Pennine Care NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on the best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of the legal regulation relating to consent to care and treatment (Regulation 11).

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 30 sets of care records covering all 9 wards. Records showed that staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission. All the records we looked at included a completed needs assessment and staff told us that this was completed as part of the admission process. However, where needs assessment had been completed on another ward, we did not always see evidence that this was reviewed when they were transferred, to ensure that their assessment and associated care plans remained relevant and up to date.

Staff usually assessed patients’ physical health needs in a timely manner after admission. Most records included a completed physical needs assessment and staff told us that this was part of the admission process for all patients. However, we saw 4 sets of records (across 3 wards) which did not include a completed physical health needs assessment.

Staff did not consistently develop care plans that met the needs identified during assessment. Patients did not have care plans on their records to address a range of relevant needs including mitigation of falls risks, communication needs (including where patients were unable to clearly articulate their needs verbally) and care and support relating to long term conditions such as diabetes.

Care plans were not sufficiently personalised, holistic or recovery orientated. The care plans we reviewed on all 9 wards contained generic statements which were not person-centred, showed minimal evidence of patient and carer involvement and did not include detailed information to support staff in meeting the patient’s identified needs. For example, we saw a care plan for nutritional needs for a patient who had lost weight on the ward which made no reference to this and contained no information about the nutritional supplements they had been prescribed to respond to this. We also saw multiple care plans relating to the covert administration of medicines which contained either no information or incorrect information about how the person was receiving these and which medicines they were receiving covertly and which overtly,

Staff did not consistently update care plans when patients’ needs changed. We saw some records where the patient’s care plans had not been updated when they were transferred to the ward they were on at the time we inspected, and the plans did not fully reflect the care they were receiving on their current ward. We also saw care plans which had not been updated following incidents on the ward, such as falls. We saw care plan recommendations from external professionals, for example dieticians and speech and language therapists, which had not been incorporated into the individual’s care plan (although the external care plans had been placed on ward handover files to bring the recommendations to staff’s attention, the lack of this information in the individual’s ward care plans risked the information being missed, particularly by staff unfamiliar with the ward).

The trust did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. They did not always ensure care was in line with legislation and current evidence-based good practice and standards.

The service did not always provide a range of care and treatment interventions suitable for the patient group. Due to vacancies in the allied health professionals’ teams, patients did not always benefit from the full range of appropriate treatments due to no occupational therapy and/or psychology support being available to the wards, which is recommended in national guidance, for example the National Institute for Health and Clinical Excellence (NICE) guidance on the treatment of adults with complex psychosis (psychology) and the Royal College of Psychiatry Dementia Care Pathway (occupational therapy). Patients were also not consistently having one to one sessions with their named registered mental health nurse due to vacancies in the nursing team and the overall pressures on the ward-based staff. The trust’s model of care with respect to psychology was not clear as there were psychologists either working or about to commence work on some of the wards, however there was no reference to psychologists being part of the multi-disciplinary team in the written information the trust provided on the models of care for the older people’s wards.

Patients were receiving medical care for their mental health needs on all wards in line with national expectations. Records showed that patients had their care regularly reviewed at multi-disciplinary ward round meetings led by their consultant psychiatrist. Staff usually ensured that patients had good access to physical healthcare, including access to specialists when needed. Records showed that patients had their physical health regularly assessed through monitoring of their vital signs during their admission and any concerns about patients’ physical health were promptly escalated to a doctor, including out of hours. The National Early Warning Score (NEWS2) system was used to identify when a patient’s physical observations indicated a medical referral. Patients requiring admission to an acute hospital were supported with this without undue delay. However, some staff told us that it could be challenging to access timely physical healthcare support, for example tissue viability care for patients at risk of developing pressure ulcers and speech and language therapy support for patients with swallowing needs and increased risks of choking or aspiration of food. Staff told us that there had previously been a service level agreement with the acute trust which provided services on the same site as many of the wards and since this had ended it had become more difficult to access physical healthcare support for patients.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. Records included assessments of patients’ nutritional needs using the nationally recognised Malnutrition Universal Screening Tool (MUST), menus showed that patients had access to a range of nutritious food and patients were supported with modified diets to meet their needs, for example where people needed a soft diet this was provided and modified cutlery was available for patients who needed this. Where patients were at risk of weight loss or malnutrition this was identified and care was provided to mitigate the risk, including obtaining advice from a dietician where needed. However, patients’ care plans did not always include up to date information about their nutritional needs and the care being provided to meet their needs, which presented a risk that people would not always receive care which met their nutritional needs, particular in light of the fact that temporary staff regularly worked on the wards.

