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 requires improvement. At this assessment, the rating has remained 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.

The service was in breach of the legal regulations relating to provision of safe care and treatment (Regulation 12) and provision of effective staffing (Regulation 18).

This service scored 59 (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 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.

The trust worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. 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. Patients’ records showed that information about their needs and any specific risks relating to their care was gathered on admission from the patient, their carers and any previous health or social care setting they had transferred from. Staff told us that they had all the information they needed to enable them to meet patients’ needs when they were admitted to the ward.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Patients’ community care coordinators and/or social workers were invited to ward round meetings and involved in their patients’ care during their admission. Care records showed that patients had discharge care plans. These were not always individualised, and patients told us they were not always aware of the content of their discharge plan. However, we did not see any evidence that this had significantly impacted on patient safety when patients were discharged from the wards.

The trust did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The trust did not always share concerns quickly and appropriately.

Staff were trained in safeguarding to a level which was appropriate to their role. On 7 out of the 9 older adults wards, over 95% of staff were up to date with level 1 and 2 training in safeguarding children and adults at risk of abuse. Compliance rates were lower on Rowan and Davenport wards due to the impact of staff sickness levels. Training compliance rates on several wards were below the trust target of 85% of eligible staff for level 3 training for both children and adults at risk. We were told that this was due to challenges in accessing face to face training courses for these modules. Lower levels of compliance in relation to level 3 training safeguarding modules leads to a risk of managers and safeguarding leads not being familiar with the up to date national guidance and local procedures for investigating serious safeguarding concerns.

Staff generally knew how to make a safeguarding alert and did so when appropriate. However, we saw some examples of concerns not being identified as a safeguarding issue until this was brought to the attention of staff by our inspectors. When this was brought to the trust’s attention, the concerns were then promptly notified to the relevant local safeguarding team. Where safeguarding concerns were raised, we saw that these were investigated appropriately, and wider action was taken where needed to ensure patients were safe. For example, the trust carried out a quality review of all older people’s wards following serious safeguarding allegations which were raised on one ward in September 2024.

The staff we spoke with were able to give relevant examples of concerns they would report as safeguarding issues and could describe the process for reporting a safeguarding concern, including out of hours. 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 followed safe procedures for children visiting the service. All wards had access to a family visiting room which was separate to the main ward area. The staff we spoke with were aware of the trust’s policy in relation to child visitors and knew how to manage any risks relating to patients having contact with children during their admission.

Levels of physical restraint, seclusion and rapid tranquillisation were low overall on all wards. Restraints were documented in patients’ care records to enable the trust to effectively monitor the holds used, the duration of the restraint and the staff involved. The staff we spoke with told us that they rarely used restrictive practices on the wards. However, the incident data showed higher levels of restrictive interventions used over the past 12 months on the 3 wards for organic mental illness.

Staff training compliance in relation to the safe management of violence and aggression (MVA) was below the trust’s target of 85% on 4 wards (Rowan (71%), Cedars (81%), Ramsbottom (61%) and Davenport (75%)). This presents a risk on these wards that staff will not be able to respond to incidents of violence and aggression using approved techniques which keep patients safe and support their human rights. Some of the staff we spoke with told us that they did not feel that the level of MVA training they received supported them to respond safely for some patients involved in incidents of violence or aggression towards their peers and/or staff. Some of the patients we spoke with complained about how they had been treated by staff who had physically restrained them.

There were blanket restrictions in place on some wards relating to activities and visits from relatives and carers which were not clearly justified based on the needs of the patients. Some patients, relatives and staff members we spoke with were confused about when people could visit or had an understanding of the rules around visiting which was not reflective of the trust’s policy. Several relatives we spoke with said they could only visit for short periods and were not aware of whether they could take their relative off the ward. Some patients also told us about fixed times being in place for mealtimes and bedtimes, for example one patient said they were not allowed to go to bed earlier than 8pm because of the systems in place on the ward to prevent falls. The TV remote control was locked away on all wards and it was stated on the blanket restrictions register that this was “to prevent damage or loss”, which may not have been a necessary restriction on all wards. On Cedars and Rowan wards, no patients had keys to their own bedrooms because the bedroom door keys were all the same, so one key would open any bedroom door. Patients were therefore dependent on staff to support them to access their rooms and during our observations, staff did not always facilitate this when patients requested it. On Hague ward we were told that all the bedroom door keys had been lost and not replaced, this also meant patients were dependent on staff to lock and unlock their rooms.

