Pennine Care NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained as requires improvement. We identified 1 breach of the regulations in relation to governance. The score of 1 for the ‘Governance, management and sustainability’ quality statement limits the overall key question score rating to requires improvement.

Requires improvement: Governance processes were not always effective at providing managers and senior leaders with consistent oversight of teams’ performance. There were differences in the quality of people’s care records across teams. However, leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the trust’s vision and values and how they applied to their work. Staff felt respected, supported and valued. The service worked well with partners to support people who used services.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most of the service had a shared vision, strategy and culture. However, some staff told us they found the recent changes to the service confusing.

At the time of our assessment, the trust was in the process of making significant changes to its service through its community transformation. Managers and senior leaders could clearly articulate the transformation’s aims and objectives. However, some staff told us they were confused about some of the changes and the reasons for these.

Most staff told us they were aware that not all teams currently worked in the same way and that standardisation was needed to reduce health inequalities for people who used services.

Teams and staff displayed the trust’s values of kindness, fairness, ingenuity and determination.

Teams across the service all displayed positive workplace cultures based on teamwork and trust. Most staff told us how supported they felt by colleagues and that they knew they could always speak to colleagues to get advice or support.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Leaders had the skills, knowledge, and expertise to perform their roles. Leaders spoke to us with openness and expressed passion and pride when telling us about the work their teams were doing, whilst acknowledging areas they wanted to improve.

Leaders understood the services they oversaw. They told us about specific challenges their teams experienced, including any recent incidents. Leaders spoke enthusiastically and knowledgably about quality improvement work that was underway and how their teams supported the delivery of care to different populations.

Most staff across all teams told us they felt supported by managers and that they found managers and leaders approachable and accessible. They all told us they felt able to seek support from managers and leaders as needed. Across teams, staff praised managers and leaders for their skills, knowledge, support, and leadership.

However, some staff told us leaders were not always visible to all teams. Leaders told us they made additional efforts to regularly base themselves in different teams to ensure they stayed connected.

The service fostered a positive culture where staff felt they could speak up and their voice would be heard.

The trust had a Freedom to Speak Up Guardian and Freedom to Speak Up Ambassadors across teams. Most staff and managers were aware of Freedom to Speak Up and told us they felt able to raise any concerns within their team. Managers across teams told us they tried to foster an open and supportive environment in which they hoped staff would feel able to raise any concerns directly with them.

The trust marked National Freedom to Speak Up month in October each year. In 2024, it used Freedom to Speak Up month to promote work around the role and recruitment of Freedom to Speak up Ambassadors.

In May 2025, a Freedom to Speak Up deep dive review of concerns raised in 2024/25 was presented at the People and Workforce Committee. It showed that across the trust there was almost double the number of concerns raised compared with the previous year. The data was not specific to the service. Across the trust, the most frequently reported concerns related to policy and procedures, bullying and harassment, management practices, and worker safety and wellbeing. The paper made several recommendations and noted that some of the actions were being included in the ongoing work to create the trust’s Freedom to Speak Up Strategy.

The trust had reviewed its Freedom to Speak Up provision against the 5 recommendations for all trust boards made by the National Guardians Office. The trust had a full time Freedom to Speak Up Guardian role, and the draft Freedom to Speak Up Strategy addressed the other recommendations in relation to strengthening feedback loops, investing in line manager training and monitoring resolution and impact.

Staff said they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards people who used services without fear of consequences and told us they had done this through the freedom to speak up guardian in the past. They were aware of the trust whistleblowing policy and how to raise concerns with a manager.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust had a range of staff support networks that supported staff equality and diversity. The staff support networks provided opportunities for staff to seek support and learn from each other. The trust told us the networks also aimed to influence positive change across the trust, support the career development of their members, and help the trust improve its understanding of the needs of both staff and people who used services.

Staff could attend support networks including the Carers Network, Faith and Beliefs Network, LGBTQ+ Network and Allies Group, Men’s Wellbeing Network, Neurodiverse Network, Positive Ability Network, Race Equality Network, and Women’s Network.

Some of the networks, such as the Men’s Wellbeing Network, organised events and talks to promote wellbeing for its members.

The trust had health and wellbeing champions across services. Champions were from all staff levels, demographics and backgrounds. They signposted colleagues to local and national health and wellbeing support offers and met regularly to connect and share ideas.

The trust undertook equality monitoring to ensure its staffing was diverse and representative of the people who used services. The trust reviewed its 2024/2025 Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results and identified actions to improve equity for racialised and disabled staff. The actions were taken forward and reported through the Equality, Diversity and Inclusion working group. WRES and WDES data are only available at trust-wide level.

The trust carried out equality impact monitoring through staff surveys. These helped senior leaders assess the impact of equality and diversity initiatives on staff’s experiences at work. For example, the trust had introduced a Lead Positive Programme which developed professional and interpersonal skills to address systemic discrimination.

The trust had a zero-tolerance approach to discrimination. The trust website included their anti-racism statement and transgender and non-binary statement.

Most staff and managers told us that the trust was supportive of offering flexible working arrangements to staff. The Flexible Working Policy and Procedure supported staff who wished to make flexible working requests and stated the stages and timeframes of the process. Some staff told us about their own flexible working arrangements that supported their caring responsibilities or health needs.

There were inconsistencies in responsibilities, roles, systems of accountability and governance across care hubs and teams, which the trust was in the process of standardising. The quality of care records varied across teams, and there continued to be gaps in completion of Mental Health Act documentation and ensuring patients had their rights explained to them when detained under section 136. However, the service mostly acted on the best information about risk, performance and outcomes.

