Pine House Rehabilitation Unit

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of regulation for: Regulation 17 good governance

We have not awarded this service a score for Well-led.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff we spoke to did not feel they belonged to part of a wider organisation and did not know who the most senior people in the organisation were. The provider’s senior leadership team had not successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff told us, they had not had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. An example of this was when staff told us their pay date had been changed at short notice with very little consultation with them. Staff told us they were left in financial difficulty as the pay date changing at short notice, meant they did not have enough money to pay some bills, but the provider did not listen to them when concerns were raised.

There were concerns raised from staff about their ability to deliver high quality care within the budgets available. Staff did not always have access to funds that they required to make improvements both at the service and for patients. We were told and observed whilst onsite, that staff did not have enough funds to make purchases of larger items and this included the fire doors that were missing at the service. We were told by the manager onsite, that the company credit card had a limit on for each month and that it had reached the limit for that month so they could not order more items. We were told by more senior leaders when we spoke with them, that higher amounts could be authorised if they were raised to them, but staff at the service were not aware of this when we spoke to them, and therefore the doors had not been ordered. This was similar for the card used to pay for supplies for activities, this card had been retained by a cash machine 3 months prior to our on-site inspection and had not been replaced. This had meant ward level staff had used their own money at times to try and ensure patients could still benefit from activities and days out, but again senior leaders told us they only had to ask for more money to be released, however this had not been communicated to staff. We could see this was mentioned in team meeting minutes and no evidence was documented of communicating the availability of funds to staff.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Although we found that leaders had the knowledge and experience to perform their roles, we found a significant number of shortfalls within the service during our inspection, and data analysis of the service. This included concerns around areas such as fire safety, patients’ progress, access to essential professionals, restrictive practice, and the maintenance of the estate. The presence of these unaddressed issues meant that leaders were not effective in implementing robust governance processes to ensure the service was running safely.

Leaders told us they had a good understanding of the service they managed. However, this was often at odds with the views of the staff at the service. An example of this was when we asked about the rehabilitation model of care for the service, this is the strategy the team would be expected to work to when assessing and treating patients and progressing them through the service. Staff on site at the service told us there was not one, and that they had recently begun to look at writing a new one with a team in place to do this. However, when we spoke to the Hospital Director, they were of the opinion that there was a very clear model of care in place for the service. This was not only concerning in terms of the impact of the lack of communication of a clear process for staff to follow, but also the impact this had on patients’ outcomes in terms of rehabilitation.

Senior leaders were not as visible in the service as staff and patients would have liked. This meant they did not feel approachable for patients and staff. During our on-site inspection, there was a new Hospital Manager in post who had only been at the service for 4 weeks. They did not have support from any senior members of the organisation and the leader who was covering the service in the absence of the Hospital Director, had not visited the site during this time. Although, the Medical Director was the allocated person to be onsite during this time, this person was not the correct person to support the new manager, for progressing things such as issues with the environment or lack of access to essential funds. The new manager subsequently left their post during our inspection period, so the service was without a manager at the completion of the inspection. The hospital had been without a Registered Manager since November 2023 and remained without one at the time of our inspection.

We asked for a summary of all management and leadership training undertaken by managers and leaders working in the service in the past 12 months, as a data request following the inspection. We were given a list that included courses such as safeguarding level 4, NVQ5, NVQ3, Right to Work and an MSc in healthcare leadership, but it did not tell us who had completed these courses and when.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

Feedback from staff we spoke with about confidence in speaking up was mixed. 5 of the 11 staff we spoke with told us they did not feel confident raising concerns to managers. They told us this was because when they had spoken up in the past, no changes had been made. Staff gave examples of the ward environment and staffing levels as things they had raised concerns about with very little change occurring. Staff also raised that they were not clear on the chain of escalation up the service, they did not know who to contact above the Hospital Director with concerns and they were not aware of a representative in human resources they could contact or a freedom to speak up guardian at the service.

Patients and carers had opportunities to give feedback on the service they received, there were patient community meetings as well as patient feedback surveys. We reviewed the minutes of community meetings and the feedback in patient and carer surveys. We did see some examples of changes as a result of patient feedback, such as moving the fence around the garden to make it bigger and changing one of the lounges to an activity room.

Patients and carers had minimal involvement in decision-making about changes to the service. We asked for evidence of changes made to the service as a result of patient and carer feedback in the 12 months preceding our inspection. Although there was some evidence, as above such as change of use of a room or adding space to the enclosed garden, we did not see evidence of patient involvement in the service at a more strategic level, for example such as a patient representative who attended meetings regarding the service. However, we did see in staff files that some interview records did show questions created by patients.

