Blackheath Brain Injury Rehabilitation Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

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.

We have not awarded this service a score for Safe.

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

We spoke with 6 family members as part of this assessment. They told us they knew how to make a complaint, although none had needed to use the provider’s formal complaints process. Family members said staff responded promptly to any concerns they raised, and these were resolved quickly.
Leaders told us there was a process in place to ensure incidents and complaints were reported and investigated appropriately. They said no themes had been identified from complaints raised in the past 6 months.
Staff we spoke with understood what types of incidents required reporting and were able to discuss learning identified from these.
Page 4 of 19
At our previous inspection, the provider had not embedded learning from incidents, which breached Regulation 17. At this inspection, the provider had taken action to improve. Staff were able to discuss learning from incidents, and a monthly lessons learned bulletin supported this process.
The provider made the bulletin available to all staff and updated it monthly. It included information about recent incidents and other relevant safety updates.

Family members we spoke with as part of the assessment were able to discuss patients’ ongoing discharge planning. They confirmed they were invited to attend discharge planning meetings. Family members also said they could attend regular multi-agency family meetings, either in person or virtually.
Staff told us they attended joint referral meetings and signposted patients to the most appropriate service based on factors such as therapy needs and location. They also said they had established close working relationships with commissioners.

The provider regularly attended the Specialised Rehabilitation Collaborative Meeting and had effective working relationships with external teams within the organisation. Care records showed updates on patient care shared with other external organisations, including the local authority and physical health NHS teams.

Patients told us they felt safe and knew how to raise concerns. They said staff were approachable and caring.
At our last inspection, the service had failed to ensure Deprivation of Liberty Safeguards (DoLS) applications were submitted in a timely manner. At this inspection, we found clear evidence of sustained improvement. Staff training in the Mental Capacity Act (MCA) had increased significantly, from 62% at the time of the last inspection to 91%. DoLS remained a standing item in the provider’s clinical governance meetings, where applications were reviewed and discussed regularly. We found no evidence of delayed DoLS applications during this inspection.
The provider had a clear policy on the MCA and DoLS, which staff could describe and access when needed. Staff knew where to seek accurate advice on the MCA and DoLS, and they understood how to make a safeguarding referral and who to speak with if they had concerns.
The service attended monthly provider safeguarding meetings and quarterly external meetings.
The provider’s processes promoted people’s safety, protecting them from abuse, neglect, and avoidable harm. We saw evidence of effective systems, processes, and practices in place to ensure people were safeguarded from abuse and neglect. The service had a comprehensive local safeguarding procedure, which included strong working relationships with external agencies, including the local authority. Overall, 91% of staff had completed Mental Capacity Act training, and over 90% were trained in safeguarding adults and children.

Some patients told us they had not received a copy of their care plan or were not fully involved in developing it. However, most patients said they felt engaged in their care and were able to involve family members in decisions. On Heathside ward, one patient described how a staff member stayed beyond their shift to offer ongoing reassurance and support. These examples reflected variable experiences across the service. The provider had taken steps to strengthen personalised care planning and multidisciplinary input.

Staff told us there was a multi-disciplinary team approach to formulating care plans for risk, using a recognised risk assessment tool. These plans were expected to be reviewed monthly or in response to changes in risk. In our review of five care records, risk management plans were in place for four patients. However, we found that some risk assessments had not been recently reviewed. For example, one patient with a known risk of absconding had no documented review of their care plan since July 2024.

The provider had a falls prevention and care policy in place, which included guidance for falls risk assessments. Clinical risk was discussed at monthly clinical governance meetings. However, in the small sample of care records reviewed, we did not consistently see evidence that falls risk was assessed or documented.

During the inspection, none of the wards had hot water, and both patients and the inspection team raised concerns. The boiler was broken, mould was present, and most toilets were out of order. On Thames ward, the clinic room was not clean, despite a completed cleaning schedule. Staff told us they had completed an environmental risk assessment and recorded actions to address the issues.

Staff told us that refurbishment of toilets and bathrooms was scheduled to begin in the weeks following the inspection, with wider plans for redecoration and new furniture across the location. They also confirmed that weekly fire alarm tests and monthly environmental audits were in place to support safety and compliance. The provider later confirmed that hot water had been restored shortly after the inspection.

The environment required improvement. There was limited space for therapeutic engagement, and therapy rooms were very small. We found patches of mould, and most toilets were out of order at the time of the inspection. Bedrooms needed redecoration, and furnishings such as chairs showed visible wear and tear. The provider informed us of ongoing refurbishment plans, which included addressing these issues through redecoration and maintenance. A cleaning schedule had been completed on the Thames ward.

