Pine House Rehabilitation Unit

On this page

• 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 assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. We assessed seven quality statements in the safe key question. The service was in breach of regulation for people’s safe care and treatment and the environment of the service. At this assessment, although improvements had been made to the environment since the last inspection, environmental issues regarding maintenance and decoration remained, in particular on Aspen ward. Processes that the provider had in place to log and monitor ongoing areas such as safeguarding, maintenance and learning from incidents were not always robust and detailed. Staff on the wards 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. However, the service had implemented a daily morning staff huddle at which essential areas for the safety of the service were discussed and reviewed. The service had undertaken work on supporting staff and trying to ensure that there was a consistent and permanent staff team to support patients. Patients that we spoke to generally felt safe within the service.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients were able to give feedback through community meetings and feedback forms. We saw that patients were able to use these forums to suggest improvements or raise any concerns they may have. There was a section in the community meeting minutes in which staff provided feedback from the last meeting including any updates on whether specific items had been implemented or dates when the provider expecting things to be completed.

Staff we spoke to were aware of what incidents they should be reporting and how they would do so. Managers noted that the quality of incident forms could vary and any forms they felt did not meet the service’s standards would be raised with the relevant staff member and asked for the form to be re-submitted. The hospital manager had developed some training on clinical documentation that they were planning on delivering to staff to improve staff understanding and knowledge of the importance of well-recorded documentation. Incidents were recorded on paper forms. We sampled the paper incident forms during the assessment and noted that the quality of the forms and the documentation of the actions taken was poor. The paper form included a box for any “immediate actions” to be recorded and so it was not always clear what further actions, if any, had been taken to manage or follow up on the incidents. For example, for an incident where a patient was hugging a peer without their consent, the only immediate action recorded on the form was that the patient “was asked to disengage”. It was not clear how or if any further actions would be taken in relation to this incident.

The provider had an internal log to record when safeguarding referrals had been made to the local authority, along with notifying other relevant agencies and if the incident met the threshold for the duty of candour. The log itself had gaps for some of the entries and it was therefore not clear if all steps had been considered or not. On the log, the provider had identified two incidents as meeting the threshold for the duty of candour in relation to medication errors. No harm was noted as being sustained by the patients involved, which would not have met the threshold for formal duty of candour consideration. The log indicated that the duty of candour had been completed. The Hospital Manager confirmed that the verbal apologies were not followed up in writing. Whilst it is important to apologise following any incident regardless of the level of harm, the robustness of processes and management around incidents that meet the threshold of the duty of candour should be considered. The organisation had a duty of candour policy which set out how any incidents meeting the threshold should be managed. All incidents were reviewed and discussed at the daily morning staff huddle. Managers had implemented a monthly staff bulletin which included lessons learnt from recent incidents and safeguarding issues. Managers also shared learning within team meetings and through the governance meetings. The service monitored incident data and could review themes and trends by utilising this information. Whilst incidents were discussed at huddles and team meetings, due to the fact incidents were not all fully investigated, we were not assured that staff had all the information they needed.

We reviewed patient records and it was not always clear how patients were involved or engaged in their care planning; or if their care plans were offered to them or declined.

Staff described how patients were supported on admission into the service and how discussions on discharge would be had with patients. Managers noted that all patients had a discharge plan and stated that all relevant partners would be invited to meetings for specific patients.

We saw that partners were consulted on care decisions and attended meetings to discuss the care of patients.

The service had successfully discharged a patient into supported accommodation at the start of November 2024. Staff and managers reflected on the significant progress the patient had made whilst at Pine House. The provider had implemented a discharge pathway map to support this process and put plans in place to support the patient to transition into their new accommodation. The discharge was in line with the patient’s wishes when they had first discussed discharge on admission into the service. The service had further patients that were, or were close to being, ready for discharge. Managers described how they were working with external organisations and partners to find suitable placements for where patients may be able to be discharged to.

Patients that we spoke to did not raise any concerns about safeguarding. Patients generally felt safe within the service.

Staff were aware of how to monitor and escalate any safeguarding concerns on the wards. Managers were confident that staff would be able to identify any concerns and would escalate appropriately. There was one open safeguarding concern at the time of the assessment. Managers described how work was being undertaken by the service to improve and strengthen the relationship with the local authority safeguarding services.

We observed the daily morning huddle meeting. Any new or emerging safeguarding concerns were discussed as part of this meeting. Information in respect of safeguarding was available to staff on the wards.

The service had an identified safeguarding lead. The provider had an internal log to record when safeguarding referrals had been made to the local authority, along with notifying other relevant agencies. The log itself had gaps for some of the entries and it was therefore not clear if all steps had been considered or not. There were also some incidents logged which did not specify what actions had been taken to ensure that patients had been appropriately safeguarded, such as an example of peer-on-peer verbal and physical assault where the comments / progress entry was recorded as “N/A”. There were entries on the log that did provide clear details of what actions had been taken to safeguard the patients at that time. Managers had implemented a monthly staff bulletin which included reminders in relation to safeguarding along with any themes or lessons learnt from recent safeguarding issues. Managers also shared learning within team meetings and through the governance meetings.

