Pennine Care 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

Safe:

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 remained.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations relating to people’s safe care and treatment (Regulation 12).

The service was in breach of legal regulations relating to premises and equipment (Regulation 15).

The service was in breach of legal regulations relating to staffing (Regulation 18).

This service scored 47 (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 had a proactive and positive culture of safety based on openness and honesty in which concerns about safety were listened to. However, safety events were not always investigated and reported thoroughly, and lessons learned were not always embedded as good practices.

The trust recorded 12 serious incidents at the service in the last 12 months. Incidents included self-harm, and unexpected death on the wards. Incidents were not focused on any one ward but occurred across all wards. All staff knew what incidents to report and how to report them.

The trust had an incident’s policy which was in date and provided guidance about how to report and manage incidents. However, it was not clear that all serious incidents were being recorded in line with the policy. The trust provided us with a list of incidents which required a duty of candour report. All these incidents had been graded as serious or catastrophic but only 4 of these incidents were included in the list of serious incidents.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. However, incidents were not investigated in a timely way due to a lack of trained staff to carry out investigations. Staff discussed incidents and lessons learned in team meetings, but we found learning was not always embedded and there were still concerns around practices that had been identified as concerns through learning from incidents. For example, following a self-harm incident on Aspen ward, senior staff had identified issues with observations being carried out safely and we found this was still an issue during our inspection.

Staff were debriefed and received support after a serious incident. For example, managers told us that clinical excellence leads completed debriefs with staff following incidents.

Quality Statement Score:3

The trust worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They ensured continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

The trust did not always work with people to understand what being safe meant to them as well as with their partners on the best way to achieve this. The trust concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure they shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. All staff had received safeguarding adults and safeguarding children training at an appropriate level. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. However, the safeguarding section of patient’s care plans was not always completed. We reviewed 3 records where the safeguarding care plans had not been completed despite this being identified as a concern in the patient’s risk assessment. Staff followed safe procedures for children visiting the service.

There were core blanket restrictions on all wards and restrictions that applied to individual wards. These included restrictions to accessing rooms such as the dining room due to equipment such as the toaster and food serving trolley being present in those rooms. This was not individually assessed and was restricting the rooms patients could access, this was a particular challenge on wards such as Aspen ward, where the space that patients could access unaccompanied was limited. Patients had access to key cards for their bedrooms on some but not all wards. This meant that some patients could not access or lock their rooms without asking a staff member to do this for them.

The trust did not always work with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

We reviewed 37 risk assessments / risk management plans during our assessment. Staff mostly completed risk assessments with patients and identified risk concerns. However, identified risks were not always reflected in patient’s risk management plans or care plans and not always managed effectively. We reviewed 37 care records and found 19 of these contained insufficient detail to keep patients safe. For example, we found a lack of risk management for a range of issues including wound care, anaphylaxis and violence and aggression. We served a warning notice relating to these concerns.

There were 690 incidents of restraint involving 926 holds in the 6 months prior to our inspection. There was a high level of prone restraint, prone restraint is where a person is held face down. There were 115 instances of prone restraint in the 6 months prior to our inspection. 91 of these were for the purposes of administering intramuscular medication. Incident forms were completed following incidents of prone restraint, however there was no evidence of senior staff considering whether prone restraint was required during these incidents or of how prone restraint could be reduced during any future incidents.

There were 199 instances of delivering rapid tranquilisation in the 3 months prior to our inspection. Of these North ward and Aspen ward had the highest use with 38 instances each.

There were 128 incidents of seclusion in the 6 months prior to our inspection, the highest levels of seclusion were on Woodbank psychiatric intensive care unit which had 38 incidents of seclusion. However, most seclusions were for a brief period of time with 6 seclusions which lasted longer than 72 hours.

