Pine House Rehabilitation Unit

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

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

This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of regulation for:

Regulation 18 Staffing

We have not awarded this service a score for Effective.

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

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 11 care records during our on-site inspection and our Mental Health Act Reviewer visit.

We found that staff completed a mental health assessment of the patient in a timely manner at, or soon after, admission. This included previous placements, mental health diagnosis and physical health monitoring and current needs.

Staff assessed patients’ physical health needs in a timely manner after admission. We saw that all patients were registered with the local GP soon after admission, staff at the hospital described a good relationship with the local GP and that they understood the needs of the patients at the hospital well.

Although staff developed care plans for the identified needs of the patients, we did not see evidence of these being recovery orientated. Care plans did not contain achievable goals based on what the patient or another profession such as an occupational therapist had identified. Up to date, functional assessments carried out by an occupational therapist showing patients goals and current levels of activity, were not contained within the patient records, therefore we could not clearly see what patients were working towards achieving, and patients also told us they did not know what the purpose of their admission was. No patients were managing their own medicines or working towards this, despite it being part of the medicines policy for patients to be supported to do this. Likewise, no patients were self- catering or working towards this. Staff we spoke with identified 2 patients who had an interest in cooking, but this interest had not been pursued with staff in order to incorporate that into the patients’ care plans and goals to guide them to take this from just an interest, to a functional skill required in the community.

Staff updated care plans when necessary, and we saw regular reviews of care plans taking place, we did not however, see this review effecting change in accordance with the patients’ presentation. For example, when patients declined groups for several months, no action was taken to find out why or to try and tailor the care plan to encourage this in a way that suited the patient.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Staff did not provide a range of care and treatment interventions suitable for the patient group. The interventions offered were minimal and rather than being individually care planned, were a blanket offer for most, if not all patients. The offer for psychology groups in the 3 months preceding our inspection were relaxation, an emotional regulation group and in January 2026 only, a goal setting/motivation group. We saw that the attendance at these groups was poor, only 31% of those offered attended relaxation, 41% attended emotional regulation and despite 61% attending the goal setting group, this was not offered the following month. We saw no psychological formulation of why these groups were required for patients, and there were no formal psychological therapies being provided, such as cognitive behavioural therapy for psychosis. We saw 1 patient who had been at the hospital for over 4 years and was only recently being considered for cognitive behavioural therapy for psychosis. It was unclear why this was only now being considered after such a lengthy admission and who would provide this, given there was no Psychologist within the service. National Institute for Health and Care Excellence guidance for rehabilitation of patients with complex psychosis (NG181) recommends the primary intervention for patients to be cognitive behavioural therapy for psychosis (CBTp).

There was no Occupational Therapist in post at the hospital at the time of our inspection due to maternity leave, prior to that person being in post, there was also a gap in this provision. There was a new Occupational Therapist in the provider’s onboarding process, but staff believed that this person would only work one day a week at the hospital. The provision of an Occupational Therapist is a key part of the multi-disciplinary team in a rehabilitation setting, in order to assess patients functioning and identify areas where support is required. Due to this lack of provision, patients were not benefiting from regaining their practical daily living skills which were essential to transition safely into the community, leading to a high risk of prolonged institutionalisation.

There were no patients involved in voluntary work, paid work or education opportunities. We asked for this information as part of a data request following our on-site inspection. We were given information in a general sense rather than patient specific examples, such as “applied for a job as a kitchen porter” or “attended college for a bricklaying course” under the ward name, we were not given information as to whether this related to current patients or if this information was historical. During our on-site visit, we asked staff and patients the question if anyone was involved in this type of opportunity, everyone we spoke to told us nobody was. We also reviewed the care and quality governance data collection document, which was embedded in the March 2026 governance meeting minutes, this noted out of 14 patients, 0 were involved in educational or vocational work.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. We saw a good working relationship with the local GP service, where patients were registered on admission to the service. We also saw specialists’ referrals where required, for example speech and language therapist for a patient with swallowing difficulties. However, despite having a patient at the hospital with these needs for several years, training in IDDSI (International Dysphagia Diet Standardisation Initiative) was not mandatory for staff and compliance was very low, with only 60% compliance for registered nurses and 53% compliance for support workers. This alongside low compliance in basic and immediate life support meant staff may not have been competent to deal with complications of dysphagia such as aspiration and choking.

