Greater Manchester Mental Health 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 Requires Improvement. At this assessment the rating has changed to Good.

Good: This meant people were safe and protected from avoidable harm.

This service scored 63 (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 were no serious incidents in the last 12 months.

CAMHS Patient Safety Group meetings took place weekly. There were representatives from inpatient CAMHS and the community CAMHS teams. Any incident meeting the threshold for a Rapid Review of Care was discussed as well as learning responses. Themes and trends of incidents were discussed in the meetings.

Learning was shared in team meetings, with minutes showing learning shared with teams, including the story board which included lessons learnt.

All staff knew what incidents to report and how to report them. They used the electronic incident reporting system.

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

Positive learning events took place where 7-minute briefings (a succinct summary of the incident, learning and actions required) were presented with timely targeted summaries of incidents and learning. Minutes showed a 7-minute briefing in relation to professional curiosity which was shared.

There was evidence that changes had been made as a result of feedback. This included training with the acute care providers and activities offered at the day service. Additional training arranged to meet the gap in knowledge identified for some colleagues regarding incident reporting and safeguarding actions.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They did not always make 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 person was received to determine if the young person’s needs could safely be met. Staff on duty managed the referrals and contacted the family of the young person for additional information and to triage the referral. Outcomes from triage were that the young person was accepted for assessment or they were signposted to another service. However, within Bolton and Wigan CAMHS, a few young people were waiting to access the service for more than the recommended time of 18 weeks.

Staff did not always involve all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge. Stakeholders told us there could be delays or a lack of response to consultation requests and some children were discharged from the service quickly without clear communication. Also, stakeholders told us that the CAMHS teams were not always clear on what they could offer and how long the waiting times were for the services. However, the Children and Young People’s Eating Disorder Service had close working relationships with the local paediatric wards and had staff based in them to offer support to young people with eating disorders and support, training and guidance to staff working in the service.

In Wigan CAMHS, staff worked on rotation in the partnership hub, with colleagues from other providers to offer advice on cases that were being referred to the hub and if appropriate to offer a mental health assessment for possible CAMHS involvement. This venture provided a timely response to young people and their families and shared knowledge and expertise from colleagues from different organisations with the aim of supporting the young people, input from the Wigan’s CAMHS practitioner included formulation of mental health and guidance regarding mental health risk management.

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. They did not always 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 did not always share concerns quickly and appropriately.

Staff were not always trained in safeguarding. At the last inspection, there was a breach in relation to staff training, staff were not receiving safeguarding adults and children level 3 training. However, this had improved at this assessment. Out of the 10 teams, 8 teams had over 80% training compliance with safeguarding adults level 3. Bolton CAMHS had 65% compliance and Wigan parent infant mental health team had 60% compliance. For safeguarding children level 3, there were 9 teams with over 80% compliance. Bolton CAMHS had 68% compliance.

Staff knew how to make a safeguarding alert and did that when appropriate.

Staff could give examples of how to protect young people from harassment and discrimination, including those with protected characteristics under the Equality Act. Examples included joint work with other services due to a young person’s parents’ mental health needs. Records showed staff attended child in need meetings with a variety of professionals from other organisations.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. In Wigan, staff worked in the social care hub, offering guidance to social workers and providing mental health assessments to young people.

Mental Capacity Act

All teams had over 75% compliance for training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it.

At the Junction 17 day service, there was a tick box within the care record to say if the young person had capacity, however there was no assessment to support this. Within the other teams, the care records we reviewed did not include assessment of capacity in 11 out of 12 records reviewed. However, staff gave examples where capacity assessments had been completed on the electronic care record.

Staff took all practical steps to enable young people to make their own decisions

For young people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw in the Children and Young People’s Eating Disorder Service, capacity assessments completed regarding physical health needs.

The service did not have arrangements to monitor adherence to the Mental Capacity Act. Staff did not audit the application of the Mental Capacity Act or took action on any learning that resulted from it.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 17 risk assessments during the assessment.

Staff did not always involve young people in care planning and risk assessment. At Bolton CAMHS, in the care records we reviewed, risk assessments had not been recently reviewed, 1 was last reviewed in 2022, 1 in 2023 and another in 2025. At the Children and Young People’s Eating Disorder Service, 1 of the risk assessments we reviewed was last reviewed in 2024. At Wigan CAMHS, of 5 care records reviewed, 2 did not have a risk assessment completed, another 2 risk assessments were not competed in full and there was no evidence of the risk assessments being reviewed. At the Junction 17 Day service, in the 4 records reviewed, the clinical Risk Assessments and safety plans were not clear what staff needed to do to manage the risk. This meant young people were not regularly involved in the review of their risk assessments.