Staff did not always involve patients in care planning and risk assessments; we saw 6 records where patients had either not been involved in their care plans or had been involved in some but not all their care plans. Staff mostly communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

The trust did not always detect and control potential risks in the care environment and did not always make sure that the equipment, facilities and technology supported the delivery of safe care.

Staff did not carry out regular risk assessments of the care environment on all wards. For example, we found significant gaps in fire checks on Hollingsworth ward and Moorside ward.

The ward layout did not allow staff to observe all parts of ward on all wards for example there were blind spots on North ward and Moorside ward which were not mitigated and were a risk to staff and other patients. All wards had an up to date ligature risk assessment which included mitigation measures for ligature anchor points. However, identified actions to reduce the risk of ligature and self-harm were not always completed in a timely manner. For example, on Norbury ward an action had been identified in January 2025 to replace screws on door sign with anti- tamper screws, this had not been completed at our inspection in June 2025. There was also a ligature risk in bedroom 4 on Hollingworth ward which had been identified in February 2025, mitigations were in place for this room but the broken item had not been fixed by the time of our inspection.

Seclusion rooms did not allow clear observation and two-way communication on all wards. The seclusion room for Walkerwood psychiatric intensive care unit did not always allow staff to clearly observe patients. Staff used the health based place of safety (HBPoS) for seclusion purposes on Arden ward, Moorside ward and Aspen ward. The seclusion room on Arden ward did not have a working 2-way communication system or clock. The seclusion room for this ward was situated off the ward and therefore staff had to transport patients off the ward in order to seclude them. Patients on Aspen ward and on Moorside ward had to be transported downstairs in order to seclude them and there was no guidance either in the trust’s seclusion policy or use of force policy to support staff to carry this out safely.

Staff had easy access to alarms and patients had easy access to nurse call systems. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff mostly checked regularly. However, the grab bag on Arden ward which contained emergency equipment had not been checked as regularly as required.

The trust did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

Vacancies levels varied between wards, the average current vacancy rate was 12% with the highest level of vacancies on North ward at 22% and the lowest level of vacancies on Woodbank PICU at 3%. The average turnover was 8% and varied between 14% on Taylor ward and 2% on Arden ward. The average sickness absence over the last 12 months was 9% with the highest sickness level being on Aspen ward. The number of shifts covered by bank staff in the 3 months prior to our inspection was 7205 and the number of shifts covered by agency staff was 1258. Levels of shifts covered by bank staff was particularly high on Aspen ward.

Managers had calculated the number and grade of nurses and healthcare assistants required. The trust was in the process of completing the Mental Health Optimal Staffing Tool (MHOST) which was a process for reviewing the numbers of staff on the wards. This had been completed on several wards and senior managers had agreed to an increase in staff for several wards.

The number of nurses and healthcare assistants did not always match the establishment figures for each ward on all shifts. For example, the number of nurses on Aspen ward did not always meet their required staffing numbers, this was particularly the case on the weekends. The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers could use bank nursing staff to maintain safe staffing levels. However, managers were no longer able to use agency staff to cover health care assistants. Staff told us this was causing challenges on Aspen ward as managers were struggling to fill some shifts with bank staff.

When agency and bank nursing staff were used, those staff received an induction, however induction templates varied in content, for example not all templates included a tour of the ward. Induction templates also contained inconsistent checks for staff training, for example, Aspen ward asked staff if they had completed fire safety and enhanced observation training but this was not on the induction for all wards. This meant we could not be assured that all staff had had a meaningful induction to the ward.

Staffing levels allowed patients to have regular one-to-one time with their named nurse and staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency.