We scored the service as 2. The evidence showed some shortfalls. The service did not always listen to and understand people’s needs, views and wishes. Staff did not always respond to people’s needs in the moment or act to minimise any discomfort, concern or distress. 

The provider had an equality and diversity policy, which we reviewed as part of our inspection. This noted that reasonable adjustments would be made for disabled employees and applicants in accordance with the Equality Act 2010. This included adjustments to the recruitment processes, working arrangements and premises and equipment. One staff member told us the service had allowed them to work flexibly following a period of illness to remain in their role, which they said was handled well. However, 2 staff members we spoke with told us that during periods of personal issues at home, the provider had not been supportive and they then felt they needed to attend work when they would have preferred to have taken time off to manage the situation, this was in relation to fears over disciplinary around sickness and loss of pay, the staff were not offered any type of carers leave to support with this.

Training compliance with equality and diversity training was at 90%.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was not a clear framework of what must be discussed at team or directorate level meetings, to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed the last 3 sets of team meeting minutes prior to our inspection and found them all to be in different formats, with different agendas and that actions from previous meetings did not follow through to the next month.

The governance meeting minutes did follow a set agenda, and we reviewed the last 3 sets of minutes for these meetings. However, we did not see a clear flow of information being fed up from the team at ward level to the leadership team and vice versa. We saw that items were often discussed with the action simply stating, “to be discussed at next meeting”, with no clear actions identified in this timeframe and therefore nobody identified to ensure actions took place. An example of this was contained in the transcript of the governance meeting for 21 April 2026, where the risks of the missing fire doors were discussed as well as the general state of the environment. There were no formal minutes from this meeting and no actions identified as to how the work for replacing the fire doors would progress and who would be responsible.

During our on-site visit on 30 April 2026, the fire doors were still missing and 2 of those fire doors had not been ordered. A second example of this was contained in the minutes and action log following the governance meeting dated 19 March 2026. This meeting did not discuss any issues in relation to missing fire doors despite this being a known issue at that time. It did, however, discuss some environmental issues and noted slow progress in improvements. There was no action identified to improve the environment at this meeting with the action date just stating, “to be discussed at next meeting”. Leaders did not identify the urgency of this issue and did not prioritise action to resolve this.

Staff undertook or participated in clinical audits. However, the audits were not sufficient to provide assurance, and staff did not act on the issues identified when needed. We noted numerous audits where staff had either not picked up on significant concerns, or, where they had picked up on them and no action was taken to improve those issues. This included, fire safety, the physical environment of the service, Mental Health Act records and patient care records.

We reviewed the fire risk assessment dated October 2025 and found that several issues had been raised in relation to damaged fire doors and environmental concerns that could exacerbate the spread of fire. We found that the action plan associated with this did not capture all the risks identified in the audit, and that issues that were captured, were not effectively mitigated or eradicated.

We reviewed the most recent Mental Health Act audit for the service. This was dated 12 April 2026. The audit highlighted several issues including, medicines being administered without relevant consent or second opinion, patients’ rights not being read at the correct intervals and annual statutory reports to the Ministry of Justice not being completed. However, during our on-site visit on 30 April 2026 and our Mental Health Act review on 18 May 2026, these issues remained. Although the audit highlighted the findings, it did not identify actions required or an identified person to ensure this was completed. There was no action plan within the audit document and the conclusion section just stated “ongoing”.

We reviewed several audits that included reviews of the physical environment at the service. This included the environmental risk assessment dated 27 January 2026 which noted the missing fire doors as well as the wider environmental concerns, the action plan section at the end of this audit was left blank. The closed cultures audit dated 12 February 2026, notes the environment as only partially met due to the issues identified, the actions section at the end of this audit states “ongoing” with no plan to improve the environment and by when. Finally, the health and safety audit dated 18 March 2026 was not an accurate reflection of the environment, it noted in two sections that all fire doors were in good condition, despite doors being missing and 45 being damaged at the time of our on-site inspection 4 weeks later.

We requested the 3 most recent care records audit on each of the 3 wards. We did not receive the audits, despite a follow up email to request these were sent. However, the overview sent by the provider noted minimal issues with patient care records, noting patients had not signed finance care plans and that risk assessments were not always linked to care plans. However, during our on-site inspection, we found that care plans were not recovery focused and did not contain individual goals set by the patients and their care team. We also found that the patients’ voice was not captured in any of the care plans we reviewed. None of these concerns were noted in the overview of care records audits we received. We did not receive the audit tool, so could not comment on whether this asked the correct questions to identify these issues, and we were not sent any action plans relating to the minor issues the overview told us the audits identified.

We reviewed the risk register for the service. Although this did contain some of the risks we also identified, including the environment and fire risks. The risk register did not evidence how these risks were being mitigated and how improvements were being carried out and monitored.

