Pennine Care NHS Foundation Trust

Ratings - Acute wards for adults of working age and psychiatric intensive care units

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Requires improvement

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

• We carried out the assessment for Pennine Care NHS Foundation Trust acute wards for working age and psychiatric intensive care units on 24, 25 and 26 June 2025.
• We carried out the assessment in response to concerns raised about the service and due to the length of time since the service was last inspected.
• Pennine Care NHS Foundation Trust acute and PICU services had 12 wards across 5 locations including 10 acute wards and 2 psychiatric intensive care units. The locations we visited at this inspection were: Stepping Hill hospital in Stockport; Fairfield General Hospital in Bury; Tameside General hospital in Ashton-under-Lyne; Birch Hill hospital in Rochdale and Royal Oldham hospital in Oldham.

We visited the following wards as part of our assessment:

Arden ward - male acute ward with 24 beds

Norbury ward – female acute ward with 23 beds

Woodbank psychiatric intensive care unit - female ward with 7 beds

North ward – female acute ward with 23 beds

South ward – male acute ward with 22 beds

Saxon ward – male acute ward with 23 beds

Taylor ward – female acute ward with 22 beds

Walkerwood psychiatric intensive care unit – male ward with 10 beds

Hollingworth ward – male acute ward with 18 beds

Moorside ward – female acute ward with 18 beds

Oak ward – male acute ward with 22 beds

Aspen ward female acute ward with 22 beds

We gathered information from people using the service and their loved ones, staff and managers, other stakeholders and carried out our own observations. We reviewed a range of documents including care records, policies and procedures. We looked at 33 quality statements.

We rated the service as Requires Improvement. We found 4 breaches of the regulations in relation to safe care and treatment, premises and equipment, good governance and staffing.

• Staff did not always identify risks to people's health and safety or mitigate them where identified.
• Patients did not always have care plans which were person centred and relevant to their needs.
• Staff had not always received supervision or relevant training. Staff were mostly compliant with mandatory training, but compliance levels for role essential training were low.
• Physical health monitoring had not always been carried out consistently.
• Complaints and incidents were not always investigated in a timely manner.
• Governance systems and audits were not always effective in identifying or addressing areas for improvement.

However

• There were mostly sufficient staff to provide patients with 1 -1 time and to support patients to take their section 17 leave.
• Patients had their rights explained to them in a way they could understand and had access to advocacy where needed. All detained patients were referred to an independent mental health advocate.
• Most patients told us that staff were respectful, caring and provided support when they needed it.
• Staff mostly felt supported by leaders and felt they could speak up about any concerns they had.

Action we have taken

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance Mental Health Act

Not all staff had received training in the Mental health Act the Code of Practice and the guiding principles. 46% of staff had received Mental Health Act training.

Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and its code of practice. Staff knew who their Mental Health Act administrators were and the provider had relevant policies and procedures that reflected the most recent guidance and staff could access these when they needed to.

Patients had easy access to information about independent mental health advocacy, detained patients were automatically referred for independent mental health advocacy support. Staff explained their rights under the Mental Health Act to patients, in a way that they could understand, repeated it as required and recorded that they had done it.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted. The service displayed a notice to tell informal patients that they could leave the ward freely. Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

Staff requested an opinion from a second opinion appointed doctor when necessary. Staff carried out regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the 5 statutory principles. 58% of staff had had training in the Mental Capacity Act.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice regarding the Mental Capacity Act, including deprivation of liberty safeguards. There were 4 deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regards to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

People's experience of this service

During our inspection we spoke with 40 patients and 7 carers. We also reviewed the minutes for 2 patient community meetings and reviewed feedback from surveys the trust sent out to families and carers to gain feedback on care.

Patients mostly told us that staff were respectful, caring and treated them well. However, patients on South ward and some patients on Aspen ward told us they did not feel supported and that they felt staff did not spend time with them. Patients also felt there was a difference between the care they received from permanent staff and the care they received from bank and agency staff. Not all patients felt safe on the wards.

Patients did not always feel involved in developing their care plans, this varied between wards for example most patients on Oak ward felt involved in developing their care plans, whilst patients on Moorside ward did not feel they were involved in the development of their care plans. Patients felt they could speak to staff about their medicines and said that staff had given them information about the medicines they were taking.

Carers mostly told us that staff were caring and respectful, for example carers said the staff were amazing, that they were always really friendly, and that they were invested in patients getting well and being able to come home. However, some carers raised concerns about their loved ones’ care. For example some carers felt that there was insufficient support when patients went home on leave or were discharged and concerns were also raised about some patient’s receiving insufficient physical health care. Carers were invited to ward rounds and told us they felt involved in patient’s care planning.