Pennine Care NHS Foundation Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as outstanding. At this assessment the rating has changed to requires improvement. We found staff had not received all their mandatory and role essential training especially in relation to the Mental Health Act and Autism and learning disability. We also found the unit was often short staffed with shifts not filled by bank or agency staff. The Hope unit was, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

The evidence showed an exceptional standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

There had been 1 serious incident in the last 12 months, learning from the incident had been discussed and improvements made. Safety alerts are shared by ward managers, and these were cascaded to all staff on the ward. Local safety alerts were discussed with the team via daily safety alerts in the Hope unit nursing handover (twice daily) and again at the multidisciplinary team handover (once a day). They asked staff to read the safety alert and to sign to say they had read the alert.

All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Staff received feedback from investigation of incidents. Staff met to discuss that feedback. There was evidence that changes had been made because of feedback. Learning was discussed and fed back to staff. We observed a multi-agency leader meeting (MALM) and discussions about an incident that had happened on the ward was discussed. SWARM huddles were held on the ward following an incident. The huddle is a meeting used to identify immediate learning from patient safety incidents and deliver learning.

Improvements in safety specific to this service were medication error improvement plans. Mental Health Act (MHA) Section 17 leave improvements due to the checklist being cumbersome and time consuming and to capture the patient’s voice. Other examples were the introduction of a safety nurse role on each shift. Funding had been approved to raise the height of the perimeter fence in the garden area due to a number of Absent without Leave (AWOL) incidents. A care planning workstream had also been completed and there were twice weekly reporting on care plan review compliance. At the date of the assessment CAMHS was 100% compliant. Enhanced therapeutic observation of care policy was introduced that aligns with the new national policy to look at enhancing practice within this area.

Staff were debriefed and received support after a serious incident as well as patients.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

We observed a MALM escalation solutions focused meeting where the trust and partners captured all relevant information in relation to an individual young person. This included information regarding barriers to discharge, any recent incidents along with discussions and actions from each MALM meeting. This meant that all professionals involved in the care and treatment of individual young people were kept up to date and informed.

Staff made sure there was always continuity of care, including when people moved between different services and trusts. Where young people had been transferred to Hope unit from another trust, staff from the transferring trust are invited to join Care Planning Approach meetings and professionals’ meetingsto keep updated on the young person’s care and treatment.

Care records demonstrated young people and family involvement in treatment pathways. There was a pathway in place for people to access emergency treatment at the local general hospital which was on site where appropriate. There were systems in place to oversee the transition of young people to adult services.

The evidence showed a good standard. 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, knew how to make a safeguarding alert, and did that when appropriate. Staff completed child and adult safeguarding mandatory training. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. The Hope Unit delivers services to children across Greater Manchester and beyond and the service made referrals to all local authority safeguarding teams wherever the child resided.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Shared learning was cascaded with the Hope unit in relation to statutory reviews into child safeguarding. There were clear policies and governance around safeguarding restraint, restrictive practice and blanket restrictions.

Staff followed safe procedures for children visiting the service. This required a procedure to be followed to ensure the safety of the child. They had information leaflets and posters to inform families and young people of relative visits which had been coproduced with people with lived experience.

Staff had received training in preventing radicalisation and preventing radicalisation (Mental Health) Level 3.

Restrictive practice and blanket restrictions were reviewed monthly by the Hope unit team. Any new restrictions for consideration were brought to the weekly patient safety panel (PSP) for discussion prior to implementation. Restrictions were discussed at the panel, and any actions or considerations were addressed with the ward via the quality matron. Evidence we reviewed identified that restrictions were being reviewed and removed where needed.

Mental Capacity Act MHA

89% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions. When young people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Best interest meetings were held on the Hope unit and were arranged with the Multi-Disciplinary Team (MDT) with the young person’s capacity being assessed.

Gillick competence was used (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment.) Capacity to consent to care and treatment was documented for each young person.