Patients that we spoke to did not raise any concerns about how risk was managed within the service or about patient involvement with this. The service held regular patient community meetings at which patients could give feedback on the service including anything that could be done better.

Managers stated that there were low levels of physical restraint used within the service. Any incident reported within the service was reviewed and discussed in the daily morning huddle. The new hospital manager had implemented this meeting to improve oversight and monitoring of any risks and incidents. Managers noted that the risk assessments used were useful at providing a level of detail and background in them for staff to use when considering risk. Managers did recognise that these documents could be quite lengthy and may be difficult for staff who were new to the service or unfamiliar with the patients on the ward to understand the risks and how these should be managed. Managers had plans to implement a snapshot booklet which had been introduced at other sites within the organisation as a way to mitigate this and provide an overview in a more use friendly way. We asked staff on Aspen ward for a copy of the current ligature risk assessment. 3 staff were not aware of how to locate the ligature risk assessment or if one was in place. A printed copy of the ligature assessment was later given to the assessment team dated 28/10/2024. Following the assessment, the provider stated that they had addressed staff awareness regarding the ligature risk assessment and that physical copies were now present on all wards.

At the time of the assessment, there were two fire doors which were not in place on Aspen ward. The service had risk assessed this and, as part of the risk controls section of this risk assessment, it stated that individual personal emergency evacuation plans (PEEPs) were “to be followed and risk controls implemented”. A staff member could not initially locate the PEEPs when asked, although noted they would be on the computer system. When staff eventually located the folder containing physical copies of the PEEPs, only 3 of the 5 PEEPs for the patients on Aspen ward were present. A staff member proceeded to print the 2 remaining PEEPs and added them to the folder. This indicated a lack of staff knowledge and awareness about essential safety information for the ward, along with a gap in oversight because not all of the PEEPs were in the relevant folder which was intended to be used in an emergency. The service had a blanket restriction register. The blanket restriction register did not include dates of when the items had been added and it was not always clear when the restriction was last reviewed, referring only to being reviewed monthly at local governance. The register did include a clear rationale as to why restrictions were in place. We reviewed patient records. All patients had a risk assessment that was up to date. Some of the risk assessments reviewed were detailed and indicated a thorough knowledge of the patient, their background and the relevant risks. The quality of the risk assessments and management plans was not consistent across the records we reviewed, with some having more limited detail and information included within them. Staff were allocated to patient observations for the shift. We reviewed observation records for the day of the onsite assessment which indicated that these checks were occurring and being recorded on the relevant forms.

Patients that we spoke to did not raise any concerns about the environment of the service. Staff had access to personal alarms along with radios to communicate across the 3 wards. The service had one maintenance member of staff at the time of the assessment who had recently joined the service. They had jointly developed the new maintenance log with the hospital manager. The maintenance staff member was busy throughout the day of the assessment attending to jobs and decoration. Managers explained that, although the service had plans in place to continually improve the environment and decoration, any urgent work or jobs would be prioritised over the routine activity. Managers described that the new processes that had been introduced assisted them with having better oversight of the environment and any potential issues. The provider had made improvements to the environment following the last inspection, although there were still issues identified during this assessment.

On Aspen ward, two fire doors had been removed having been damaged by a patient in early September 2024. The doors had not been replaced which would have impacted the ability to contain and manage the spread if a fire had occurred. The provider had undertaken a risk assessment and attached a copy to the wall and in the nursing office however, this version was basic and did not include clear consideration as to how the risk would be managed. A more detailed risk assessment was provided electronically following the on-site assessment. The provider confirmed that new fire doors were in place on the 22 November 2024. A bedroom on Aspen ward had been damaged by a patient in an incident which had also led to a staff injury. The door had 2 wooden boards on areas of the door to make it safe. The patient had been moved to a different bedroom & the damaged room was now in the process of being re-decorated. The incident had occurred at the start of September 2024. Managers had considered an option to prevent similar incidents from occurring in the future but had decided this was not appropriate due to it being overly restrictive for patients. Managers stated that the lesson learnt from the incident was that staff and other patients should not approach patient doors when such incidents were taking place. We reviewed further documentation following the onsite assessment which did not indicate that a thorough review of the incident and learning was effectively undertaken by the provider, although the provider had taken some actions following the incident. The provider had not undertaken a formal risk assessment of the damaged doors to understand what actions should be taken to mitigate risk going forwards. The learning from the incident stated that staff should “keep their distance” when patients were acting aggressively, which would have prevented the staff member being injured in this circumstance.

