- Independent mental health service
Pine House Rehabilitation Unit
Assessment report published 11 September 2026
Contents
Ratings
Our view of the service
Pine House Rehabilitation Unit has been registered with the CQC since November 2021. It is registered with CQC to deliver the regulated activities:
- Treatment of Disease, Disorder or Injury
- Assessment or medical treatment for persons detained under the Mental Health Act 1983
The service did not have a registered manager at the time of our inspection and had not had one since November 2023. The service had a Nominated Individual at the time of our inspection who was also the controlled drugs accountable officer. Pine House Rehabilitation Unit consisted of 3 wards: Pine ward, a 4-bed ward on the ground floor, Lyme ward, an 8-bed ward based on the first floor and Aspen ward, an 8-bed ward based on the second floor. At the time of our inspection there were 12 patients, one of which was on long term leave.
We carried out an unannounced on-site inspection on the 30 April, 1 May, 7 May 2026 and 13 May 2026.
We gathered information from patients and their family/carers, staff and managers, other stakeholders and our own observations of care. We reviewed a range of documents including care records and policies and procedures. At this assessment we assessed 1 assessment service group; Long stay or rehabilitation mental health wards for working age adults where we assessed 33 quality statements.
The inspection was planned due to the length of time since our previous inspection, and to follow up on concerns from our previous two inspections at the service. Our overall rating at this inspection for this service is inadequate. We identified 5 breaches of Regulation in relation to Regulation 9 Person Centred Care, Regulation 12 Safe Care and Treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance and Regulation 18 Staffing.
The service will therefore be placed into special measures.
Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
Pine House Rehabilitation Unit was last inspected in 2024 and was rated Requires Improvement with 3 breaches of Regulation in the following areas:
Regulation 12 safe care and treatment. Ward staff could not locate documentation regarding the safety of the environment, such as the ligature risk assessment, along with patient emergency evacuation plans which would be required in an emergency. Physical health folders contained inconsistent recording, incomplete documentation and gaps in some ongoing checks.
Regulation 15 premises and equipment. Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained.
Regulation 17 good governance. Although governance processes and procedures had been implemented following the previous inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this inspection.
All these breaches of regulation remained at this published inspection.
Prior to the inspection in 2024, the service was inspected in October 2023 and was rated requires improvement overall with an inadequate rating in safe, with breaches of Regulation in the following areas:
Regulation 12 Safe care and treatment. We issued a warning notice to tell the provider to make significant improvements in relation to failures to identify, assess and take consistent actions to mitigate and manage risks in relation to the environment.
Regulation 15 Premises and equipment. Repairs and maintenance to the ward areas did not take place in a timely way. Damage to the environment posed risks to patients and staff.
Regulation 17 Good governance. Governance processes were not effective in identifying and mitigating risks in relation to the environment, incident reporting, management of patient finances, medication management and quality assurance.
Regulation 18 staffing. The provider did not ensure that the number and skill mix of staff on each shift met the needs of patients. Staff providing care did not have access to training and support to meet specific patients’ needs safely and competently.