Pennine Care NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated effective as requires improvement. At this inspection the rating has remained requires improvement. We identified 1 breach of the regulations in relation to people being informed of their rights under Community Treatment Orders.

Requires improvement: Not all staff correctly carried out their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice in relation to people under Community Treatment Orders. Some people’s care plans were brief and not holistic. Staff did not always record people’s consent in care records and rates of Mental Capacity Act training were low. However, staff assessed the physical and mental health of everyone on admission to the service. Staff provided a range of treatment and care based on national guidance and best practice. Teams included or had access to the full range of specialists required to meet the needs of people who used services. Staff worked well as a multidisciplinary team to benefit people.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s holistic care and treatment needs were regularly reviewed with them and documented. However, in some teams there was evidence of frequent evidence-based and holistic care planning.

The quality of care plan documentation varied across teams. We reviewed 33 care records in relation to care plans. Of the 33 we reviewed, 7 did not contain an up-to-date care plan. Two of those 7 records had care plans that had no date on them, so it was not possible to know if they were current. One of the 33 records contained a care plan that was out of date by less than a month. In one of the 33 records, the most current care plan was dated 2021. In most teams we observed care plans were person-centred and included goals and interests that were specific to that person. They also considered the medical, physical, psychological and social aspects of care people needed. However, in Bury CMHT and Heywood and Middleton CMHT, there was limited or no evidence of the patient voice in some of the documentation we reviewed.

The trust had undertaken a large-scale audit of care plans, the results of which were published in April 2025. The audit showed that there were inconsistencies in the quality of care planning across the adult community mental health service. There were several recommendations made to improve the quality of care planning and record keeping. At the time of our inspection, the trust was in the process of improving its care planning process. In addition to teams across the adult community mental health service ‘buddying’ for care record audits to support quality improvement, one CMHT was piloting a new way of developing care plans. The pilot used a nationally recognised patient-rated satisfaction tool to improve the quality and consistency of care plans. Staff told us, and we saw, plans confirming the new approach to care planning was scheduled to be implemented across the service in early 2026.

Although some care plans did not provide comprehensive person-centred information about people’s needs and recovery goals, we did observe that progress notes across all teams were generally detailed and provided information on people’s current needs. For example, we saw evidence of correspondence in progress notes to highlight people’s physical health monitoring and medicines needs following blood test results.

Our review of care records showed evidence of people receiving in-depth mental health assessments upon admission to the adult community mental health service. In 32 of the 33 care records we reviewed, there was also evidence of people receiving regular mental health reviews in line with trust policy. However, one record from Bury CMHT showed someone last had a mental health assessment in 2021. Trust policy stated mental health reviews should be carried out every 12 months unless there was a need to do one sooner.

Staff reviewed people’s needs after assessment as a multidisciplinary team. We observed an assessment feedback meeting in which Heywood and Middleton CMHT reviewed the assessment outcomes of 20 people. Staff displayed a good understanding of holistic assessment and in most cases used trauma-informed assessment techniques. Discussions were thorough and considered people’s risk to themselves or others, impact of any previous interventions, and any additional needs such as neurodiversity. The team agreed next steps for people, including onward referral or psychiatrist review. When discussing the assessments of new referrals, staff showed a non-judgemental approach and emphasised the importance of considering any unmet needs people may have and how the team could support in addressing them.

The service did not always follow legislation and current evidence-based good practice and standards regarding Community Treatment Orders. However, the service offered a range of evidence-based care and treatment options.

On 16 October 2025, the trust had a total of 152 service users who were subject to a Community Treatment Order (CTO). A CTO enables people who have been detained in hospital under the Mental Health Act 1983 for treatment to leave hospital and continue their care in the community. CTOs set out certain rules or conditions people have to follow in the community.

From 1 January to 16 October 2025, a total of 25 people receiving care whilst on a CTO had not had their rights explained to them in relation to their CTO in line with trust policy. In 3 of those cases, people had not had their section 132a rights explained to them over 12 months after their CTO had been renewed. This meant people were not always made aware of their statutory rights under the Mental Health Act 1983. Section 132a of the Mental Health Act states that hospital managers must provide information to people and their nearest relatives about the legal provisions that apply to them under their CTO, and about the rights and safeguards they are entitled to.

Across teams in the adult community mental health service, the average rate of compliance for Mental Health Act training was 59% in October 2025. The following teams had low compliance for Mental Health Act training:

• Stockport EIT– 36.4%,
• Stockport West CMHT – 7.7%,
• Stockport East CMHT – 23.1%,
• Tameside EIT – 50%,
• Bury Active Care Co-ordination – 66.7%,
• Bury EIT – 50%,
• Heywood, Middleton and Rochdale CMHT – 33.3%,
• Heywood, Middleton and Rochdale EIT – 53.8%,
• Oldham CMHT – 66.7%.