Staff participated in clinical audit. However, this was ineffective in identifying concerns or taking action to improve the service.

Medicines audits were completed by an external provider who supplied medicines to the hospital. We reviewed the audits for the 6 months preceding our inspection, we found that generally the service was compliant in most areas with some minor lapses, such as 1 occasion liquid medicines were opened with no date of opening on them and on 1 occasion the medicines trolley was found to be unlocked. These were not found to be recurrent themes but one-off incidents.

We requested the 3 most recent care records audits, we were not sent the actual audit, but an overview of what concerns were found. We saw that concerns were noted in relation to signing of Section 17 leave, risks being linked to care plans and also that patient involvement in care plans needed improvement. However, we still identified these concerns during our on-site visits, and we were not provided with an action plan of how the service planned to improve on these issues following the audit identifying them.

We reviewed the last audit for consent to treatment. Consent to treatment is a legal requirement where a patient must either voluntarily agree to any mental health treatment or, if they are unable to or lack capacity to do so, for the treating team to enforce treatment against the patients’ wishes. We saw a weekly audit took place to monitor compliance with this and to ensure any medication being given was covered on the correct authorisation documentation. We saw that 3 patients were identified as being prescribed medication that was not on their consent forms, on all 3 occasions this was picked up on 3 consecutive weeks for the same patients and was still outstanding. This showed that although the audit was being completed and identifying issues, actions were not then taken to correct to concerns in a timely manner. This is of particular importance when a patient is being treated against their will and without consent.

The team did not include or have access to the full range of specialists required to meet the needs of patients in the service. There was no Clinical Psychologist at the hospital, although staffing data told us that there was a bank Neuropsychologist who was supposed to undertake one session per week and a bank psychotherapist on a zero hours contract. Staff we spoke with and patient records reflected, that patients were not regularly accessing a psychologist as part of their rehabilitation. We did not see a psychologist in attendance at the MDT we attended during our on-site inspection. We did not find up to date formulations completed by a clinical psychologist in patient records. A psychological formulation is a comprehensive map of a patient’s history, including trauma, triggers and coping mechanisms. Without these in place, it was impossible for care plans and positive behavioural support plans to be created that ensured staff were clear on what could potentially help a patient, what may trigger a relapse in their mental health and what coping strategies and techniques may help to ensure the patient did not become agitated or distressed. This left a high risk of increased violence and aggression, and in turn restrictive practice to manage this, ultimately resulting in a lack of patients moving through the rehabilitation pathway. We found all these issues to be present at the hospital. In addition to this, the Assistant Psychologist was completing positive behavioural support plans for patients but they had no training to be able to do this. This meant there was a high risk that incorrect techniques could be suggested to manage patients’ behaviours which were not based on a psychological formulation.

The assistant psychologist received supervision from a Clinical Psychologist contracted by Pine House. Managers provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. The percentage of staff that had had an appraisal in the last 12 months was 80%. The percentage of staff that received regular supervision was 80%.

Managers ensured that staff had access to regular team meetings. We reviewed the minutes of the last 3 team meetings prior to our on-site inspection. These were dated January 2026, February 2026 and April 2026. January and February followed a set agenda, but each agenda was different and therefore, actions were not effectively identified or carried forward to the next meeting. An example of this is that the missing fire door on Pine ward was discussed in the January meeting as item 4. However, in the February meeting item 4 was a patient discussion and the fire door was not reviewed or discussed. We then found at our on-site visit on 30 April 2026 that the door was still missing. This meant the service did not consistently share important information with staff and did not follow up on actions.

Managers did not always ensure that staff received the necessary specialist training for their roles. Examples of this included no specialist training in positive behavioural support for the person responsible for completing these plans. Although there was mandatory training in positive behavioural support, this was the same for staff at all levels and was not a recognised qualification, rather an introduction to positive behavioural support providing staff with basic knowledge. Another example was lack of training for staff in specialist diets for patient with dysphagia, again this was the same level for all staff with low compliance.

