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 Good. At this assessment the rating has changed to Requires improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Requires improvement: This meant people were not always safe and protected from avoidable harm.

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.

There were 8 serious incidents between 01 November 2024 and 31 October 2025. Of those, 5 had complete investigations and 3 were awaiting completion.

Staff knew what incidents to report and how to report them on the electronic recording system.

Staff reported all of the incidents that they should report and were able to give examples of these when we spoke with them.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service.

Staff met to discuss that feedback at staff meetings, handovers and during supervision.

There was evidence that changes had been made as a result of feedback. An example of this occurred after a rise in substance-use-related incidents and their subsequent impact on individuals’ mental health, which led to the introduction of weekly Cocaine Anonymous (CA) Hospitals Institutions (HI) meetings for service users The purpose was to reduce incidents of substance misuse on the wards, promote peer-led recovery, and support continuity of care upon discharge.

Staff were debriefed and received support after a serious incident. Managers supported to staff take further action if they received injuries at work and made well being phone calls if staff were off sick as a result of injury.

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. There was a central referral team and a weekly referral meeting was held to ensure that admissions were appropriate to the service. On some occasions the ward managers attended assessments.

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. Care coordinators, advocates and representatives from new placements were routinely invited to patient meetings and provided input where appropriate.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Safeguarding training compliance was above 90% at Prospect Place and the Tatton Unit at the time of the assessment. Prospect Place had made 26 safeguarding referrals and 2 PREVENT referrals over the last 12 months. PREVENT is national programme that protects people who may be vulnerable to radicalisation. The Tatton Unit had made 14 safeguarding referrals over the last 12 months. There was an up to date safeguarding policy in place which staff could access on the staff intranet.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff routinely liaised with local authority Children’s Services departments and the hospital social worker supported staff and patients with any issues of concern.

Mental Capacity Act

Staff had received training in the Mental Capacity Act and compliance was at 74%.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Staff were able to talk about this confidently during the assessment.

There were no deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

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 on the staff intranet.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. They spoke to the nurse in charge or contacted the Mental Health Act office for guidance.

Staff took all practical steps to enable patients to make their own decisions. This included encouraging patients to attend their meetings, discussing care and treatment in one to one sessions and including them in the development of their care plans.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw completed capacity assessments and notes of best interest meetings in patients records. Examples of best interests decisions included placing a patient on a fluid monitoring chart due to them having hyponatraemia (excess fluid intake) and a patient who was sending money to their family but needed support to manage their finances safely.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies. There had been no DOLS applications in the last 12 months.

The service had arrangements to monitor adherence to the Mental Capacity Act. There were routine record keeping audits which addressed this and any shortfalls were escalated for improvement.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it. This was discussed during ward rounds and routinely reviewed.

Staff followed safe procedures for children visiting the service. Visits took place in the visitors’ room and parental authorisation was always sought prior to the visit. All visits involving children took place with ward staff present.

There was a blanket restrictions register for each ward detailing the rationale for any restrictions and evidence that restrictions were regularly reviewed to ensure that they were still necessary and proportionate. There were 11 incidents of restraint on the recovery and intervention ward and 17 incidents of restraint on the engagement and assessment ward at Prospect Place. There were 18 incidents of restraint at the Tatton Unit.

We reviewed 12 risk assessments during the assessment. All risk assessments were up to date and had been updated after an incident. There were crisis plans and safety plans in place which gave clear guidance on how staff could support patients to manage if their mental health deteriorated.

There were 17 incidences of restraint on the engagement and assessment ward and 11 incidences of restraint on the recovery and intervention ward at Prospect Place. There were 18 incidences of restraint at the Tatton Unit. Of those there were 2 prone (face down) restraints on the engagement and assessment unit and 1 prone restraint on the Tatton Unit. All 4 of these prone restraints were for the administration of medication and these had been reviewed accordingly.

Staff involved patients in care planning and risk assessment. This was shown by evidence in care plans, participation in multidisciplinary team meetings and staff offering patients a copy of their care plans.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received. There were weekly community meetings on each ward and a quarterly patient’s survey which was reviewed by staff and the outcomes were collated and themes identified for improvements in patient experiences.

Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate. However, at the time of the assessment there were no advance decisions in place.

Staff ensured that patients could access advocacy. There were advocacy posters and leaflets displayed on the wards and staff phoned the advocacy service at the request of patients.