Only 58% of staff had received Mental Health Act training. The staff we spoke with confirmed they had received some training on the Mental Health Act as part of their induction and/or ongoing continuing professional development.

Staff had access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew how to contact their Mental Health Act administrators. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice via the trust’s intranet. Policies and procedures reflected up to date legislation and national guidance. The trust’s Mental Health Act team provided a weekly summary report to each ward, flagging any Mental Health Act compliance issues which needed to be addressed. This was reviewed by the ward manager and any actions disseminated to the team to read young people their rights.

Consent to care and treatment was audited under the MHA and care records we looked at stored information on their IT system about the sectioning of young people under the MHA, associated reports and S17 leave documentation. The trust was incident reporting where planned S17 leave was cancelled. There had been 1 incident reported in the last 12 months, and this was due to staffing issues.

Information was available on the ward for the young people to access to inform them about the MHA.

Patients had access to information about independent mental health advocacy. This was displayed on the ward in communal areas. The patients we spoke with were aware of how to seek advocacy support and said that advocates were able to attend ward meetings to support them when they requested this. Family members had access to family ambassadors and lots of information for parents was available on the trust website.

Care records referred to Section 117 aftercare services for those who had been subject to section 3 or equivalent powers under the Mental Health Act. Where patients were covered by Section 117 of the Act in relation to their care post-discharge, this was included in their discharge plans and discussed at the MALM (multi agency leadership meeting).

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

Staff explained rights under the Mental Health Act to patients in a way that they could understand, repeated them as required and recorded that they had done this.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at 4 risk assessments / risk management plans and care plans during the assessment.

Restraint was used as a last resort. Incidents requiring the use of restraint were documented on the trust incident reporting system and included details around the incident, the type of restraint used and the length of time it was used for. Incidents of restraint were reviewed by the head of quality and reducing restrictive practice lead. They involved where needed the managing violence and aggression team and safeguarding.

Rapid tranquilisation (RT) had been used 24 times in the last 11 months, and this involved 4 patients. Staff monitored patients following any use of RT; this was done in line with the trust policy “short term management of acutely distressed patients and rapid tranquillisation”. Monitoring forms of visual observations were completed and uploaded to the patients care record. The reducing restrictive practice lead had oversight to ensure completion of the relevant forms following use, as well as being reviewed by the ward pharmacist to ensure that it was prescribed effectively and safely. This was also audited through the monthly quality matron audits and was incident reported. The medicines safety officer also audited this on a monthly basis to ensure this had been incident reported and if physical health checks had been completed.

There had been 33 episodes of seclusion involving 6 patients over an 11-month period. Procedures detailed in the seclusion and long-term segregation policy support safety around the use of seclusion, with information to help decision making around whether seclusion was required. We also saw completed, use of seclusion quality checklist and reviews. Periods of seclusion were reviewed by the ward, using a seclusion pack. They were also monitored at the weekly network patient safety panel and added to the incident reporting system. There was an out of hours duty system in place along with a night manager and medical out of hours cover.

There were 18 incidents where staff were injured in the last 11 months, but 32 injuries sustained. This was because they captured more than one injury per incident. For example, this might be a single incident in which a staff member sustained an injury to a joint but also a skin injury, such as scratching or a skin tear. All incidents were reported and overseen by the violence reduction and response group, security management group and health and safety committee where these incidents, causes, location, gender, race and learning were understood in greater detail across the groups. In response to incidents of violence and aggression within the trust, the trust has developed a tool kit to support managers and staff in how they respond to incidents.

Staff involved patients in care planning and risk assessment, shown by evidence in care plans, and participation in multidisciplinary team reviews. Young people had access to a copy of their care plan if they wanted. There was evidence in the care plans and risk assessments that the young people and their parents where possible were involved in creating these.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Some young people chose to use whiteboards and notes to communicate. We did not see any technology being used to help with communication.

Staff enabled patients to give feedback on the service they received for example, via surveys and community meetings. The patients owned their community meetings and led on these meetings. An information leaflet on the use of restrictive practices and use of force had been produced with young people and carers with lived experience.

