Pine House Rehabilitation Unit

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant people were not safe and were at risk of avoidable harm. Staff did not ensure wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff did not always assess and manage risks to patients and themselves well. Staff did not understand how to protect patients from abuse and the service did not always work well with other agencies to do so.

The service was in breach of regulation for:

Regulation 12 Safe care and treatment

Regulation 15 Premises and equipment

We have not awarded this service a score for Safe.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

As part of our data request following the on-site inspection, we requested the number of serious incidents over the 12 months preceding our inspection. We received data from the service that told us there were 3 serious incidents during that time period, none of these were patient safety incidents and no themes were drawn from reviewing these incidents.

Staff that we spoke with knew how and when to report incidents. They used an electronic incident reporting system to document incidents.

Staff received mandatory training in the duty of candour. The compliance for this was at 90% for registered nurses and 96% for all other staff. We requested any incidents meeting the duty of candour threshold in the 6 months preceding our inspection. We were told of two incidents and the patients had received an explanation and an apology. However, 2 carers we spoke with felt they had not been informed when something had gone wrong with their relative, and that at times they had not been told about significant incidents such as falls and physical health issues until some days after the incident, despite patients wanting them involved in their care.

We saw some evidence in staff meeting minutes of feedback following incidents at the service. We also saw this discussed in the morning flash meeting we observed on the first day of our inspection, where incidents for the last 24 hours were discussed and staff were asked if a debrief had taken place. We did not see discussion of any incidents external to the service but within the provider to give staff with opportunities for learning from them. Staff we spoke with told us they did not hear of incidents in the other rehabilitation services in the provider’s portfolio, this could have been a missed opportunity for shared learning across similar services.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes did not ensure that all essential information about the patient was received, to determine if the patient’s needs could safely be met. We spoke with staff who told us that the referrals were screened and processed by the senior leaders at the hospital and that ward-based staff were not involved in this discussion or decision. Staff that we would expect to be involved in this process such as the Assistant Psychologist (in the absence of a Clinical Psychologist) and the Occupational Therapy Assistant (in the absence of an Occupational Therapist) were not involved. This meant that staff who would be assessing, planning and developing goal-based care plans did not meet patients until they were admitted. We found that this then led to patients being in the service who were not appropriately placed and were not engaging with any rehabilitation at the service. This in turn led to delays in finding appropriate placements for those patients to move on to.

Staff did not always involve all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We saw that 1 patient had been on leave to a care home since January 2026, this was originally documented as being for one week but had continued on for 6 months. The service told us this was due to delays in the local community mental health team allocating the patient, but the local community mental health team reported it was due to delays in the service completing the Community Treatment Order paperwork for the patient. Our review found that despite it being agreed that the patient would need a community treatment order to be safely managed in the community in January 2026, the provider did not provide this paperwork when asked between February and May 2026. When the service reached out for the support to manage the patient, it was noted that the provider were difficult to get hold of and this was noted in emails between the provider and the patient flow team.

We spoke to community-based staff as part of our inspection, who told us that they felt it was difficult to get information from the service regarding their patients. They felt the service was overly restrictive and risk averse, meaning they struggled to get appropriate placements to review their patients without trialing things such as unescorted leave to step them down into a lesser restricted service. This essentially led to patients being in the service for much longer than was necessary without progressing in their rehabilitation.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

We spoke with 10 staff during our on-site inspection. They were able to give examples of what may constitute a safeguarding concern and what they would do to report this. Staff were trained in safeguarding, and compliance was at 90% at the time of our inspection. However, whilst reviewing recent incidents at the service as part of our data review following our on-site inspection, we noted there had been some incidents we would have expected to be notified to CQC as a safeguarding concern, as well as the local authority. This included sexually inappropriate behaviour in ward areas and in the community. We were not informed of these incidents, but the local authority safeguarding team were.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for children visiting the service, there was a family visiting room on the ground floor.

