Pennine Care NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

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

Good: This meant people’s needs were met through good organisation and delivery. Staff delivered person-centred care. People were given information about their care and treatment. Staff were knowledgeable about health inequalities and sought to address these. The service treated concerns and complaints seriously, investigated them and learnt lessons from the findings. However, there were high rates of abandoned calls and some people stayed in the Health Based Place of Safety for longer than they should.

This service scored 71 (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 mostly made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

People we spoke to said that staff understood their individual needs including cultural and religious needs. Staff helped people who used services with social issues, such as unemployment and access to services.

Staff discussed people’s specific needs in regular meetings. Staff made sure people could access information on treatment, local services, and how to complain.

Staff from the home treatment teams (HTTs) were able to record people’s individual needs and preferences in care records, and whether they had any communication or accessibility needs.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff ensured that people who used services had access to support groups to build relationships and community integration. For example, some people told us about recommendations staff made around community groups based on people’s interests and supported them to connect with and attend these groups.

Staff supported people to maintain contact with their families and carers. Patients detained in the health-based places of safety (HBPoS) at Fairfield General Hospital and Tameside General Hospital could keep their own mobile phones after an individual risk assessment. Staff told us at the Royal Oldham Hospital HBPoS that patients would be required to hand their phones to staff on admission, irrespective of an individual risk assessment. However, we were advised that after a risk assessment had taken place, the phones would be returned where appropriate. Staff confirmed that a phone was available for patient use with staff support as required.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff could provide information in accessible formats and usually had access to British Sign Language translation services and interpretation services for people with English as a second language. Staff ensured, where possible, that while people used services they could obtain information on treatments, local services, patients’ rights, and how to complain.

However, during our assessment, staff at Stockport HTT told us 1 person was still waiting for their initial assessment 2 weeks after being referred, as the trust’s contracted interpreter service had a 6-week waiting list for an interpreter of the required language. We were told this had been raised as an incident relating to delay of care and had been escalated to managers and the Evaluation and Diversity panel. Staff told us they had submitted a purchase order to gain approval to use an alternative interpreter provider, and at the time of our visit, were still waiting for this to be approved. We remained on site and escalated our concern to management to secure assurance that the person’s initial assessment would be facilitated the next day. Staff told us they had made efforts previously to support the person’s communication needs in various ways, for example by printing off communication cards, using online platforms to support typed communication, and using handwritten communication.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and treatment.

We saw evidence HTTs enabled people who used services to provide feedback on their care via a survey which could be accessed through a QR code on leaflets and posters. Leaflets also offered paper copies of the form. All staff we spoke to had good knowledge of the service’s complaint process and knew how to handle complaints appropriately.

Between October 2024 and September 2025, the HTT services received 14 complaints. The most common theme of those 14 complaints was patient care and clinical treatment, followed by staff values and behaviours.

Across the care hubs, which included both HTTs and adult community mental health service teams, the trust received 31 complaints between October 2024 and September 2025. Of those 31 complaints, 12 were not upheld, 4 were unsubstantiated and 15 were partially upheld or upheld. The data did not state the number or themes of complaints specifically in relation to the crisis and health-based places of safety service.

Between October 2024 and September 2025, the Parliamentary and Health Service Ombudsman (PHSO) informed the trust of 3 complaints it had received in relation to the service. Of those 3, the PHSO decided to take no further action in relation to 2 complaints and was considering whether to proceed with the third complaint at the time of our assessment. The trust confirmed the PHSO had not upheld any complaints in relation to the service in the 12 months prior to our assessment.

We spoke to 12 people who used services and 11 carers. All of them told us they either knew how to make a complaint or would feel able to find out how if needed and 3 told us they had raised concerns. Two of these told us they felt listened to by the service and were happy with the outcome.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

There were high numbers of calls to the 111 Option 2 for mental health service that were abandoned. This meant some people who used services requiring urgent help may not have been able to get through to a staff member. Data provided by the trust showed that between January 2024 and October 2025, the average rate of abandonment of calls was 41.1%. This placed people who used services at risk of harm as they may not have been able to access the service at a time when their needs were higher.

We requested data from the trust, including the number of breaches of 24 hours or 36 hours and the total length of people’s stay in HBPoS. The trust’s Mental Health Act (MHA) office provided a section 136 MHA activity and compliance report. The trust told us that of the 473 uses of section 136 in the period 1 January 2025 to 20 September 2025, 38 patients under section 136 were detained for longer than the permitted 24 hour detention period. The report provided did record the start and end time of people’s detention, however it did not include the total length of stay. We also requested the length of time from detention under section 136 to assessment by an AMHP and doctor. The trust told us staff do not record time specific data in relation to assessments undertaken by AMHPs or doctors, and there was no audit in place which would be able to provide this information. We also requested the reasons for extended stays, however data provided by the trust showed that this information was not routinely recorded.

HBPoS staff told us a weekday ‘operation escalation level’ meeting took place which was a bed management meeting. Any section 136 detentions that may potentially breach the 24-hour timeframe would be escalated to this meeting. Staff said that senior leaders were present at these meetings and they could make decisions on out of area placements. In addition, staff told us that a proposal had been made to fund an independent Approved Mental Health Professional (AMHP) to reduce delays, but at the time of our visit, a final decision had not yet been reached.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes.

In 2024 the trust established its Health Inequalities Oversight Group and one of its focuses was on implementing the Patient and Carer Race Equality Framework (PCREF). PCREF is a national framework which aims to reduce the racial inequalities often seen in mental health. The trust worked with a neighbouring trust on implementing PCREF across Greater Manchester and had participated in community engagement events as a Greater Manchester Reducing Racial Inequalities Provider. The trust had presented on their progress to date at the NHS England Advancing Mental Health Equalities Task Force Meeting in June 2025. We saw evidence the trust had received praise for the progress it was making, particularly in the development of a local dashboard to help monitor inequalities, from NHS England. The trust’s PCREF self-assessment had identified areas of focus, such as on collecting demographic data. We saw evidence in care records and in Community Treatment Order (CTO) application data that demographic data was collected.

Health inequalities were included in the trust’s strategy and annual plan. The trust told us their strategy adopted a ‘prevention first’ approach. Staff and senior leaders told us the trust’s community transformation aimed to reduce health inequalities by providing a greater level of preventative support.

Staff were trained in equality and diversity. All teams across the mental health crisis and health-based places of safety service had at least 95% compliance.

All staff, managers, and senior leaders were knowledgeable about the health inequalities often faced by people who used services.

Senior leaders told us care hubs had been set objectives as part of their business plan to improve understanding about access and outcome inequalities locally.

People were supported to plan for important life changes, so they could make informed decisions about their future.

People told us the service helped them plan what to do if their condition deteriorated and ensured they had contact details to use if this happened.

Staff usually ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. Staff told us they were able to refer to other teams and services if appropriate, such as drug and alcohol or physical healthcare services, and people told us they had experienced this.

Discharge planning from HTTs usually included discussion with family members and development of crisis plans.

However, some people who used services told us they felt they were discharged too early, sometimes without clear expectations around next steps. Some people we spoke to, and their carers did not feel they had been given the necessary information they needed. One person told us their carer “was told nothing about how to deal with me – I went home and I was still ill”. Another person we spoke with said “they discharged me when I was still poorly”.