The Care Quality Commission
  • Mental Health
  • Independent mental health service

Pine House Rehabilitation Unit

Overall: Inadequate read more about inspection ratings

Yorkshire Street, Bacup, OL13 9AE (01706) 619300

Provided and run by:
Kibo Hospital Services Limited

All Inspections

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Pine House Rehabilitation Unit has been registered with the CQC since November 2021. It is registered with CQC to deliver the regulated activities:

  • Treatment of Disease, Disorder or Injury
  • Assessment or medical treatment for persons detained under the Mental Health Act 1983

The service did not have a registered manager at the time of our inspection and had not had one since November 2023. The service had a Nominated Individual at the time of our inspection who was also the controlled drugs accountable officer. Pine House Rehabilitation Unit consisted of 3 wards: Pine ward, a 4-bed ward on the ground floor, Lyme ward, an 8-bed ward based on the first floor and Aspen ward, an 8-bed ward based on the second floor. At the time of our inspection there were 12 patients, one of which was on long term leave.

We carried out an unannounced on-site inspection on the 30 April, 1 May, 7 May 2026 and 13 May 2026.

We gathered information from patients and their family/carers, staff and managers, other stakeholders and our own observations of care. We reviewed a range of documents including care records and policies and procedures. At this assessment we assessed 1 assessment service group; Long stay or rehabilitation mental health wards for working age adults where we assessed 33 quality statements. 

The inspection was planned due to the length of time since our previous inspection, and to follow up on concerns from our previous two inspections at the service. Our overall rating at this inspection for this service is inadequate. We identified 5 breaches of Regulation in relation to Regulation 9 Person Centred Care, Regulation 12 Safe Care and Treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance and Regulation 18 Staffing.

The service will therefore be placed into special measures.


Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.’

Pine House Rehabilitation Unit was last inspected in 2024 and was rated Requires Improvement with 3 breaches of Regulation in the following areas:

Regulation 12 safe care and treatment. Ward staff could not locate documentation regarding the safety of the environment, such as the ligature risk assessment, along with patient emergency evacuation plans which would be required in an emergency. Physical health folders contained inconsistent recording, incomplete documentation and gaps in some ongoing checks.

Regulation 15 premises and equipment. Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained.

Regulation 17 good governance. Although governance processes and procedures had been implemented following the previous inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this inspection.

All these breaches of regulation remained at this published inspection.

Prior to the inspection in 2024, the service was inspected in October 2023 and was rated requires improvement overall with an inadequate rating in safe, with breaches of Regulation in the following areas:

Regulation 12 Safe care and treatment. We issued a warning notice to tell the provider to make significant improvements in relation to failures to identify, assess and take consistent actions to mitigate and manage risks in relation to the environment.

Regulation 15 Premises and equipment. Repairs and maintenance to the ward areas did not take place in a timely way. Damage to the environment posed risks to patients and staff.  

Regulation 17 Good governance. Governance processes were not effective in identifying and mitigating risks in relation to the environment, incident reporting, management of patient finances, medication management and quality assurance.

Regulation 18 staffing. The provider did not ensure that the number and skill mix of staff on each shift met the needs of patients. Staff providing care did not have access to training and support to meet specific patients’ needs safely and competently.

Mental Health Act and Mental Capacity Act Compliance Summary

We found shortfalls in the management of the Mental Health Act (MHA) and adherence to the code of practice during our onsite visit. We therefore later carried out a full Mental Health Act review of the service and found significant failures.

Mental Health Act training was not mandatory at the service however, 90% of registered nurses and 95% of support workers had received training in the Mental Health Act.

We found one patient was nursed in segregation without the required safeguards.

All 8 Section 17 leave forms we reviewed were either expired or unsigned, meaning leave had not been legally authorised, until we asked for this to be urgently rectified and received confirmation it was complete Patients’ rights under the Mental Health Act were not consistently reviewed or documented, with evidence that some patients who did not understand their rights, were not given further support or repeat explanations.

There were also continued concerns around restrictive practices, including reduced Section 17 leave, blanket restrictions such as locked kitchens and limited garden access, and rules not based on individual risk assessments which were routinely applied. In addition to this, required Section 61 reviews for compulsory treatment were missing. This meant there was a lack of assurance that treatment without consent remained justified.

Care Programme Approach meeting records were frequently completed after meetings had taken place, limiting patients and professionals’ access to important information.