There were 14 items on the blanket restrictions register for the service. Each blanket restriction was for all patients, and none had a review date or expected removal date. All reported they were reviewed monthly at the hospital governance meeting, but most noted “no plans to remove whilst the service remains locked”. We saw some of these items were not blanket restrictions, an example of this was a pre leave risk assessment, which would be deemed an essential part of patient care, to keep patients safe, rather than a blanket restriction. We saw some blanket restrictions which were not in keeping with a rehabilitation service and were overly restrictive, such as restrictions in the number of takeaways a patient could order per week. We would expect to see work ongoing with patients to budget for meals, create shopping lists and meal plans for the week, rather than focusing on limiting the number of takeaways a patient can purchase during a week.

There were 18 incidents of restraint in the 12 months preceding our on-site inspection, 7 of these related to 1 patient. It is unusual to see restraint being used on a monthly basis in a rehabilitation ward, as patients placed there should have been assessed as ready to work through a rehabilitation pathway with a view to community living once complete, suggesting a lower level of risk as well as generally more stable mental health and compliance with medicines. The regular use of restraint suggests that either patients were not appropriately placed, mental health symptoms were not well managed, or that the restrictions placed on the patients were causing undue frustrations leading to outbursts of violence or aggression. 3 patients we spoke with told us that they did feel frustrated at the restrictions on their Section 17 leave, and that this had led to them becoming angry at times during their admission and for some patients this had led to use of restraint.

Mental Capacity Act

90% of staff had had training in the Mental Capacity Act.

However, senior leaders did not have a good understanding of the Mental Capacity Act (MCA), in particular the five statutory principles. As part of our data request following the on-site inspection, we requested information relating to the MCA. We requested the most recent MCA audit for each ward. We received a note on the data return to say this was captured within the Mental Health Act audit, however, on review of this audit the MCA was not mentioned, nor was compliance with this reviewed. This meant that any potential learning from use of the MCA was not identified and acted upon to improve practice in this area.

We saw during our review of patients records that decisions were sometimes made to withhold important information about patients care, without being assessed under the Mental Capacity Act. An example of this was relating to a physical health diagnosis that had not been disclosed to the patient, but no formal capacity assessment or best interest meeting was documented to discuss why this needed to be kept from the patient.

There were no deprivation of liberty safeguards applications made in the 12 months prior to the inspection.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it, but we did find evidence during our inspection that showed staff were not always following it.

There was an identified lead within the service who staff could contact to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed all 11 patient records during our on-site inspection.

There were 18 incidents of restraint and 1 incident of long-term segregation during the 12 months preceding our inspection. We would not expect to see restraint used on a regular basis in a community rehabilitation hospital, we would not expect to see long term segregation used at all, and if this was deemed to be needed, we would expect to see a clear rationale for the therapeutic purpose, with frequent reviews from the multidisciplinary team, with an active plan to reintergrate the person back into the wider service. . We did not see that this had happened in this case, nor did we see the appropriate safeguards in place for this patient to ensure their care and treatment was appropriate and necessary during this time. We alerted the local authority safeguarding team to this case, as well as the patient’s commissioners.

We did not find that care plans were patient centred. We did not see evidence of staff involving patients in care planning, goal setting and risk assessment. All risk assessments and care plans we reviewed, lacked evidence of the patients’ voice and involvement. When we spoke with patients, they told us they did not know what their care plan was, with 3 patients telling us they had asked what they needed to do to be discharged from the service and did not feel this was clearly explained to them. We found that patients care plans often documented a lack of engagement with planned groups, but we did not see evidence of how staff had tried to engage the patient in a way that was meaningful to them. We saw that week after week it would be documented that patients were “unwilling to engage” or “refused to engage” in groups led by the psychology assistant and occupational therapy assistant, but we did not see a review of that patient’s plan of care to see why this was the case. Most importantly, there was no evidence of involvement from a clinical psychologist to formulate a plan of care based on the patients’ actual recovery needs, rather than what was on the plan that week for all patients.