Staff were experienced and qualified and usually had the right skills and knowledge to meet the needs of the patient group. However, some nursing and support staff had not received any dementia awareness training and we saw examples of care being provided to patients with a dementia diagnosis which was not person-centred and compassionate. National and local guidance on dementia care, for example NICE guidance on dementia, the Royal College of Psychiatrists’ Dementia Care Pathway and the Dementia Quality Standards for Greater Manchester, all state that people living with dementia should receive care from staff appropriately trained in dementia care. Managers provided new substantive staff with appropriate induction. However, temporary staff did not always receive an induction when they first started work on the wards. We observed temporary staff working a first shift on wards without receiving an induction and the records of temporary staff induction which were available did not show that all temporary staff working on each ward on the day we inspected had received an induction.

Managers provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. However, systems for tracking supervision were not centralised so data including the percentage of staff receiving supervision within the timescales set out in the trust’s policy across all the older people’s wards (4-6 weeks for both clinical and management supervision) was not available. The ward-based tracking systems showed that this had not been happening consistently across all wards in 2024. Across the whole of the older people’s inpatient services, 85% of staff had received an appraisal within the past 12 months, which was in line with the trust’s target, but at individual ward level, 3 out of 9 wards were not ensuring 85% of staff or more were receiving 12 monthly appraisals at the time we inspected.

Managers usually ensured that staff had access to regular team meetings, although on Rowan ward, team meetings were not taking place due to a high level of staff vacancies impacting on the team’s capacity. Where meetings were taking place, staff told us they were usually able to attend, and they received copies of minutes by email following the meetings. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Staff told us that they had the time and capacity to complete their mandatory training, and they were able to access additional training to support them in meeting patients’ holistic healthcare needs. Records showed that staff on the older people’s wards had received additional training as part of their continuing professional development which was relevant to the needs of the patients they were caring for, for example falls prevention, diabetes management and trauma-informed care.

Managers dealt with poor staff performance promptly and effectively. Rates of staff disciplinary investigations were low, with only 2 in the 12 months preceding our inspection across all 9 older people’s wards.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

The trust supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives – for example, through participation in smoking cessation schemes, provision of healthy eating advice and supporting patients with issues relating to substance misuse. Managers and staff told us how patients were supported to reduce smoking where they did not wish to quit and the trust had a detailed action plan relating to the organisational move towards all trust premises being smoke free, which included smoking cessation support and provision of e-cigarettes for patients.

Ward activities helped promote a healthy lifestyle for patients in ways which were appropriate for the patient group, for example chair yoga, relaxation sessions, cooking sessions and walking groups. On Beech ward there was information displayed about previous themed activity months which had been arranged to promote patient health and wellbeing, for example relating to hydration, which was an example of particularly good practice. However, on some wards, patients told us that there were not many ward-based activities taking place, which was due to vacancies in the occupational therapy teams and a lack of capacity for the nursing and support staff to support these activities in addition to meeting people’s care needs.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

Staff did not consistently take all practical steps to enable patients to make their own decisions. On the wards for patients with functional mental illnesses, such as schizophrenia or bipolar disorder, patients usually told us that they were asked for consent before care was provided and/or we saw that the safeguards set out in the Mental Health Act were in place where treatment for mental disorder was being provided without consent. However, on the wards for people with an organic mental illness, such as dementia, some patients were not able to clearly articulate their needs verbally and patients did not have communication care plans on their records to support staff in seeking as much information as possible about people’s preferences relating to their care. We saw examples of care being provided to patients with minimal interaction with them on these wards, in a task-focused rather than a patient-centred way. The patients we spoke with who were not detained under the Mental Health Act were not always aware of their right to leave the ward as an informal patient.

For patients who might have impaired mental capacity, staff did not always record capacity to consent appropriately and on a decision-specific basis. Where patients were receiving care without consent, for example covert administration of medicines, we did not always find a documented assessment of capacity on their care records which pre-dated commencement of the covert administration of their medicines. Where records of capacity assessments had been made, for example within ward round records, some of these lacked detail and so it was not possible to see whether the requirements of the Mental Capacity Act had been complied with in relation to the assessment process (for example that the assessment related to a specific decision and that the assessor was satisfied the patient had been supported to make the decision themselves as far as possible).

When patients lacked capacity, staff told us that they made decisions about their care in their best interests. However, records of best interests' decision making were mostly either not available or insufficiently detailed to enable us to establish whether this process involved patients and their relatives or carers where appropriate, and recognised the importance of the person’s wishes, feelings, culture and history.