Pine House Rehabilitation Unit

On this page

• 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 assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. We assessed five quality statements from this key question. The service was in breach of regulation for governance at the service. There were ineffective governance systems in place to ensure that the service was safe and that gave managers appropriate assurance about care and treatment being provided at the service. Although 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. It was not clear that staff understood their responsibilities in respect of this and the importance of undertaking these activities. However, staff gave positive feedback about the culture of the service and the improvements that had been made since the last inspection. Staff and managers were positive about their roles and were passionate about continuing to improve the service. Managers were continuing to review and consider areas where improvements could be made to the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff described that the culture of the service had improved since the last inspection. Staff were positive about their roles and were keen to ensure that the service continued to progress to improve patient care and treatment. Managers also reflected that they had identified an improved culture and morale within the staff team. Managers described that, with a more permanent staff team in place, they felt that the service was in a stronger position moving forward and managers were keen to ensure that they retained the staff to give the service consistency. Managers were confident that, if staff had any concerns, then they would raise this with management.

The service held monthly staff team meetings. The hospital manager had also held a nursing meeting to share learning and knowledge. The service had implemented monthly closed culture audits in September 2024. The most recent staff survey had been conducted in July 2024 with 28 staff completing it. The majority of questions had a positive response rate from staff.

Staff felt supported by managers and described that the overall culture of the service had improved since the last inspection. Managers described that the changes to the structure of management had made a positive impact in allowing better oversight and scrutiny. Although new in post, the new hospital manager felt positive about coming into the role and had a plan of work they wished to implement to continue to improve the service.

The service had appointed a new hospital manager in September who was in the process of applying to become the Registered Manager. The Director of Operations had been overseeing the management of the service pending this appointment and was continuing to provide support to the new manager. The service had implemented a Lead Nurse role following the last inspection to improve the oversight and management of the clinical aspects of 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.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Managers recognised that the paper-based records had caused issues for both staff in terms of record-keeping and for managers at having effective oversight of patient records and documentation. Managers were hopeful that the pending implementation of an electronic record system would improve consistency of record-keeping and reduce the pressures and demands on staff. Managers noted that some of the newly implemented meetings and audits were helping to improve the oversight and management of the service. Managers were keen to continue to ensure these processes were embedded and effective. Whilst the service had implemented changes and new processes since the last inspection, it was not always clear that staff understood their responsibilities in relation to these processes, due to the assessment team identifying gaps and inconsistencies across documentation and records. There were also examples during the assessment where ward staff could not find certain documentation in relation to the safety and management of the wards. The service was using paper records along with electronic folders for patients. These patient records were inconsistent between the physical records and the electronic documentation. Staff had not ensured that the latest documentation was printed off and placed in the physical folders. We also observed examples of documentation and checks that had been started and were incomplete in the physical folders. It was not clear as to whether these should have been continued or not. There was no evidence that these issues had been identified by the provider and addressed with staff to improve record keeping. The service undertook care plan audits however the size of the paper patient folders did not assist with good oversight and ease of reviewing documentation.

We also identified inconsistent recording and gaps in the physical health folders. This included examples of where physical observations had been recorded on individual pieces of paper which did not indicate good practice or effective record keeping, along with examples of gaps in and incomplete documentation. Managers explained that an electronic care record system was due to be implemented in 2025. Following the onsite assessment, the provider gave an update that they had been agreed at regional governance that the system would be fully implemented by the end of March 2025. We identified gaps in the emergency bag checks on Aspen ward. There were 2 missed days in November 2024 and 4 missed days in September 2024. The sheet for October 2024 had half of the days crossed out with a note stating “new sheet started”. The previous sheet was not present and staff were not aware of what had happened to it. Following the onsite assessment the provider added this to the morning flash meetings to ensure that staff were undertaking the appropriate checks. It was also discussed in the staff meeting for staff awareness. We reviewed the fridge temperature recording sheet for the fridge in the patient kitchen on Aspen ward. The temperatures were not being recorded daily with some gaps of over 4 / 5 days at a time. The service had monthly local governance meetings and regional governance meetings which were held every 3 months. Managers would filter any key messages from the meetings to ward staff via email or through meetings. Although messages were shared through staff meetings, it was not clear that all essential information could be shared due to processes and procedures within the service not always being robust and efficient.

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. The service had an information booklet about the local area which included details of local services, activities and groups that patients may be interested in. It also included information about volunteering, education and work opportunities in the local area. The occupational therapy team would help patients to access these if required.

Staff and managers explained how they were attempting to establish links within the local community. The occupational therapy team had created a link with a local community service who provided a weekly meal for people who required carers, which was based in a local church. The occupational therapy staff would take any patients that wished to attend once a week for a 3-course meal. This was free for patients and enabled them to have time outside of the service. Managers reported that staff were complementary about the work undertaken by the occupational therapy team including how they cared for and supported patients.

The service had recently had a visit from a local commissioner. Managers noted that they had received positive feedback from the visit and this had been a positive experience for the service.

The provider worked with a local GP to manage any physical health issues and the prescribing of medication in relation to this. Managers also advised that any specialists that may be required, such as podiatry or dieticians, could be accessed as required. Two patients in the service were being seen regularly by podiatry. The GP had also run a small clinic at Pine House to provide flu and COVID-19 vaccinations.

The new hospital manager had an aim to achieve accreditation for the service although acknowledged that this would not be immediately achievable. They saw it as a long-term goal and would start to work towards this in a realistic timescale. Managers noted that lessons learned across the company were shared at regional governance and these could then be filtered down to staff within the service. The hospital manager explained that they had links with the managers of other services within the organisation and that information was shared in more informal ways between managers. Following liaison with one of the other services, the manager was planning to implement induction booklets that had been successfully introduced at the other service.

All incidents, emerging risks and safeguarding concerns 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. We reviewed a sample of incidents during the assessment. The incident report forms were very limited in considering actions taken and int the oversight and review of the incident. The provider had a lessons learnt matrix and we observed evidence of sharing learning at team meetings and in a monthly bulletin. The lessons learnt matrix had gaps and did not always give a clear understanding of how the learning has been identified. It was not clear that all incidents have been reviewed as extensively as they should have been, given some of the circumstances involved. The provider also had a safeguarding internal log. There were some gaps on the spreadsheet and some incidents that had been identified as “not meeting threshold” for CQC notification which, given the circumstances, could potentially have been a notifiable incident such as patient on patient physical violence.