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

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We identified1 breach of the regulations in relation to staffing levels, training and supervision.

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. In some teams there were high numbers of people awaiting allocation to a care co-ordinator or key worker. There were low rates of compliance on some mandatory training courses. There were significant vacancies and high numbers of unfilled shifts in some teams. There were some gaps in pharmacy oversight to support medicines management across teams. Some of the buildings did not reliably support the delivery of safe care. However, the service had a well-embedded culture of learning in which incidents were reported and reviewed in a timely manner, and learning was shared to support good practice. People’s care record documentation was generally comprehensive. Safeguarding processes were effective. Infection prevention and control measures were well-embedded and effective.

This service scored 59 (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 had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff demonstrated a good understanding of the types of incidents that might take place in the adult community mental health service. For example, they told us about safeguarding concerns, acts of aggression and violence and incidents of self-harm and suicide. Staff and managers at all levels told us how they would report any incidents on the service’s incident reporting system.

The trust had implemented the Patient Safety Incident Response Framework (PSIRF). Its PSIRF policy stated the roles and responsibilities of all staff in response to safety incidents and emphasised the focus on learning from incidents rather than identifying blame. Staff and managers across the adult community mental health service told us that following any safety incidents, the focus was on learning rather than apportioning blame.

The adult community mental health service had a well-embedded culture of incident reporting and learning from incidents. Most staff and managers told us they reported near-misses as well as incidents, to help identify learning that could prevent near misses from escalating to incidents in the future. A near miss isa patient safety event that had the potential to cause harm but did not.

The service used various approaches to share learning from incidents across teams. For example, most staff told us about monthly business meetings in which “learning briefings” was a standing agenda item. Some staff told us about 7-minute learning bulletins that were shared across the trust, and we observed some of these posted in staff areas. The service also held reflective sessions for staff to attend.

Most staff could give us examples of learning from recent incidents. For example, following the death of a person who used services, a training event was held by the safeguarding team to support staff with how to communicate between teams when they had concerns about people.

Managers and leaders told us they shared learning from other trusts with their staff. For example, the trust had reviewed its policy to support disengaging patients following an incident at another trust. Managers and leaders told us they made sure learning that was shared with staff included any areas of positive practice. They also tried to ensure that practice implications of learning were identified for staff to make the learning more meaningful.

In the 3 months prior to our inspection, 155 incidents had been reported across all teams in the adult community mental health service. Of those 155 incidents, 116 had caused no injuries, 15 had resulted in minor injuries, 13 had resulted in moderate injuries requiring hospital treatment, 1 had resulted in extensive injuries and 10 had resulted in death. The adult community mental health service had recorded 9 serious incidents in the previous 12 months. We saw evidence that incidents were investigated, and areas of good practice were identified alongside learning and areas for improvement. We saw evidence that the findings of incident investigations were shared with teams during business meetings.

The trust had a Suicide Prevention Plan that had 5 key priorities based on local and national evidence about suicides. The priorities supported the trust’s aim to meet the 10 key principles for safer care identified by the National Confidential Inquiry into Suicide and Safety in Mental Health. Each priority had identified actions, in addition to information about the responsibilities of individuals, teams, leaders and the organisation in supporting the plan, which meant staff understood how their work contributed to the plan.

The trust’s Mortality Review Group had identified an increase in unexpected deaths of people who used services during 2025. The group agreed that a comprehensive review and analysis was needed to better understand if the increase was a cause for concern, or whether it reflected the increased number of people being supported by the service. The review was underway at the time of our inspection. Managers told us about the growing focus on triangulating learning from deaths, PSIRF processes and inquest activity. To achieve this, they worked with internal and external partners, such as medical examiners and other mental health trusts, to share learning.

We saw evidence the service made improvements to its processes following concerns raised by coroners in Prevention of Future Deaths. For example, they changed their triage process for new referrals to Living Well.

The trust reported there had been no incidents which met the criteria for recording as Never Events in the adult community mental health service in the previous 12 months. Never Events are defined as wholly preventable patient safety events.

Staff and managers understood the duty of candour. The duty of candour is a legal obligation for healthcare providers to be open and honest with people who use services, or their families, when something goes wrong with their care or treatment and causes harm or has the potential to cause harm. Managers were able to explain the process involved when duty of candour applied. They told us that following an incident, they would complete an incident report before phoning the person who used services and/or their family, to apologise and offer to see them in person. Managers told us they would involve the person who used services and/or their family in the process as much as they wanted and keep them updated on any actions the trust or service were taking in response. Most managers and senior leaders told us they would support families for as long as needed following incidents.