Staff did regular risk assessments of the care environment. Staff identified a security nurse at the start of each shift and they were responsible for daily checks of the environment.

Ward layout allowed staff to observe most parts of ward. There were concave mirrors in place where blind spots had been identified such as the garden at the Tatton Unit.

There were potential ligature anchor points on each of the wards. However, there were ligature risk audits which identified all ligature points, rated them according to risk and staff had mitigated the risks adequately.

Staff had easy access to alarms and patients had easy access to nurse call systems. The staff accessed personal alarms at the commencement of their shift and patient bedrooms all had a nurse call bell on the wall.

The seclusion room on the engagement and assessment ward allowed clear observation and two-way communication and had toilet facilities, a clock and temperature and lighting controls. There were bathroom facilities and an outside space that the patient could access. The seclusion room on the Tatton Unit also had the expected facilities in line with Mental Health Act Code of Practice. However, the room was very hot and the temperature could only be controlled by staff making a request to an external department and awaiting the temperature change, which could take a day or two to be actioned. This meant that the patient would have to remain secluded in a very hot environment until the temperature change had been made.

We inspected all 4 clinic rooms and saw that they were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There were 41 permanent qualified nurses across the 3 wards at Prospect Place and 12 qualified nurses at the Tatton Unit. There were 42 permanent support workers across the 3 wards at Prospect Place and 17 permanent unqualified nurses at the Tatton Unit. Staff turnover rates were low on all wards except on the Recovery and Intervention ward. This was higher at 10.16%, but only 1 member of staff had left the organisation completely. Other staff members had gained internal promotions and moved to other wards within the secure care pathway or been redeployed to another ward within the Trust.

Managers had calculated the number and grade of nurses and healthcare assistants required according to the acuity on the ward and the number of observations in place.

The number of nurses and healthcare assistants matched this number on all shifts.

The ward manager could adjust staffing levels daily to take account of case mix. When observation requirements increased on the ward, managers were able to request an additional staff member to cover this. Managers considered the acuity and requirements of individual patients and ensured the staff skill mix matched this.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. Bank and agency staff received the same induction as permanent staff which included a corporate induction, security induction and a local induction to the wards. We saw records of inductions during the assessment.

A qualified nurse was present in communal areas of the ward at all times.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. The service had a standard for a minimum weekly 1:1 time with a patient’s named nurse. Managers monitored compliance with this standard via a weekly documentation audit.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. Leave had been cancelled on one occasion in the 12 months prior to assessment. This had occurred for a group trip due to staff sickness and being unable to replace driver.

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

The service had vacancy for a Responsible Clinician and some cover arrangements had been put in place whilst further recruitment took place. We could not be certain that a doctor could always attend the ward quickly in an emergency.

Staff had received and were up to date with most of the mandatory training. Core mandatory training was at 88% at Prospect Place and the Tatton Unit. There were some elements of essential mandatory training where rates were low. This included Prevention and Management of Violence or Aggression (PMVA) personal searches which was at 34% at Prospect Place, PMVA violence reduction which was at 36% at Prospect Place and rapid tranquilisation which was at 19% across the forensic services. In April 2025, initial updates to staff profiles were implemented following the quality improvement initiatives undertaken by the trust. As part of this process, a number of existing courses were reclassified as essential for specific roles, and new training packages were developed. These changes temporarily impacted compliance figures. To address areas of low compliance the trust had increased the number of available training sessions, provided updates to staff about changes in training requirements and reviewed training packages based on feedback and performance.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Cleaning on the ward took place daily and there was a system for the additional deep cleaning of specific areas regularly.

Staff adhered to infection control principles, including handwashing. We saw handwash signs in communal areas and in the bathrooms. Infection control training level 1 was at 99% and infection control level 2 was at 91% at the time of the assessment.

Staff followed good practice in medicines management including the transport, storage, dispensing, administration, medicines reconciliation, recording and disposal, and did it in line with national guidance. Medicines management was routinely audited and the results were shared with ward teams. Recent actions included ensuring that identification photographs were attached to patient prescription charts, routine checks of the medicines trolley to identify expired medication and labelling liquid medication with an opened date and expired date. However, we found 2 bottles of opened medication in the clinic room at Prospect Place. The medication was opened with the ‘opened on’ date sticker not completed; the medication was labelled

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. Staff used a high dose monitoring form and increased the level of physical health monitoring. Staff contacted the pharmacist, or the pharmacy technician for additional support and guidance if required.