- SERVICE PROVIDER
Pennine Care NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 8 May 2025 assessment
Contents
Ratings - Wards for older people with mental health problems
Our view of the service
Pennine Care NHS Foundation Trust was formed in 2002 as a mental health trust. The trust has an income of approximately £280 million and employs more than 4,300 staff. Pennine Care NHS Foundation Trust provides inpatient, community and specialist mental health services across the areas of Bury, Heywood, Middleton and Rochdale, Oldham, Tameside and Glossop and Stockport to a total population of 1.3 million people, providing care to over 70,000 people in 2023/24.
The trust provides 150 different services including:
- Acute mental health wards for adults of working age
- Community based mental health services for adults of working age
- Long stay/rehabilitation mental health wards
- Child and adolescent mental health wards
- Child and adolescent mental health community services
- Forensic/low secure mental health wards
- Mental health wards for older people
- Community based mental health services for older people
- Mental health crisis services and health-based places of safety
- Community based mental health services for people with a learning disability
- Substance misuse services
- Adult social care - respite services at Cambeck Close
The trust also provides mental health services for military veterans across the whole of Greater Manchester, working in partnership with other trusts which cover Lancashire, Cheshire and Merseyside.
This assessment covered the mental health wards for older people only. It was a responsive assessment which was triggered due to concerning information we received about several of these wards between June and October 2024 from complaints, whistleblowing concerns and notifications from the trust. The assessment included an on site inspection of all 9 of the trust’s wards for older people which took place on 4, 5, 6 and 7 November 2024. We gathered information from patients and their loved ones, staff and managers, other stakeholders and our own observations of care. We reviewed a range of documents including care records, policies and procedures. We looked at 28 quality statements.
We rated the service as requires improvement. We found 5 breaches of the Regulations in relation to person-centred care and involvement of patients, consent to care and treatment, patient safety, governance and staffing.
Care plans did not usually show how care was centred on the individual or that their views and the views of their carers and close relatives had been taken into account in a meaningful way. Due to vacancies in occupational therapy teams and other pressures on ward based staff, patients did not always have access to a good range of meaningful and health-promoting activities on the wards. Where patients lacked the capacity to consent to their care and treatment this was not always formally assessed for specific decisions in line with the expectations of the Mental Capacity Act and records of decisions taken in patients’ best interests did not always show how this process included the safeguards required by the Act. Where risks relating to specific aspects of people’s care had been identified, for example relating to falls or specific health conditions, they did not always have clear plans of care setting out how these risks would be mitigated.
The trust’s governance systems, for example records audits, did not always have the capacity to identify shortfalls in people’s care and some areas of care, for example compliance with the Mental Health Act and Mental Capacity Act were not subject to any documented quality monitoring process at the time we inspected. Although the wards were usually staffed to safe levels, we saw a high use of temporary staff to cover vacancies, staff sickness and enhanced clinical need on the wards and the systems for induction and training of temporary staff did not always ensure that staff were familiar with the wards and the needs of the patients they were caring for. Substantive staff were not always up to date with their mandatory training and supervision sessions. The mandatory training for staff did not always fully equip them to meet the needs of the patients they were caring for, for example many staff caring for people living with dementia had not received any dementia awareness training as this was not a mandatory training module at the time we inspected.
However, the wards were usually safe and clean and staff complied with infection prevention and control best practice such as handwashing and use of personal protective equipment. Patients had access to the equipment they needed to be safe and to maintain their independence, such as mobility aids. Clinic rooms were kept clean and tidy and medicines were stored safely. Patients had access to the medicines they needed to support their mental and physical health. Much of the care we observed was compassionate and patients told us that staff generally treated them well and were able to meet their needs. Levels of physical restraint and other restrictive practices such as seclusion were low. Staff usually complied with the requirements of the Mental Health Act and patients detained under the Act were aware of their legal rights. Patients had access to medical care when they needed it and were able to participate in weekly reviews of their care at multi-disciplinary ward rounds. Patients had access to independent advocacy on all wards and accessible information about the service was displayed and made available in introductory packs when they were admitted. Staff and patients told us they were aware of how to raise concerns and said they would feel safe to do this if needed. There were governance systems in place which ensured that shortfalls in care quality were usually escalated to the trust’s Board of directors via appropriate sub-committees so action could be taken at an organisational level to improve.
Action we have taken
We have asked the provider for an action plan in response to the concerns found at this assessment relating to patient safety, governance and consent to care and treatment.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
People's experience of this service
We spoke with 28 patients and 22 relatives/carers during the inspection.
Patients who were able to give us verbal feedback usually told us that staff were caring and supportive and provided care which met their needs. Patients said they were not usually subjected to undue restrictions on the wards, with most patients reporting that they had never been physically restrained by staff. Patients said they felt safe on the wards. Patients and their relatives said that wards were clean and well maintained and most patients said the food was good, although some said that good quality food which met their cultural needs was not always available. Some patients told us that the wards could be short-staffed at times, sometimes they were cared for by unfamiliar staff, particularly at night, and that sometimes staff did not have time to chat with them while providing care. Some patients told us that they were bored on the wards and that there were not a lot of activities available, however some patients were more positive about the activities available. Some patients told us that they were not having one to one time with their named nurse and/or they did not know who their named nurse was. Patients told us that they had access to all the information they needed about the wards, their rights under the Mental Health Act and how to raise concerns about their care and said they were able to access independent advocacy support when they needed to. Some patients told us they did not have access to spiritual support on the ward when they would have liked this.
