Pine House Rehabilitation Unit

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

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

This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of regulation for:

Regulation 9 Person Centred Care

We have not awarded this service a score for Responsive.

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

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Patients and their carers told us they did not feel their care was well coordinated and that they did not always feel included in plans. Although they told us they felt they could approach staff to ask for information, they did not feel that the information provided was clear and allowed them to understand their care pathway and discharge plans. However, staff had a good understanding of patient’s individual needs, and these were respected for the most part, notwithstanding the high levels of restrictive practice and blanket restrictions we found within the rehabilitation environment.

The family and carers we spoke with said they did not have any specific support for their own needs, there were no carers groups at the service and carers we spoke with told us communication from the service was poor, with delays in letting carers know about significant events such as physical health emergencies. They also said they were not always invited to multidisciplinary meetings and if they said they were available, links were not always provided in a timely way, or at all, so they could not join the meeting. Care and treatment plans we reviewed did not evidence patient involvement well, the patients voice was not used in any of the care plans we reviewed and clinical language was used rather than tailoring it to suit the patients understanding.

We did observe ward staff engaging with patients in a person-centred way and adjusting their approach according to the patients’ needs. Some information was displayed informing patients of how to give feedback on care, but there were no displays on the wards explaining to patients about different treatment options or even therapeutic activities and groups available.

Although there were activity plans for each of the wards we visited, we found that engagement from patients in many of these was poor. The planner included things such as Maths and English groups and boxing in the community, but we were told by staff and records supported the view, that these were planned but patients did not engage, suggesting the groups were not capturing the interests of patients and there was low motivation to attend. Groups provided by the service had low attendance for January and February 2026, for example, relaxation had 31% and 37% attendance respectively. Although some of the groups were rehabilitation focused, it was clear that motivation in the patient group was low and that could have been due to patients very long lengths of stay with a lack of professional assessments identifying achievable goals that were meaningful for patients. Despite low attendance in groups and activities, the offer remained the same and it was documented week after week that patients did not want to attend, rather than reviewing the offer and the reasons why this was the case to improve patient outcomes.

We saw records that evidenced patients did not have access to one to one time with a named nurse or key worker. We reviewed the one to one key worker records for February 2026 and noted that only 4 key worker sessions were completed. This meant that out of all the patients in the hospital at that time, 2 were on leave, and 9 did not have a one to one session with their key worker that month.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. There were significant shortfalls in how the service understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

We were told by staff we spoke with that none of the patients at the service currently were engaged in any education or work opportunities. We also asked patients and their carers about this and none of the patients or their carers reported any involvement. We requested a summary of patient engagement with any recovery initiatives in the service as part of our data request following the on-site inspection. We also reviewed the care and quality governance data collection document, which was embedded in the March 2026 governance meeting minutes, which noted out of 14 patients, 0 were involved in educational or vocational work. The summary provided by the provider was vague, it noted things such as visits to family and attending community groups but did not note which ones. It also noted a patient involved in budget planning and finance management, we reviewed patients records during our on-site inspection and found no evidence of formal work around this in the month preceding our inspection. Similarly, we were told patients were involved in work experience and college courses, but on site, staff, patients and the care and quality governance data provided did not show any evidence of this in recent months.

Staff did support patients to maintain contact with their families and carers to an extent, and we saw evidence in patient records of patients visiting family with staff. However, 2 carers that we spoke with felt they were not notified about important updates on their relative, such as physical health incidents and meetings about their care. We were also told that family and carers were not allowed onto the wards to visit patients. The family visiting room was very small and families felt that it was not private as staff stood at the door throughout the visit, which felt intrusive and overly restrictive given the rehabilitation environment.

We scored the service as 1. The evidence showed significant shortfalls. The service did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff did not always make notifications to external bodies as required. We found evidence of two safeguarding incidents that were notified to the local authority safeguarding team but not to CQC. It is a statutory requirement for services to inform CQC under the registration regulations.

Information governance systems included confidentiality of patient records. The electronic patient record system was accessed via an individual log in and password. We did, however, note in the care records audit that it was noted a member of staff had used another staff members log in details to access patient records.

Staff did not always ensure that carers, families and commissioners were regularly updated about the patient’s progress. We spoke to carers, family and commissioners as part of our inspection. It was noted that information was not always passed on in a timely manner regarding patients. Community staff found it difficult to get information about their patients and they felt this hindered discharge planning. Some of these concerns had been raised with commissioners. We notified commissioners of our concerns about the service following inspection. Patients also told us 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.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They did not involve people in decisions about their care or tell them what had changed as a result.

We requested the complaints policy as part of our data request following on-site inspection. The policy was due for review in February 2026, and this had not been completed at the time of the inspection in May 2026. The policy also mentioned another hospital throughout, indicating this policy had not been created solely for Pine House Rehabilitation Unit.

There were 13 complaints in the 12 months preceding our inspection. We were sent the complaints log which also detailed compliments, of which there were 24, although all but 3 of these were made by internal staff complimenting internal staff, so many were more of a staff recognition than compliments received by patients, families or external professionals about the service. Complaints were a mixture of complaints from patients and staff performance and disciplinary procedures, this raised a concern that if staff performance issues were being managed under the complaints policy, the provider was not effectively managing poor performance from staff. The complaints policy noted that each complaint should be logged and allocated a complaint number, as well as clearly documenting how the process was followed, for example, a letter of acknowledgement, timescales for responses and so on. We did not see evidence of complaint numbers in the log and the summary of outcome would often be vague, for example “to review in community meeting” or “letter shared with rationale for blanket restrictions”. This did not provide any assurance that complaints were thoroughly investigated in accordance with the provider policy and did not document if complaints were resolved informally or were made formal, triggering a different process.

