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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

This service scored 86 (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 a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The trust had a strategy in place over the next five years. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. All information was available on their website.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. This was discussed during team meetings, daily ward meetings and during supervision and appraisal sessions.

Staff could explain how they were working to deliver high quality care within the budgets available.

The evidence showed an exceptional standard. The service had exceptionally 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 always did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. There was a trust wide ward manager forum which was held monthly, supporting conversations and development of all ward managers in post. The ward manager was currently taking part in NHS England funded Culture of Care Ward Manager Leadership Development programme. Leadership development opportunities were available. The ward manager had supported two Band 6 nurses who expressed an interest in developing into Band 7 ward manager roles during individual supervision.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working together to provide high quality care. Hope unit had retained their accreditation certificate for the quality network for impatient CAMHS until January 2028 accredited by the Royal College of Psychiatrists. The Hope Unit received a quality review visit in October 2025 by the Lead Provider Collaborative. The quality reviews are intended to promote sustained quality, share good practice and where necessary, identify areas for improvement. At the time of the inspection, Hope Unit was on level 1 of quality surveillance meaning there were no/minimal quality concerns.

Senior managers actively promoted patient involvement through a variety of structured and informal approaches. Hope Unit hosted weekly community meetings, providing a regular forum for patients to voice their views and contribute to service development. In addition to these group settings, 1:1 sessions were held by the ward manager, clinical excellence lead and service manager to ensure individual patient needs and feedback were addressed. Patients were also directly involved in recruitment processes, reflecting their commitment to co-production and shared decision-making.

The ward manager contacted all parents to introduce themselves, when their children were admitted to the unit and kept in regular contact with them throughout the inpatient stay ensuring that parents and carers remain an active part in their child’s recovery. The senior management team approached parents/carers if concerns or compliments are raised to ensure that their views are heard and if necessary, address any early resolution needs as required. This feedback was shared with the wider team also.

Leaders were visible in the service and approachable for patients and staff. Senior Leadership completed both scheduled and unscheduled visits to the CAMHS inpatient unit. They occurred at Chief Executive Officer level, executive deputy, network leadership team and care hub leadership team level. These visits could be informal, part of a scheduled listening event or as planned quality and safety visits. They occurred both within and out of hours and routinely involved both patients and staff engagement. Carers were also engaged with if they are present during visits. For example, the Chief Executive, and executive director of quality, nursing and Allied Health Professionals (AHPs) regularly dropped in to the service out of hours. Staff we spoke with confirmed this.

Senior leaders attended monthly lead provider collaborative (LPC) quality and pathway meetings with other senior members across the Greater Manchester (GM) CAMHS services, to share good practice, learn from incidents and discuss service development needs in Greater Manchester.

Hope Unit senior clinicians attended the weekly GM CAMHS clinical activity panel to discuss complex cases, referral pathways, gatekeeping and mutual aide for complex cases in Greater Manchester.

The psychology team provided reflective practice sessions across the unit twice weekly, themes from these were shared with leaders and actions taken where appropriate. They had also completed quarterly staff pulse surveys. The results from these were monitored by the workforce team and shared by network business partners.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The results from the friends and family tests were positive and complementary about the staff and service. Patients could raise any concerns at their community meetings and during their 1:1 time with their named nurse and with other staff. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Patients and carers were involved in decision-making about changes to the service.

The trust had a freedom to speak up guardian and had policies in place to guide staff should they need to access or contact the freedom to speak up guardian. The guardians had visited the unit and attended team meetings.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The moving forward group is the young persons’ and parent/carer council, who meet and shaped service delivery through lived experience. Recent changes to the moving forward group had contributed to include a 360 virtual tour of the ward on the website. They had decided what is and what is not included in the young people welcome leaflet they are provided when admitted to the unit. They had contributed to the addition of other information for the Hope unit website so that young people can look things up on their phones independently if they do not feel comfortable asking staff. They had also been involved in the discussions about the use of force CAMHS leaflet.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider has a number of staff networks, including race equality, LGBTQ+, positive ability, multi-faith, women's and men's wellbeing networks, as well as carers’ networks, neurodivergent and health and wellbeing champions. There are equality and diversity champions within the service.

The Patient and Carers Race Equalities Framework (PCREF) was in place. This framework is used to support NHS trusts to improve ethnic minority community experiences of care in mental health services. There was a governance structure in place for equality, diversity and inclusion at the Trust. The Trust has an anti-racist statement on their website to acknowledge, challenge, and tackle racism and health inequalities.

The Workforce Race Equality Standard (WRES) was reported by the trust yearly which highlights the experiences of Black, Asian and minority ethnic colleagues compared to their white counterparts within an organisation. They also have a WRES improvement plan in place. The provider undertakes equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

The trust has signed up to the ‘advancing mental health equalities’ national resource, developed with the Royal College of Psychiatrists England and NHS Improvement. This has allowed them to work with targeted portions of the population, embed innovative approaches and strategies, and reduce mental health inequalities.