Blanket restrictions registers were in place for all wards, these were usually displayed on patient noticeboards. We saw records which showed that the restrictions in place on each ward were being reviewed monthly. However, the records did not generally include details of the rationale for restrictions remaining in place and it was not always possible to identify if the review had been a meaningful investigation of whether each restriction was justified on the basis of current risks relating to the patients on the ward at the time of the review.

The trust did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 30 care records and found that records always contained a risk assessment which was completed promptly following admission and was usually regularly reviewed. However, patients did not always have risk management or care plans on their records to support staff in providing care which mitigated each risk as far as possible. For example, some patients had been assessed as being at risk of falls and they did not have a care plan on their records to outline how staff should mitigate this risk. Patients’ risk assessments were not always reviewed following incidents, for example we saw records where the risk assessment had not been updated following an unwitnessed fall on the ward. Patients with long term physical health conditions and/or deteriorating physical health did not always have care plans relating to how their needs would be met and risks mitigated relating to these aspects of their care. For example, it was not always possible to see from the records how patients were being cared for to minimise the risk of aspiration pneumonia when they had swallowing needs requiring modified food and thickened fluids due to a lack of risk management plans and detailed records relating to this aspect of their care. Some patients who were able to give us verbal feedback told us that they were not always well supported in relation to their long-term physical health conditions, for example diabetes. Some staff told us it could be a challenge to access physical healthcare support, for example tissue viability nursing and speech and language therapy, for patients who needed this, although we did not see evidence of any significant delays in the records we reviewed.

The ward documentation we reviewed did not give staff clear guidance on the level of therapeutic observations each patient should be receiving. Observations levels were stated on handover records, the Patient Status at a Glance board in the nursing office on each ward and on the observations records themselves, however the observations level for each patient was not always consistent across all three, which presented a risk that a patient would not receive the level of observations prescribed to meet their needs and mitigate the risks relating to their care. However, we did not see any evidence that this had happened from the records we saw and during our time on the wards patients were being supported with therapeutic observations at the level they had been prescribed.

Levels of restraints, rapid tranquillisation and seclusion were low overall (132 instances of physical restraint, 17 instances of rapid tranquillisation and 6 instances of seclusion across the 9 wards in the 6 months preceding our inspection). However, patients did not have care plans or positive behaviour support plans on their records to support staff in caring for people in a way that would minimise the risk of restrictive interventions being required, even when they were presenting a risk to themselves or others when distressed.

Staff did not consistently involve patients in care planning and risk assessment. The records we reviewed showed minimal evidence of patient involvement, often this was just a statement or a check box that the patient was involved, without any meaningful information being documented about patients’ views or preferences in relation to their care. Some of the patients we spoke with told us that they were not involved in the development and review of their care plans and most patients said they did not have copies of their care plans. However, patients were invited to their weekly ward rounds and usually attended. We observed the ward rounds and observed that patients were given opportunities to share their views and information about their care was shared with them in an accessible way.

Where patients had limited capacity to understand information about their care and/or specific communication needs, we did not see any information on their records about how staff should support them. Patients did not have communication care plans, and we did not see any specific arrangements in place to support patients who were not able to clearly express their views and preferences verbally. Some patients told us that they did not feel listened to. Community meetings were taking place on 8 out of 9 wards, however these were not always an effective method of gaining meaningful patient feedback, particularly on the wards for patients with organic mental illness such as dementia. On Summers ward we were told that community meetings were not taking place because all the patients had a dementia diagnosis, but there were no alternative systems in place to involve patients in the running of the ward as far as possible bearing in mind their capacity for this. Patients had access to an independent advocate on all wards and staff enabled them to speak with advocates and invite them to ward rounds where needed.