We reviewed the minutes of the last 3 community meetings before our on-site inspection. We saw that these were taking place monthly and were generally attended by around 4 to 6 patients. We saw that patients were able to feedback on things such as the food and ideas for days out. Staff enabled patients to give feedback on the service they received via feedback forms and community meeting minutes. We reviewed feedback forms for the 6 months preceding our inspection. We found that feedback included patients raising they felt they should have access to the garden, did not agree with restrictions on takeaway food, that they were not being offered copies of care plans and that cleaners were not coming into their bedroom more than once per month. These concerns were in keeping with concerns we found on our on-site inspection and remained at the time of our visit. This meant the service was not responding to patients’ concerns.

Patients did have access to advocacy, but we found for one patient who had been detained for some time, advocacy had not been informed of the change from informal to detained status and therefore this patient had not been seen by the advocate. We requested for this to be actioned during our on-site visit.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We found that fire safety was not managed safely at the service. On our first day of on-site inspection, we toured the whole building. We found that 3 fire doors were completely missing from their hinges and 45 doors were damaged either beyond repair or in need of significant improvements to reduce the risk of spread of fire.

We reviewed the most recent fire risk assessment, which was dated October 2025. We found that this highlighted issues with damage to fire doors as well as other issues such as the wrong type of fire extinguisher in the plant room. We saw that an action plan was created by the provider after this, but not all issues raised in the fire risk assessment were captured on the action plan. An example of this was the wrong type of fire extinguisher in the plant room, this was not captured in the action plan and when we checked the plant room, the incorrect fire extinguisher remained in situ. We asked for this to be removed immediately and to be replaced with the correct extinguisher, this was completed whilst we were onsite.

Prior to leaving on the second day of our on-site inspection, we discussed our concerns with the fire service, who gave advice on what they would want in place to mitigate some of the urgent fire risks we had highlighted. The fire service assured us they planned to visit in the days following our onsite inspection to carry out a full review of fire safety at the service. Following on from this conversation, we issued the provider with an urgent request to ensure the actions the fire service recommended were completed. We requested that risk assessments were completed and shared with staff, detailing what to do in the event of a fire with 3 fire doors missing. We also requested that the provider reviewed staffing levels to ensure they could safely evacuate patients in the event of a fire. We requested that they carried out a test of the fire alarm system to ensure it was working correctly, so that early detection was in place should a fire break out. We asked that the kitchen and lounge doors were closed at nighttime as they were the higher risk areas for fires starting and lastly, we asked the provider to ensure that any non-mobile patients were moved to another service. The provider sent us assurance that these actions had been completed before we left site.

Despite some mitigation being in place, we still had ongoing concerns regarding fire safety. Lancashire Fire Service attended the service the following week and agreed with our concerns stating that patients were at risk in the event of a fire at the service. They issued the service with an action plan to improve, and they will revisit the service in 4 months’ time.

We saw evidence in 4 different audits between October 2025 and the first day of our on-site inspection in April 2026 that asked questions to identify concerns regarding fire safety. We saw that these either noted that there were no issues, such as in the health and safety audit dated 18 March 2026, or noted that there were issues, with no subsequent actions on how improvements would be made, such as in the environmental risk assessment dated January 2026. This evidenced that audits were not effective in reliably identifying issues. We saw that governance meeting minutes and transcripts, did not show effective oversight of these concerns and did not have a clear plan on how they would improve the fire safety at the service, often noting no completion date and no planned actions other than to be reviewed at the next governance meeting. We saw that although fire was noted as a risk on the risk register, this had not been updated since the October 2025 fire risk assessment was completed and did not detail the missing or damaged doors we found onsite. The fire risk had been added in 2022.

We found that many areas of the building continued as at previous inspections to be in a state of disrepair. This included missing flooring, chipped paint, dirt and dust on ceilings and staircases, broken doors, boarded up windows in bedrooms, holes in walls and ceilings where items had been removed and not repaired. Both staff and patients told us this environment effected their morale and staff in particular, noted that being left to work in such a poor environment was not in keeping with a provider that cared about their staff and patients. Again, we noted that audits were ineffective in either identifying or improving on these issues. The hospital governance meeting minutes for 19 March 2026 noted slow progress with environment improvements and for a date of completion stated, “to be confirmed”.

