Providing high quality care for patients is our top priority and underpins everything we do here at Pennine Care, but it’s important that we can demonstrate this at any time, to anyone.

The Care Quality Commission (CQC) is responsible for ensuring that providers are meeting fundamental standards of care. They assess this as part of a planned visit involving up to 120 external inspectors, or an unannounced visit involving a smaller team of inspectors looking at a particular service.

CQC inspection teams include clinical professionals and other experts, such as people with experience of receiving care. They take an in-depth look at everything a trust or service does and all staff need to be able to answer their questions clearly and demonstrate supportive evidence.

An inspection should build on what we are doing already and provides us with an opportunity to showcase our good work, areas and actions for improvement, how we involve and listen to patients and how we learn from mistakes.

Based on their findings, the CQC will rate us as ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’.

Pennine Care has a good track record of quality and is placed within the CQC’s lowest rate of concern, but we mustn’t become complacent and need to monitor our effectiveness continuously.

Five quality questions

During an inspection, the CQC will be looking for evidence for how we ensure the care we provide is:

  • Safe - People are protected from abuse and avoidable harm.
  • Effective - People's care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
  • Caring - Staff involve and treat people with compassion, kindness, dignity and respect.
  • Responsive - Services are organised so that they meet people's needs.
  • Well-led - The leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

Read more about inspections on the CQC website.

Our inspection

The Care Quality Commission (CQC) inspected our Trust between 18 and 27 September 2018, visiting a cross-section of our community and mental health services.  

They spoke to our staff about how their service is performing under the five key domains, asked to see documentation and observed the care that is delivered. They also spoke to service users about their experiences of care and gathered feedback from a range of other key stakeholders, such as parents, carers and partners

Our rating

Our overall CQC inspection outcome is ‘requires improvement’.  Within the five key domains, our ratings are:

  • Caring: Good
  • Responsive: Good
  • Safe: Requires improvement
  • Effective: Requires improvement
  • Well-led: Requires improvement

To further break down our overall rating:

  • One service rated as ‘outstanding’, ten rated as ‘good’, and six rated as ‘requires improvement’ overall
  • No services rated were as ‘inadequate’

Clare Parker is our executive director of nursing, healthcare professionals and quality governance and senior lead for the inspection.  She said: “While the ratings have not changed since our last inspection in 2016, this report feels very different.

“It recognises the significant improvement we have made in many in areas and that we are on a positive journey towards achieving a ‘good’ outcome.  Of course, our ultimate aim is to be outstanding and we’re committed to achieving this as soon as possible.

“We are delighted that our mental health older people’s wards have improved their rating to good and that our dental services, which were inspected for the first time, were also rated as good.

“We are also proud that our caring staff have been acknowledged with a ‘good’ rating. This is testament to their compassion and dedication to patients.

“We are also very encouraged by the recognition of positive changes around our culture and our clear commitment to improving quality.”

“We will continue to focus on areas for improvement, including making sure all records are up to date, and a stronger focus on equality and diversity.”

We will now work with our staff and the CQC to develop an action plan, so that the required improvements can be made as quickly as possible.

View our full CQC report.

Following our 2018 CQC inspection we’ve made the following improvements. You can download our CQC improvement plan with all these on too.

Medicines to be managed safely

  • All pharmacy posts appointed to
  • Senior pharmacy staff at transformation meetings and events to ensure medicines management requirements met

Eliminate mixed sex wards and dormitories

  • All adult and older people’s wards are now single gender and all shared dormitories removed

Care plans meet the communication needs of learning disabilities patients

  • Adult inpatient assessment created
  • Hospital traffic light assessment created
  • Learning disabilities traffic light care plan created

Psychological therapies to be provided to all wards

  • All adult inpatient posts in the process of being fully recruited

​​​​​​​​​​​​​​Implementation of electronic recording for patient records​​​​​​​

  • Rolled out our electronic patient records, Paris, to all our inpatient and outpatients teams, and progressing roll out with psychological therapies and older people’s services

Advocacy services to be made accessible to all patients

  • All care hubs have access to advocacy services

Alternatives to ward admissions

  • Daily and weekly huddles to operationally manage patient flow in acute services

New values and vision to be implemented

  • Vision, values, and behaviour framework launched
  • Five-year strategy launched 2020 (updated June 2022), reflecting our four big ambitions

Improve diversity and equality

  • We have made great strides in improving equality and diversity
  • Published anti-racist statement and transgender and non-binary statement
  • Focus on diversity in recruitment to ensure we reflect the communities we service
  • Developed and extended our staff networks
  • Developed our anti-racist action plan
  • Launched an anti-racist survey with more than 800 people responding. Actions currently   being finalised with a focus on recruitment, retention and supporting diverse colleagues

Lack of development opportunities for managers/leaders

  • Leadership development programmes
  • Management skills development programme reviewed
  • Board development sessions held
  • Apprenticeship scheme for leaders

Obtain views of patients

  • Appointed a patient and carer experience and engagement manager
  • Refreshed and relaunched our Triangle of Care care hub and trustwide forums
  • Co-designed involvement toolkit for staff to use to engagement meaningfully
  • Established IAPT patients’ council
  • Patients and carers speaking directly to our Board, members of project groups and forums, participate in recruitment and training of staff
  • Launched feedback calendar, obtaining data from service users and carers about experience of care
  • Started to embed lived experience participants in our quality and safety forums


Additional improvements
  • Implemented the integrated leadership structures
  • Installed Oxehealth in our section 136 and seclusion rooms
  • Launched mental health joint response service in partnership with Greater Manchester Police (GMP) and North West Ambulance Service NHS Trust (NWAS).
  • Opening a new female psychiatric intensive care unit (PICU) spring 2023
  • Launched an all age 24/7 helpline
  • Launch of part of the Oliver McGowan mandatory training on learning disability and autism

The CQC has published the results of the 2021 Community Mental Health Survey, which 54 providers of NHS mental health services in England participated in. The survey looks at the experiences of people who use community mental health services.

You can read the national summary report which presents the key findings for England and our benchmark report.