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 visual resources used at the Children and Young People’s Eating Disorder Service and examples of joint working with the schools-based teams to share resources.

Staff enabled young people to give feedback on the service they received via experience questionnaires.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We toured the facilities of the teams we visited. At the last inspection, there was a breach in relation to the maintenance of emergency equipment. This has improved since the last inspection, and all emergency equipment was in date and equipment was serviced and was regularly maintained.

Emergency bags were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Staff did regular risk assessments of the care environment called Health, Safety and Security Site inspection. These included action plans for specific health and safety risks identified in the premises with a date for completion.

There were completed ligature assessments, and we saw a heat map in place at Wigan CAMHS. There were ligature cutters at each base too.

The day service at Junction 17 was small, with a lounge area, relaxation/sensory area and dining room. If the service was full, there would not be enough space and seating for all young people to be in the same room, for example the lounge or dining room.

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 were vacancies in the intensive support team for an assistant psychologist and occupational therapist. In the Children and Young People’s Eating Disorder Service there were vacancies for a nurse associate, healthcare assistant and Cognitive Behavioural Therapist. In Wigan CAMHS there were vacancies for a psychotherapy lead and 3 CAMHS practitioners. At Bolton CAMHS there were vacancies for 3 CAMHS practitioners.

Sickness levels were highest for Junction 17 day service with 28% over the last 12 months. Then Bolton CAMHS with 10% sickness over the last 12 months. The crisis team and Wigan CAMHS had 7% sickness over the last 12 months. Bolton intensive support team and the Children and Young People’s Eating Disorder Service had an average of 5% sickness over the last 12 months. Bolton MHST had 4% sickness, and Wigan MHST had 3% average sickness over the last 12 months. Wigan BABS and the school link service had 1% average sickness over the last 12 months.

Turnover within the service was highest for the number of staff leaving at Bolton CAMHS, with 16 (28%) staff leaving over the last 12 months. At Wigan CAMHS, 4 (10%) staff left in the last 12 months. Wigan BABS service had 3 (44%) staff leave over the last 12 months. The Crisis team, Wigan and Bolton MHST teams each had 2 staff leave over the last 12 months. The Children and Young People’s Eating Disorder Service had 1 staff member leave over the last 12 months. This meant there were waiting lists to access some of the services and young people had to meet new workers or have sessions cancelled due to staff unavailability.

There had been a bank worker at Bolton CAMHS to assist with reviewing young people on the waiting list which the service had found helpful. However, this role had ended.

When agency and bank nursing staff were used, these staff received an induction and were familiar with the service. Records showed that staff received a fire induction and a service induction.

Staff had received and were up-to-date with most of the mandatory training. Courses with less than 75% compliance were:

• Basic life support eLearning, 72% compliance for Bolton CAMHS.
• Fire safety, 74% compliance for Bolton CAMHS.
• Managing an incident in In Phase with 50% compliance for Junction 17 day service and 67% for the Children and Young People’s Eating Disorder Service.
• Mental Health Act code of practice with 67% compliance for Wigan BABS, 71% compliance for Children and Young People’s Eating Disorder Service and 73% compliance for Bolton CAMHS.
• Safeguarding adults level 3, 60% compliance for Wigan BABS and 65% compliance for Bolton CAMHS.
• Safeguarding children level 3 with 68%
• Smoke free awareness with 0% compliance for Bolton MHST, 33% compliance for Bolton intensive support team, 71% compliance for Children and Young People’s Eating Disorder Service and Wigan CAMHS.

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.

All service areas were clean, had good furnishings and were well-maintained.

The cleaning records were not available on site as the cleaning was completed by an external organisation.

Staff adhered to infection control principles, including handwashing.

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.

Medicines were not routinely administered by the teams we visited. However, emergency medicines were kept. These were stored safely, regularly checked, were in date and matched the contents of the emergency bags.

Staff reviewed the effects of medicines on young peoples’ physical health regularly and in line with NICE guidance, especially when the young person was prescribed a high dose of antipsychotic medication. These reviews usually took place with the consultant psychiatrists at Wigan CAMHS, Bolton CAMHS and the Children and Young People’s Eating Disorder Service.