The ward layout did not allow staff to observe all parts of the 3 wards. There were blind spots at the end of the corridors on both Aspen and Lyme ward. This was not mitigated by the use of a parabolic mirrors and was not noted on the environmental risk assessment. We were told by staff we spoke with that they were aware of the blind spots and that these were checked as part of zonal observations, in addition those entrances to the wards were generally not used unless there was a reason the main door could not be used. However, due to the fact this was not documented on the environmental risk assessment, it was unclear how the provider assured itself that all staff, including more unfamiliar staff such as bank and agency, were aware of this risk and how to maintain safety for both staff and patients in those areas.

We were sent the most recent ligature risk assessment (audit and annual risk assessment). This was completed and reviewed regularly but was not detailed enough. It did not give staff clear guidance on where high-risk ligatures were situated in the service and how to manage them safely. There was no heat map to show staff visually where high-risk areas were situated. There was a risk matrix on the first page of the ligature risk assessment which indicated the score should be calculated using the impact and probability of the risk. However, we did not see this matrix being used to calculate the score, instead the score was calculated using the room rating multiplied by the impact. We could not see how the impact score was decided on and the matrix did not tell staff what action should be taken for areas calculated as high risk.

Staff had access to personal alarms along with radios to communicate across the 3 wards. There was no patient nurse call system in the service.

There were 2 clinic rooms for the 3 wards at the service. There was only a manual blood pressure monitor in clinic rooms, and we were told there was one electronic one for the service. However, staff could not locate the electronic one on the day of our inspection. Staff on duty told us they were not confident in using the manual blood pressure monitor and had received no training in how to use it. The resuscitation bag was in the clinic room on Aspen ward, we checked the contents and found one item to be missing, we raised this at the time and staff replaced this item. The list of contents was not kept with the bag, so in an emergency it may have been difficult for staff to locate items required. There was not a consistent approach to checking the contents of the bag, with large gaps in between checks for as long as 3 months. This meant the service did not ensure the emergency equipment was available, in date and safe to use.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

At the time of our inspection there was 1 vacancy at the service for a registered nurse, this vacancy had been filled and that person was going through the provider’s onboarding process. Sickness levels were not provided to CQC as a percentage, but there had been 4 episodes of sickness in March and April 2026 and no episodes of sickness in January or February 2026. Sickness episodes were fairly stable over the 12 months prior to our inspection, with a peak of 8 episodes in August 2025.

There had been 18 staff leave the service over the 12 months preceding our inspection, this was mostly support workers but did also include registered nurses, chefs, administration staff, a manager and a domestic member of staff. Reasons for leaving were documented as termination of contracts of bank staff who had not worked on the unit for 3 months or more, 2 employees had their contract terminated after not passing probation due to absence and 6 left to pursue other opportunities. We noted in the data we received, that 3 staff left within 6 months of their start date and 6 staff within 12 months of their start date, indicating the service struggled to retain staff for long periods.

Managers had calculated the number and grade of nurses and healthcare assistants required, but we found this failed to ensure appropriate levels of staff were on shift to keep patients safe. On each shift there were 4 support workers on Lyme ward and 1 registered nurse, on Aspen ward there were 3 support workers and on Pine ward 1 support worker. One registered nurse was shared across Aspen ward and Pine ward. On a night shift, there was 1 registered nurse for the whole service. Staff reported that until the month prior to our inspection, there was only one registered nurse on duty for all 3 wards during the day and at night. Staff felt that this was not adequate and that it was not safe, telling us it was a struggle to complete medicines rounds for all 3 wards, plus multidisciplinary meetings whilst trying to ensure all patients were ok. This was raised by the nurses at the service and staffing was then increased back up to 2 nurses on duty during the daytime. However, for Aspen and Pine ward the registered nurse was shared during the day. Pine ward had a patient nursed in segregation and this meant that at times throughout the day, the patient was nursed on a ward alone with just one support worker and no registered nurse. This was not good practice and the Royal College of Psychiatrists (RCP) quality network data, suggests that wards sharing a registered nurse can result in poorer patient outcomes. Cross cover of wards by nurses should usually only happen when a short notice emergency situation occurs, such as sickness. The RCP also maintain clear guidance that each ward should have a dedicated nurse on shift particularly in terms of managing medicines and the Mental Health Act for detained patients.