At the time of our inspection, not all pathways were safely managed. The split between community mental health teams (CMHTs) and local authorities meant some teams had high numbers of people without an allocated key worker or care co-ordinator. However, the service had systems in place that safely managed most people’s care.

In Bury CMHT and Heywood and Middleton CMHT, there was insufficient staff to allocate all people who used services to a care-coordinator. The recent split from local authorities had significantly reduced the number of available care co-ordinators in some teams. Some staff told us care co-ordinator caseloads in CMHTs had recently been amended. Some staff told us this had helped to ensure staff were not spread too thinly to properly support people who used services. However, some other staff told us they felt overwhelmed by the higher caseload numbers, and that they limited the time staff could spend with people on their caseload.

Whilst some teams were able to reallocate care co-ordinators, in other teams the unallocated people who used services were now overseen by the duty function. The duty function oversaw and responded to any unplanned contact made to the team that required a timely response. We asked the trust to send us their standard operating procedures. The draft standard operating procedure stated that after assessment, people would have an allocated keyworker to ensure they could build a consistent, trusted relationship with an individual who understood their history and who could support them to engage. The people held on the duty function caseload had neither a care co-ordinator or a key worker. The trust had added “unallocated cases within community teams” to its risk register in 2025.

In Bury CMHT, there were 196 people who used services who were sitting on the duty function caseload whilst awaiting allocation to a new care co-ordinator. This meant the service had reduced oversight of those people’s needs and risks. The demand on Bury CMHT had been listed on the Bury care hub risk register and was reviewed weekly. At the time of our inspection, the risk rating for Bury CMHT’s high level of demand had been increased to red, which was the highest level of risk.

Oldham CMHT had 68 people awaiting allocation to a care co-ordinator, and Heywood and Middleton CMHT had 12. All other teams had no waiting lists for people to be allocated to a care co-ordinator. The trust told us that they did not monitor incidents whilst people were on waiting lists. However, they confirmed that in the 12 months prior to our inspection, there had been 2 safety incidents in which waiting for services was noted as an element in the investigation.

The assertive outreach team operated a joint team caseload. At the time of our inspection, the caseload was 27 between 5.5 full time equivalent staff.

Referrals to the adult community mental health service were triaged in team screening meetings. We observed screening meetings in which robust multidisciplinary discussions were held to identify if referrals met the criteria to be accepted by the teams. In instances where someone did not meet the criteria, the teams identified the most appropriate response, including onward referral to other teams and services, or referral back to a GP. In instances where there was not enough information on the referral to make a decision, staff sought additional information from the referrer or person referred.

After being referred to a community mental health team (CMHT), people were generally assessed within 4 weeks. After that, they were either allocated a key worker or care co-ordinator, or were put on a waiting list for allocation if needed. Staff and managers told us about ongoing caseload audits that were happening across the adult community mental health service to support people’s transfer back to primary care services where possible.

Staff told us about, and we observed staff using, a weighting tool that was used to support caseload management by assessing the level of need and risk people had. People’s care and treatment interventions were discussed as a team. We observed an assessment feedback meeting in which staff shared the outcome of new and ongoing assessments and discussed the next steps to support people. There was a significant focus on identifying any unmet needs and ensuring appropriate support was requested to address these.

The adult community mental health service had worked with police, other mental health trusts, the ambulance service, acute trusts, the Integrated Care Board and voluntary sector care organisations to create a robust Right Care, Right Person process. Right Care, Right Person is a national initiative designed to ensure that people experiencing mental health crises receive the most appropriate response from the right service, rather than defaulting to police intervention. The service had created useful guides for staff, including escalation processes and welfare check guidance. The trust contributed to learning events about phase 1 of its Right Care, Right Person implementation in March 2025.

The service had a disengagement from services policy which provided a framework for staff to address risks associated with people not attending appointments, disengaging or not providing access to staff on home visits. Staff and managers told us about the disengagement policy and we saw flowcharts in meeting rooms for staff to follow. This ensured staff actively monitored and addressed the safety of people who used services who disengaged. We observed people disengaging from services being discussed in zoning meetings.

