Blackheath Brain Injury Rehabilitation Centre

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 and fair culture.

At our last inspection, we rated this key question requires improvement. At that time, the provider was in breach of Regulation 17 (Good governance). While the service had addressed the areas relating to that breach, there were still areas where improvements were needed. At this inspection, the rating has improved to good.

The provider had made improvements since the last inspection. The governance structure had developed, with monthly local governance meetings led by a senior clinical representative. These meetings covered health and safety, infection prevention and control, audits and catering, with representation from all disciplines to support collaborative service oversight. Operational group meetings fed into the governance structure, providing updates and action plans from specific service areas.

The quality team monitored performance against internal and external standards, including CQC methodology, and used an internal data system to track physical health needs and incidents of challenging behaviour. Relevant data was shared in governance meetings, and key updates were communicated to staff through team meetings and notice boards. The provider had introduced a monthly lessons‑learned bulletin, which included learning from incidents and safety updates.

The provider had a Freedom to Speak Up policy, and staff were aware of it. Posters promoted the speak‑up guardian. Staff told us they could contact the guardian by phone or through an app. Although the guardian had not visited the service in person since February 2024, staff confirmed they could access the guardian through the available channels. The monthly bulletin included a section on staff wellbeing.

A Service Level Agreement with a local GP surgery supported continuity of care, with the GP conducting regular ward rounds and clinical assessments. The provider had policies in place to support equality and human rights. Staff demonstrated an understanding of how to support patients with protected characteristics and how to prevent discrimination and harassment.

Some areas still required improvement. While governance systems had developed, including structured meetings and improved incident reporting, gaps in assurance remained and improvements were not consistently embedded. Staff reported mixed experiences with leadership, and communication was not always effective. These issues resulted in a breach of Regulation 17 (Good governance).