Staff had mostly received and were up to date with appropriate mandatory training. Mandatory training compliance for the service was at 93%. However, staff were 25% compliant in moving and handling level 2 and 74% compliant in immediate life support training with Saxon suite at 53.30% compliance for this course. The trust was aware of the low compliance figures for these courses and managers had put plans in place to mitigate risk and improve compliance figures. Staff were not up to date with role essential training, compliance levels for role essential training was 46%. Mandatory training did not cover Mental Capacity Act and Mental Health Act training. These courses were recorded under essential to role training and staff were 58% compliant for Mental Capacity Act training and 46%. compliant for Mental Health Act training. The safe use of insulin was also part of essential to role training and the compliance for this course was at 15%. Restraint training was recorded under essential to role training figure, however, only 5 wards had training compliance figures for this course. It was therefore not possible to know if sufficient staff had received restraint training. The trust was carrying out a piece of work to improve their oversight of the training compliance for this course.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. All ward areas were clean. Cleaning records were mostly up to date and demonstrated that the ward areas were cleaned regularly and cleaning audits had been completed to provide oversight of this. However, there were gaps in the cleaning records for Norbury ward. Fridge temperatures for the patient food fridges on Norbury ward and Moorside ward were not checked daily as required.

Not all wards had good furnishings or were well-maintained. There was ripped and damaged furniture on Taylor ward and North ward and damaged paint and plasterwork on Taylor ward and Arden ward. There was a large hole in one of the bedroom walls on North ward. Repairs of damage to the environment identified on ligature audits was sometimes taking a long time. For example, there were broken door locks on Taylor ward that were reported in December 2024 and had not been replaced at the time of our inspection.

Staff adhered to infection control principles, including handwashing. However, there was no handwash available at 3 of the sinks on Arden ward and the infection prevention control audit highlighted that masks and hand sanitiser was not always available on the all the wards.

The trust did not always make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Records of medicines administration were usually clearly made. However, as seen at our previous inspection in 2019, staff did not consistently record patients’ physical health observations in line with trust policy. For example, when people first started to take clozapine, or on occasion following rapid tranquilisation. Following a benchmarking audit (reported December 2024), the trust had carried out focused work to improve the oversight of the use of rapid tranquilisation (an emergency measure using injectable medication to quickly calm a severely agitated person). A new patient monitoring pack had been recently launched (June 2025). Practice was being monitored by ward managers with support from trust Quality Matrons, reducing restrictive practice leads and pharmacy staff. Trust improvement work was also ongoing for the safe management of Clozapine, and Valproate but actions had not yet been fully embedded. The trust carried out a range of medicines related audits to provide assurance and help drive improvement.

A trust wide ‘Listen to Improve’ event had been held to share medicine safety themes and to share experiences in a collaborative approach to drive continuous improvement. Oversight of medicines use was also being strengthened through the roll out of weekly ‘quality assurance and safety checks’ which included a view of medicines. These safety checks included record keeping, rapid tranquilisation and physical health monitoring. Information about smoking and any possible effects on medicines had been shared in a trust medicines safety bulletin in advance of the trust going ‘smoke free’. Policies had also been revised to support smoking cessation.

Where required, the appropriate authorisation for the administration of mental health medicines under the Mental Health Act was in place.However, on occasion care records did not clearly record prescribing decisions and reviews about high dose antipsychotics, or for one patient the use of an antipsychotic injection as part of their initial treatment. Additionally, the indication for ‘when required’ medicines that can be used for example, to aid sleep or for agitation was not always correctly recorded.

Medicines information was not always included within people’s care plans for example, about Lithium or Clozapine to help ensure patients are knowledgeable about their safe use and side-effects. Patient-held ‘purple’ Lithium booklets were not available on Aspen ward and staff could not confirm who would go through these with the patient. However, pictorial, easy read and quick response (QR) code links to medicines information was available should patients wish to learn more about their medicines. We saw one example where pharmacist advice had not been sought when medicines were crushed before being given, to help ensure this is done safely. Patients were assessed for the risks of blood clots on admission to hospital. However, we saw one example where the advised graduated compression stockings were unavailable a week after this assessment.

The trust completed audits of the safe and secure handling of medicines. Appropriate arrangements were in place for escalating any out-of-range temperatures in medicines storage areas.