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 assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. We identified 1 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. In some teams there were high staff vacancy rates. There were low rates of compliance on some mandatory training courses. People’s care record documentation was not always complete or person-centred. 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. Safeguarding processes were effective. Infection prevention and control measures were well-embedded and effective. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

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 learnt to continually identify and embed good practices.

Staff understood which incidents needed to be reported and the correct process to follow. They provided examples of incidents they would report using the trust’s online reporting system. For example, they told us about safeguarding concerns 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), which is a national NHS initiative designed to improve how healthcare organisations in England respond to patient safety incidents. Its PSIRF policy stated the roles and responsibilities of all staff in response to safety incidents and emphasised the focus on embedding a just and learning culture. A just culture ensures individuals are fully supported to report concerns and safety issues, and are treated fairly, with empathy and consideration, when they have been involved in an incident or have raised a concern. Staff and managers across the service told us that following any safety incidents, the focus was on learning.

The service had a well-embedded culture of incident reporting and learning from incidents.

The service used various approaches to share learning from incidents across teams. For example, most staff told us that learning was shared by the trust via emails, as well as regular discussion in team meetings and supervision. The service also held reflective sessions for staff to attend.

Staff at Fairfield General Hospital health-based place of safety (HBPoS) said that they attended regular safety huddle meetings. These meetings were for the senior leadership team to report any issues or concerns from the previous week, to review any risks, follow up actions and to identify any lessons learnt. Staff told us that the liaison diversion team attended these meetings. They told us they had support from a mental health police link worker. Their role was to liaise with the police and Pennine Care NHS Foundation Trust mental health staff on issues such as how to support the patients who regularly presented to the service and discuss any lessons learnt.

In the 3 months prior to our assessment, 84 incidents had been reported across all home treatment teams (HTTs). Of those 84 incidents, 32 had caused no injuries, 14 had resulted in minor injuries, 30 had resulted in moderate injuries requiring hospital treatment, 4 had resulted in extensive injuries and 4 had resulted in death. The HTT service had recorded 5 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.

The service monitored the number of incidents reported in HBPoS and the number of times rapid tranquilisation was administered. Rapid tranquilisation refers to the use of tranquiliser medicines that are fast acting and are typically injected. In the 3 months prior to our assessment, no incidents were reported by the HBPoS teams.

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 assessment.

The trust reported there had been no incidents which met the criteria for recording as Never Events in the mental health crisis and health-based places of safety services in the previous 12 months. Never Events are defined as wholly preventable patient safety events.

Most 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. The trust told us that there were 6 duty of candour incidents in the 12 months prior to our assessment. 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.

There was one Prevention of Future Deaths report in relation to someone who used the service where there was limited evidence that lessons around discharge planning had been embedded. A Prevention of Future Death (PFD) report is issued by a coroner following an inquest or investigation when there is concern that circumstances surrounding a death could recur.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety or make sure there was continuity of care when people were transferred into health-based places of safety (HBPoS).

The trust told us police carried out personal searches of patients before they entered the HBPoS, and that any items deemed to be a risk were held in storage at the HBPoS. Staff had access to a safe in the nursing station to keep items safe.

The HBPoS form required confirmation as to whether the patient had been searched and the outcome of the search. However, we observed that this section had not been completed in any of the 9 forms that we reviewed. We raised this on the day, and staff told us that on transfer into the HBPoS they would always ask the police to search the patient but acknowledged that this was not consistently documented.

Staff told us that a joint risk assessment should always be completed by staff and the police prior to the police leaving the HBPoS. However, in the 9 records we reviewed, we noted that the joint risk assessment within the HBPoS form was not completed consistently.

Additionally, at Tameside HBPoS in 1 record we reviewed the risk assessment on the section 136 form had not been completed. The patient had remained detained under section 136 for approximately 12 hours.

For HTTs, 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 staff areas 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. The trust told us there was no formal disengagement from services audit process in place, and that disengagement was monitored and addressed at team zoning meetings.