Fire safety was noted as a high risk, the date this risk was added was 12 June 2022 and the description of the risk was general fire safety concerns rather than the significant concerns identified in the fire risk assessment from October 2026. The risk was noted as being the responsibility of all staff, so no one person was responsible for ensuring the risk was managed. The progress on actions had not been updated since September 2025 when it was noted damage had occurred to room 16’s door. The risk register did not discuss the findings of the October 2025 fire risk assessment, nor did it contain any updates in relation to the 3 missing doors we noted on our inspection or the 45 doors noted to be damaged in the internal audit completed after we raised urgent concerns.

The environmental risk was also added in June 2022, 4 years prior to our inspection, and noted the environment was in need of improvements, such as redecorating, plastering and new furniture. Despite our inspections in 2023 and 2024 highlighting these issues, they remained unresolved, and internal audits continuing to highlight these concerns, did not contain any plans or actions taken of how the provider would improve the environment at the service significantly, although some minor updates were made. The progress on actions section, noted that this issue was ongoing but only showed updates from February 2025, and where new concerns were highlighted, such as a broken sofa, it did not detail what action would be taken, such as when a new one would be ordered and by whom. The missing fire doors were added to this section in February 2026, and highlighted the increased fire risk, but again no action was noted as to how this would be resolved, and it was not noted in the fire risk section on the risk register.

We did not find that staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. We spoke to external stakeholders as part of our inspection. We found that there was a strong theme of lack of communication from the provider. For example, struggling to get information about discharge plans, lack of transparency around rationale for increased restrictions, and paperwork for treatment in the community not being completed in a timely manner despite chasing.

Staff working day to day at the service such as registered nurses on the wards, did not always have access to information to support them with their role. We did not see good use of data within the service to improve outcomes for patients. Team meeting minutes did not evidence use of data to highlight trends and themes, nor did it drive improvements or highlight where areas were lacking. This, in addition to the ineffective audit process at the service also added to the lack of essential data that staff needed to improve their own practice and outcomes for patients. This included information on the performance of the service, staffing and patient care.

Issues raised at previous inspections still remained, despite us raising them and the provider submitting action plans of how they planned to improve them. At our inspections in both 2023 and 2024 we found breaches of regulation in relation the environment, governance and restrictive practice, as well issuing a warning notice in relation to these issues at our 2024 inspection. These issues remained at this inspection along with other issues noted throughout the report.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records.

We scored the service as 1. The evidence showed significant shortfalls. The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Although leaders of the service did engage with external stakeholders, such as commissioners and local authorities, we found they had not formed strong working partnerships with them. Following our on-site inspection, we notified commissioners of all patients at the service of our significant concerns.

There was only a small senior leadership team at the service. This consisted of the Operations Director, a Medical Director and then the Chief Executive Officer of the company. Despite this relatively small senior leadership team, staff at ward level could not tell us who the most senior people in the organisation were and did not feel they were visible within the service.

The Operations Director was on leave at the time of our inspection but was not usually based on site each day at Pine House Rehabilitation Unit when in work, although staff did tell us they saw them on a regular basis. We noted that during the time the Operations Director was not in work, there was little or no senior leadership at the organisation to support other staff and patients, even after we raised significant concerns.

We scored the service as 1. The evidence showed significant shortfalls. The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. 

We requested data detailing innovative practice in the 12 months preceding our on-site inspection. The provider sent us information detailing a new morning risk meeting that had been introduced where staff would discuss things such as bowel monitoring, enhanced observations and clinic room temperatures. Although this was a new introduction at the service, this is standard practice in most mental health services and would not be considered innovative practice, but good practice in the oversight of risk of patients on a daily basis.

The service did not take any students on placement at the time of our inspection.

The service had not been accredited by the Royal College of Psychiatrists Quality Network for Rehabilitation Wards, although associate accreditation was completed the previous year. The associate accreditation supports wards to prepare for full accreditation by identifying areas for improvement. Following on from this, the service had decided not to go for full accreditation.

The service also sent information detailing how over the last 12 months, the service had “moved away from traditional ward-based rehabilitation and focus on practical, real-world skill development.” The data included information about their vision to shift away from “passive engagement towards patients actively structuring their time and working towards discharge goals.” This noted supporting patients into volunteering, education, and employment. Although this was submitted to us by senior leaders at the organisation, this was the first time we had heard about this vision, despite spending 5 days on site speaking with leaders at service level and ward-based staff. This again highlighted a clear disconnect between what leaders felt was happening at the service and what was communicated and embedded with staff working at the service. As noted previously in the report, we did not see evidence on site and records of engagement documented, that no patients were taking part in paid work, voluntary work or education at the time of our inspection.