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 assessment we rated effective as requires improvement. At this assessment the rating has remained requires improvement. We identified 1 breach of the regulations in relation to people being informed of their rights under the Mental Health Act 1983 (MHA) and in line with the Mental Health Act Code of Practice (MHA COP).

Requires improvement: Not all staff correctly carried out their roles and responsibilities under the MHA and in line with the MHA COP in relation to people detained under section 136. Staff did not always record people had been informed of their rights, searched, nor offered food and drink. Rates of Mental Capacity Act (MCA) training were low. Some people’s care plans were brief and not holistic, and care plan templates across teams were not standardised. However, staff in home treatment teams (HTTs) provided a range of treatment and care and 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 multi-disciplinary team to benefit people.

This service scored 54 (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 care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

The quality of care plan documentation varied across teams. We reviewed 15 care records across HTTs and of these, 3 did not contain an up to date care plan. Most care plans we reviewed were not personalised, holistic or recovery oriented, and there was limited evidence of the patient voice in most of the care plans we reviewed. Fourteen of the 15 care records we reviewed contained a mental health assessment, but quality of these also varied. Some mental health assessments were comprehensive and holistic, whilst others were brief and basic.

However, we did see some evidence that people were involved in care decisions, for example, where it was documented that a person had declined medication.

The trust had last undertaken an audit of care plans in December 2024, the results of which were published in April 2025. The audit showed there were inconsistencies in the quality of care planning across the service. There were several recommendations made to improve the quality of care planning and record keeping. Staff told us, and we saw, plans confirming the new approach to care planning was scheduled to be implemented across the service in March 2026.

Of the 15 care records we reviewed, most had evidence of initial physical health screening being completed in a timely manner. Staff told us that for people detained in the health-based places of safety (HBPoS), the duty doctor completed a physical health screening of all patients who gave consent. We reviewed 9 records which supported this across all HBPoS.

The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards in relation to being detained in HBPoS.

The trust told us there were no routine audits for Section 135 and Section 136 of the MHA. We observed, and data showed, staff did not always accurately record mandatory information in relation to people detained under section 136 of the MHA. For example, data provided by the trust indicated that in 2024 the percentage of section 136 cases with no evidence of rights being explained to people was 35%. From 1 January to 30 September 2025, this was 25.8%. Additionally, the section 136 form required confirmation that the patient had been searched and the outcome of the search. However, we noted that this section had not been completed in any of the 9 forms that we reviewed.

An Approved Mental Health Professional (AMHP) is a professional responsible for assessing people and making decisions about their treatment and admission to hospital. We found that in 2024, 169 cases (24%) had no evidence recorded as to whether the AMHP arrived. This increased from 1 January to 30 September 2025 to 172 cases (36.3%). The data showed that in 2024, 7% of all section 136 cases had no recorded outcome, and this figure increased from 1 January to 30 September 2025 to 10.4%.

At Tameside and Oldham HBPoS, we reviewed 4 patients’ records where the diet and fluid intake were not documented. For 1 of these patients, the observations showed that the patient had been asleep through the night. However, there was no evidence that food or fluid had been offered when they were initially admitted during the afternoon or evening.

We asked the trust for MHA training compliance data. The trust did not supply this data for Bury, Heywood, Middleton and Rochdale, Oldham and Tameside HTTs, nor for staff deployed to any of the HBPoS. Data provided by the trust stated that 33.3% of staff at Stockport HTT were compliant with MHA training.

However, most teams had access to a full range of specialists required to meet the needs of people who used services, such as nurses, support workers, psychologists, social workers and consultants.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff told us they held regular and effective multi-disciplinary meetings. We observed that staff shared information about people who used services at effective MDT and handover meetings. Most staff told us teams had effective working relationships, including good handovers, with other relevant teams within the organisation. The HTTs held gatekeeping responsibilities, and effectively managed referrals from other teams and services. For example, Stockport HTT worked closely with inpatient wards and liaison teams to support early discharge for people. Staff and managers told us that teams carried out joint reviews of people who used their services, involving other teams such as the community mental health teams and liaison team. Stockport HTT had a daily meeting with AMHPs and liaison team.

We reviewed records of a patient who had recently been in the Tameside HBPoS. We saw an enhanced crisis plan had been recorded and they were being supported by staff from a community team.

Most staff told us they had effective working relationships with teams outside the organisation including the police and local authority social services.

However, we heard that at the time of our assessment there was no police liaison officer in place for Stockport HTT. Some staff told us that community mental health teams (CMHT) were sometimes referring people who used their services to Stockport HTT too late, and some staff also told us that the gatekeeping process could sometimes hinder good relationships between internal teams. We heard that regular meetings had been established with the CMHT to address these issues.

The service supported people to manage their health and wellbeing to 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 service supported people who used services to live healthier lives. Staff told us they had helped promote a healthy lifestyle for people who used services and told us they would refer people to smoking cessation support services if the person expressed interest in this.

The service referred people to external organisations such as substance misuse services if there was a need. For example, we reviewed a care record where a person had been referred to the drug and alcohol service, and we observed the team discussing referrals to community rehabilitation teams.

Some care records we reviewed included support for physical health, lifestyle and wellbeing needs. For example, we reviewed a care record which noted a carer’s concerns around the person’s diabetes, diet and exercise, and the service had sent a letter to their GP to communicate these concerns for follow up.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We asked the trust to provide us with details of outcome measure audits, however the information provided did not relate to HTTs or HBPoS. Most staff we spoke to during our assessment told us they were unaware of any outcome tools they should use to monitor people’s care and treatment.

However, staff at Bury HTT told us they had used a nationally recognised outcome assessment tool since 2022, and we saw evidence of this being used in the 5 care records we reviewed for this team.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

We saw evidence that people’s capacity to consent and that people’s rights had been explained, was not routinely documented by all teams in the service.

We reviewed 15 care records across HTTs. At Stockport HTT, 3 of 5 care records had no details of informed consent recorded. At Heywood, Middleton and Rochdale HTT, we reviewed 5 records, 3 of which had consent recorded, but 2 of these had very limited information and the third was not recent. However, at Bury HTT, details of informed consent were documented in all 5 care records we reviewed.

Within its Section 136 policy, the trust had a ‘Rights of persons detained in places of safety’ policy. This stated that the recording of rights must be clearly documented on the 136 monitoring form by a designated section 136 co-ordinator. In the records we reviewed at Tameside HBPoS, for 1 patient we could not find evidence that they had been given information about their legal position and rights. The trust also provided us with data which showed between 1 January and 30 September 2025, 25.8% of records did not evidence that people had been informed of their section 132 rights in relation to detention under section 136.

We asked the trust for mandatory training compliance data, including Mental Capacity Act (MCA) training. The trust did not supply this data specifically for HBPoS staff, as at the time of our assessment these were staffed by inpatient wards.

HTTs had variable compliance rates for MCA training, averaging 77.9%, with the highest being 100% at Bury and the lowest 58.8% at Heywood, Middleton and Rochdale.