Pennine Care NHS Foundation Trust

On this page

• 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

Well Led

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained.

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulations for governance (Regulation 17).

This service scored 62 (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 shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The values were shared with staff during their induction and were included in newsletters to staff. The trust had produced a video which was available to staff and the public which explained their values and ambitions.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. For example, the trust held a listen to improve event which included staff in discussions about improving medicines optimisation.

The trust had inclusive leaders at all levels who understood the context in which staff delivered care, treatment and support. They embodied the culture and values of their workforce and organisation. Leaders carried out their roles with integrity, openness and honesty. However, leaders did not always have the skills, knowledge and experience to lead effectively.

Leaders did not always have the skills, knowledge and experience to perform their roles. Governance oversight was not always effective and we had concerns that some of the multidisciplinary team meetings were not well managed. Managers mostly had a good understanding of the services they managed. They could explain clearly how the teams were working to provide patient care and what actions they had taken to maintain oversight of the ward. However, oversight of the services at a senior level was not always effective, for example the trust could not accurately tell us how many staff had received supervision.

Leaders were visible in the service and approachable for patients and staff. Senior leaders carried out scheduled and unscheduled visits to clinical areas. Managers felt supported by senior leaders including matrons and clinical excellence leads although managers told us they did not always receive supervision.

Leadership development opportunities were available, including opportunities for staff. For example, managers could access a 6-month manager’s development training course.

The trust created a positive culture where people felt that they could speak up but people did not always feel that their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received. Families could complete the family, friends and carer feedback survey and patients could give feedback to staff either individually or at patient meetings. The family, friends and carer feedback survey numbers were low on most wards, for example Oak ward and Hollingworth ward had received 1 survey each. South ward had received 9 surveys which was the highest number of surveys across the wards. The friends and family test had received 32 responses across all wards between April and June 2025. 84% of the comments were positive.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Patients and carers were involved in decision-making about changes to the service.

The trust had a freedom to speak up guardian. The last report showed an increase in concerns being raised by staff. 71.1% of staff felt safe to raise concerns, although 59.9% of staff felt confident their concerns would be addressed. The trust had recruited 30 new freedom to speak up ambassadors to support this work.

The trust valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were equality and diversity champions within the service and the service had developed a set of anti-racism actions for staff and patients. However, this was not embedded within the service at the time of our inspection.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role. The trust had developed a reasonable adjustment toolkit to provide guidance to managers who were supporting staff who required a reasonable adjustment although this had not been implement at the time of our inspection.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. The trust had planned a supporting Black, Asian and Minority Ethnic staff into leadership event which was due to take place in September 2025.

The trust did not have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. They did not always act on the best information about risk, performance and outcomes. They shared this securely with others when appropriate.

There was not always a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. There was no standard agenda for team meetings which meant there was no consistency in the core topics discussed by teams. Governance meetings covered the North Network, the South Network and the specialist network which covered the psychiatric intensive care units. There was no standard agenda for these meetings which meant that the basic content for these meetings was inconsistent, for example the North network contained an agenda item on Chief Executive Officer (CEO) communication, which was not included in the minutes for the South network and the South network contained a patient story which was not in the minutes for the North network. The trust told us that work was being undertaken to standardise meeting minutes. Governance meetings were not always happening on a regular basis. For example, the last 2 governance meetings we received for the South network were from April and March, the North network had held a meeting in June and prior to this a meeting in March whereas the specialist network was having monthly meetings. It was not always clear from meetings what actions were being taken from the concerns raised.

All wards had a site-based quality matron who supported service manager in maintaining oversight of the wards. Wards had a daily safety huddle where staff review areas such as patient flow, safer staffing and concerns that needed escalating.

Staff had not always fully implemented recommendations from reviews of deaths, and incidents at the service level. For example, the trust had partially completed advice to install door top alarms following a ligature incident at the service. 3 doors had been identified to install these. This was on the risk register and was recognised as a risk on the ligature audits. There were insufficient staff who were trained to carry out incident investigations. There were also delays in completing investigations into complaints within required timescale.

Staff undertook or participated in local clinical audits. These included observation form audits and key performance indicator and physical health form audits, quality audits and named nurse audits. We reviewed audits on Oak ward and Saxon ward. There were gaps in the completion of the audits. Audits did not always provide sufficient assurances, as they had not identified some of the concerns we found with record keeping during our inspection.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Staff maintained and had access to the risk register at ward and trust level. Staff at ward level could escalate concerns when required. Managers were aware of the risks for their wards and had escalated these to the risk register. Staff concerns matched those on the risk register. For example, there were concerns about not having psychology provision on North and South ward, and there were concerns about staffing levels on Aspen ward which were reflected on the risk register. Risks were discussed at governance meetings and at the trust’s risk management group.

Staff did not always have access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, did not always work well. The computer systems did not always work and this impacted staff carrying out day to day work and also impacted senior staff who were carrying out audits. Information governance systems included confidentiality of patient records.

Leaders did not always have access to sufficient information to support them with their roles and to enable them to have accurate oversight of the service. For example, managers did not have accurate information about which staff had received supervision because the system in place for recording this was overly complicated and recording was inaccurate. It was clear that not all staff had received supervision as often as they needed it, but the scale of this was unknown. Complaints and incidents were delayed in completion which meant that there were delays in accessing learning from these. There were issues with the management of staff training. Although overall mandatory training was in line with the trust’s targets there were issues with certain courses and there were significant issues with role essential training which were not being addressed in governance meetings or team meetings.

The trust understood their duty to collaborate and work in partnership, so their services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Directorate leaders engaged with external stakeholders, such as commissioners, the community mental health team, the local authority, probation and the families rehabilitation team. The trust conducted regular meetings with stakeholders which provided oversight of patient care, contract monitoring and finance. Stakeholders told us they had strong relationships with trust and that communication with the trust was open, honest and authentic. They told us they felt there was a patient centred approach to care and that leaders demonstrated the values of the organisation.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

The trust focused on continuous learning, innovation and improvement across their organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff had opportunities to participate in research. There were different research projects occurring on each ward, for example 8 wards were taking part in vision quest which explored the prevalence and impact of visual hallucinations and 2 wards were involved in a piece of research called understanding anger and aggression which involved examining psychological factors that drive aggression and measuring the thinking and beliefs that lead to aggression in people with psychosis.

Innovations were taking place in the service, although this varied between wards. For example, Walkerwood PICU were introducing teaching sessions on Wednesdays and members of the team were planning to carry out a presentation on their culture.

Staff participated in national audits relevant to the service and learned from them. For example, staff participated in a national audit relating to rapid tranquilisation in the contest of the pharmacological management of acutely disturbed behaviour. This reviewed practice such as whether patients received post incident debriefs and whether triggers and early warning signs were identified in patients care plans. The survey identified that these were often not occurring. There was ongoing work taking place at the time of our inspection to improve the administration of rapid tranquilisation.

The trust did not share any accreditation schemes relevant to the service that they were part of.