Staff were able to apply to work flexibly with flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers have put reasonable adjustments in place for staff members to help them carry out their role. Some examples include, arrangement of a workplace assessment, change in shift patterns,1:1 coaching, allocated additional supervisions and assistive technology.

The evidence showed an exceptional standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

Staff undertook and participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Quality matron audits were in place, and the ward manager completed assurance checks on a daily, weekly and monthly basis. This was in line with the inpatient quality assurance framework. The Hope Unit had developed an accountability map with named individuals responsible for actions, alongside information as to where assurance can be sought. Quality improvement/assurance methods were used within the service; this included medication error improvement plans.

The unit management supported local, small-scale projects through their change champion’s programme. This provided staff with practical training and support, with the aim of delivering real changes. These included improving the ward handover process, promoting hydration of nursing staff, standardising safety plans and care plans across the CAMHS care hub.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Ward managers attended monthly ward managers forum.

Management of risk, issues and performance were discussed at quality monthly feedback meetings and at team meetings. Qualified nurses attended monthly meetings to discuss any concerns they had on the unit.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Information governance systems included confidentiality of patient records.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement at ward level.

The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders such as commissioners. We observed senior leaders that attended the Multi-Agency Lead Meetings (MALM) where they engaged with senior decision makers to expedite efficient and safe discharge plans

They had relationships with commissioners and provider collaboratives. Daily updates of any risk incidents were sent to commissioners, and they had 6 weekly progress reviews with the commissioning case manager.

Senior leaders attended monthly quality and pathway meetings across the Greater Manchester (GM) CAMHS services, to share good practice, learn from incidents and discuss service development needs.

Hope unit senior clinicians attend the weekly GM CAMHS clinical activity panel to discuss complex cases, referral pathways, gatekeeping and mutual aid for complex cases in GM.

Commissioners and senior leaders attend the monthly moving forward participation group to engage with parents, young people and carers to discuss and review service development plans, such as pathways and processes.

Senior leaders engaged with local authority designated officers and liaised with them and seek advice for any potential safeguarding issues.

Senior leaders in the Trust have engaged with Right Care Right Person processes, procedures and escalations. This is a partnership initiative to ensure vulnerable individuals receive specialised support from health and care professionals to support people in distress or crisis.

There was a patient security lead in the trust who participated in advice and liaison with the Greater Manchester Police. They attended a monthly police liaison meeting. Senior leaders engaged in child safeguarding rapid reviews and child safeguarding practice reviews to contribute to safeguarding and learning from incidents.

The managers attended children and young people (CYP) Pennine Care Foundation Trust footprint meeting working together as system partners to share learning, themes, barriers, challenges and risks.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

The evidence showed a good standard. 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 contribute to safe, effective practice and research.

Staff were given the time and support to participate in opportunities for improvements and innovation and this led to changes. Innovations were taking place in the service. For example, we saw that a training room had been created when a gap in staff knowledge and skills around relational security was identified within the staff team. The room was set up with safety/risk hazards and concerns around the quality of the environment. Staff were given a clipboard and 1 minute to go into the room and write down anything they identified as concerning. This simulated the interaction time staff would have, when entering a young person’s room to check on their wellbeing during observations.

Naso-Gastric insertion, care and feeding was identified by Hope unit as a training need due to an increase in young people who needed this. Training was updated, taken through appropriate governance and rolled out to staff. The Clinical Excellence lead alongside two of the qualified nurses have since been trained to deliver this in house, rather than using external providers. The nursing team have been upskilled to provide this intervention.

The ward manager was completing The Culture of Care Programme, which is part of NHS England’s Quality Transformation Programme, launched to enhance the culture within inpatient mental health, learning disability and autism wards. Its primary goal is to create safe, therapeutic and equitable environments for both patients and staff, ensuring that these settings are fulfilling places to work, and receive care. It is based on the Culture of Care Standards.

A guidance document had been developed around roles and responsibilities for the named nurse role. This was completed collectively with staff alongside patient feedback. It had been disseminated amongst the teams, discussed in supervision and was part of the CAMHS bespoke induction that takes place on the ward for new starters.

Staff used quality improvement methods and knew how to apply them. The unit had identified a number of medication errors and implemented a medication error improvement plan. They also clarified the role of the treatment nurse so that staff were clear of their responsibilities when dispensing medication.

Staff had opportunities to participate in research. Within the trust they have a young people’s mental health research centre. Some of the examples were The BAY trial that looks at behavioural activation for young people with depression in specialist child and adolescent mental health services (CAMHS). The ChUSE trial was available for up to 60 young people aged 8-16 years old who experience distressing sensory experiences, such as hearing voices or seeing visions others cannot see. Patients can put themselves forward and information about all the available research programmes were highlighted on their website.

Staff participated in national audits relevant to the service and learned from them. The unit had participated in accreditation schemes relevant to the service and learned from them. Hope unit had been accredited for the Quality Network for Inpatient CAMHS (QNIC) by the Royal College of Psychiatrists and an action plan had been produced in response to the accreditation.