The service had worked with police, other mental health trusts, the ambulance service, acute trusts, the Integrated Care Board (ICB) 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 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 service. Average training compliance rates across eligible teams were above 94% for Safeguarding Adults Level 1 to 3, and above 91% for Safeguarding Children Level 1 to 3.

Almost 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 sexual abuse and financial exploitation.

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.

Safeguarding referrals were made with the appropriate local authority, logged on to the trust’s incident reporting software, and details were added to the safeguarding section of people’s care record. We saw evidence staff correctly followed the trust’s safeguarding processes.

Heywood, Middleton and Rochdale HTT told us a new paper safeguarding capture form had recently been introduced. They told us that this form would be completed at assessment and uploaded to the system. The team had 2 nominated safeguarding leads and could get advice and support from the trust safeguarding team.

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.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 15 care records across the HTTs. Of these, 3 had no risk assessment on the system. Of the 12 care records that had risk assessments, 1 was out of date and 1 was missing information.

We saw some evidence of people being involved in their care planning. For example, 2 of the 15 care records we reviewed were written by people who used services, and 1 record documented that a person had declined being involved in care planning. However, most records we reviewed did not indicate people’s involvement.

At the time of our assessment, the trust provided details of their Care Planning Improvement Programme, which showed planned implementation for the Community Crisis pathway was scheduled for February 2026. 

The trust provided details of their internal risk assessment audit. This data indicated that whilst all HTTs had a high level of compliance for risk assessments being present, some teams had low rates of compliance for risks being assessed without the use of predictive risk rating tools. NHS England guidance says that these tools cannot reliably predict individual suicide risk and can lead to unsafe decisions.

Some teams also had low compliance for safety plans reflecting all risks identified in the risk assessment, and for evidence that people who used services had been offered a copy of their safety plan.

However, multi-disciplinary meetings were well attended and showed evidence of considering individual people’s needs.

We spoke to 12 people who used services and 11 carers. Most people told us they felt safe and supported from the care the HTTs offered them. They told us they knew what to do if they needed additional help. However, 1 person told us they felt the service did not meet the level of support they required.

The trust told us there were no incidents within the service during the last 6 months where restrictive practices were used.

The service did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.

Tameside Hospital had 2 suites at the HBPoS, and these had been in use since summer 2025. In these suites, we observed and staff told us that CCTV monitors located at the nursing station were clearly visible to patients within the suites. This visibility meant patients could potentially observe one another during the periods of detention. At the time of our visit, staff told us the estates department had been contacted to request for these monitors to be placed out of sight of patients. However, there was no timeframe for when this would happen, and it was not listed on the trust’s risk register. We raised this issue with the trust, and they conducted their own review. The trust’s review at that time did not conclude patients could observe the CCTV monitors showing the adjoining suite at any point.

The trust’s risk register stated that the Oldham HTT office was “not fit for purpose and is significantly over occupied”. It further noted poor ventilation, insufficient seating, insufficient computers, and excessive noise. The risk register recorded that this was negatively impacting staff wellbeing and may compromise patient quality and safety of care. This risk had been added in June 2024, and the risk rating had not changed.

Additionally, we observed premises concerns impacting both Bury and Stockport HTTs. The trust’s Estate Strategy 2023-2028 stated that at Fairfield General Hospital, the lack of parking caused delays to staff and reduced clinical and therapy hours available. Staff from Bury HTT also told us about these impacts to the service.

Stockport HTT was relocated to Stepping Hill Hospital in early 2025, and it was widely acknowledged by staff at all levels that this had facilitated improved joint working with inpatient wards to support inpatient discharges. However, all staff told us that car parking issues at this location negatively impacted service delivery, presenting challenges to planning home visits and reducing staff availability. These issues were recognised in the trust’s estate strategy 2023-2028. Some staff also told us they did not feel safe walking to and from the car park when working evening and night shifts.

