- SERVICE PROVIDER
Pennine Care NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 21 May 2026
Contents
Ratings - Mental health crisis services and health-based places of safety
Our view of the service
We carried out an assessment of Pennine Care NHS Foundation Trust’s (PCFT) mental health crisis services and health-based places of safety (HBPoS) from 14 – 24 October 2025. The mental health crisis services and HBPoS form part of the trust’s mental health services in the community. This assessment was completed as part of CQC's Adult Community Mental Health Programme. We also assessed community-based mental health services for adults of working age as part of the programme. The programme of assessments contributes to CQC's commitment to assess the standard of care in community mental health services across the country. We undertook a short notice announced, comprehensive assessment of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well-led.
PCFT is part of the Greater Manchester Integrated Care System (ICS), and its mental health crisis services and HBPoS provide care and treatment to a population of over 1.2 million people living across 5 local authorities; Bury, Rochdale, Oldham, Tameside and Stockport. PCFT covers a diverse area, with all 5 local authorities being more ethnically diverse than the national average, with higher proportions of people from an Asian or Asian British background than average. Oldham has the highest proportion of people from an Asian or Asian British background, at just under a quarter of the population. In the Index of Multiple Deprivation, Rochdale local authority ranks in the 10% most deprived local authorities nationally, whilst Tameside and Oldham rank amongst the 20% most deprived local authorities. Deprivation is linked with poorer health outcomes. The 2021 Health Index scores indicate that Stockport had better health than across England in 2015. The remaining local authorities had worse health than the rest of England in 2015, with Rochdale and Oldham experiencing the worst in the ICS. Stockport was the only local authority with life expectancy greater than the national averages for males and females. All local authorities have higher proportions of people aged 0 to 17 years than the national average, and lower proportions of people aged 18 to 64 than the national average. Data from 2023/24 showed Tameside had rates of emergency admissions due to self-harm higher than the national average for males and females, though suicide rates were lower than the national average for both males and females. Bury and Rochdale both had higher rates of suicide for males and females than the national average.
Crisis and home treatment teams (HTTs) are specialist teams of mental health professionals including nurses, doctors, social workers, psychologists, occupational therapists, and support workers who provide short term support to people experiencing a mental health crisis. They aim to prevent admission to hospital by providing treatment and support to a person in their own home. These teams offer a range of therapeutic interventions including assessment, crisis intervention, medication management, therapy, and support for carers. They can help people manage and resolve their crises while minimising disruption to their lives. They may also support inpatient discharges to reduce length of hospital admissions.
At the time of our assessment, PCFT was not commissioned to provide a full crisis assessment service, and only routinely delivered a HTT offer in each locality, which was not always available 24 hours a day, 7 days a week. The trust was in the process of implementing its community services transformation and had submitted a crisis services expansion proposal to the Integrated Care Board (ICB). The proposal sought to secure investment to support the future delivery of a Crisis Resolution and Home Treatment Team service which would meet national guidance recommendations. If approved, this would include a 24-hour, 7 day a week urgent response assessment service which would meet NHS England guidance that very urgent presentations should receive a face-to-face assessment within 4 hours, and urgent presentations within 24 hours.
PCFT’s mental health crisis and health-based places of safety service include 5 HTTs and 3 HBPoS. The main functions of the HTTs include crisis intervention to prevent hospital admission, supporting discharge from inpatient services, and discharge follow-up for people leaving inpatient services who do not require ongoing support from community mental health services.
A health-based place of safety (HBPoS), also known as a 136 suite, is a designated space within a hospital or other health facility where individuals detained under Section 136 of the Mental Health Act can be safely assessed. People can be detained in a place of safety for up to 24 hours, allowing for the necessary assessment.
The service also included a 111 Option 2 for Mental Health service, delivered in partnership with another mental health NHS trust.
PCFT’s HTTs and HBPoS are:
- Bury HTT
- Heywood, Middleton and Rochdale HTT
- Oldham HTT
- Stockport HTT
- Tameside HTT
- Royal Oldham Hospital HBPoS
- Tameside General Hospital HBPoS
- Fairfield General Hospital HBPoS
The trust also operated a local 24/7 Mental Health Helpline which closed on 3 November 2025. People who use services could continue to access urgent mental health support by calling NHS 111 Option 2.
The teams were managed as part of locality care hubs within area networks. South Network included Tameside care hub and Stockport care hub. North Network included Heywood, Middleton and Rochdale care hub, Bury care hub and Oldham care hub.
During the assessment we visited 3 HTTs (Bury, Heywood, Middleton and Rochdale, and Stockport) and all 3 HBPoS. We also visited the 24/7 Mental Health Helpline, and NHS 111 Option 2 teams.
We last inspected PCFT’s mental health crisis services and health-based places of safety in 2019 when we rated it requires improvement. In 2019 we identified 4 breaches of the regulations in relation to having sufficient staff to provide services safely, providing staff with management supervision, safe medicines management, and ensuring staff comply with the requirements of the Mental Health Act (including the completion of Mental Health Act documentation fully and ensuring patients have their rights explained to them when detained under section 136).
At this assessment, we identified 2 breaches of the regulations in relation to staffing levels, training and supervision, and governance (including the completion of Mental Health Act documentation and ensuring patients have their rights explained to them when detained under section 136). The service still did not always ensure it deployed enough suitably trained and supervised staff to provide safe care and treatment. The service still did not ensure staff complied with the requirements of the Mental Health Act, including the full completion of Mental Health Act documentation and ensuring patients had their rights explained to them. Governance processes were not always effective.
However, the service was no longer in breach of regulations related to medicines management.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People’s experience of the service was mixed.
We spoke to 12 people who used services and 11 carers. Most people who used services gave positive feedback about their experience of the service. They told us they found the staff kind, understanding and supportive, and gave examples of staff treating them with respect and supporting their mental health.
However, some people told us they felt communication was not good. One carer and 1 person who used services told us they felt staff had been dismissive, and 2 people who used services reported feeling they had been discharged too early.
Feedback from local Healthwatch and carer support groups highlighted people’s difficulties with accessing care and treatment. During our assessment, we observed a carer who, whilst experiencing a distressing situation, was left unattended and visibly upset in a waiting area and was not offered somewhere private to be. Staff also told us about a delay to someone’s initial assessment as an appropriate interpreter could not be secured to meet their communication needs.
Between October 2024 and September 2025, the teams in scope for this assessment received 6 compliments from people who used services and carers. The service received 14 complaints in the same period.