Staff in the assertive outreach team told us about the people who used their services, who might become very unwell and with increased risks if they did not engage in their care and treatment, and the need to be proactive and persistent in supporting them to stay well.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding children and adults and there were high rates of safeguarding training compliance across the adult community mental health service. Average training compliance rates across eligible teams were above 83% for Safeguarding Adults Level 1 to 3, and above 92% for Safeguarding Children Level 1 to 3.

All staff had completed Prevent training which helped them understand their responsibilities to safeguard people from radicalisation and becoming involved in terrorism.

Staff understood the specific risks and vulnerabilities often experienced by people who used services. Some staff told us about safeguarding situations they had recently identified and supported people with, including financial abuse.

We observed zoning meetings in which safeguarding concerns were discussed. Staff showed a proactive approach to safeguarding and displayed a good understanding of the specific risks and vulnerabilities of the individuals involved.

Staff understood their responsibilities in relation to safeguarding and knew how to report safeguarding concerns. Safeguarding policy and guidance documents were clear to follow and helped ensure staff carried out their safeguarding responsibilities correctly, including when to escalate concerns.

In April 2025, the trust introduced a new process for recording safeguarding referrals to gain greater oversight. Safeguarding referrals were made with the appropriate local authority, logged on the trust’s incident reporting software, and details were added to the safeguarding section of people’s care record. The trust’s safeguarding team monitored whether safeguarding records were added to people’s care records. We saw evidence staff correctly followed the trust’s safeguarding processes.

The trust worked with partners and external agencies to safeguard people who used services and their families. Meeting minutes showed the trust senior leadership were active members of the different local authorities’ safeguarding adults boards and safeguarding adults partnership boards. They also participated in domestic homicide reviews.

Staff told us about how they worked with other agencies to safeguard people from harm. For example, staff told us they were working closely with the local authority to support someone who was highly vulnerable to financial abuse.

Staff worked with people who used services to regularly assess and manage risks and ensured this was documented in people’s care records.

We reviewed 33 care records in relation to risk assessments. Of those 33 care records, 31 had an up-to-date risk assessment. Of the 2 that were out of date, 1 was out of date by less than a month and the other record contained a very recent and thorough risk management plan.

Risk assessments and safety plans were written with people who used services. In most care records, we saw evidence of people’s engagement in the risk assessment process. For example, safety plans included specific people, interests and hobbies that people identified they found supportive when their mental health was deteriorating.

Risk assessments were comprehensive. We saw in people’s records that the risk assessment tool included past and present risks, safeguarding, family dynamics, any specific vulnerabilities people had, and what other agencies were supporting someone. Staff told us, and we observed, that a nationally recognised risk formulation approach was used to determine people’s current level of risk and need.

Staff used dynamic risk assessments to determine someone’s risk rating and ‘zoned’ them into different colour categories. The colour indicated the level of staff input needed at that time to safely support them. Risks were discussed throughout the day, and we observed clinical discussions in offices between appointments.

Risk was discussed as a multidisciplinary team in zoning meetings which took place twice a week. We observed a zoning meeting in which staff displayed a good level of knowledge and understanding about people’s illness, their lifestyles and their risks. Staff worked together to identify suitable short and long term interventions, to help safely manage people’s risks. We saw evidence that zoning meeting minutes clearly documented the rationale for people’s risk rating and included actions and action owners to ensure people were appropriately supported.

We observed care delivered on site and in people’s homes. In all cases, staff discussed current risks with people and sensitively explored whether people had any thoughts of harming themselves or others.

We spoke to 12 people who used services and 10 carers. They all told us they felt safe and supported from the care the adult community mental health service offered them. They told us they were involved in planning how to keep themselves safe and knew what to do if they needed additional help.

The service mostly detected and controlled potential risks in the care environment. However, some of its equipment, facilities and technology did not always support the delivery of safe care.

Most of the adult community mental health service's buildings and premises were suitable to provide therapeutic care and treatment. However, in Stockport early intervention team (EIT) we observed consultation rooms had no privacy screens or blinds on windows to protect the dignity and privacy of people using them. Staff told us this was a risk-related decision so that they could see into all rooms, though the rooms all had alarms in them. The other teams we visited had consultation rooms that provided privacy. We saw no evidence of complaints from people who used services about the lack of privacy screens.

Bury community mental health team (CMHT) was based in a local authority building in which the boiler had broken some time ago. Oil-fired heaters were used, but some staff said these did not provide sufficient heat. However, all other teams we visited were based in accessible buildings that were fit for purpose. Bury CMHT was scheduled to move into new, fit for purpose premises in December 2025.