The trust had processes in place to monitor whether people had been given their rights under a CTO. The trusts mental health law offices had registers of people on CTOs and they provided people with written copies of their rights by mail. Unless staff had a conversation with people to make them aware of their rights under a CTO, they could not guarantee people properly understood their rights under the Mental Health Act 1983. In line with CQC’s Right support, right care, right culture guidance, CQC expects providers to consider the needs of autistic people and people with a learning disability when delivering care. This includes making sure information is provided to people in different formats relevant to their communication preferences. For some people under CTOs, a conversation would be necessary to ensure they understood their CTO and their rights.

The mental health law offices’ registers were circulated to all responsible clinicians, clinical leads, care co-ordinators and community mental health team (CMHT) managers on a monthly basis as a reminder to check any outstanding actions due including revisiting section 132a rights. We saw emails were sent to responsible clinicians and care co-ordinators chasing outstanding actions, with their managers copied in. We saw evidence that when people did not have their rights renewed, this was recorded as an incident. However, despite these measures, a high number of people did not have their rights renewed in line with trust policy.

However, staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice from the trust’s mental health law office. We saw evidence in people’s records that staff corresponded with the mental health law office when they had questions about people’s CTOs.

We saw evidence that the mental health law office monitored the service’s use of the Mental Health Act 1983. It produced annual reports that provided information on the application of the Mental Health Act 1983, including how many new CTOs were applied for, how many people were discharged from CTOs and how many people on CTOs were recalled to hospital. This helped managers and senior leaders review the effectiveness of CTOs within the service.

Although different teams had different staffing models, across the adult community mental health service teams had access to a wide range of specialist staff. In addition to psychiatrists, nurses, social workers and support workers, there were psychologists, occupational therapists, non-medical prescribers, engagement workers, employment support workers, advanced practitioners, peer support workers and mental health wellbeing practitioners.

There was an operational early intervention in psychosis clinical lead who oversaw all EIT. Managers told us the role helped to embed clinical and operational consistency across teams. Clinical leads in EIT told us they supported with complex clinical cases and held small caseloads of their own.

Clinical leads were in all CMHTs except those in the Heywood, Middleton and Rochdale care hub. Clinical leads provided additional clinical expertise through delivering clinical supervision to qualified practitioners and supporting with joint working of complex cases. They were also responsible for delivering training, induction and responding to complaints, completing clinical learning reviews, quality improvement, and embedding recommendations and learning from incidents. Staff across CMHTs told us they valued the additional expertise that clinical leads brought to the teams, and found it helpful to have clinical supervision with them.

All teams either had designated occupational therapy provision or had access to occupational therapy. Occupational therapists provided a range of interventions dependent on individual need.

All teams offered a wide range of medical and psychological interventions. At the time of our inspection, there was some variation in available psychological interventions. However, there was good availability of core therapies, as outlined in the NHS England ‘Psychological Therapies for Severe Mental Health Problems: PT-SMHP’ paper, across all care hubs. This included access to cognitive behavioural therapy (CBT), eye movement desensitization and reprocessing (EMDR), mentalisation-based therapy (MBT), dialectical behaviour therapy (DBT), structured clinical management (SCM) and cognitive analytical therapy (CAT. Senior leaders told us they were continuing to work towards reducing variation and had conducted a skills audit of all psychology colleagues to inform a training plan.

Staff had access to regular team meetings and training sessions to keep their clinical practice and knowledge up to date. In Heywood, Middleton and Rochdale EIT, some staff told us about their monthly education sessions in which external speakers were invited to host sessions on topics such as safeguarding or perinatal mental health.

Some areas of staff poor performance were identified and addressed effectively. For example, care record audits had identified some staff who required additional support with that aspect of their role.

The service worked well across teams and services to support people. They supported people to transition smoothly between teams and services and shared information with others to assist with this.

Teams in the adult community mental health service worked collaboratively with others, both inside and outside the trust. Stockport assertive outreach staff told us, and we saw evidence in care records, of staff visiting people who used services who were in hospital to begin working with them before they were discharged into the community. This helped staff build a rapport with people and start making plans with them to support a safe and effective discharge into the community.

The adult community mental health service worked with partners across the health and social care and emergency services. Staff and managers told us about the positive working relationships they had with the police. Some managers told us they were looking at how to strengthen the relationship with police liaison workers to ensure they maintained oversight of incidents.

Staff told us about other partners they worked with to support people who used services. These included housing services, the probation service, local pharmacies, and drug and alcohol misuse services. We saw evidence in care records of communication with other agencies involved in supporting people, and of joint visits to people. This helped people reduce the need to tell their story multiple times as they accessed different teams.

