Pine House Rehabilitation Unit

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

This means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect.

At our last inspection we rated this key question Good. At this inspection the rating has changed to Inadequate.

This meant people were not treated with compassion and there were breaches of dignity. The services caring attitude had significant shortfalls.

The service was in breach of regulation for:

Regulation 9 Person centred care

We have not awarded this service a score for Caring.

Find out about when we will not publish a key question score and what we look at when we assess Caring.

We scored the service as 1. The evidence showed significant shortfalls. The service did not treat people with kindness, empathy and compassion, or respect their privacy and dignity. There were high levels of restrictive practice, and at time without the appropriate safeguards to ensure patients were safeguarded. However, staff at the service did treat patients with kindness and dignity and we observed positive interactions between them and the patients.

Ward staff attitudes and behaviours we observed when interacting with patients evidenced that they were discreet, respectful and responsive, providing patients with help, emotional support and advice at the time they needed it. We observed interactions between patients and staff on all 3 wards and found that staff showed a caring and empathetic attitude towards patients. Patient told us that staff treated them with kindness and behaved appropriately towards them. However, we noted there had been an issue raised in patient meetings where staff had been using their work phones to document observations whilst speaking with patients. It was agreed that staff would not use them when speaking to patients, but it was sad to see that patients had to raise this issue rather than staff recognising that it was not appropriate to be on a device whilst speaking to a patient.

Staff maintained the confidentiality of information about patients. Records were accessible only by a password and information relating to patient care was in the office that was not accessible to patients.

Staff we spoke with as part of the inspection knew patients well. They were able to tell us about patients interests and what kind of things may help them if they were becoming distressed or agitated. Examples of this included staff discussing patients’ favourite music that could be talked about and played in order to distract or divert. Another patient enjoyed cooking and staff said historically they enjoyed doing this if they were becoming anxious, however, staff reported in recent months the patient did not want to engage in cooking.

However, staff did not support patients to understand and manage their care, treatment or condition. We found that care plans were not patient focused and were not always written in a way patients could understand. Several of the patients at Pine House Rehabilitation Unit had an acquired brain injury, this meant that there could be cognitive deficits for those patients as well as processing and understanding difficulties. Care plans for these patients were written in exactly the same way as all other patients, we would usually expect to see some consideration of what would work best for that patient in terms of communication and understanding, such as pictorial care plans or easy read format. Care plans were not centred around goals and rehabilitation and 6 out of 11 patients told us they did not know what they needed to do in order to leave the service.

Staff did not always direct patients to other services when appropriate and, if required, support them to access those services. We saw examples of patients who required support for substance misuse, the data we received told us the service ran a substance misuse group, but we didn’t see any evidence of this taking place from January 2026, and we did not note in any records that patients were attending external groups for this support.

Staff said they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients without fear of the consequences.

We scored the service as 1. The evidence showed significant shortfalls. The service did not treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The service did not take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

The service made adjustments for disabled patients. There was step free access available at the back of the building, although the main entrance did have some steps to go up, and there was a lift that served the upper floors.

Staff did not always ensure that patients could obtain information on treatments, local services, patients’ rights, how to complain and so on. We saw that patients’ rights were not read as required, even when patients did not understand their rights. There was no evidence of how staff were supporting patients who did not understand their rights to engage in a way that was meaningful to them, for example easy read versions. Patients’ rights had been read in April 2026, but prior to this had not been documented since April 2024. Patients told us that they did not understand their plan of care at the service and that they were unsure of their discharge plans.

We did not see any information on the wards in an accessible format for patients with an acquired brain injury.

Staff told us they could make information leaflets available in languages spoken by patients if required. There was nobody who required this at the time of our inspection, so we did not see evidence of this.

Patients had a choice of food to meet the dietary requirements of religious and ethnic groups and to account for allergies and intolerances. The kitchen had recently had an environmental health visit and was awarded a rating of 5.

We did not see evidence of access to spiritual support and whilst nobody raised this as an issue during our conversations with them, there was no multi faith room on site and some patients did not have access to leave. Faith leaders did not visit the service, and in a rehabilitation setting, we would expect to see patients visiting their own place of worship in the community where possible rather than the service coming to them.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not promote people’s independence, so people did not know their rights and have choice and control over their own care, treatment and wellbeing.

Patients we spoke with, and their carers/family did not feel very well informed about their care and treatment. Patients described that they had not received information about their medicines and said that although they were involved in reviews about their care and treatment it was not always clear what their plan was, and they did not feel this was explained to them or their family/carers clearly. Patients reported that, where they wanted their family/carers involved in meetings about their care, they were not always kept informed of updates or invited to meetings. One carer we spoke to said that they had not been updated when their relative was physically unwell until several days later.

