Lancashire mental health unit placed in special measures after serious safety concerns

A Lancashire mental health rehabilitation unit has been placed into special measures after inspectors found serious concerns including missing fire doors, unsafe medicines practices and insufficient numbers of appropriately qualified staff.

The Care Quality Commission (CQC) downgraded Pine House Rehabilitation Unit from requires improvement to inadequate following an inspection carried out between 30 April and 13 May. The service, operated by Kibo Hospital Services Limited, consists of Pine, Lyme and Aspen wards, all of which were included in the inspection.

The regulator had previously identified breaches relating to safe care and treatment, premises and equipment and the management of the service. Inspectors found these breaches remained at the latest inspection, while additional breaches were identified relating to staffing and person-centred care.

Pine House is now rated inadequate across all five areas assessed by the CQC. Ratings for effectiveness, caring and responsiveness fell from good to inadequate, while safety and leadership declined from requires improvement to inadequate.

Inspectors raised significant concerns about leadership and oversight of the service, which had been without a registered manager since November 2023. The CQC found leaders did not have the necessary skills, knowledge or experience to effectively manage the unit and ensure people consistently received safe care.

Problems were also identified around the Mental Health Act. Inspectors found medicines had been administered without the relevant consent or second opinion in some cases, while people’s rights were not always clearly explained. This included people not fully understanding what was expected of them before they could leave the service, which inspectors found had negatively affected their mental health.

Fire safety was another serious concern. Three fire doors were completely missing from their hinges and a further 45 doors were either damaged beyond repair or required significant work to reduce the risk of fire spreading. The findings were considered serious enough for the CQC to escalate its concerns to the fire service, with immediate action taken during the inspection to protect people.

The hospital was also found to be poorly maintained and insufficiently clean, increasing the risk of infection. Inspectors identified wider problems with the environment alongside concerns that there were not enough qualified, skilled and experienced staff to safely meet people’s needs.

Access to specialist professionals was limited. People were not being routinely assessed by a psychologist as part of their rehabilitation, making it more difficult to develop appropriate care and support plans which identified what could help an individual and what might trigger a deterioration in their mental health.

Inspectors also found an assistant psychologist had been completing support plans without having received the required training. The CQC warned this created a risk that inappropriate techniques could be recommended for managing people’s behaviour.

Levels of restraint and long-term segregation were another area of concern. The CQC found both were being used frequently despite this being a community rehabilitation hospital, where such practices would not ordinarily be expected on a regular basis. Where segregation was considered necessary, inspectors did not always find clear reasons for its continued use or plans to support people to return to the wider service.

Problems were identified from the point people entered the service through to their eventual discharge. Referral and admission processes did not always ensure staff received all the information required to determine whether someone’s needs could be safely met, while different healthcare services were not consistently involved to ensure continuity of care.

In one case, a person had been sent on leave to a care home for what was intended to be one week but remained there for six months. Inspectors found their aftercare and discharge arrangements had not been adequately planned to provide a smooth and timely transition from hospital.

Despite the serious concerns about the service, people receiving care spoke positively about individual ward staff, telling inspectors they felt safe with them and describing staff as kind and doing their best to provide appropriate support.

Pine House will now be closely monitored under the CQC’s special measures process while improvements are made. The regulator has also begun the process of taking further regulatory action in response to its findings, which Kibo Hospital Services Limited has the right to appeal.

Stay informed with the stories shaping health and social care.

Register with The Daily Round for the latest sector news, inspections & reports, wellbeing content, workforce insights, expert features and practical updates—delivered free to your inbox.