The trust did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment, these included fire risk assessments and ligature risk assessments, which were updated annually. Weekly fire safety checks were also made. However, we saw gaps in the records of these on 2 out of 9 wards. A separate ligature risk assessment had not been carried out on Saffron ward as this ward did not provide care to people who would usually be at risk of self-harm by ligature. Environmental audits were taking place, but these had been recently introduced and had not been carried out on all wards at the time we inspected.

Avoidable ligature risks were not always removed in a timely manner. For example, on Rowan ward the ligature risk assessment identified air vents in patient en suite bathrooms as being a high risk and it was documented on the risk assessment (which was completed in April 2024) that a request had been made to maintenance for these to be removed. We checked one bedroom, and this was still in situ. The maintenance request log did not include details of the request for these to be removed, the ward manager said this was no longer being updated as requests were now made by email but there was no replacement system where requests for maintenance of the ward environment were being documented and reviewed. We saw on other wards that maintenance logs were out of date for the same reason, so it was not possible for us to see whether maintenance requests were being resolved in a timely manner. We also saw avoidable ligature risks in the secure garden on Cedars ward.

We saw other instances of the ward environment requiring maintenance to ensure patient safety, including damaged decking on Beech ward and damaged furniture on Davenport ward. On Rowan ward there had been ongoing incidents relating to the en suite bathrooms flooding. The ward manager said the estates team had recommended installing longer shower curtains, these had been ordered but had not arrived yet. Again, there was no reference to this on the maintenance logs we reviewed. One patient said their shower did not work and they thought a lot of patients used the communal showers.

The ward layouts usually allowed staff to observe all parts of the ward and, where this was not the case, the risks were mitigated by systems of zonal staff observations. There was no mixed-sex accommodation, all wards were single gender. Staff had easy access to alarms and there were nurse call systems in all patient bedrooms and throughout communal areas used by patients. There were no seclusion rooms on any of the wards, which is appropriate for services for older people. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs. However, we did see gaps in the records of the emergency equipment checks on 3 out of 9 wards.

The trust did not always 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 always work together well to provide safe care that met people’s individual needs.

Staffing establishment levels for each ward for day and night shifts had been calculated using the nationally recognised Mental Health Optimal Staffing Tool (MHOST) and were being reviewed every 6 months. Wards were consistently staffed up to their establishment levels. However, the ward managers of several wards told us that the establishment levels were insufficient to meet the needs of patients on the ward which led to continual reliance on bank and agency staff. Patients on several wards told us that the wards could be short-staffed at times and there was not always a member of staff available if they needed support, particularly at busy times such as shift handovers. Nursing and support worker vacancies as reported by ward managers varied by ward, they were low on some wards and high on others, for example Rowan ward, where staff told us that the level of qualified nurse vacancies was impacting on their ability to meet patients’ needs. In the 6 months preceding our inspection, sickness absence figures were above the trust’s target of 5% on 7 out of 9 wards. Staff turnover was low (under 3% on average in the 6 months preceding our inspection) on all wards.

The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing and support staff to maintain safe staffing levels. Use of agency and bank staff was low on all wards, according to the trust’s staffing data (between 0.5% and 5.5% of shifts on each ward were filled by a bank/agency staff member in the 6 months preceding our inspection). However, during our time on the wards we observed that a high proportion of staff were bank or agency workers, and staff and patients told us there were a lot of temporary workers on the ward on a regular basis. The trust policy was for all temporary staff to have an induction completed when they arrived on the ward, however we saw that this was not always happening for new temporary staff who started their first shift while we were on the wards. The records of temporary staff induction which were available on the wards also did not provide assurance that all temporary staff had received an induction. Staff and patients told us that there were sometimes staff working on the ward who were unfamiliar with patients’ needs, which they said increased the pressures on substantive staff members. We observed some temporary staff delivering care who appeared to be unfamiliar with the needs of the patients, for example not knowing whether someone was able to mobilise independently or not being aware of whether someone needed continuous observation. Some of the temporary staff we spoke with told us that they had not received relevant training, for example in relation to the local safeguarding processes.

