‘improve my life chances’, ‘personalise my care’ and ‘bring me the future’. There were 5 identified cross-cutting goals to help achieve this which were ‘push ourselves to always provide the best experience’, ‘use our combined knowledge and resources’, ‘harness the latest technology’, ‘understand our people better’ and ‘break through barriers to breach new ground in care.’

Senior managers and leaders we spoke with were able to describe Vision 2030 and discuss how the Community and Mental Health division and the CAMHS service were working to deliver them. Divisional and service level pilots and projects were aligned with the identified objectives. Staff we spoke with knew and understood the provider’s vision and values and how they were applied in the work of the team. Senior management and leaders had successfully communicated the provider’s vision and values to frontline staff.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff were able to contribute through staff surveys, away days and ad-hoc consultation events. Staff we spoke with told us that managers were approachable and open to new ideas and initiatives. Service users and their families were also able to feed into discussions around visions, values and service development through feedback and consultation events. There were also well-established participation and support groups for children and young people (Camhelions) and parents and carers (FRESH PLUS parent/carer support group). These groups were regularly consulted on any changes and encouraged to develop their own ideas.

Leaders had the skills, knowledge and experience to perform their roles. They had an excellent understanding of the services they managed and were able to describe how teams worked together and collaborated with other services both within and external to the Trust to deliver high quality, joined up and holistic care. They understood the challenges the service faced and were able to outline short, medium and long-term plans to address these concerns. Team managers were visible and active presences within services.

Staff told us that they felt very supported and that team managers were approachable for both service users and staff. They told us managers were receptive to feedback and supported them to help identify solutions and facilitate service improvements. For example, within the CAMHS services a peer support worker had been encouraged and supported to work with service users in the development of a support group.

There was a range of leadership development opportunities available, including opportunities for staff. The Trust had development pathways and manager apprenticeship schemes for staff who wanted to progress into leadership roles. These included an internal development programme called Strong Foundations – Compassionate Leadership Programme which featured modules on leading me, leading others and developing others. This was supported by a suite of ‘management Essentials’ workshops that managers could access as required including workshops on stepping into management, quality improvement, crucial conversations and PDR / appraisal training. At the time of our inspection the Trust was developing leadership programmes specifically for staff from black and minority ethnic communities and specific development courses for both clinical and operational leads. In addition to internal courses staff had also accessed external training such as the Mary Seacole programme.

Staff knew how to raise concerns and told us that they felt confident to do so. Staff were aware of whistleblowing and Freedom to Speak Up policies and processes. There were Freedom to Speak Up Guardians and Champions in place within the service and the wider Trust. Staff we spoke with knew who these individuals were and how to contact them. Freedom to speak up processes were embedded within the service and the Trust. The Freedom To Speak Up Guardian provided regular updates and reports to the Trust board. They attended staff network meetings. Freedom to speak up data was incorporated into revies of the Patient Safety Incident Reporting Framework and also in the Trust’s Thriving Teams Index. The Thriving Teams Index was an initiative to provide a real time measure of team functioning and reduce inequalities in team experience and performance. The Trust had also introduced a Freedom To Speak Up app to streamline the process. The app made it quicker and easier for staff to raise concerns and helped the Freedom To Speak Up Guardian to manage and track cases and report to the Trust board and national bodies.

Information on Freedom to Speak Up processes was available to staff in both leaflet and poster form within services and was covered on staff induction programmes. Staff we spoke with described an open and honest culture and told us they would raise a concern without fear of reprisal and were confident it would be managed appropriately and professionally.

In the 12 months prior to our inspection (1 March 2024 until 28 February 2025) there were 2 reports from the CAMHS service to the Freedom to Speak Up Guardian. In the 12 months prior to our inspection (1 March 2024 until 28 February 2025) there were 2 reports from the CAMHS service to the Freedom to Speak Up Guardian. In addition, there were 2 reports to the Freedom To Speak Up Guardian from staff in the Mental Health Support Teams. One concern remained open at the time of our inspection. The remaining 3 concerns had been properly reviewed and responded to. There was evidence of changes being made as a result of the Freedom To Speak Up processes. For example, changes that created improved guidance for managers and a process that led to better communication between staff.

