Pine House Rehabilitation Unit in Bacup, operated by Kibo Hospital Services Limited, received the lowest rating from the Care Quality Commission (CQC) following an inspection between April 30 and May 13.
The facility, which includes Pine, Lyme, and Aspen wards, was inspected as part of ongoing monitoring and to follow up on concerns from the last two inspections.
Craig Howarth, CQC deputy director of mental health in the north west, said: “When we inspected Pine House Rehabilitation Unit, we found leaders didn’t have the skills, knowledge or experience to lead the service effectively, and deliver the high standard of care people deserve.
Pine House Rehabilitation Unit, Bacup (Image: Google Maps)
“Also, there hadn’t been a registered manager in place since November 2023 to have oversight and ensure people were receiving safe care.
“It was concerning that leaders didn’t have a good understanding of Mental Health Act requirements.
“We found issues including medicines being given without relevant consent or second opinion, people’s rights not being clearly explained so they didn’t always understand them, including what they had to do to be able to leave the service.
“This had a negative effect on people’s mental health.”
The CQC found the service continued to breach regulations relating to safe care and treatment, premises and equipment, and good management, and also identified new breaches around staffing and person-centred care.
Ratings for effectiveness, care, and responsiveness dropped from “good” to “inadequate,” while the service declined from “requires improvement” to “inadequate” for being safe and well-led.
The service is now under special measures, meaning it will be closely monitored and given a set timeframe for improvement.
The CQC has also started regulatory action, which Kibo Hospital Services Limited has the right to appeal.
Inspectors raised serious concerns about fire safety at the site.
Mr Howarth said: “Three fire doors were completely missing from their hinges, and 45 doors were damaged either beyond repair or in need of significant improvements to reduce the risk of a fire spreading.
“Due to the seriousness, we escalated our concerns to fire services and ensured the service took immediate action during the inspection to keep people safe.”
The inspection found that the hospital was not clean or well-maintained, increasing the risk of infection, and that there were not enough qualified or experienced staff to ensure patient safety.
Referral and admissions processes were found lacking, meaning essential information about patients was not always obtained to support safe care.
Continuity of care was also an issue, with staff failing to consistently involve other healthcare services.
One patient had remained on leave at a care home for six months, despite only being scheduled for a one-week stay.
Discharge planning was found to be inadequate, resulting in delays and a lack of smooth transitions from hospital care.
The unit also saw high levels of restraint and long-term segregation, which the CQC said should not be routine practice in a community rehabilitation setting.
Mr Howarth said: “We’ve shared our findings with leaders and will be monitoring the service closely to ensure changes are made, and people are kept safe while this happens.”
The full inspection report is expected to be published on the CQC’s website in the coming days.