There were nursing and support staff always present in the communal areas of the ward during our time on the wards. Patients and staff told us that escorted leave and ward-based activities were not usually cancelled due to staffing pressures. However, staff and patients told us that staffing pressures did prevent regular one to one sessions between patients and their named nurse taking place. Staff told us that there were enough staff to carry out physical interventions safely – staff told us they felt safe at work and levels of staff injuries were low on most wards (although higher on Cedars and Rosewood wards) in the 6 months preceding our inspection.

There was adequate medical cover day and night, and a doctor could usually attend the ward quickly in an emergency. However, staff at Bury and Rochdale told us that there could be challenges in accessing a doctor quickly due to one team of doctors covering both sites. There was a locum staff grade doctor based on Beech ward in Rochdale, but this had been a temporary arrangement which was due to end and staff shared concerns about the impact of this on their ability to access timely medical support for patients. Some of the patients on the Oldham wards who had been admitted several days prior to our inspection said that they had not yet seen a doctor since their admission.

There were vacancies in allied health professional staffing which were impacting on patient care on all wards. There were no psychologists working on 6 out of 9 wards at the time we inspected, although we were told an assistant psychologist had just been recruited to work on the 2 wards in Oldham. There was no occupational therapist working on the 3 wards in Bury and Tameside at the time we inspected and there was no social worker on the multi-disciplinary team at Rochdale, which staff told us negatively impacted on their capacity to support patients with their discharge, particularly since the move to single gender wards had increased the geographical area from which patients were admitted to the ward. There were minimal ward-based activities taking place on some of the wards we visited, and staff told us that this was due to a lack of occupational therapy and activities staff. Some patients and carers told us that they/their relative were bored on the ward and there were not many organised activities to take part in.

Staff had received and were usually up to date with appropriate mandatory training. However, less than 75% of staff across multiple wards were up to date with modules where face to face training was required, such as basic and intermediate life support, moving and handling and management of violence and aggression, for example 69% for basic life support, 63% for intermediate life support and 27% for level 2 moving and handling on Ramsbottom ward, 65% for moving and handling level 2 on Beech ward and 74% for MVA training on Davenport ward. Managers and staff also told us that there were delays to face to face training courses due to challenges in accessing suitable venues for these courses. The training was mostly appropriate for the patient group using the service. However, staff were not receiving any mandatory dementia awareness training, even on the wards specialising in caring for patients with a dementia diagnosis. The trust’s training data showed that only 20 members of staff across all 9 wards had received any dementia awareness training in the 12 months preceding our inspection.

Not all staff were receiving supervision and annual appraisal in line with the trust’s policies. The trust’s appraisal compliance figures showed that Summers, Hague and Davenport wards were all below target, with 78% (Summers), 45% (Hague) and 79% (Davenport) of staff having received an appraisal in the past 12 months on these wards as of November 2024. There was no central tracking system in place to monitor staff supervision, so we were not able to establish the proportion of staff who were receiving supervision in line with the trust’s policy across all wards. However, most staff we spoke with said they had met with their line manager on a one to one basis recently. Ward managers had individual tracking systems, some of which showed staff receiving supervision monthly but some less frequently.

The trust 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. Any ‘clean’ stickers were visible and in date. Cleaning records in clinic rooms were up to date and we did not observe any cleanliness issues with the equipment on the wards during our inspection.