Children, young people and family members and carers had opportunities to give feedback on the service in a manner that reflected their individual needs and were involved in decision making about the service. Children, young people and family members and carers had access to feedback surveys including the family and friends survey. The service and divisional governance team collated feedback from these surveys and other assurance processes such as complaints, compliments, audit and incident reporting and analysed it for themes and tends. There was a participation and service user representation forum for children and young people called the Camhelions and one for parents and carers called FRESH PLUS. Staff consulted these groups on any changes to service or if analysis of feedback had identified particular concerns, themes or trends.

The service was committed to supporting workforce equality, diversity and inclusion. There were equality, diversity and inclusion champions within the service who fed into Trust-wide networks and forums. The Trust had completed and published their annual Workforce Disability Equality Standards (WDES) and Workforce Race Equality Standards (WRES) assessments and reports. Action plans had been developed as a result of these assessments and were monitored through the Trust Equality, Diversity and Inclusion steering group which included representatives from the Community and mental health division and CAMHS services. Results of the WDES and WRES assessments are based at Trust level and aren’t broken down to individual services. However, the Trust results for both the WDES and WRES were positive and compared well with those from similar services and against national results. For example, the Trust performed better than the national average against questions around staff from non-white ethnic groups or staff with long-term physical health conditions experiencing bullying, harassment or aggression from either patients, colleagues or managers. The Trust also performed better that the national average for staff from ethnic minority groups or with long-term physical health conditions who felt they were provided with equal opportunities for development and carer progression.

The Trust had also completed and published Equality Delivery System (EDS) and gender pay gap reports, and developed action plans which were monitored through the same governance processes. In addition, the Trust had published an anti-racism statement and commitment on its website. The Trust regularly circulated information on religious and cultural events to staff and the service sought to support staff where applicable, for example by providing prayer mats or supporting staff members who were fasting.

Staff had access to a range of support forums at Trust level each of which had a chair, deputy chair and executive sponsor. These included the Race Ethnicity and Cultural Heritage network (REACH), the Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex, Asexual, Agender plus network (LGBTQIA+), the Ability Celebrate Educate network (ACE) which supported staff with disabilities and long-term conditions and an Armed Forces Community network. Networks aimed to understand the needs of the different staff groups they represented, provide education and support around issues, promote inclusion and provide guidance to the Trust, services and staff where required. Networks had representatives within the CAMHS service.

Managers and staff had access to a range of policies to support flexible working and staff support. These included a Flexible Working Policy and toolkit, a Reasonable Adjustment policy, a Menopause policy and a Supporting Sickness and Attendance policy. There were processes and systems in place to monitor staff data and compliance with these policies which was managed through divisional and Trust level governance groups.

Staff were able to apply to work flexibly and to request reasonable adjustments. We spoke with staff who had flexible working arrangements such as condensed hours and 9 day fortnights as well as staff who had reasonable adjustments in place, including the provision of specialist equipment.

Our findings from the other key questions demonstrated that governance processes operated effectively.

The service had an established governance structure, forums and processes that ensured service managers and leaders had effective oversight of performance and quality. There were systems and processes to identify, understand, monitor and address current and future risks. Governance within teams fed into the divisional governance structure which in turn fed into the Trust governance structure. There were clear pathways to escalate concerns and issues within that framework. Policies and procedures were subject to quality impact assessments as part of their development and implementation.

There was a clear framework of what must be discussed in meetings and governance forums at team and divisional levels to ensure that essential information was shared and discussed. Staff regularly discussed incidents, performance, risk and quality improvement. There was a structure to ensure that learning from incidents, complaints and feedback processes was identified and shared.

Staff undertook or participated in local clinical audits. Audits were sufficient to provide assurance. The implementation of actions plans developed through audit, reviews and investigations was monitored within the governance structure. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts.