Staff ensured that patients could access advocacy.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The unit was welcoming, clean, and well-staffed during the dates of the assessment. They had been awarded a 5-star cleanliness award by the trust. Staff explained that the décor was created in collaboration with young people.

The environment included a variety of therapeutic spaces, such as a female only lounge that also provided a space at lunchtime for meal support with the young people. The sensory room was well equipped and regularly used by young people. There was an activity room, and it included a large screen. They had “grab and go” activities available so that young people could choose their own activities. There was a spacious communal area, dining room and a kitchen area. The large outdoor garden area on the ground floor was accessed via a locked stairwell. Due to the fence being too low the patients who accessed the garden area were accompanied by staff. The fence surrounding the garden area was due to be replaced and funding had been agreed to make the fence higher as children and young people had been able to go absent without leave (AWOL) over the fence. All bedrooms were ensuite and there were rooms where children or young people could meet with visitors. There was a large conference room.

Staff did regular risk assessments of the care environment and access to the kitchen area was supervised and risk assessed in the morning pathway review.

The ward layout did not allow staff to observe all parts of ward. However, mitigations had been put in place to manage any blind spots this included staff being positioned in areas where blind spots were identified.

There were some potential ligature anchor points, and these were highlighted in the ligature heat map and staff had mitigated the risks adequately by always having staff in these areas. CCTV was in place in the patient areas of the ward apart from the patients’ bedrooms with mirrors placed where blind spots were evident. There were 3 ligature cutters on the ward, and they were clearly marked on the ligature heat map. The ligature risk assessment was dated July 2025.

Fire risk assessments and policies and procedures were in place as well as fire evacuation plans. 79% of staff had completed their fire safety training with staff who needed an update had been booked onto training. They had completed personal emergency evacuation plans for patients that needed one.

The unit was a mixed gender ward and the unit complied with guidance on eliminating mixed-sex accommodation. With patients having access to their own ensuite in their bedrooms with showering and toilet facilities.

All staff had access to alarms and patients had easy access to nurse call systems.

The seclusion room allowed clear observation and two-way communication and had toilet, shower facilities and a clock. The unit had access to a monitoring system that used infrared cameras to track patient breathing, pulse and movement whilst in seclusion.

The clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Establishment levels of staff by role as a WTE (whole time equivalent) was 69. However, this included staffing numbers for another unit at the site that was currently closed to admissions.

There had been 226 shifts filled by agency staff and 2072 shifts filled by bank staff in the last 12 months. However, the trust informed us the system used to capture the data was not fully correct. When agency was used these were incident reported. The trust provided data that indicated that there were 403 shifts which were not filled by bank or agency staff.

The ward manager told us there were often times where the ward was short staffed and this was due to high levels of incidents and observations and agency and bank staff were used daily due to sickness and long-term sickness. However, this was escalated to senior management.

There were safety planning mechanisms in place. There was a safety huddle held every morning with the nurse in charge, shift coordinator, ward manager and the operational manager. They reviewed the staffing shift by shift for the proceeding 72 hours and checked for the skill mix of senior nurses, preceptee nurses, paediatric immediate life support staff and those who were trained in managing violence and aggression. Prioritisation was given to ward acuity, observations and unit activity and interventions for the young people. Senior oversight of this was communicated to the acute pathway service lead and to the associate director of operations for any staffing shortfalls and requests for agency in exceptional circumstances. Out of hours the night manager and on call were informed of any staffing shortfalls and management plans for this. This allowed for a review of staffing across the trust footprint and support gained from other areas.

Staff from North and South ward and Ramsbottom ward would come to support when required and available. North and South ward were not in the same building they are on the same site. Ramsbottom ward is in the same building and staff from all wards will respond when needed. This was to help ensure minimum staffing levels were met.

Young people who required enhanced observations such as 1:1, 2:1 continued to receive these as prescribed.