We asked the trust to provide environmental risk assessments for the service, including any ligature audits. The trust told us that following a visit from the Health and Safety Executive, a programme of revised environmental risk assessments had been undertaken in 2024/25 and had been completed for inpatient areas. However, at the time of our assessment, the implementation for community teams and bases was still in progress and the trust was unable to provide the requested environmental risk assessments. The trust did provide ligature audits for community clinics and HBPoS.

Some staff told us that they regularly experienced outages of the trust’s electronic patient record system. Though some staff told us about paper-based contingency plans for these instances, they also explained that these were not robust systems and could impact quality of care. For example, during an outage of the system, staff may not have had access to people’s risk assessments and other information key to delivering safe care.

The trust was in the process of delivering its digital transformation plan at the time our assessment. The trust’s estates strategy 2023-2028 included ensuring services had estate that supported the delivery of care and treatment. Loss of internet and critical systems was listed on the trust’s risk register.

However, all HBPoS had recently been refurbished, had the same layout and fulfilled the MHA Code of Practice requirements. The police were able to access the HBPoS through a private entrance to support patient privacy and dignity, and each HBPoS contained a bedroom with a fixed bed, toilet and washing facilities.

All HBPoS had access to a small secure courtyard for fresh air. This was accessed through a locked door and staff told us that patients would always be supervised in this area. There was no seating available in any of the HBPoS in the courtyard. At Fairfield General Hospital HBPoS, a blind spot, unseen from the closed-circuit television (CCTV) was noted in the secure courtyard but staff told us patients would always be supervised in this area. This was not listed on the trust’s risk register.

Across the service, equipment and furnishings were well-maintained and clean. We saw evidence of completed cleaning checklists.

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 service did not consistently have enough appropriately trained and supervised staff in all teams. Across the 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 mental health crisis and health-based places of safety service, however the data shared was for both the mental health crisis and health-based places of safety service and the adult community mental health service, which were not able to be separated. This showed the average rates of compliance for training across both of these services, 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 – 21.0%,

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 assessment of the service, in 2019, the trust was in breach of regulations in relation to staff training compliance.

All HTTs had rates of sickness exceeding the trust’s target staff sickness rate of 5%, and the overall trust sickness rate between November 2024 and September 2025 was 6.6%. In the 12 months prior to assessment, the rates of sickness were as follows:

Bury HTT – 9.3%,

Heywood, Middleton and Rochdale HTT – 6.1%,

Oldham HTT 9.2%,

Stockport HTT – 8.2%,

Tameside HTT – 14.9%.

Some teams had sufficient staffing levels. However, at Tameside HTT there were 16.79 full time equivalent (FTE) vacancies in September 2025. The team’s target staffing level included 14.46 FTE Band 6 nurses, however 8.58 FTE of these positions were not filled. From April 2025 to September 2025 the team had an average 59% vacancy rate for FTE Band 6 nurses. Additionally, at Stockport HTT there were 8.31 FTE vacancies in September 2025. The team’s target staffing level included 5.6 FTE Band 6 nurses, however 2.9 of these were unfilled. From April 2025 to September 2025 the team had an average 69% vacancy rate for FTE Band 6 nurses.

At the time of our assessment, the HBPoS were manned by staff working on inpatient wards. The trust was in the process of recruiting a second staff team exclusively for the HBPoS. The aim was to have 2 teams across the trust. Staff said the minimum staffing for the HBPoS was 1 registered nurse and 1 non-registered staff member. Staff told us that the use of agency staff was not standard practice. However, bank staff employed by the trust could be used, if required.

