Pennine Care NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

The service was in breach of the legal regulation relating to the provision of person-centred care (Regulation 9).

This service scored 61 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The care plans we reviewed on all wards lacked sufficient detail to support staff in caring for patients in an individualised way and did not evidence the involvement of the person and/or their relatives and carers in the development of the care plan. Care plans did not always reflect the care the individual was receiving. Some staff said the records management system used by the trust made it hard to write detailed person-centred care plans. Patients did not have care plans in place for a range of issues we would have expected to see considering their individual needs, including communication needs, specific risks or health issues and ‘as required’ and/or covert administration of medicines. Mental health care plans did not demonstrate evidence-based interventions to support people with dementia and other complex mental health needs. This meant that some patients did not have their needs met and the risks relating to their care mitigated in a person-centred and holistic way.

During our time on the wards observing care, and from reviewing care records and speaking with staff and patients, we were not always assured that patients were receiving person-centred, individualised care. This was particularly the case on some of the wards for people living with an organic mental illness such as dementia. Some staff on these wards appeared unfamiliar with the individual needs of the patients and much of the care we observed was delivered in a task-focused way. However, on the wards for people with functional mental illness we saw more individualised care delivered by staff who appeared to know patients and their individual needs well. Also, we saw an example of good practice on Rosewood ward where a snapshot of each patient’s individualised needs had been documented on ‘forget-me-not’ boards in their rooms.

There were limited activities taking place on some wards for patients to engage in. Although each ward had an activity timetable which included a range of activities, we saw that these were not always taking place. Some patients told us they were bored and staff acknowledged that there were vacancies within the occupational therapy teams which had led to a lack of varied activities on some wards. Ward staff said they did not always have time to support patients with meaningful activities throughout the day. An exception to this was Beech ward, where a programme of varied and themed activities was in place which was an example of good practice. A number of the patients on Beech ward commented positively about the activities in the NHS Friends and Family Test feedback from the 6 months preceding our inspection, in contrast to some other wards where the feedback from patients was that they would like more activities to be available. Also, patients on the wards at The Meadows and their relatives spoke positively about their visits to the vintage café which was available on site.

We did not see evidence of meaningful patient and carer involvement in patients’ care plans. Community meetings were not taking place consistently on the wards for people with organic mental illness and, where these had not proved to be an effective way of involving patients and gaining regular feedback on their experience, no alternatives had been explored that might better meet the needs of the patient population on these wards. The staff we spoke with did not always demonstrate an awareness of how and when they should be involving patients in their care. Carers told us that they had not been asked to give any feedback of their experience during or following their relative’s admission. This meant that the views and experiences of people using the service, and their carers were not always captured and considered in the provision of the service.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

The trust supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information governance systems were in place including an electronic records system which was password protected to maintain confidentiality of patient records.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights and how to complain. Information was made available to patients in booklets which were offered to patients on admission and was also displayed on noticeboards in the communal areas of all wards. Most of the patients we spoke with were aware of the procedures for raising concerns, services available such as advocacy support and patients detained under the Mental Health Act were aware of their legal rights. The service complied with the Accessible Information Standard in relation to the written information available for patients and some written information could be made available in alternative formats such as large print or Braille and in other languages where needed. The service had equipment in place to promote accessibility, such as hearing loops.

Staff ensured carers, families and commissioners were regularly updated about each patient’s progress. Care records showed that carers and relatives were invited to attend the weekly ward rounds and most of the carers we spoke with told us that they found it helpful to attend ward rounds and said they were given information about their relative’s care which they could understand. We received feedback from commissioners who told us that weekly meetings took place at which information was shared about each patient’s progress and their pathway towards discharge from the wards.

The trust shared information as required with CQC, the Greater Manchester Integrated Care Board and other bodies responsible for monitoring the quality of care on the wards.

The trust had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

The trust had a detailed incident reporting policy and standard operating procedure which were last reviewed and updated in September 2024 to incorporate the national implementation of the Patient Safety Incident Response Framework (PSIRF). Staff were aware of the trust’s incident reporting procedures and felt safe to report concerns. Safety events were usually reported promptly and in line with trust policy and were thoroughly investigated. There were 85 serious incidents reported across all 9 wards in the 12 months preceding our assessment, with no significant themes of concern arising from these. Staff received feedback about lessons learned from incidents both internal and external to the service at staff meetings and via email bulletins, although some bank and locum staff said they did not consistently receive this information. Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation when things went wrong. We saw evidence of changes being made because of lessons learned from incidents. For example, changes had been made to how staff documented omitted medicines to reduce the risk of future prescribing errors. Improvements had also been made to the systems for documenting patient seclusion to ensure staff maintained records of seclusion and nursing/medical checks in line with the requirements of the Mental Health Act. Staff told us that they were debriefed and received support following serious incidents.

We did not look at Equity in access during this assessment. The score for this quality statement is based on the previous rating for Responsive.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Staff within the service and the wider organisation did not consistently promote a culture in which the patients felt empowered to give their views. Some of the patients we spoke with told us they would not know who to speak to if they wanted to raise concerns or give feedback about their care. On the wards for people with organic mental illness such as dementia, patients did not have communication care plans on their records and the systems in place for gathering feedback from patients were not always accessible to people who found it difficult to give clear verbal feedback about their views.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. All the trust’s policies went through an equality impact assessment process prior to approval and implementation and the date of this was documented in the summary section at the start of each policy.

Staff were trained in equality, diversity, inclusion and human rights. Equality and diversity training was a mandatory module for all staff working on the older people’s wards and the training compliance data showed that over 90% of staff on all 9 wards had completed this training.

The trust had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

The trust had a detailed incident reporting policy and standard operating procedure which were last reviewed and updated in September 2024 to incorporate the national implementation of the Patient Safety Incident Response Framework (PSIRF). Staff were aware of the trust’s incident reporting procedures and felt safe to report concerns. Safety events were usually reported promptly and in line with trust policy and were thoroughly investigated. There were 85 serious incidents reported across all 9 wards in the 12 months preceding our assessment, with no significant themes of concern arising from these. Staff received feedback about lessons learned from incidents both internal and external to the service at staff meetings and via email bulletins, although some bank and locum staff said they did not consistently receive this information. Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation when things went wrong. We saw evidence of changes being made because of lessons learned from incidents. For example, changes had been made to how staff documented omitted medicines to reduce the risk of future prescribing errors. Improvements had also been made to the systems for documenting patient seclusion to ensure staff maintained records of seclusion and nursing/medical checks in line with the requirements of the Mental Health Act. Staff told us that they were debriefed and received support following serious incidents.