There were systems and processes to ensure effective oversight of performance. Managers had access to information to support them in their management role. This included information on the performance of the service, staffing and patient care. The service held monthly business meetings which reviewed performance and produced monthly reports for commissioners detailing performance against quality metrics and key performance indicators. The service used systems to collect data from teams that were not over-burdensome for frontline staff.

The governance framework provided for the effective management of risk. There was a risk register held at divisional level which was reviewed and updated regularly. Staff within teams could escalate concerns when required. Staff concerns matched those on the risk register. The service had business continuity plans in place in the event of emergencies such as adverse weather, loss of information technology systems or closure of premises. These were underpinned by the Trust’s Emergency preparedness resilience and response policy.

Staff had access to the equipment and information technology needed to do their work. Information governance systems included confidentiality of patient records. The information technology infrastructure, including the telephone and text systems, worked well. However, we identified some concerns regarding the patient records system.

Risk information was presented in narrative form in a summary letter. However, full risk assessments were not always easy to find and access and risk concerns were not clearly RAG rated to enable an easier understanding of risk levels. Practitioners were not able to easily add risk ‘flags’ to highlight specific concerns to staff viewing the record. In addition, risk assessments relating to waiting lists needed to be better documented and supported within the system.

The Trust had identified these IT issues through their own governance processes and had added them to their risk register. They had begun a number of projects to begin to address these concerns. Following our inspection the Trust expediated this work. Shortly after our inspection they provided a demonstration of the changes that had been made.

A Risk and Care plan function had been developed which gave staff easy access to key risk documents and which provided a clearer overview of service user risk. A Systematic Risk Management Tool had been introduced to provide easier access to documents provided by other organisations and providers. The Special Indicators function had been altered to enable staff to add risk flags directly to the system and they were now more prominently displayed on screen.

Changes had been made to triage risk assessment forms which supported staff to gather and formulate risk information about the child or young person. This information was now easily accessible to staff to enable the better management of risk on waiting lists. Managers could access risk information through Power BI dashboards which were used in divisional waiting list meetings.

In addition to introducing the changes to the IT system the Trust had delivered training to staff on the improvements and the new functionalities. At the time of the presentation, training compliance was 94%. The service had gathered staff feedback on the changes which had been positive. A programme of audit and assurance had been introduced to ensure that staff were using the system properly.

Directorate and service managers and leaders regularly engaged with external stakeholders including multi-agency bodies.

The ADHD and ASD services worked in partnership with local schools to help deliver better joined up and coordinated care, including delivering clinics within school settings. The Alder Hey ADHD Team team were awarded a National Special Education Needs and Disabilities (SEND) award for their partnership with a local school and the positive impact that this had on outcomes for students. The service and Trust were also contributors to, and part of, the Liverpool Neurodiverse All Age Strategy which sought to make the city a neuroinclusive and welcoming environment to neurodiverse individuals.

The Crisis Care service had developed a new s136 framework in partnership with local Police forces. This helped to prevent unnecessary admissions to the s136 suite at Alder Hey and promoted better outcomes for children and young people in mental health crisis. The service was also part of a multi-agency gateway meeting chaired by the Integrated Care Board to help coordinate and manage the care provided to children and young people in crisis including those from out of area.

The CAMHS services worked with a range of voluntary and third sector organisations to help offer children and young people a holistic range of treatment and post discharge options to support their care and wellbeing. In addition, the service worked with these organisations and the local primary care network to help deliver specific care pathways such as the Additional Roles Reimbursement Scheme (ARRS) in Sefton which provided a pathway for children or young people whose needs were too complex for Mental Health Support Teams but not complex enough for CAMHS services.

Teams were part of wider multi-agency initiatives and collaborative approaches. Enhanced Support Teams within CAMHS services were part of local Vanguards which were a multi-agency approach to offer joined up care to vulnerable children and young people who required assertive outreach and enhanced support.