We requested data for the number of shifts covered by bank or agency staff, and for the number of shifts that were unfilled. From the information provided by the trust, it was not clear whether 2 HBPoS and 2 HTTs had made any requests for bank or agency staff, nor how many shifts requiring bank of agency cover were filled or unfilled. The 2 HTT and HBPoS were Royal Oldham Hospital HBPoS, Tameside General Hospital HBPoS, Heywood, Middleton and Rochdale HTT, and Stockport HTT. In the 3 months prior to assessment, the trust’s data showed that across the service, a total of 45 HBPoS shifts and 245 HTT shifts were covered by bank or agency staff to cover sickness, absence or vacancies. Most teams requesting bank or agency staff were able to fill almost all shifts. For example, Bury and Oldham HTTs each had over 120 shifts to fill, and only 1 of these remained unfilled. However, the data also showed that Tameside HTT had 16 shifts requiring bank or agency staff cover, and none of these were filled.

Staffing risks were captured on the care hubs’ risk registers. Tameside care hub’s risk register included risks related to the HTT, with a lack of psychology provision added in January 2025, and limited leadership added in October 2025. Stockport care hub’s risk register included a risk relating to Band 6 nursing vacancies in the HTT that had first been added in June 2022. These risks were reviewed every 3 months, and at the time of our assessment, the risk ratings all remained unchanged from when they had been added to the register.

We reviewed patient safety incidents as part of our assessment and saw evidence that staffing levels had been a contributory factor in some instances. Ten of the 84 incidents reported by the service in the 3 months prior to assessment had a primary cause of ‘Staffing’ recorded.

Data provided by the trust at the time of our assessment showed that three HTT teams had low rates of management supervision compliance, though the timeframe of this data was unclear. These teams and their compliance rates were:

Heywood Middleton and Rochdale HTT – 42.1%,

Oldham HTT – 73.9%,

Tameside HTT – 30.0%.

However, most staff told us they had regular clinical and management supervision. 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.

We looked at clinic rooms, consultation rooms and reception and waiting areas at the locations we visited. All were visibly clean and tidy.

Cleaning records were up to date and demonstrated all areas were cleaned regularly. The service had appropriate policy and guidance for staff to follow in relation to preventing and controlling infections.

Staff in the service were trained in infection control. Across teams, compliance in Infection Control Level 1 training was 99.0% and Infection Control Level 2 training was 82.0%. Staff carried out their roles in line with the trust’s infection prevention and control policy.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

Most people we spoke with described good support with medicines. One person explained they ‘helped me sort out my medicines’ and described the team as ‘really supportive'.

Medicines information was available to people who used services in different languages and in easy read formats. People were offered and encouraged to have the appropriate physical health assessments. 

Medicines care and treatment plans were well documented throughout people’s care records. They were detailed and included information about physical health monitoring, side effects and actions for staff to take to ensure people were kept safe when taking medicines.

Records showed that compliance with medicines was discussed with people, and where appropriate their relatives. When needed, staff provided support with daily administration of medicines. 

The service considered medicines risks. For example, the service prepared and supplied smaller quantities of people’s own medicines to help minimise risks. The HTT provided support for clozapine initiation through the ability to monitor side effects and make any adjustments to medicines seven days a week. Clozapine is a drug that requires careful monitoring due to its potential for serious side effects. Medicines changes were shared with people’s GPs and where applicable other specialists, so that their prescribing records could be updated.

The pharmacy team provided expert support to the HTTs on all aspects of medicines optimisation. Between April and June 2025, all people’s medicines were reconciled within 72 hours, with 65% completed in 24 hours. Pharmacy technicians provided good oversight of medicines management processes. Medicines were safely stored and controlled stationery, for example blank prescription forms and other medicines trust stationary, were securely managed.

Staff handling medicines completed the trust’s medicines management training, with overall compliance of 82% in October 2025. The pharmacy team additionally delivered a programme of bespoke training to the HTTs to help support compliance with trust policy when supplying and administering medicines. Processes were in place for the supply and recording of medicines in the HBPoS.

There was a supportive culture regarding reporting and learning lessons from medicines incidents. Concerns about medicines could be escalated in daily meetings, which were discussed, reviewed and actions put in place to help ensure people remained safe. The trust worked with the Integrated Care Board (ICB) to support delivery of medicines optimisation priorities such as the review of promazine and propranolol, supporting the safe use of medicines.