The complaints policy detailed that complaints should be reviewed at the monthly governance meetings that were held, we reviewed the minutes for meetings in February and April 2026. We found that complaints were a standing item on the agenda, but that not all complaints on the log were discussed, and it did not show that due process was followed for investigations, for example with one just noting “reviewed complaint re garden access” with no other information on what process was being followed, informal or formal and when this was expected to conclude. We also noted as above, that staff disciplinary and performance concerns were also contained on the complaints log. For example, allegations of staff consuming alcohol on shift and a staff member behaving in an unprofessional manner whilst accompanying a patient on leave. We would expect to see a separate process followed for this type of concern.

The total number of complaints upheld was not noted in the complaints log or in the governance meeting minutes we received and reviewed. Nor were number of complaints referred to the Ombudsmen or number of complaints upheld by the Ombudsmen.

Reviewing the list of 13 complaints we were provided with, themes included patients raising concerns about their health and weight due to the absence of a chef and agreement for takeaways to be ordered each day for food, lack of patient engagement, staff sleeping on shift and families and carers struggling to get in touch with the service as the phones or doorbells were not answered. These themes echoed concerns we found still to be an issue during our on-site inspection, further supporting the concern that complaints were not effectively managed and resolved in accordance with the policy.

Patients knew how to complain or raise concerns at ward level and told us they felt safe to do so. However, we did note in the governance meeting minutes for February 2026, that it was noted complaints information needed to be displayed as this was raised during the governance meeting minutes for February 2026.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of patients with mobility issues were met – for example, we were told that if needed, wheelchair users were placed in bedrooms at ground level or had access to lifts.

As the service was a rehabilitation unit in the community, they would use 999 or the GP for medical and physical health concerns. The consultant psychiatrists were not based at the service and would not be able to get there quickly in a mental health emergency. Although they were contactable by telephone.

Staff did not always ensure patients had access to post-discharge care – for example, Section 117 aftercare, community mental health services and crisis services. We noted a patient who had been on long term leave from the service at another provider and remained on leave due to Pine House Rehabilitation Unit not progressing a Community Treatment Order for the patient. Although the local CMHT had accepted the patient, they were still awaiting this to happen at the time of our inspection.

Although we were told there had been successful discharges from Pine House Rehabilitation Unit by senior leaders, we did not see evidence that these had been planned and progressed by the service. Rather, that commissioners and community teams had decided to move patients to preferred providers so had set discharge plans in motion for all patients at the service. We did not see evidence of recovery orientated goal-based care plans including discharge plans for patients when we reviewed records. In addition, with the absence of professional assessments from key members of the MDT, (no Psychologist or OT at the service) it was unclear what support individual patients needed to progress through the pathway.

In the 12 months preceding our inspection, there was 1 patient identified as a delayed discharge from the service. Although no others were formally identified by the provider as a delayed discharge, lengths of stay were considerably long, with the longest patients having resided at the service for over 4 years, with little evidence of progression. We spoke to patients and carers as part of our inspection, who told us that they had more freedom at previous placements, and felt they or their loved ones had regressed rather than progressed during their admission to Pine House Rehabilitation Unit. Examples of this included, leave being reduced or becoming escorted rather than unescorted, patients who previously cooked for themselves now declining, and one patient going from being an informal patient on admission, to detained and in long term segregation by the time of our on-site inspection.

We scored the service as 1. The evidence showed significant shortfalls. Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

Staff within the service and the wider organisation did not promote a culture in which the people using the service felt empowered to give their views. Although we saw examples of patient community meetings and some feedback forms completed by patients, we did not see the service was truly patient led. We did not see any patients who led on their meetings with professionals or partially led with support from staff. Alongside this, patients’ feedback told us they often left meetings feeling unheard and with no clear understanding of their plan of care. Patients felt disempowered and did not know what they needed to do to achieve fewer restrictions and progression within the service. Patients care plans did not include patient voice, and patients’ views and wishes were not captured in a way that clearly told us what the patient wanted to achieve whilst at Pine House Rehabilitation Unit. This was at odds with the provider’s equality and diversity policy that states that “patients will be: involved in care planning and decision-making and will be supported to express preferences”.

Staff were trained in equality, diversity, inclusion and human rights and this training was mandatory for all staff. Compliance was over 90% for all levels of staff.

We scored the service as 1. The evidence showed significant shortfalls. People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff did not always support patients to make decisions about their care and treatment and their future. We observed a multidisciplinary team meeting and reviewed care plans for all patients at the service. We found that discharge planning was not part of care plans for patients and that this was not discussed as part of the patients ongoing plan at the multi- disciplinary meeting.

Staff did not create personalised care plans to account for the patient’s needs, wishes and feelings. We did not see evidence of care plans being created in collaboration with patients. We saw care plans that were generic with little patient specific evidence included,

Care for people who are nearing the end of their life was not always managed and communicated in a sensitive and dignified way. The service did not make decisions based on capacity assessments and in the best interest of patients regarding sharing information about significant health conditions.