The Heywood, Middleton and Rochdale EIT was based in a building for which internet connection had gone down before we arrived onsite. This meant the team's phone, which used internet connection, was not working. The team implemented their business continuity plan and calls were diverted to a mobile phone. However, the building was in a mobile phone signal 'black spot', meaning people who used services might not be able to get through to the team if they needed to. Some staff told us this was a frequent issue, and the internet went down for brief periods 2 to 3 times a week. However, people who used services and carers were given information about where they could seek help and were provided with other numbers to contact in case of emergency, so they were not dependent on speaking to the EIT in an emergency.

The trust was in the process of delivering its digital transformation plan at the time our inspection. The trust's estates strategy 2023-2028 included ensuring the adult community mental health service had estate that supported the delivery of care and treatment. The strategy acknowledged some of the estate was not fit for purpose and identified the actions it was taking to create technology-supported multi-disciplinary hubs in each locality. Loss of internet and critical systems was listed on the trust's risk register.

Across the adult community mental health team, equipment and furnishings were well-maintained and clean. We saw evidence of completed cleaning checklists.

Environmental risk assessments were conducted, along with ligature audits. The trust had recently changed its risk assessment process at the time of our inspection and had not yet implemented the new approach across all teams. However, the ligature audits we saw were thorough and included photographs of any potential ligature points to aid staff in assessing and monitoring risk individuals. A ligature point is any fixture, object, or part of the environment that someone could use to attach a rope or other material to attempt to harm themself.

There were security processes in place to keep staff safe. Building security measures included staff-only areas with secure access and alarms in consultation rooms.

The service did not make sure all staff were trained and had supervision in line with trust policy to ensure they had the most up to date knowledge and skills to provide the best care and treatment. The service did not make sure teams and shifts were always sufficiently staffed. However, staff worked well together to provide care that met people’s individual needs.

The adult community mental health service did not consistently have sufficient numbers of appropriately trained and supervised staff in all teams. Across the adult community mental health service, most teams had variable rates of essential training compliance. The trust’s core and essential skills training policy did not include the trust’s target for training compliance. We asked the trust for data on training compliance for the teams in the adult community mental health service, however the data shared was for both the adult community mental health service and the mental health crisis service, which were not able to be separated. Across both of these services, the average rates of compliance for training as of 15 October 2025 were as follows:

• Conflict Resolution Level 2 (PMVA 2/3) - 61.6%,
• Dementia Awareness - 66.7%,
• Resuscitation Level 2 Adult Basic Life Support (BLS) - 73.7%,
• Learning Disability and Autism Tier 1 - 21%,
• Learning Disability and Autism Tier 2 - 8.6%,
• Carer Awareness - 30.6%,
• Clinical Risk - 33.3%,
• Clozapine for Nurses - 6.5%,
• Clozapine for Prescribers and Pharmacists - 0%,
• Controlled Drug Recorded Drug - 38.3%,
• Management of Violence and Aggression 4 - 66.3%,
• Management of Violence and Aggression 4.1 - 66.7%.

The trust told us it had identified there were inconsistencies across the trust in how training was allocated to roles earlier in 2025. Since then, the trust reported it had seen improvements in overall training compliance between the end of July and middle of October 2025. At our last inspection of the service, in 2016, the trust was in breach of legal regulations in relation to staff training compliance.

Some of the teams in the adult community mental health service had high rates of staff sickness. The trust’s target staff sickness rate was 5% and the overall trust sickness rate between November 2024 and September 2025 was 6.63%. In the 12 months prior to inspection, the rates of sickness above trust average were as follows:

• Bury Active Care Co-ordination – 8.94%,
• Bury Treatment – 22.47%,
• Bury Early Intervention – 7.61%,
• Heywood and Middleton CMHT – 7.72%,
• Heywood, Middleton and Rochdale Early Intervention – 10.95%,
• Heywood, Middleton and Rochdale Treatment Support – 9.94%,
• Oldham Health Support – 18.02%,
• Stockport East CMHT – 8.4%,
• Tameside Health Support – 8.06%,
• Tameside North CMHT – 6.79%,
• Tameside West CMHT – 9.09%.

However, the adult community mental health service had a significant focus on supporting staff wellbeing. Most staff told us, and we saw evidence in team meeting minutes, that staff wellbeing was a regularly discussed and prioritised topic across teams.

