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 good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation relating to governance and quality monitoring (Regulation 17).

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 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 had 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 did so with integrity, openness and honesty.

The trust had a culture and leadership plan for the period 2024-2027 which incorporated the standards of the nationally recognised NHS Leadership competency framework. There were clear operational and clinical management structures in place on all wards. Leaders had the skills, knowledge and experience to perform their roles. The managers and senior leaders we spoke with were appropriately qualified and experienced for their role and demonstrated a good understanding of the services they were leading. Ward managers could explain clearly how their teams were working to provide high quality care. The staff and patients we spoke with did not raise any concerns about ward managers and senior leaders.

Leaders were visible in the service and approachable for patients and staff. Ward managers were based on the wards and staff told us that they found their local leaders to be accessible. At the time we inspected a new cohort of quality matrons had been recruited and we heard from staff on the wards that having this additional clinical leadership and support was helpful in enabling them to deliver a good standard of patient care. Staff also told us that the trust’s Chief Executive was visible on the wards and spent time with staff and patients, however some staff said that other senior leaders above ward manager level were less visible in patient care areas.

Leadership development opportunities were available for staff. The trust’s training data showed that 40 managers within the older people’s inpatient services completed leadership training courses in the 12 months preceding our inspection. The managers we spoke with told us that they had access to sufficient leadership training to support them in their role and we saw that the trust’s supervision and appraisal processes enabled ongoing discussion with staff about their career development aspirations. The staff we spoke with told us they felt well supported by managers and had opportunities to progress within the organisation if they wished to. The trust had succession planning processes in place in relation to senior executive roles which was overseen by the trust’s appointments and remuneration committee.

People did not always feel they could speak up and that their voice would be heard.

Patients and carers did not consistently have opportunities to give feedback on the service they received in a manner that reflected their individual needs. Minutes of community meetings on the ward showed that meetings were not taking place regularly on some wards, were not in place on one ward and repeated issues were raised by patients at some meetings without any evidence of action being taken in response to this. On the wards for people with organic mental illness we did not see evidence that accessible feedback processes were in place considering the needs of people living with dementia. Some of the relatives and carers we spoke with told us that they had not been asked to give any feedback on their experience. However, we saw that NHS Friends and Family Test feedback forms were available on all the wards we visited and information about feedback processes was displayed on the wards.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. The trust collated Friends and Family Test responses and information was shared with staff through email bulletins and at staff meetings about changes made in response to staff feedback.

Staff had access to a confidential Freedom to Speak Up process and all the staff we spoke with about this were aware of the system for raising concerns and said they would feel safe to do so with no concerns about any reprisals or detrimental impact on them. An anonymised overview of Freedom to Speak Up concerns raised by staff, any trends of concern and action taken in response to the information shared by staff was reported to the trust board every six months.

We saw limited evidence that patients and carers were involved in decision-making about changes to the service. The patients we spoke with told us that they had not been involved in any strategic decision making about the service and where feedback was gathered from patients about ward-level changes, for example at community meetings, it was not always possible to see whether action had been taken in response to repeated issues patients had raised. We saw no evidence that systems were in place for patients and staff to meet with members of the provider’s senior leadership team and governors to give feedback other than ad hoc visits to the ward by senior leaders.

The trust valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were staff networks in place, for example for Black and minority ethnic staff, staff identifying as LGBTQ+ and staff with disabilities, each of which was sponsored by a member of the trust’s executive team. Nationally recognised inclusivity promoting events such as Black History Month were promoted via staff meetings, email bulletins and patient activity programmes.

Staff were able to apply to work flexibly and had access to flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role where this was needed due to disability, caring responsibilities or other personal circumstances.