On the day of the assessment, the security room door on Aspen ward was sealed pending a replacement lock arriving. Staff stated that patients had been damaging the lock and door to gain access to items such as cigarettes. Staff on the ward could not confirm when the lock had been damaged or when it was due to be replaced and there was no documentation to say if and when a replacement lock had been ordered. Maintenance staff confirmed that the lock had been ordered but was taking a while to arrive. The lock arrived whilst the onsite inspection was taking place and was subsequently fitted. The Aspen ward clinic room fridge temperature sheet was reviewed. On the 16 November 2024, the entry stated “fridge not working”. All previous days and the following 2 days had been recorded. Staff on the ward stated that this had not been handed over to them and were not aware of any issues. Staff did note that there had been some separate issues with the fridge a few weeks prior to the 16 November and the stock had been moved to the fridge on Lyme ward at that time. It was not clear what these separate issues were or if this had been escalated. No stock was present in the clinic fridge on Aspen ward during the onsite assessment. The issue was raised with managers who were not aware of any issues. Following the onsite assessment, the provider confirmed they had reviewed the circumstances and liaised with the pharmacist. It was concluded that it appeared to be a staff knowledge issue regarding resetting the fridge as opposed to an actual error. The provider confirmed that all relevant staff would be made aware of the appropriate processes.

Improvements had been made to the environment since the previous inspection with there being less significant damage to the ward, although there were a lot of areas on walls which had been plastered & not yet repainted. There were ongoing decoration projects on the wards as well. This did not contribute to a positive therapeutic environment. There were doors on the wards that continued to bang loudly if they were not shut carefully. This had been an issue at the previous inspection. No patients raised this as a concern during this assessment. The service had implemented a new maintenance log which was located off the wards. On review of this log, there were some gaps and entries which had not been fully recorded. It was difficult to identify specific issues within this log. The log did not appear to include some of the issues which were identified during the assessment, such as the fire doors, bedroom door and security cupboard lock on Aspen ward. There was no clear plan for when things would be done and no evidence of how things were prioritised within the log. Staff did regular risk assessments of the care environment. The service had a ligature risk assessment which was dated 28/10/2024. Staff were also undertaking regular environmental reviews and audits.

Patients did not raise any concerns about staffing levels during the assessment. None of the patients that we spoke to raised a concern about the service being unsafe due to staffing levels. One patient commented that they felt there were high levels of agency staff used at the service.

Staff that we spoke to during the assessment felt that staffing levels were generally positive at the service, although did note that it could be pressured on lower numbers. Managers explained that significant work had been undertaken around staffing within the service to ensure that a consistent and permanent staffing team was in place.

Staffing levels at the time of the assessment meant that the wards could be managed safely. During the day shift, the service had one registered nurse based on Lyme ward and one registered nurse covering both Pine and Aspen wards. On the night shifts, one registered nurse would cover all three wards. Staff noted that there could be challenges in relation to this if a nurse was required on multiple wards at once, although did not say that this was an issue on a regular basis. During core hours the hospital manager and lead nurse, who were both registered nurses, were on site to assist if the wards needed them.

The service had low numbers of staff leavers for the 12 months prior to the assessment, with 9 staff leaving their posts during this period. At the time of the assessment, the service had 3 vacancies for recovery workers. The service was fully staffed aside from these posts. For the 12 months prior to the assessment, the service generally had low levels of sickness, with absence levels of 2.8% for registered nurses, 8% for recovery workers and 1.5% for therapy staff. Between August 2024 and October 2024, the service had 251 shifts covered by agency recovery workers and no shifts covered by bank recovery workers. For the same period, the service had 44 shifts covered by agency registered nurses and 28 shifts by bank registered nurses. There had been no shifts that were not able to be covered during this period. Staff had received and were up to date with appropriate mandatory training. At the time of the assessment, the service had an overall mandatory training compliance rate of 85%. The training was appropriate for the patient group using the service. The hospital manager had been undertaking work to improve supervision and appraisals for staff. Managers noted that supervision compliance for October 2024 was at 100% and the service was on track to maintain that level for November. The manager had plans to conduct appraisals in February 2025 as part of a month of celebrating staff.

Patients that we spoke to did not raise any concerns in relation to the cleanliness of the environment.

Staff followed infection control policy, including handwashing. Managers had put in place audits to ensure staff cleaned all areas when required to do so.

The wards were generally clean and tidy during our on-site assessment. Furniture available for patients was mostly in good condition and comfortable. There was some staining on the carpets of Aspen ward & some water stains on the walls of Lyme ward. There was a significant unpleasant smell upon entering Aspen ward. Staff informed us there was a patient on the ward who was incontinent, had been urinating in the corridors and refused to have their personal hygiene attended to. Staff were making attempts to attend to this during the time on the ward through encouragement and engagement with the patient. On Pine ward, one of the bedrooms was odorous. The patient was being offered a daily strip wash as they refused to use the shower chair which had no lap strap and he did not feel safe. The patient had not been accepting a wash with the help of staff. The service was making attempts to resolve this situation which we discussed with managers, who had received authorisation to order a new shower chair which they were hoping would meet the patient’s preferences.

The service undertook monthly cleaning audits. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The service was also using an environmental cleanliness audit tool which involved a review of the full building and noted down any specific comments or actions that were required to be addressed. The service had an infection prevention and control action plan.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.