Most of the teams had sufficient staffing levels. However, in Oldham community mental health team (CMHT), there were 16.38 full time equivalent (FTE) vacancies in September 2025, which was a reduction from 22.38 FTE vacancies in April 2025. Of the 16.38 FTE vacancies, 15.65 FTE vacancies were for Band 6 nurses. In the 3 months prior to our inspection, Oldham CMHT had 574 shifts covered by bank or agency staff to cover sickness, absence or vacancies. A further 212 shifts were unfilled to cover sickness, absence or vacancies.

Some of the teams in the adult community mental health services did not require the use bank or agency staff in the 3 months prior to inspection, whilst others successfully utilised bank or agency staff to cover staff absence, sickness or vacancies. Most staff told us there was a trust-wide freeze on using bank or agency staff. It was unclear how some of the teams had mitigated against lower staffing levels due to staff sickness.

Staffing risks were captured on the care hubs’ risk registers. Oldham care hub’s risk register included a risk related to staffing levels in both its CMHTs. The risk had initially been rated red, the highest level of risk. At the time of our inspection, the risk rating had decreased to amber, a medium level of risk, and was reviewed every 3 months.

Bury care hub’s risk register included a risk about demand for CMHT services being greater than commissioned capacity. The risk had initially been rated amber, as it was assessed as a medium level of risk. At the time of our inspection, the risk rating had increased to red, the highest level of risk, and was being reviewed weekly. Bury care hub’s risk register also included a risk about increased demand for Bury’s Living Well neighbourhood mental health team. The risk level was amber, and there had been no change since its initial risk rating. The risk was assessed monthly.

Stockport care hub’s risk register included a risk of increased demand in both Stockport East CMHT and Stockport West CMHT. The risk level was amber, and there had been no change since its initial risk rating. The risk was assessed monthly.

The Tameside care hub’s risk register included a risk about the Tameside Living Well neighbourhood mental health team’s capacity. The risk level was amber, and there had been no change since its initial risk rating. The risk was assessed every 6 months.

Each risk was assigned an impact score, actions and action owners, and updates on progress to date were included. A target date was set for each impact score to be lowered. Heywood, Middleton and Rochdale care hub’s risk register did not contain any risks related to the change in staffing capacity or demand because of the split from the local authority.

Staff received regular management supervision and clinical supervision. Teams with low rates of management supervision compliance in October 2025 were as follows:

• Bury Active Care Co-ordination – 70%,
• Heywood and Middleton CMHT – 50%,
• Oldham CMHT – 68.6%,
• Oldham Early Intervention – 69.2%,
• Tameside Early Intervention – 34.8%,
• Tameside North CMHT – 70%.

This meant not all staff and managers met regularly to review staff’s work and provide support to address any concerns. However, most staff told us they had regular clinical and management supervision, which they found useful both personally and professionally. Clinical and management supervision gave staff opportunities to discuss case management, reflect on and learn from practice and identify any additional support they needed.

The Living Well neighbourhood mental health teams were at different stages of implementation, so some were not yet fully recruited to at the time of our inspection.

The trust’s induction policy applied to both substantive and temporary staff, as well as volunteers. All new permanent, volunteer and bank staff were required to attend the trust induction before completing their local inductions. Agency staff were required to complete local inductions. The trust and local inductions were mandatory, as were initial training courses. The induction policy had checklists for managers to work through with new staff to ensure they had the equipment, access and knowledge needed to do their jobs.

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 in the adult community mental health service were trained in infection control. Across teams, compliance in Infection Control Level 1 training was 99% and Infection Control Level 2 training was 79%. Staff carried out their roles in line with the trust’s infection prevention and control policy.

Across the adult community mental health service, premises and equipment were clean and well maintained. Waiting areas, toilets, clinic rooms and consultation rooms were clean and well maintained. Clinic rooms had the necessary equipment available, such as hand washing facilities, to enable staff to adhere to infection prevention and control principles.

However, in Stockport East community mental health team (CMHT), we saw a sharps bin in a clinic room that had not been dated. This meant staff would not have known when it was due for disposal in line with trust policy.

The service mostly made sure that medicines were safe and met people’s needs and preferences. They involved people in planning, including when changes happened. However, access to pharmacy support was limited and varied across the service, reducing oversight of medicines management in some areas.

