Blackheath Brain Injury Rehabilitation Centre

Updated 14 February 2023

Blackheath Brain Injury Rehabilitation Centre is provided by Active Neuro Limited. Blackheath Brain Injury Rehabilitation Centre in south east London is a provider of specialist inpatient rehabilitation for individuals with an acquired brain injury or other complex neurological conditions. Blackheath Brain Injury Rehabilitation Centre comprises of two wards and provides 39 beds for male and female patients. Thames Unit admitted patients with complex cognitive or behavioural problems following a brain injury or as a result of a neurological condition. Heathside Unit admitted patients with less challenging behavioural problems who had ongoing physical therapy needs. At the time of the inspection 34 patients were using the service.

Blackheath Brain Injury Rehabilitation Centre is registered with the CQC to carry out the following activities:

• treatment of disease, disorder or injury

• assessment or medical treatment for persons detained under the Mental Health Act 1983

Patients using the service are admitted from an acute hospital and most return to their own home after rehabilitation.

There have been nine previous CQC inspections of Blackheath Brain Injury Rehabilitation Centre when it was registered under a different provider, with a different name. Thames Ward was last inspected in August 2018 and there were no regulatory breaches identified. The service was rated as Good overall. Heathside Ward was registered and regulated separately until March 2021 and was last inspected in September 2019. There were no regulatory breaches identified and service was rated as Good overall. This service registered under this provider had not been inspected before.

The service had a registered manager.

What people who use the service say

We spoke with 8 patients and most of the feedback was positive. Patients told us what they most liked about the service was the kindness and encouragement of the staff. Patients told us they felt safe and had observed the staff being kind to other patients. Patients attended a weekly community meeting with the advocate where they were able to give feedback and request improvements for the service and themselves. However, some patients told us they were not involved in their care planning and they did not have a copy of their timetable. Patients gave us mixed feedback about the food. Some patients said it was fine, whereas other patients thought the quality of meals was poor.

We spoke to 13 carers and families. They had mixed views about the service. They told us the patients felt safe and were well cared for. However, carers and families did not always feel involved in the service, or aware of their relative’s care. Families and carers told us communication with the service was not always easy and there was no process to give formal feedback. Families and carers told us they were unhappy that the hydrotherapy pool was not available for use.

Updated 14 February 2023

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

• The service had over 360 medicine errors in the 6 months prior to inspection. The biggest themes were medicines being out of stock and recording omissions. Meeting minutes showed these were discussed at clinical governance and team meetings. Some actions were taken to address medicines being out of stock. The provider had contacted the GP surgery about the medicines being out of stock from the 19 April 2022, and was communicating with the GP surgery to address this concern. However, an incident took place in October 2022 where a patient had been left without medicine for 7 days. Actions to address recording omissions included peer reviewing records to ensure no recording omissions. However, medicine audits showed errors were still happening.
• Staff did not always discharge their responsibilities under the Mental Capacity Act 2005 in a timely way. Two patients under deprivation of liberty safeguards (DoLS) had not had a further application made after their DoLS had expired. This meant the patients were unlawfully deprived of their liberty for several months
• Although the service had governance systems to assess and the quality and safety of the service, these systems were not always effective. The service had a site improvement plan to manage any identified improvements and actions from audits. However, these did not include many of the issues we identified during the inspection. The service had a quality assurance framework to help manage their audits. However, additional audits to monitor identified areas of concern had not been done monthly, as required. The service risk register did not reflect some of the risks we identified during the inspection
• While learning from incidents was shared at morning handover meetings, in team meetings and in clinical governance meetings, the ongoing medicine errors showed this learning was not always embedded
• The service did not have a formal process to collect feedback from patients, carers and families. This meant the service was not able to use this feedback to make improvements to the service. The service had a process to obtain feedback from staff in the form of a staff satisfaction survey. The most recent survey had been completed in November 2021. The survey for 2022 had been delayed as the service had changed their methodology, and this took place in January 2023
• The occupational therapy team had 6 vacancies with only 1 rehabilitation technician and an activities co-ordinator in post. There was a risk that patients were not getting the appropriate support in this area
• A few patients told us they were not always involved in the planning of their own therapy goals, or were not aware of their discharge plans
• One patient was concerned they had not been instructed in the proper use of a mobility aid
• Not all staff knew of the accessible information standard (AIS) which is a legal standard aimed at making sure people with a disability or sensory loss are given information they can understand in the way they would like it and their communication needs are flagged on their health records
• The premises were a smoke-free environment, but patients were supported to smoke in the garden. This meant that the service was not operating within its own policy or being mindful of national public health guidance
• Some patients told us that did not like the quality of the food. One patient said the food was bland and another patient showed us a photograph of burnt food they had received
• Staff annual appraisals were not always completed on time. At the time of inspection appraisals for the therapy team were at 63%, and for non-clinical staff 54%

However:

• Staff treated patients with care and kindness and encouraged them in their rehabilitation goals
• Staff spoke highly of the managers and their team. The said there was good teamwork and support from the therapy teams and from each other
• The therapy teams developed holistic, recovery-oriented care plans informed by the initial risk assessment.
• The wards were fully staffed with nurses and doctors. Staff assessed and managed risk well
• The service was engaged in a range of quality improvement projects.

Updated 14 February 2023

Please see the overall summary above for the summary of this service.