The Care Quality Commission
  • Mental Health
  • Independent mental health service

Pine House Rehabilitation Unit

Overall: Requires improvement read more about inspection ratings

Yorkshire Street, Bacup, OL13 9AE (01706) 619300

Provided and run by:
Kibo Hospital Services Limited

All Inspections

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Dates of onsite assessment: 19 November 2024; with additional offsite interviews taking place on 26 to 27 November 2024. Pine House Rehabilitation Unit is a 20-bed hospital for male patients. There are 3 wards across 3 floors: Pine ward on the ground floor; Aspen ward on the first floor; and Lyme ward on the second floor. We carried out an unannounced assessment of all 3 wards. This assessment was a follow up to a warning notice that was issued to the provider following the previous inspection in August 2023. We assessed 15 quality statements across the safe, effective, caring, responsive and well led key questions. Our overall rating for this service remains requires improvement. We identified 3 breaches of regulation in relation to safe care and treatment; premises and equipment; and good governance. Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained. 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. Although governance processes and procedures had been implemented following the last inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this assessment. However, the service had implemented a staff huddle at which essential safety areas of the service were discussed and reviewed. Patients generally felt safe within the service and gave positive feedback about staff and activities. Patients had opportunities to give feedback on the service. Staff gave positive feedback about the culture of the service and the improvements the service had made. We have asked the provider for an action plan in response to the concerns found at this assessment.

During an assessment of the hospital overall

Dates of onsite assessment: 19 November 2024; with additional offsite interviews taking place on 26 to 27 November 2024. Pine House Rehabilitation Unit is a 20-bed hospital for male patients. There are 3 wards across 3 floors: Pine ward on the ground floor; Aspen ward on the first floor; and Lyme ward on the second floor. We carried out an unannounced assessment of all 3 wards. This assessment was a follow up to a warning notice that was issued to the provider following the previous inspection in August 2023. We assessed 15 quality statements across the safe, effective, caring, responsive and well led key questions. Our overall rating for this service remains requires improvement. We identified 3 breaches of regulation in relation to safe care and treatment; premises and equipment; and good governance. Although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained. 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. Although governance processes and procedures had been implemented following the last inspection, issues in respect of record keeping, documentation and ongoing checks were still identified at this assessment. However, The service had implemented a staff huddle at which essential areas for the safety of the service were discussed and reviewed. Patients generally felt safe within the service and gave positive feedback about staff and activities. Patients had opportunities to give feedback on the service. Staff gave positive feedback about the culture of the service and the improvements the service had made. We have asked the provider for an action plan in response to the concerns found at this assessment.

3 August 2023

During an inspection looking at part of the service

Our rating of this service ​went down​. We rated it as ​requires improvement​ because:

  • Wards were not always safe, clean or well maintained. Repairs did not happen quickly and the environment was not therapeutic.

  • Staff did not assess and manage risks well. Risk assessments and management plans did not address the needs of all patients. Some opportunities to prevent or minimise harm were missed.

  • Information relating to patient care and treatment was not kept up to date or easy for staff to find.

  • Staff had not always completed training to meet the specific needs of patients.

  • Incidents, including the use of restrictive interventions were not well recorded. Lessons learnt were not always identified and shared with the whole team. Managers could not be assured physical restraint was being carried out in line with guidance.

  • Managers had not ensured staff had received training necessary for their roles.

  • The service was not well-led at all levels. Governance processes did not ensure that ward procedures ran smoothly. Some audits to evaluate the quality of care provided were not completed.

  • The approach to service delivery and improvement had sometimes been reactive. This meant risks and improvements were not always managed appropriately or rectified quickly enough.

However:

  • Staff were respectful to patients and were caring in their approach.

  • Staff we spoke to were enthusiastic about the service and most felt supported in their role.

  • Some improvements had been made following our previous inspection. Leaders had an action plan for future improvements and needed time for changes to be embedded.

4 and 5 October 2022

During a routine inspection

This service has not previously been inspected or rated. We rated it as good because:

  • The wards had enough nurses and doctors. There were some staff vacancies but gaps in rotas were covered by bank and agency staff. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Although there were vacancies for an occupational therapist and a psychologist, provision was provided from another hospital site as a temporary measure. Managers ensured that these staff received supervision. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

However,

  • Staff were not appropriately trained in all methods of physical intervention as required by the service. Training compliance was low. There were not enough staff trained to safely restraint a patient.
  • The service had not ensured that staff were appropriately trained in other mandatory training modules such as immediate life support and first aid.
  • The ward layout required some revision. For example, doors opened into each other and rooms were too small. There was no dining room and patients often ate in their bedrooms. The service were aware of this and considering changes.
  • Opportunities to access the local community and other external activities were limited.
  • Managers and governance systems did not prevent vital staff training from falling below standard.

The acquired brain injury service is a small proportion of hospital activity. The main service was long stay or rehabilitation mental health wards for working age adults. Where arrangements were the same, we have reported findings in the long stay or rehabilitation mental health wards for working age adults section.