Managers told us they felt confident to deal with poor staff performance. However, some staff we spoke with felt this was punitive in nature, and it was noted in the team meeting minutes that staff had raised that disciplinary action was used as a way to drive improvement. We reviewed staff files as part of the on-site inspection and found that disciplinary processes were not always documented well to show due process had been followed. An example of this was the outcome of 1 disciplinary process, where a staff member was to be downgraded from their current role, but the staff member was still working at the same level. We asked the provider what process had been followed to overturn this decision, we were provided with an email response to say that although the complaint record and lessons learnt documentation recommended the demotion, this was subsequently changed to a recommendation of supervision and reflective practice. However, we were never provided with any copies of these records to support this change in the recommendation.

Mental Health Act

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

Mental Health Act training was not mandatory at the service however, compliance at the time of our inspection was 90% for registered nurses and 95% for healthcare support workers. Despite this, staff did not have a good understanding of the Mental Health Act, the code of practice and the guiding principles. This included the responsible clinicians for patients.

We found one patient was nursed in segregation away from other patients without any necessary safeguards in place for that patient. We raised this whilst on site with the local authority safeguarding team and the service.

We reviewed 8 Section 17 leave forms. We found them all to be expired or not signed by the Responsible Clinician, meaning Section 17 leave was not legally authorised despite being used by patients. We requested that this was rectified urgently, so as not to stop patients leave due to administration errors, and we did receive copies of all Section 17 leave forms that were complete, in date and signed for the following day.

We found patients' rights were not documented as being read on a regular basis. We found one patient’s Section 132 rights form stated their rights were last read in April 2025 or 2026 (the form was unclear), but the part to say if the patient understood or not was left blank. We noted that prior to this, the patient’s last Section 132 rights form stated their rights were last read in July 2024, the patient did not understand their rights, but these were not repeated and no effort had been made to try and present the information in a way the patient could understand. All other patient rights were completed in April 2026 but prior to this, we found the last time patients' rights were read was April 2024. The MHA Code of Practice mandates that rights must be routinely revisited to account for fluctuating capacity and understanding. In addition to this, we found a culture of restrictive practice where patients’ Section 17 leave was decreased rather than increased, and we did not always find an explanation of why this had been done in patient records.

For patients who did not consent to treatment, or were unable to due to being too unwell, we did not see a Section 61 form in place. This is a statutory annual review used to report on compulsory treatment and the clinical condition of the detained patient. This is the responsibility of the responsible clinician and is required to justify the ongoing clinical necessity for treatment. In the absence of these, we were unable to assure ourselves that treating the patient against their will was the appropriate action.

Patients attended Care Programme Approach meetings 6 monthly, this was a desired outcome on all patients’ care plans. However, we saw that reports for the meetings were often dated after the meeting date. This meant that patients, other professionals and advocates did not have access to the information they needed in order for the meeting to be meaningful and progress outcomes for patients.

We saw the use of restrictive practices in the service, although these would have been viewed as restrictive in most mental health wards, these were particularly restrictive for a rehabilitation environment where patients were there to progress and integrate back into the community. We saw blanket restrictions that were not individually risk assessed but applied to all patients. This included locked kitchens, no open access to the garden, rules around not eating food in bedrooms and Section 17 leave that was reduced since admission, rather than increased in several cases.

Staff had access to administrative support on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

Multidisciplinary meetings were held monthly. These were attended by the nurse from the ward, the responsible clinician, and generally the occupational therapy assistant and the assistant psychologist as well as the lead nurse. However, we observed during our on-site visit and patients and staff told us, that responsible clinicians would not always attend in person and would join remotely. Patients told us they did not feel like they saw their consultant regularly enough, and that a month wait between visits was too long if they had something they wanted to discuss.

We observed a multidisciplinary meeting on the first day of inspection, we found that the meeting was not working effectively based on the current risks of the patients. We observed a patient who had been on increased one to one observations for some time. The patient requested for this to be decreased as it felt overly restrictive to them. The patient had not had an incident since February 2026 and prior to that October 2025, but the patient remained on one to one observations and the rationale for this restriction was not made clear. It appeared from the clinical records we reviewed and in the absence of sufficient information on decision making, the MDT were working on historical risks rather than current presentation. This was not in keeping with least restrictive practice or a rehabilitation model.

