Blackheath Brain Injury Rehabilitation Centre

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection, we rated this key question requires improvement. At that time, the provider was in breach of Regulation 12 (Safe care and treatment) and Regulation 11 (Need for consent). At this assessment, the rating has improved to good.

The service had strengthened several aspects of safety. Staff understood incident‑reporting processes and received monthly lessons‑learned bulletins. Compliance with Mental Capacity Act (MCA) training had increased, and there was oversight of Deprivation of Liberty Safeguards (DoLS) applications. Safeguarding systems were in place, and staff knew how to raise concerns. Most patients reported feeling safe. Family members reported involvement in discharge planning. Staff were trained in safeguarding and infection prevention, and regular audits supported oversight.

Since the last inspection, the provider had made improvements in medicines practice. Staff ordered and administered medicines on time, including time‑specific prescriptions. Records showed checks were completed, and medicines were documented accurately. No medicine errors were observed.
Some areas required further improvement, including aspects of the environment. Patients raised concerns about cleanliness, broken facilities, and limited therapeutic space. Although refurbishment was planned, issues including mould, out‑of‑service toilets, and some clinic room conditions remained. Hot water was unavailable in some areas. Oxygen cylinders were not always stored safely, and some clinic rooms were small and cluttered. These issues resulted in a breach of Regulation 15 (Premises and equipment).

Care planning and medicines oversight also required improvement. Care plans were not consistently updated to reflect current risks. Medicines management, particularly on the Thames unit, showed shortfalls in storage, stock control, and oversight of ‘when required’ (PRN) medicines. Although emergency medicines were available, these issues resulted in a breach of Regulation 12 (Safe care and treatment).

At the last inspection, we recommended improvements in the timely completion of appraisals. At this inspection, most staff reported receiving supervision and appraisals, which were discussed at monthly clinical governance meetings. Staff confirmed access to core and specialist training, including Parkinson’s disease, pressure ulcer prevention, and seizure management, and took part in reflective practice.

We also recommended previously that areas used for patient examinations comply with infection prevention and control (IPC) policies. The provider continued to use an IPC checklist and discussed findings at monthly clinical governance meetings. A weekly environmental walkaround checklist supported compliance monitoring.