Staff and managers told us community mental health teams (CMHTs) had close working relationships with local authorities, even after they split. This enabled the service to work effectively with social work staff to address people’s social care and safeguarding needs.

All teams across the service had effective multidisciplinary working relationships. In all assessments, morning huddles, zoning meetings and screening meetings we observed, staff from all disciplines contributed fully. Staff listened to each other and asked for others’ input, whilst also respectfully and professionally challenging each other when opinions differed. Staff displayed a sound understanding of the needs and risks of people on their caseloads and communicated these effectively.

Throughout teams, there was a strong emphasis on the need to involve family and carers. Staff told us that when people consented, they would include carers in risk assessments, safety planning and care planning. We saw evidence of this in care records. Some staff told us that when people did not provide consent to have carers involved, they would ensure they provided the appropriate level of support to the carers without breaching confidentiality. For example, they would signpost to carers’ support groups or make referrals to have a carer’s assessment. We saw evidence of this in care records.

The service supported people to manage their health and wellbeing to fully maximise their independence, choice, and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The adult community mental health service had a strong focus on supporting and improving people's physical health and wellbeing. Most teams in the adult community mental health service delivered regular, comprehensive physical health screening and support from the point of admission. Where commissioned, teams had dedicated physical health teams to support people who used services.

We reviewed 33 care records and in all of them it was evident that people's physical health had been assessed and was regularly considered in care planning and risk assessments. In teams with access to dedicated physical health support, people had access to regular and comprehensive physical health monitoring. We observed an annual physical health check in which staff offered health advice.

Staff had a good understanding of the impact serious mental illness has on a person's physical health, and vice versa. Some staff told us they particularly enjoyed being able to support people's physical fitness as part of their care and treatment, for example by going on walks with them.

Teams promoted healthy lifestyles. There were leaflets and posters about smoking cessation support and walking groups people could access in waiting areas. In Oldham EIT, we observed a well-equipped clinic room with all the necessary equipment to effectively monitor people's health. Staff told us they focused on supporting people's physical health immediately upon receiving a referral by inviting them in for a physical health check. The Oldham EIT clinic room had a range of health-related information leaflets for staff to give to people, which covered a range of topics from healthy eating advice to managing cardiovascular risks.

Where people who used services refused to engage, this was noted in their records. Some staff told us they sent text message reminders to people who used services to try to increase the attendance rate of annual physical health checks.

Teams across the service ran groups that supported people's health and wellbeing. For example, in Stockport assertive outreach team, staff ran a walking group. Some staff also told us about snooker clubs and gardening groups they ran. Some staff told us they made sure they mixed activities up and offered 1:1 physical activity to people who preferred a more individual approach.

The service monitored people's care and treatment to continuously improve it.

The adult community mental health service used a variety of recognised outcome measures to monitor people's care. We reviewed people's care records and saw evidence of recognised outcome measures being used in most teams.

The consistent use of outcome measures was particularly evident in the EIT and Stockport assertive outreach team. EIT routinely collected outcome data for the National Clinical Audit of Psychosis. In the Stockport assertive outreach team, outcome measures were used regularly and documented in people's care records. These helped staff review how people responded to different interventions.

A patient rated satisfaction scale had been piloted in Bury community mental health team (CMHT) and was scheduled to be implemented across all the adult community mental health services in 2026.

The service reviewed the outcome measures used by mental health wellbeing practitioners when it evaluated the impact of the role. The evaluation showed the majority of people, 72%, reported 'reliable improvement' after completing their intervention with a mental health wellbeing practitioner.

The service mostly respected people’s decisions about consent when delivering care and treatment, but staff did not always record people’s consent in care records and compliance with Mental Capacity Act training was low.

Across teams in the adult community mental health service, the average rate of compliance for Mental Capacity Act training was 66%. The Mental Capacity Act is essential to supporting people to make informed decisions and identifying when decisions need to be made in a person’s best interests when they lack capacity.

We reviewed 31 care records in relation to consent. Of those 31 records, consent was not clearly recorded in 6 people’s records.

Staff were aware of people’s rights with regards consenting to or declining different aspects of their care and treatment. For example, some staff told us about sharing information with carers if the person who used services consented.

We observed care being delivered. In each case, staff explained the situation to people who used services and gained informed consent for us to observe before proceeding.

We observed a home visit that was focused on staff assessing someone’s capacity to make decisions about their care and treatment. Staff were caring and compassionate throughout the assessment process.

People who used services had access to information about independent mental health advocacy via leaflets and posters in waiting areas. Some staff told us they were keen to ensure everyone was supported to access advocacy as needed.

Staff across the adult community mental health service displayed a good understanding of the Mental Capacity Act 2005. We observed care in which staff checked people’s understanding of the information staff gave them. This helped ensure people could make informed decisions.