Overall, the findings demonstrated serious shortcomings in legal compliance, patients’ rights, documentation, and use of restrictive practice, requiring urgent improvements to ensure safe, lawful and person centred care.

90% of staff had training in the Mental Capacity Act (MCA). Staff demonstrated an understanding of the Act, particularly the 5 statutory principles. However, there was a lack of monitoring and oversight of adherence to the MCA. Whilst the provider told us that the auditing of MCA compliance was contained within Mental Health Act audit, we reviewed that audit and found it contained no information about adherence to the MCA. Meaning opportunities to identify learning and improve practice were missed.

The provider had a MCA and Deprivation of Liberty Safeguards policy.

During an assessment of the hospital overall

Pine House Rehabilitation Unit has been registered with the CQC since November 2021. It is registered with CQC to deliver the regulated activities:

  • Treatment of Disease, Disorder or Injury
  • Assessment or medical treatment for persons detained under the Mental Health Act 1983

The service did not have a registered manager at the time of our inspection and had not had one since November 2023. The service had a Nominated Individual at the time of our inspection who was also the controlled drugs accountable officer. Pine House Rehabilitation Unit consisted of 3 wards: Pine ward, a 4-bed ward on the ground floor, Lyme ward, an 8-bed ward based on the first floor and Aspen ward, an 8-bed ward based on the second floor. At the time of our inspection there were 12 patients, one of which was on long term leave.

We carried out an unannounced on-site inspection on the 30 April, 1 May, 7 May 2026 and 13 May 2026.

We gathered information from patients and their family/carers, staff and managers, other stakeholders and our own observations of care. We reviewed a range of documents including care records and policies and procedures. At this assessment we assessed 1 assessment service group; Long stay or rehabilitation mental health wards for working age adults where we assessed 33 quality statements.

The inspection was planned due to the length of time since our previous inspection, and to follow up on concerns from our previous two inspections at the service. Our overall rating at this inspection for this service is inadequate. We identified 5 breaches of Regulation in relation to Regulation 9 Person Centred Care, Regulation 12 Safe Care and Treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance and Regulation 18 Staffing.

The service will therefore be placed into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Pine House Rehabilitation Unit was last inspected in 2024 and was rated Requires Improvement with 3 breaches of Regulation in the following areas:

Regulation 12 safe care and treatment. Ward staff could not locate documentation regarding the safety of the environment, such as the ligature risk assessment, along with patient emergency evacuation plans which would be required in an emergency. Physical health folders contained inconsistent recording, incomplete documentation and gaps in some ongoing checks.

Regulation 15 premises and equipment. Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained.

Regulation 17 good governance. Although governance processes and procedures had been implemented following the previous inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this inspection.

All these breaches of regulation remained at this published inspection.

Prior to the inspection in 2024, the service was inspected in October 2023 and was rated requires improvement overall with an inadequate rating in safe, with breaches of Regulation in the following areas:

Regulation 12 Safe care and treatment. We issued a warning notice to tell the provider to make significant improvements in relation to failures to identify, assess and take consistent actions to mitigate and manage risks in relation to the environment.

Regulation 15 Premises and equipment. Repairs and maintenance to the ward areas did not take place in a timely way. Damage to the environment posed risks to patients and staff.

Regulation 17 Good governance. Governance processes were not effective in identifying and mitigating risks in relation to the environment, incident reporting, management of patient finances, medication management and quality assurance.

Regulation 18 staffing. The provider did not ensure that the number and skill mix of staff on each shift met the needs of patients. Staff providing care did not have access to training and support to meet specific patients’ needs safely and competently.

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Dates of onsite assessment: 19 November 2024; with additional offsite interviews taking place on 26 to 27 November 2024.

Pine House Rehabilitation Unit is a 20-bed hospital for male patients. There are 3 wards across 3 floors: Pine ward on the ground floor; Aspen ward on the first floor; and Lyme ward on the second floor. We carried out an unannounced assessment of all 3 wards. This assessment was a follow up to a warning notice that was issued to the provider following the previous inspection in August 2023. We assessed 15 quality statements across the safe, effective, caring, responsive and well led key questions. Our overall rating for this service remains requires improvement.

We identified 3 breaches of regulation in relation to safe care and treatment; premises and equipment; and good governance.

Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained. Ward staff could not locate documentation regarding the safety of the environment, such as the ligature risk assessment, along with patient emergency evacuation plans which would be required in an emergency. Physical health folders contained inconsistent recording, incomplete documentation and gaps in some ongoing checks. Although governance processes and procedures had been implemented following the last inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this assessment.

However, the service had implemented a staff huddle at which essential safety areas of the service were discussed and reviewed. Patients generally felt safe within the service and gave positive feedback about staff and activities. Patients had opportunities to give feedback on the service. Staff gave positive feedback about the culture of the service and the improvements the service had made.

We have asked the provider for an action plan in response to the concerns found at this assessment.

During an assessment of the hospital overall

Dates of onsite assessment: 19 November 2024; with additional offsite interviews taking place on 26 to 27 November 2024.

Pine House Rehabilitation Unit is a 20-bed hospital for male patients. There are 3 wards across 3 floors: Pine ward on the ground floor; Aspen ward on the first floor; and Lyme ward on the second floor. We carried out an unannounced assessment of all 3 wards.

This assessment was a follow up to a warning notice that was issued to the provider following the previous inspection in August 2023.

We assessed 15 quality statements across the safe, effective, caring, responsive and well led key questions.

Our overall rating for this service remains requires improvement.

We identified 3 breaches of regulation in relation to safe care and treatment; premises and equipment; and good governance.

Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained.

Ward staff could not locate documentation regarding the safety of the environment, such as the ligature risk assessment, along with patient emergency evacuation plans which would be required in an emergency.

Physical health folders contained inconsistent recording, incomplete documentation and gaps in some ongoing checks.

Although governance processes and procedures had been implemented following the last inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this assessment.

However,

The service had implemented a staff huddle at which essential areas for the safety of the service were discussed and reviewed.

Patients generally felt safe within the service and gave positive feedback about staff and activities. Patients had opportunities to give feedback on the service.

Staff gave positive feedback about the culture of the service and the improvements the service had made.

We have asked the provider for an action plan in response to the concerns found at this assessment.

3 August 2023

During an inspection looking at part of the service

Our rating of this service ​went down​. We rated it as ​requires improvement​ because:

  • Wards were not always safe, clean or well maintained. Repairs did not happen quickly and the environment was not therapeutic.

  • Staff did not assess and manage risks well. Risk assessments and management plans did not address the needs of all patients. Some opportunities to prevent or minimise harm were missed.

  • Information relating to patient care and treatment was not kept up to date or easy for staff to find.

  • Staff had not always completed training to meet the specific needs of patients.

  • Incidents, including the use of restrictive interventions were not well recorded. Lessons learnt were not always identified and shared with the whole team. Managers could not be assured physical restraint was being carried out in line with guidance.

  • Managers had not ensured staff had received training necessary for their roles.

  • The service was not well-led at all levels. Governance processes did not ensure that ward procedures ran smoothly. Some audits to evaluate the quality of care provided were not completed.

  • The approach to service delivery and improvement had sometimes been reactive. This meant risks and improvements were not always managed appropriately or rectified quickly enough.

However:

  • Staff were respectful to patients and were caring in their approach.

  • Staff we spoke to were enthusiastic about the service and most felt supported in their role.

  • Some improvements had been made following our previous inspection. Leaders had an action plan for future improvements and needed time for changes to be embedded.

4 and 5 October 2022

During a routine inspection

This service has not previously been inspected or rated. We rated it as good because:

  • The wards had enough nurses and doctors. There were some staff vacancies but gaps in rotas were covered by bank and agency staff. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Although there were vacancies for an occupational therapist and a psychologist, provision was provided from another hospital site as a temporary measure. Managers ensured that these staff received supervision. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

However,

  • Staff were not appropriately trained in all methods of physical intervention as required by the service. Training compliance was low. There were not enough staff trained to safely restraint a patient.
  • The service had not ensured that staff were appropriately trained in other mandatory training modules such as immediate life support and first aid.
  • The ward layout required some revision. For example, doors opened into each other and rooms were too small. There was no dining room and patients often ate in their bedrooms. The service were aware of this and considering changes.
  • Opportunities to access the local community and other external activities were limited.
  • Managers and governance systems did not prevent vital staff training from falling below standard.

The acquired brain injury service is a small proportion of hospital activity. The main service was long stay or rehabilitation mental health wards for working age adults. Where arrangements were the same, we have reported findings in the long stay or rehabilitation mental health wards for working age adults section.