On the wards for people with an organic mental illness such as dementia, where some patients were not able to give us verbal feedback about their care, we carried out structured observations of care. These showed a variable standard of care on the wards, with some good interactions observed and some less positive interactions where care was more task-focused rather than centred on the individual as a whole person. People’s relatives and carers mostly gave us positive feedback, feeling that their loved one was well cared for on the wards and that they were kept involved in decisions about their relative’s care and progress towards discharge. However, some relatives and carers told us that visiting times were restricted, with some reporting that they were only allowed an hour with their relative.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
Staff were usually trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The staff we spoke with all confirmed they had received some training on the Mental Health Act as part of their induction and/or ongoing continuing professional development. However, the provider’s training data showed that Mental Health Act awareness training was not a mandatory module for all clinical staff, so it was not possible to identify the proportion of staff on each ward who had completed this training or how up to date this was.
Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were and how to contact them. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice via the trust’s intranet. Policies and procedures reflected up to date legislation and national guidance. The trust’s Mental Health Act team provided a weekly summary report to each ward, flagging any Mental Health Act compliance issues which needed to be addressed.
Patients had easy access to information about independent mental health advocacy. This was displayed on all the wards on noticeboards in communal areas and was included in the information packs patients received on admission to the wards. The patients we spoke with were aware of how to seek advocacy support and said that advocates were able to attend ward rounds to support them when they requested this. We received feedback from representatives of the advocacy services and they confirmed that their advocates were supported in their role by staff and managers.
Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated the information as required and recorded that they had done this. Care records showed that patients were reminded of their rights at the intervals required by the Mental Health Act and the patients we spoke with who were detained on the wards confirmed that staff regularly reminded them of their legal rights.
Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. Staff and patients told us that when patients were granted leave this usually took place and leave was not regularly cancelled due to factors such as staffing pressures.
Staff requested an opinion from a second opinion appointed doctor (SOAD) when necessary. Patients’ Mental Health Act paperwork was stored with their medication and showed that their medical treatment had been authorised by a SOAD when this was needed.
Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.
The wards did not display notices to tell informal patients that they could leave the ward freely. Some of the informal patients we spoke with told us that they felt like they were treated as if they were detained, and they did not all have a clear understanding of their legal rights and how these differed from the rights of patients detained on the wards.
Care records referred to Section 117 aftercare services for those who had been subject to section 3 or equivalent powers under the Mental Health Act. Where patients were covered by Section 117 of the Act in relation to their care post-discharge, this was included in their discharge plans.
At the time we inspected, the trust was not carrying out regular audits to ensure that the Mental Health Act was being applied correctly. The Mental Health Act team’s weekly summaries enabled a degree of ongoing quality monitoring but there was no quality assurance process in place to check whether compliance with the Mental Health Act was taking place for each patient.
Mental Capacity Act
The staff we spoke with mostly told us that they had received training in the Mental Capacity Act, but staff knowledge about the provisions of the Act and the five statutory principles underpinning the Act was variable. Some staff told us that the course they had completed (an eleven module e-learning course) had not supported them to learn what they needed to know about compliance with the Act in the context of their role. Mental Capacity Act training did not form part of the trust’s mandatory training programme, so it was not possible to identify the proportion of staff on each ward who had completed this training or how up to date this was.
Where patients were not detained under the Mental Health Act, but unable to leave the ward freely, we saw that deprivation of liberty safeguards applications were made without undue delay. However, due to backlogs at the Local Authorities with responsibility for assessing these applications, patients did not always have a DOLS authorisation in place where this was required (7 individuals across the 9 wards at the time we inspected). The trust was monitoring these applications and taking action to try to ensure they were progressed as quickly as possible.
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. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
Patients did not always receive sufficient person-centred support to make their own decisions. Patients who were unable to clearly communicate their needs verbally did not have communication care plans or any planned individualised support to support them in making and communicating decisions about their care to the greatest extent possible.
For patients who might have impaired mental capacity, staff did not always assess and record capacity to consent appropriately. Capacity assessments should be carried out and documented on decision-specific basis regarding significant decisions and Patients’ records did not show that this was happening consistently. Where decisions had been made about patients’ care and where patients did not have the capacity to consent to the intervention, for example to administer medicines covertly, there was not always a documented capacity assessment on the individual’s records which predated the commencement of the new treatment plan.
It was not always possible to see that, when patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Documentation of best interests' decision making on patients’ records was inconsistent and not always sufficiently detailed to demonstrate that the individual and, where relevant, their relatives or carers had been involved in this process.
The service did not have effective arrangements to monitor adherence to the Mental Capacity Act. A Mental Capacity Act audit was carried out in 2021 but had not been repeated since then due to capacity pressures. This was identified as an organisational risk on the trust’s risk register.