There were some isolated maintenance issues which we identified but overall wards were well-maintained. We also identified some areas of some wards which were not clean, for example the communal shower on Beech ward, some of the sinks on Davenport ward and one of the toilets and the kitchen on Summers ward, but overall ward areas were clean and had suitable furnishings. We observed cleaning taking place on the wards during our inspection and patients and carers told us that the wards were usually kept clean. Cleaning records were usually up to date and demonstrated that the ward areas were cleaned regularly. However, on Cedars and Rowan wards these had been recently introduced and were not yet being consistently completed at the time we inspected. Monthly infection prevention and control audits showed all wards were usually compliant with the required standards of cleanliness.

Staff usually adhered to infection control principles, including handwashing. Stocks of personal protective equipment, such as gloves and aprons were available for staff. However, we did see some staff who were not compliant with the trust’s dress code policy, for example not bare below the elbows in clinical areas or wearing false nails or eyelashes. Where patients had been diagnosed with a healthcare associated infection, for example MRSA, barrier nursing procedures were in place to safeguard other patients on the ward. Where outbreaks of an infectious disease occurred, for example COVID-19 or norovirus, these were reported using the incident reporting process.

The trust did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines administration records were clearly completed. However, on two occasions Mental Health Act documentation did not match with the patient’s current prescription. We brought this to the attention of the prescriber, so this could be promptly addressed. As seen at our previous inspection where covert (hidden in food or drink) administration of medicines was used, records of best interest decision meetings were sometimes difficult to find and on occasion lacked detail. Additionally, pharmacist advice on the process for safe covert administration was not consistently recorded. A recent trust audit similarly found it ‘extremely challenging’ to find information relating to the Mental Capacity Act and best interests’ decision making on some wards. Quality matrons were working with staff on the wards to improve this.

Patients had access to leaflets about commonly used mental health medications and could speak with a pharmacist on request. Medicines self-administration was supported when safe and appropriate, to promote independence. Support was available to patients wishing to quit smoking. Nurses administered discretionary (non-prescribed) medicines for minor ailments, when required. Nurses were aware of ‘time critical’ medicines and on one ward explained how they worked with a patient to ensure doses were given on time. However, we saw one example where a patient missed several doses of medicine because they were sleeping. When needed, dietitian advice was sought, however care plans were not always updated to reference the use of nutritional supplements. The use of thickener was not recorded when drinks were prepared for one person. Where patients were prescribed medicines to be administered on an ‘as required’ basis they did not always have care plans to support staff on the appropriate use of these and the reasons for giving these medicines were not being consistently documented in patients’ notes.

Patients' physical health was checked following the use of rapid tranquilisation. However, care plans lacked detail about the use of medicines to support patients experiencing anxiety or agitation, and on occasion the reason for use and the effectiveness was not recorded. Where patients were prescribed medicines requiring additional monitoring, this was completed.However, we saw several instances of tranquillising medicines being incorrectly documented as having been given as an intramuscular injection (which would require additional monitoring) when they had in fact been given orally.

Medicines, including controlled drugs, were usually stored safely and in line with legal requirements. We did not find any out of date medicines, however we did find 2 liquid medicines which had not been marked with the date of opening to ensure safe storage. The temperature of the clinic rooms and medicines fridge were usually checked daily, although we saw gaps in the records of these checks available on the wards, we also saw evidence that daily electronic temperature readings were documented using an online system which was overseen by the ward manager on each ward. On the day we visited the temperature of the clinic room on Ramsbottom ward was noted to be 26 degrees Celsius, according to the wall mounted thermometer in the clinic room, and no action had been taken by staff in relation to this. However, following the site visit we received the records from the automatic system the trust used to monitor the temperature of the medicines cupboard which showed that the temperature of the cupboard did not exceed 25 degrees Celsius at any point during our inspection period.

There was a supportive culture regarding reporting and learning lessons from medicines incidents. Newsletters and ‘medicines safety week’ were used to share learning from incidents and national medicines alerts. Medicines training included bespoke sessions relevant to an older person's service, for example, Behavioural and Psychological Symptoms of Dementia.