As part of our data request following our onsite inspection, we requested the minutes of the last 3 community meetings on each ward and patient and carer feedback received in the 6 months preceding our inspection. We also requested examples of changes made as a result of patient feedback at the service in the 12 months prior to our inspection. In the main, community meetings appeared to be happening on a regular basis. The meeting minutes reflected patient views and suggestions, but the outcomes and actions were not always documented, and some suggestions were noted but no follow-up or actions were documented at the next meeting. Examples of suggestions included trips to the theatre, cinema and a meal out to a local restaurant. The meeting was often used to reiterate rules and restrictions to patients, and this did not feel like the correct forum to do this.

We did, however, see some minor examples of changes made as a result of patient feedback across all 3 wards. Examples included, changing one of the lounges to a games room, and patients raising that staff were using the work phones they documented observations on whilst in discussions with patients and they felt this impeded interactions, so it was agreed that staff would not use them when speaking to patients. It was sad to see that patients had to raise this issue rather than staff recognising that it was not appropriate to be on a device whilst speaking to a patient.

We scored the service as 1. The evidence showed significant shortfalls. The service did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

We saw examples of specialist care plans for issues such as swallowing difficulties and found these to have involved a speech and language therapist who had given specialist advice on how to manage the swallowing issues safely. However, staff compliance with training in texture-modified foods and thickened liquids was poor.

Staff did not always respond to the current risk patients posed to themselves or others. We found that MDT meetings often focused on historical risk as a reason to maintain increased observations and reduced leave, even when patients voiced that it felt overly restrictive, the current risk was not reviewed or considered in order to reduce restrictions. We reviewed records of 3 patients who had increased observations that related to incidents or risks and speaking to ward and community staff, appeared to have reduced significantly since restrictions were introduced and this had not been reviewed.

We observed that staff working on the wards knew patients well and were able to verbalise how they would deescalate different patients dependent on their interests.

We did review records for episodes of restraint and found that there had been 18 episodes over the last 12 months. This equates to just over one episode per month, which although low, is more than we would expect to see in a rehabilitation ward. We did see some evidence in records of staff using de-escalation techniques to reduce the need for physical interventions when patients’ behaviours became heightened.

We scored the service as 1. The evidence showed significant shortfalls. The service did not care about or promote the wellbeing of their staff. They did not support or enable staff to deliver person-centred care.

Staff did not always feel respected, supported and valued. We spoke with 10 members of staff, they told us that the environment they worked in being in disrepair for a long time, decreased morale of staff in the service. They noted that areas such as the office floor had been damaged for several years, walls and doors were damaged and broken and the environment was stark and clinical. This had an impact on staff, they did not feel like the service mattered to the senior leaders in the organisation, but they continued to try their best to care for patients in a dignified and caring way in spite of this.

Staff did not feel positive and proud about working for the provider, but they did feel passionate about the patients they cared for and their immediate teams on the ward. They reported a family atmosphere, where staff at ward level looked out for each other and made sure colleagues were ok during shifts. Staff did not feel this was mirrored by the senior leaders in the organisation, they reported they did not know who the more senior leaders above the Hospital Director were and that they would not know who to raise concerns to above the Hospital Director. In the absence of a Registered Manager and the Director of Operations being on maternity leave, no other senior leaders were visible in the service for staff to look to for support and advice other than the Lead Nurse. This remained the case even after we raised significant concerns during our on-site inspection.

Staff reported they did not have access to an occupational health service for support with their own physical and emotional health needs that they were aware of. 4 staff told us they felt they could not be off sick as this would result in disciplinary action, we saw examples in staff files and in staffing data provided to us, that staff were routinely dismissed due to sickness rates. Although this may have been in keeping with the provider’s sickness policy, it did not feel like a supportive process to the staff working at the service, and it left them fearful of becoming unwell, preferring to come to work than be at home when unwell.

The service’s staff sickness and absence rates were difficult to decipher. We were provided with a staffing list, but this also included bank staff that were on zero hour contracts who would not be included in the staffing establishment for the service. We calculated there were around 38 staff employed at the service, discounting bank staff and staff who did not work solely at the service for example the Hospital Director. This meant that over the last 12 months there were 52 episodes of sickness recorded, we were unable to see from the data provided which staff this related to and if one member of staff was off more than once so unable to present the sickness rate as a percentage.

Team meeting minutes showed that staff could nominate a colleague if they had done some particularly good work that month or something the team wanted to shine a light on for good practice. The staff would be mentioned in the meeting minutes, which were shared with colleagues.