The service was part of the Cheshire and Merseyside Young People and Families Provider Collaborative. The collaborative undertook a range of work to support the care and treatment given to children and young people with mental health concerns. This included the development of the Children and Young People’s Mental Health Escalation and Support Framework. The framework aimed to improve outcomes for children and young people by reducing avoidable admissions to Tier 4 inpatient units, enabling shorter lengths of stay and ending out of area placements. This included the development of multiagency Gateway meetings for children and young people at risk of admission and the creation of a risk stratification tool to provide an evidence-based way of identifying young people at risk of admission. The framework sought to utilise community and crisis provision where possible to remove the need for admission.

Services engaged with a range of agencies within Multi Agency Safeguarding Hubs (MASH). MASHs bring together professionals from agencies such as social services, Police and healthcare to share information and ensure a joined up approach to safeguarding concerns.

The service had an embedded and systematic approach to improvement and was committed to learning, continuous improvement and innovation. There was evidence of learning from when things had gone wrong. The service identified learning and improvement opportunities through adverse incident and complaint investigations, audits and staff and client feedback. Managers developed action plans which were monitored through the governance framework. There was evidence of improvements being embedded following these processes. Shared learning was disseminated through the governance structure.

The service encouraged staff and service users to consider opportunities for improvements and innovation. There was a Quality Improvement team at Trust level that provided support. Staff could access quality improvement training including sessions on the LEAN quality improvement methodology which aims to improve quality and safety by identifying and removing waste, as well as A3 thinking which is a structured problem-solving and communication tool. In addition, Liverpool and Sefton CAMHS as part of the wider CAMHS partnership across Liverpool and Sefton had worked with a quality improvement organisation. The Trust also had a quality improvement programme called Brilliant Basics. Brilliant Basics was a programme designed to empower staff to make improvements to everyday processes without having to go through a long process. The administrative staff in the ADHD and ASD service had used this approach to address concerns around the number of calls they received that weren’t relevant to the service and improve their response to parents and carers seeking information.

Staff and managers we spoke with detailed several quality improvement initiatives that they had been or were part of. For example, within the ADHD service staff had developed an ADHD workshop video covering ADHD medication to help parents decide on commencing medication for their child. Staff had also piloted height, weight and blood pressure clinics in schools to prevent children and young people from having to attend Alder Hey for a 10 minute appointment.

The ASD and ADHD services had also been involved in the implementation of an electronic referral platform that allowed referrers to see updates on their referral and that also ensured that only referrals that met the criteria and commissioning specification for each service were submitted.

CAMHS services in both Liverpool and Sefton had introduced pilots to improve the support offered to children and young people following the completion of treatment. In Liverpool CAMHS the service had developed a time limited offer called the Next Steps pathway. This provided monthly peer support sessions for the child or young person for up to 3 months, parallel to parent and carer support and a non-clinical space focused on reflection, identity and transition. Within 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.

The CAMHS service in Liverpool had completed work to reduce the barriers to access for Unaccompanied Asylum Seeking Children (UASC)

The service sought to encourage the participation of children, young people, family members and carers in innovation and service development, primarily through the Alder Hey Youth Forum and the Chamelions service user group and the FRESH PLUS parent and carer support group. For example, members of the Camhelions had been involved in helping to decorate and design waiting and reception areas as well as work to improve communication and key worker letters.

The service encouraged research and supported staff, service users and family members and carers to participate in them. The service was involved in a range of research projects. These included research projects looking at issues such as the psychological impact of the criminal justice system on child victims of sexual abuse, experiences of waiting for mental health services, the use of Antecedent, Behaviour and Consequence tools (ABC-I) and exploring young persons’ conceptualisation of emotional distress. In addition, the ADHD and ASD services were involved in a national research project called SupporTing pARents and their autistic Children through Anxiety Treatment (STAR-CAT) which looked at the use of the Online Support and Intervention for Child Anxiety tool (OSI-A) to make treatment for anxiety more accessible to autistic children aged 5-12 years old.