Across teams and care hubs, there were inconsistencies in how teams operated. Processes were not always effective at ensuring people who used services received care and treatment that were delivered by sufficiently trained and supported staff or their experience of care was of a consistent standard across teams.

Staff and managers were able to articulate how information flowed up and down through governance structures between staff and senior leaders. We saw care hubs held monthly meetings that covered key issues such as quality, workforce, performance and finance. However, there was not a consistent governance structure across network meetings. We saw that north and south networks’ governance meeting minutes varied considerably. In Stockport and Tameside and Glossop, monthly ‘care hub, quality, operations, performance and finance’ meetings were held. Minutes of these meetings showed a lack of consistency in agenda items. Heywood, Middleton and Rochdale, Oldham, and Bury had monthly integrated quality and operations meetings. Minutes of these meetings also showed a lack of consistency in agenda items. This meant it was unclear how some information flowed up and down in a way that ensured consistent oversight across the service.

We requested audit data about the use of sections 135 and 136. The trust told us there were no routine audits in place, however they were able to provide relevant data. We observed, and data further evidenced, staff consistently did not record key information in health-based places of safety (HBPoS) sections 135 and 136 documentation. This included failure to consistently record whether patients had been read their rights, whether searches had been carried out, and whether an Approved Mental Health Practitioner (AMHP) had been requested. At our last assessment, the trust was in breach of regulations relating to the full completion of Mental Health Act documentation and ensuring patients had their rights explained to them.

A Prevention of Future Deaths (PFD) report is issued by a coroner following an inquest or investigation when there is concern that circumstances surrounding a death could recur. In November 2024, the trust responded to a concern raised about discharge planning in a PFD report. The trust said that, in accordance with the HTT Standard Operation Procedure (SOP), service and team managers held responsibility for auditing discharges and onward referrals. However, at the time of our assessment, the trust told us the service did not conduct any audits on discharges.

We requested audits of care plans in relation to HTTs. The trust told us that there were no monthly audits of care plans but were able to provide the most recent Clinical Audit of care plans and risk assessments, which had been conducted in December 2024 and published in April 2025. We also noted, and the trust told us, that the HTT SOP’s formal review date of October 2024 had lapsed. The service told us the SOP had undergone its scheduled review in October 2024, but that this had not been formally documented. The trust explained that the document would be revised and updated as part of the Crisis Resolution and Home Treatment (CRHT) transformation programme. The quality of the care records we reviewed was variable across and within teams. We observed that some people did not have risk assessments, and some were out of date or missing information.

At the time of our assessment, the trust was undertaking a trust-wide review of its governance systems and structures. Senior leaders told us they recognised there was variation in service delivery, which they were in the process of addressing.

The trust had identified from other CQC assessments during 2025 that its staff had not all been correctly allocated the mandatory training courses necessary for their roles. It had addressed the training gaps and was making improvements in the compliance rates of essential and mandatory training courses at the time of our assessment. However, compliance rates were still low.

However, some of the trust’s governance processes were effective. The HTTs had plans for emergencies that were specific to each team. Teams’ business continuity plans included instructions for managers and staff to follow in a range of emergency situations to limit the impact on service delivery. The business continuity plans included clear escalation processes.

Staff maintained and had access to risk registers for each care hub. Each risk was assigned an impact score, actions and action owners. A target date was set for each impact score to be lowered.

Information governance systems protected the confidentiality of people’s information, such as care records.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff at all levels told us about the importance of working collaboratively with partners and other agencies to provide holistic, effective and safe care to people who used services.

The trust’s clinical strategy 2023-2028 outlined the trust’s commitment to strengthening relationships and working in partnership with local organisations to support people’s mental health and wellbeing. It stated its aim was to provide seamless pathways for people who used services between primary and secondary care by working in partnership with primary care and the local authority.

When serious incidents occurred, the trust informed the relevant bodies and worked with the relevant organisations such as the police, to investigate and share learning. Senior leaders told us they informed their commissioners about patient safety incidents or concerns and attended regular Provider Oversight Meetings. The trust’s board papers evidenced close working with the Integrated Care Board (ICB) on a range of issues that affect service delivery, such as business plans and finances.

The trust had carried out stakeholder mapping as part of implementing the Patient Safety Incident Response Framework (PSIRF). It had subsequently invited external agencies and third-party organisations identified into internal governance processes to ensure robust oversight and understanding of any incidents. For example, the physical health strategic group included representation from acute trusts to help strengthen physical health support for people with severe mental illness. The trust’s suicide prevention and self-harm reduction steering group had representation from neighbouring mental health trusts and voluntary, community and social enterprise organisations.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Most staff across different teams told us about quality improvement work that was underway regarding the care plan improvement programme. For example, some staff told us they had attended meetings about care plan design. We also heard about the service’s efforts to increase feedback by adding the Friends and Family Test QR code to all correspondence with people who used services.

We saw a report produced in May 2025, which evaluated the efficacy of an outcome measurement tool which had been implemented at Bury HTT. Analysis had been done to explore completion rates, whether people accepted by the service were at the right level of need for the service, whether people were sufficiently recovered at discharge, and whether people had improved during their time with the service. As a result of this work, areas for improvement had been identified, and there were plans to extend use of the outcome assessment tool to other teams, though no date had been set for this.