The adult community mental health service had systems and processes in place to support people with their medicines in the community. However, procedures for handling and administering people’s own medicines had not been extended to the assertive outreach team (AOT). We saw that for one person the reason for storing medicines at the AOT location rather than their home had not been recorded. Additionally, the recorded balance of medication did not match the number of tablets left. We raised this with the trust who assured us they took immediate action to address this and to consider how support with medicines administration could be better captured and recorded within individual risk assessments.

The trust’s clinical strategy recognised medicines optimisation as fundamental to support the delivery of safe care. ‘Medicines optimisation’ refers to ensuring the right people get the right choice of medicine, at the right time. It is a person-centred approach that improves safety, adherence to treatment and reduces waste. Medicines optimisation is part of the NHS Long Term Plan and aims to deliver a person-centred approach that improves safety, adherence to treatment and reduces waste. The trust also acknowledged that pharmacy support helped to deliver their clinical strategy. Where available, pharmacy support was valued by adult community mental health service staff. One staff member explained that they “always find [pharmacy] really helpful”.

Within adult community mental health teams, pharmacists engaged with zoning meetings and multidisciplinary team discussions to support medicines optimisation. However, although the pharmacy team was expanding, access to pharmacy support varied across the trust. For example, the AOT and early intervention teams (EIT) described no direct or only limited and/or remote support from pharmacy. This reduced support for medicines optimisation and oversight of medicines management processes. However, we saw pharmacy provision was included within a trust business case to support community transformation.

The region’s digital care record system was used to confirm people’s medicines on transfer to the team and clinic letters were sent electronically to GPs. There was no formal mechanism to ensure that letters were acted upon, but we saw some examples where these had been followed up by the service when actions had not been completed. When people were under a Community Treatment Order that referenced medicines, copies were kept in the person’s electronic record. To support engagement with people who used services, the trust was piloting the use of a nationally recognised patient-rated satisfaction scale to produce a personalised care and support plan, including a focus on the use of medicines and physical health. Bury CMHT was piloting this for the adult community mental health service. Additionally, the trust was promoting the use of a self-rated side-effect scale to help people who used services to track any side-effects and make sure that nothing was missed.

People’s medicines were regularly reviewed. People told us, “They give me choice with my medication and give me information on each of the options” and “I’m able to say that my medication isn’t working and then arrange a review with the doctor to discuss”. People also told us that they could discuss any medicines side-effects that were troubling them, with one person confirming, “they’re on the ball with that kind of stuff”.

There was oversight of attendance for depot clinic appointments. One person confirmed that if they missed a depot appointment, the service would call them. Staff provided practical support and advice about medicines. One person explained how staff contacted various pharmacies to find one that stocked their medication.

Medicines information was available to patients in different languages and in easy read formats. The pharmacy team provided ad hoc bespoke educational sessions for community teams and for carers groups.

Shared care uptake was variable across the adult community mental health service. Shared care is an agreement between GPs and secondary care services to transfer responsibility for prescribing and monitoring people’s treatment back to GPs. The inconsistencies in shared care uptake were captured on the trust risk register. This meant that community teams remained responsible for prescribing a range of medicines, increasing the risk that physical health checks and prescriptions may be missed or duplicated. The chief pharmacist was actively engaged with the Greater Manchester-wide shared care group, to identify opportunities to improve the shared care pathway. Shared care related incidents were captured on the trust’s incident reporting system to support effective reporting and analysis of shared care issues.

The trust had a clozapine steering group and engaged in regular audits to help ensure continuous improvement in the safe management of clozapine. Clozapine is a medication that requires regular monitoring. We saw that side effects were monitored, and GPs alerted for example, should a medicine need to be prescribed to manage side-effects. Any results that were outside the safe range were escalated to the consultant.

The trust had a depot clinic that administered olanzapine depot. This helped to ensure that people receiving this medicine were appropriately monitored in the clinic for any side-effects following administration. Olanzapine depot is a long-acting antipsychotic injection which has recognised health risks following administration and the manufacturer’s license requires people to have 3 hours of post-injection monitoring after every injection.

We saw evidence of reporting and learning from medicines-related incidents shared through both trust-wide and dedicated community medicines safety bulletins. Additionally, should incident theming identify incidents clustered to a particular area, the pharmacy team worked directly with that team to agree actions to drive improvement.

The trust supported the delivery of Integrated Care Board-wide medicines optimisation projects for example, through delivering reviews of Promazine and Propranolol prescribing, to support patient safety.