Blackheath Brain Injury Rehabilitation Centre

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last inspection, we rated this key question good. At this inspection, the rating has remained good. This meant people’s needs were met through good organisation and delivery.

At our previous inspection, we found the provider had breached Regulation 17 due to the absence of a formal process for collecting feedback from patients, families, and carers about the quality and safety of the service. At this inspection, we found the provider had addressed this. The service had implemented structured systems to gather feedback, and patients and family members confirmed they knew how to provide it. Feedback was collected through questionnaires, forums, and surveys, with actions coordinated by a senior staff member. Patients were also able to give feedback during community meetings. Contact details for the advocate were displayed throughout the service.

The provider had established processes to support carer involvement, including bi-monthly carers’ forums and family meetings every 6 to 8 weeks. A senior staff member managed concerns and escalated issues when required. Monthly walkarounds were conducted to identify and respond to patient feedback. Meeting minutes were shared on the same day. A post-discharge patient survey was in development at the time of the inspection.

Monthly patient meetings took place, although staff reported inconsistent attendance. There was evidence of action taken in response to some areas of feedback, such as food quality and therapy provision.

The provider had suitable policies in place to meet legal requirements around equality and human rights. Staff understood the importance of avoiding discrimination, considering the needs of people with protected characteristics, and making reasonable adjustments to support fair outcomes.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We did not look at Person-centred Care during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Providing information during this assessment. The score for this quality statement is based on the previous rating for Responsive.

Patients were aware of how to provide feedback.

The service gathers patient feedback through questionnaires, forums, and surveys, with the lead nurse taking responsibility for actions. Common concerns include food quality and therapy provision, with previous menu improvements made. Carers’ forums are held bi-monthly, with additional family meetings every 6-8 weeks. A post-discharge patient survey is in development, and meeting minutes are shared on the same day.

The lead nurse oversees concerns, escalating them as needed. The senior nurse conducts monthly walkarounds to monitor patient issues. Monthly patient meetings are held, though attendance varies. However, there is no evidence of changes made in response to weekend activity feedback.

At our previous inspection, the provider was in breach of Regulation 17 for not having a formal process to collect feedback from patients, families, and carers regarding the quality and safety of the service. At this inspection, we found improvements. Family members and patients were aware of how to provide feedback, which was now gathered through questionnaires, forums, and surveys. Additionally, patients had the opportunity to provide feedback during community meetings.

Patients attended community meetings, where they were able to give feedback and request improvements for the service and themselves. Information on how to contact the advocate was on display throughout the hospital.

We did not look at Equity in access during this assessment. The score for this quality statement is based on the previous rating for Responsive.

People said staff treated them as individuals and took their background, preferences and needs into account when delivering care.

Staff and leaders told us the service aimed to be inclusive and responsive to everyone who used it.
The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes.

The provider had appropriate equality, diversity and human rights policies in place. Overall, 98% of staff had completed equality and diversity training.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.