The teams did not show effective working relationships, including good handovers, with other relevant teams (for example, care co-ordinators and community mental health teams). We received feedback from a range of community staff who told us that they found it difficult to gain information from the service about their patients. They told us that the service felt overly restrictive and highlighted this impacted on their ability to source appropriate placements for patients. They told us that it was often difficult to get in touch with the service over the telephone. One patient had been on leave at a placement in another area since the beginning of 2026, the staff at Pine House Rehabilitation Unit told us this prolonged leave was due to the local community mental health team (CMHT) not allocating the patient. However, we were later told that the CMHT were awaiting Pine House Rehabilitation Unit to refer the patient for a Mental Health Act assessment. This demonstrated a lack of communication and follow up, which significantly delayed the patients’ discharge.

Staff shared information about patients at effective handover meetings within the team (for example, shift to shift). We observed a morning flash meeting where staff discussed incidents from the previous 24 hours.

The teams reported good working relationships with the local GP and patients visited the practice if required.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. The service did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

We saw very little evidence of staff supporting patients to live healthier lives. Patients who had leave to the garden spent most of the day being escorted down to smoke on a 2 hour rotational basis. We reviewed activity planners and a plan of groups offered, smoking cessation work was not contained in either.

We did see some walking groups that were run by the occupational therapy assistant, as well as fishing that 3 patients attended. One patient had their Section 17 leave suspended due to a risk of substance misuse when on leave, but there was no ongoing work either internally or with an external provider for this patient to support them to manage this risk and restart leave.

There was a blanket restriction on ordering takeaways, limiting patients to 1 per week, but just 2 months prior to our inspection there was no chef in post at the service. During this time, it was agreed that patients would order a take-away each evening for their main meal of the day. None of the patients at the service were self-catering or working towards this, this meant that opportunities for creating healthy meal plans, shopping lists and recipes were missed. However, the new chef in post received overwhelmingly positive feedback from all patients and was cooking healthy and nutritional meals.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We requested a summary of the measures in place to measure clinical outcomes relating to the rehabilitation service as part of our data request following on-site inspection. We received an overview that noted the service used the Care Programme Approach (CPA) to monitor patient outcomes, as well as Health of the Nation Outcome Scales (HONOS) but evidence of this being completed was not submitted.

We reviewed the CPA audit which was submitted, this confirmed what we found during our on-site inspection, that CPA reports were not submitted in time for the meetings on a regular basis. This meant that the patients and staff at the meeting did not have access to essential information in order to review the patient and make plans for the following 6 months. In addition to this, in the absence of key members of the MDT (there was no psychologist or OT in the service), it would be very difficult for a clear evidence-based plan to be made with the patient with clear goals and outcomes. This effectively rendered the meetings ineffective and meant that although they were taking place, they weren’t effective in progressing patients through the rehabilitation journey. This judgement was supported by the long lengths of stay (with the longest stay being 4 years) in the service and very little evidence of discharge plans in patients’ records.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not tell people about their rights around consent or respect these when delivering care and treatment.

Staff did not always take all practical steps to enable patients to make their own decisions. We saw this not only in day to day decisions such as deciding on food choices (blanket restrictions around take aways but little evidence of encouraging patients to meal plan and shop for their own food to cook healthy options), but also in more significant decisions such as levels of observations. We saw examples where patients requested for observation levels to be reduced, showing good insight into their own levels of restrictions, but the reductions were refused with little evidence as to why these needed to be continued.

For patients who might have impaired mental capacity, staff did not assess and record capacity to consent appropriately. For patients who did not consent to treatment or were unable to due to being too unwell, we did not see a review of compulsory treatment. This is a mandatory statutory requirement and should be used to report on compulsory treatment and the clinical condition of the detained patient. The responsible clinicians at the service were not completing these under their responsibility as the lead clinician, and therefore we were not assured that ongoing treatment against the patients’ will was necessary or the least restrictive option.