One ‘outstanding’ service was praised as ‘exceptional’ and ‘truly person-centred’
More than a third of ‘urgent’ 111 calls were not picked up by teams at a mental health trust, this week’s round-up of healthcare inspections reveals.
Some 41 per cent of calls to Pennine Care NHS Foundation Trust’s crisis and home treatment teams were abandoned, according to the Care Quality Commission (CQC). This means ‘some people requiring urgent help may not have been able to get through to a staff member, the watchdog said.
It is the second time in two weeks that teams within the trust have been rated ‘requires improvement’ by inspectors. Last week, its community-based mental health services were criticised after the CQC found there were a high number of people waiting to be allocated a key worker due to shortages, and some staff felt ‘overwhelmed’ by their caseloads.
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Here is a breakdown of Greater Manchester’s recently published CQC reports:
Tameside
The Pennine Care NHS Foundation Trust, which is based in Tameside but operates in a number of the regions’ boroughs, has been rated ‘requires improvement’ for the second week in a row. This week, a report into the trust’s crisis and home treatment teams was published.
The teams provide short-term home-based support to people in mental health crises with the aim of preventing hospital admission. Inspectors found a high number of calls to 111 – 41pc between January 2024 and October 2025 – were abandoned, meaning ‘some people requiring urgent help may not have been able to get through to a staff member’.
Documents, including patient risk assessments, were not ‘consistently’ completed. Some teams had high rates of risk assessments being completed with predictive tools, the report added. National guidance says these tools ‘cannot reliably predict individual suicide risk and can lead to unsafe decisions’.
Problems with buildings used by the trust were also documented. The Oldham team’s office was described as ‘not fit for purpose and is significantly over occupied’, with poor ventilation, insufficient seating and computers, and excessive noise also noted. The office had been added to the risk register almost two years ago.
The service did not have ‘enough appropriately trained and supervised staff in all teams’, the report continued. Compliance with training was a little as 6.5pc in some areas. Service users were not always told of their rights when it came to consent.
Staveleigh Medical Centre, based in Stalybridge, received a ‘good’ rating from the CQC. Inspectors said the service had ‘enough qualified, skilled and experienced staff, who received effective support, supervision and development’.
Staff also ‘worked together well to provide safe care that met people’s individual needs’. The centre also ‘thoroughly assessed and managed’ infection risks, supported people to live healthier lives, and was ‘exceptional at ensuring people could access the care, support and treatment they needed when they needed it’.
Patients told the inspectors staff were ‘kind’, ‘truly caring’ and ‘supportive’.
Wigan
Axis Care Group, based in Leigh, was also rated ‘requires improvement’ by inspectors. The CQC criticised the domiciliary care and supported living service for missing information in care plans and risk assessments.
This included a missing nutrition and hydration risk assessment for a service user who was identified as being at risk of choking and who had a medical condition impacting their appetite and digestion. A person who was at risk of pressure sores also had no mention of this, or their need to be repositioned, in their care plan.
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An individual was identified as needing at least 1500ml of fluids a day, but their monitoring records showed they were rarely offered more than 500ml, the report added. Recorded medicine dosages for service users did not match what had been prescribed by the GP, inspectors also found.
Further concerns were flagged over recruitment and training. Some staff files did not contain proof of identification, proof of address or contracts of employment, while interviews were sometimes conducted by a single staff member rather than two, and in some cases by staff who were not in senior positions, which contradicts best practice, the CQC said.
While training compliance was ‘high overall’, records ‘did not evidence’ advanced autism and learning disability training, despite the service supporting people with these needs. Most staff did not have in person training for moving and handling. It was also ‘not clear’ if staff had been ‘fully assessed as competent before working independently’.
Belong at Home Domiciliary Care Agency was the only Greater Manchester service to receive an ‘outstanding’ from the watchdog this week. The provider had a ‘strong proactive and positive culture of safety, based on openness and complete honesty’, inspectors reported.
The provider was praised as ‘exceptional’ and ‘truly person-centred’ when it came to treating people with kindness, empathy and compassion and respecting their privacy and dignity. Service users told inspectors that ‘staff went out of their way to make them feel “glamorous” by blow drying their hair and “pampering them”’.
Another person whose confidence had significantly declined following the COVID-19 pandemic, was ‘supported to gradually and sensitively expose themselves to anxiety provoking situations’, the report added. That person was ‘actively engaging in community-based activities and independently walking their dog’ by the time of the inspection.
People’s transitions into the service were described as ‘seamless’ and care as ‘safe, supportive and enabled people to do the things that mattered to them’. Compliance with training was ‘extremely high’, and staff were ‘extremely complimentary’ of the quality of that training, the report continued.