Staff reviewed activities and if required any non-essential meetings were stood down and activities were reduced for a short period. Incident reports were also completed for this. When required members of the multidisciplinary team such as the social worker, occupational therapists and psychology staff supported with activities and observations.

There was ongoing work with the recruitment team on CAMHS specific bank recruitment and the offering of shadow bank shifts to promote the service.

Managers had calculated the number and grade of nurses and healthcare assistants required however this fluctuated due to observations levels. The ward manager could adjust staffing levels daily to take account of case mix.

In the last 12 months the sickness absence rate for Hope Unit was 11.7%. Mental health was the biggest reason for absence during this period, accounting for almost half of all absences each month. During this time, there had also been a high number of pregnancy related absences. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

A qualified nurse was always present in communal areas of the ward. Staffing levels allowed patients to have regular one-to-one time with their named nurse, and this was audited.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. However, if this did happen the leave was facilitated as soon as possible.

The average turnover of staff on Hope Unit was 8.69%

There were enough staff to carry out physical interventions safely for example, observations, restraint and seclusion, and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

All staff had current and up to date Data Baring Service (DBS) checks for all colleagues in work.

Staff surveys had been completed and each clinical network in the trust had implemented their own learning from the 2024 staff survey results, sharing the results locally and discussing with staff to drive improvements within the service. These had been produced with the support of the workforce team and an action plan for the CAMHS inpatient care hub was in place.

Staff had received appropriate mandatory training. The training was appropriate for the patient group using the service. At their lowest recorded levels, the wards included in this data request showed compliance rates of 85% for Mandatory Training in July 2025 and 47% for Role Essential Training in April 2025. At the point of reporting, these figures reflected subsequent improvements to 89% and 60%, respectively. The trust had taken the following actions to address non-compliance. They had increased the number of available training sessions, utilised a variety of delivery methods, provided updates to staff about changes in training requirements, and reviewed training packages based on feedback and performance data. The Oliver McGowan tier 2 training for staff was only 9% for the unit and staff reported access to the training being a problem. However, 100% of staff had completed the Oliver McGowan tier 1 online training. The quality matron had completed the national autism trainer programme and has disseminated this to staff.

The evidence showed a good standard. 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.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained. There were cleaning staff present during our inspection who were responsible for cleaning and housekeeping duties. They provided cleaning and housekeeping 7 days a week.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The ward had received a 5-star cleanliness record. We inspected the clinic room and found it to be well maintained and clean and tidy, with all equipment cleaned. Staff completed fridge and room temperature checks in line with policy.

Staff adhered to infection control principles, including handwashing.

The evidence showed a good standard. 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.

We reviewed 6 medicines prescription charts and allergies had been noted. Appropriate T2 (consent to treatment) forms were in place and section 62 forms under the Mental Health Act were also in place as required.

Staff followed good practice in medicines management regarding transportation, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication and did it in line with national guidance. All medicines on site were in date. All controlled drugs were stored according to the Misuse of Drugs (Safe Custody) regulations. Medicines fridges were checked for their temperature, and these were in range and audit checks were completed daily. Emergency medicines and equipment were in place and in date and these were checked in line with their policy daily.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. Information was provided to the young persons about any medication they were prescribed, and quick response codes were available so that young people could access information on their electronic devices about their medication. Parents and carers could meet with the pharmacist if this was needed.

The service completed many audits and had participated in the Prescribing Observatory for Mental Health (POMH) that helps mental health services across the UK to improve their prescribing practices. They also completed audits on the safe and secure handling of medicines. The quality team reviewed the completed audits. We saw medication card audits had been completed for all patients.

There were trust wide newsletters in relation to medicines disseminated to staff and these were used to share learning from incidents and national medicines alerts. The trust identified that in response to an emerging theme around medication error incidents on the Hope unit, they undertook a Quality Improvement Project (QIP) designed around reduction of these occurrences.

The medicine safety group met every two months to discuss and share information in relation to all issues about medicines.