We reviewed the rota for the service for the 4 weeks preceding our inspection. The rota only recorded if staff were on shift or not, but did not state which ward they worked on, so it was difficult to review if each ward had the correct number of staff on each shift over the time period. We noted the following gaps in staffing; on all weekend day shifts except Saturday 18 April 2026 and Saturday 2 May 2026, there was only 1 registered nurse on duty for all 3 wards. On 4 occasions there was only 1 registered nurse on duty for part of the shift as the other registered nurse finished early. Day and night shifts appeared to be staffed as per the required number, although on 1 occasion, the registered night nurse had to come in early to cover registered nurse gaps on the day shift.

The manager told us they could adjust staffing levels daily to take account of case mix.

When necessary, managers deployed agency and bank nursing staff to try to maintain safe staffing levels, although we saw these shifts were not always covered as per the data above.

As Pine and Aspen ward were sharing 1 registered nurse, there was not always a registered nurse present on one of those wards. We did not see evidence of regular one to one named nurse time spent with patients. Records reviewed evidenced that only 4 one to one key worker sessions were completed for February 2026. This meant that out of 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. Alongside the lack of time in the service from responsible clinicians, this meant that patients had very little chance to discuss concerns relating to their care with a professional member of staff.

We were not assured there was always enough staff in the hospital at any one time who had been trained to carry out physical interventions safely (for example, restraint). In addition, due to the fact registered nurses were shared across 2 wards during the day and there was only 1 registered nurse on duty overnight, this meant that in an emergency situation, or a fast developing incident, there may not have always been a nurse on the ward to lead the team and take action as quickly as required. Despite frequent use, the compliance with training in physical interventions was only at 60% for registered nurses. It was at 90% for healthcare support workers at the time of our inspection.

There was not adequate medical cover for the hospital. Both the responsible clinicians for the hospital were based off site. They did not visit the hospital on a regular basis and staff and patients told us, that multi-disciplinary meetings would sometimes take place remotely rather than in person. As the hospital was a community-based rehabilitation service, it used the local GP surgery for physical health concerns, and in an emergency would use 999 to summon assistance.

Staff had not all received mandatory training. The data we received separated out registered nurses and healthcare support workers and other staff (administrators, chefs etc).

We noted that the following courses were below 75% for registered nurses; basic life support (70%), immediate life support (60%), CPI training (Crisis Prevention Institute) which was the training for staff to deescalate and if needed restrain patients was at 60%, tier 2 learning disability and autism training was at 60%.

We noted that all mandatory training was above 75% for support workers and other staff.

The training offered, had staff completed it, was appropriate for the patient group using the service.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The hospital was not clean and was not well maintained. As we toured the hospital, we noted that there were large scale maintenance issues, many of which posed an infection control risk. Flooring, walls and furniture were not in a good state of repair, this meant they could not be cleaned effectively and posed an infection control risk. High dusting had not taken place and there were lots of cobwebs and dust, in particular in corridors and on stairways. The environmental cleanliness audit dated 17 April 2026 did not highlight these concerns. We found that other audits of the environment, including the health and safety audit dated 18 March 2026 and the environmental risk assessment dated 27 January 2026,either did not pick up on issues or where issues were highlighted, this did not lead to an effective action plan and completion dates for concerns.

Quality Statement Score: 1. We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We reviewed all 11 patient records in relation to medicines. We found that effects and side effects of medicines were not accurately or regularly monitored. We reviewed side effect rating scales for patients and found these often contained conflicting information, such as noting loose stools and constipation at the same time and loss of appetite and overeating. For the 5 patients we reviewed side effects rating scales for, we found all were last completed in 2024, despite some noting evidence of side effects that would have required further action such as drooling. 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.

Overall, we found staff generally followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. The medicines at the service were provided by an external pharmacy, who completed audits of the medicines management at the service on a monthly basis. The audits identified some minor issues, but there were no themes to note meaning that issues identified were generally a one off rather than a monthly occurrence.