The trust produced annual reports setting out the action they were taking as an organisation to reduce the gender pay gap and comply with race and disability equality standards in their workforce. These were overseen by an equality, diversity and inclusion steering group, which reported into a sub-committee of the trust board. A system for reporting equality, diversity and inclusion metrics was in place to enable the trust to monitor any trends of concern in relation to EDI and take action to improve. The 2023-2024 report identified key priorities to improve EDI in the coming year including breaking down barriers to inclusion, improving cultural intelligence and improving the trust’s EDI evidence base.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or 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. Governance information was escalated to the trust board via relevant board sub-committees using a clear, documented board assurance framework. However, on some wards, team meetings were not taking place regularly at the time we inspected, and staff told us that this was due to staffing pressures reducing the time available for these.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. We saw evidence of this in the minutes of team meetings from all wards and other management and governance meetings which took place across the directorate at all localities.

Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients.

Staff maintained and had access to the risk register at ward level. The trust used a single electronic risk register to record, manage and monitor all risks. Within this, there was the facility to allocate risks for local ownership at ward or team level, at care hub level, at locality network level, those belonging to corporate teams or services, and those categorised as being ‘trust wide’. Staff at ward level could escalate concerns when required. Staff concerns as shared with us during the inspection usually matched those on the risk register, for example the temperature on Ramsbottom ward.

The service had plans for emergencies – for example, adverse weather or a flu outbreak. Each ward had a business continuity plan which was regularly reviewed and updated by the ward manager.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. We saw examples of effective use of technology in this respect, for example the automated system for recording and collating data on clinic room and fridge temperatures to ensure medicines were stored safely.

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.

However, staff did not always have access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, did not always worked well and staff on all wards told us that the challenges they experienced with internet connectivity negatively impacted their ability to deliver the best quality of care. We saw that the trust had an action plan to make improvements to their technology to address this issue.

We saw that a range of audits were taking place on the wards including environmental checks, audits of care records, medicines audits and infection prevention and control audits. We saw that action plans were put in place following audits to ensure action was taken to address any shortfalls identified and the action plans included clear allocation of responsibility for each action and realistic timescales for compliance. However, we did see some evidence that issues identified by audits were not always rectified in a timely manner, for example patients not having sufficient one to one time with their named nurse had been identified as an issue on one ward by an audit and the feedback we received from staff and patients during our inspection indicated that this was an ongoing issue on the ward. Also, we saw that some audits did not enable the identification of shortfalls in the quality of care, for example the annual care plan audit which took place across the older people’s wards in 2023 (the 2024 audit was not complete at the time we inspected) did not include questions about whether the care plans were person-centred and recovery-oriented, which we found to be a concern on all wards.

We saw that improvements were taking place on some wards, for example to the internal and external care environments. However, in some cases these were impacting the quality of patient care, for example resulting in a lack of access to fresh air where a secure garden was closed entirely due to ongoing maintenance work, which patients told us had been ongoing for some time.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

At the time we inspected the trust was rolling out a transformation programme across all its inpatient services, to ensure a high level of compliance with national and local quality improvement standards relating to adult inpatient mental health services. Internal priorities for improvement work were also identified in business plans for the North Network (including Bury, Oldham and Heywood, Middleton and Rochdale), Stockport and Tameside.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Ward managers told us that they met regularly at a ward managers’ forum for the older people’s inpatient services to share learning and good practice and we saw minutes of these meetings which confirmed this. Senior leaders within the older people’s inpatient service also attended trust-wide quality and shared learning forum meetings. The trust engaged with relevant national quality networks, for example the Royal College of Psychiatrists’ Quality Network for Older Adults Mental Health Services.

The trust gave us some examples of quality improvement projects which had taken place on the ward, for example introduction of summary documents to highlight patient needs to staff, the introduction of safety huddles to reduce the risk of falls and an awareness raising programme to improve the management of dysphagia (swallowing impairment). However, we saw no evidence that the staff leading on these projects had been supported by an underlying quality improvement framework incorporating evidence-based QI methodology. Staff told us that they did not have opportunities to participate in research or quality improvement initiatives. Quality improvement training did not form part of the mandatory training for ward-based staff.