At this inspection, staff told us there was a risk register and a site improvement plan, both of which were reported to be regularly reviewed at governance meetings. Staff also told us that environmental risk assessments were completed regularly. The service carried out an annual ligature audit and only admitted patients assessed as low risk in terms of self-harm. Staff used observations and admission screening to help mitigate risks.

While these arrangements were described by staff, we observed unresolved environmental issues, including mould, broken toilets, and wear and tear in therapy areas, which reduced the effectiveness of the reported processes in practice. The reliance on staff-reported measures, rather than verified implementation, limited assurance that risks were being fully mitigated

Most patients said staff were available when they needed support.

At our previous inspection, we suggested that the service ensure staff appraisals are completed on time. At this inspection, we found that most staff reported having supervision and appraisals, and there was evidence that these matters were discussed at monthly clinical governance meetings.

Staff we spoke with told us they had access to training, including additional or specialist training on topics such as Parkinson’s Disease, pressure ulcer prevention and management, and seizures. They also confirmed they had access to reflective practice sessions.

At the time of inspection, there were vacancies in the therapy department, including the Lead Occupational Therapist role. The service had access to bank staff if required, although it was not confirmed whether bank staff were being used during the inspection. There was no evidence that these vacancies had affected patient care. The provider was actively progressing recruitment, and staffing in this area remained under review to ensure continuity of therapy provision.

In August 2024, supervision compliance was 95% for Heathside Ward, 96% for Thames Ward, and 93% for non-clinical staff. Therapy staff supervision compliance was lower at 67%, and the provider told us they were addressing this through ongoing recruitment and workforce planning. Overall, appraisal compliance was above 85%, and mandatory training compliance reached 92% in September 2024. These indicators were reviewed at monthly clinical governance meetings, demonstrating a structured approach to staff oversight. While therapy staff compliance was an outlier, the provider had appropriate governance in place to identify and respond to this.

Family members we spoke with said they felt the environment was clean. However, they all commented that it was outdated, with some damaged furniture, and in need of refurbishment, though these observations did not raise concerns about infection risk or cleanliness.

Staff followed infection control policies, including handwashing, and managers ensured staff received appropriate infection control training. At the time of the assessment, the compliance rate for infection prevention and control training was 97%.

Staff told us there was an infection prevention and control lead in place.

During the inspection, the clinic room on Thames unit was small, cluttered with stock medication, and not clean. Oxygen cylinders were not stored safely, with some rubbish on top, and these issues had not been identified through routine audits. Medicines belonging to discharged patients or not currently prescribed were also present. On Heathside unit, the medicines trolley was broken, although staff confirmed a replacement was on order. Staff reported plans to convert a larger room for clinical use.

At our previous inspection, we suggested that the service ensure areas used for examining patients comply with infection prevention and control policies. At this inspection, we found that the provider continued to use an infection prevention control checklist to monitor compliance. Findings and areas for improvement were discussed at the monthly clinical governance meetings. The weekly environment walkaround checklist, which included waste disposal, further supported this.

Patients received their medicines as prescribed, and staff recorded medication administration. However, during the assessment, we observed a staff member administering medication to 2 patients without explaining to them what medication was being given.

Staff were trained and assessed to safely administer medicines. They also received additional training to support people with specific needs, such as those experiencing seizures.

The clinic room on the Thames unit had significant limitations. There was insufficient storage space for patients’ own medicines, and large quantities of stock were retained that were not currently prescribed, including medicines belonging to patients who had been discharged. Oversight of stock levels was lacking, and these were not regularly reviewed. Although emergency medicines were available and checked, oxygen cylinders were not stored safely. In contrast, medicines on Heathside were stored safely, demonstrating that safe practice was in place in other areas of the service.

At our last inspection, we identified a breach of regulation as medicines were out of stock when needed, and 360 medicine errors had been recorded. At this inspection, we found improvements had been made. Staff were able to order and administer medicines on time, including those prescribed at specific times. Records showed that medicines were checked and accurately documented. The service had appropriate emergency medicines available, and we found no evidence of medicine errors during this inspection. Although the service was no longer in breach, we continue to have concerns about some aspects of medicines management, which require further oversight and sustained improvement.

Monthly audits were completed by the service; however, issues found during the inspection had not been identified, such as unsafe storage of oxygen. There was a process in place to record medicine errors and incidents, with actions taken and some lessons shared through staff newsletters.

Medicines prescribed on a 'when required' basis were recorded when administered. However, staff were unable to demonstrate how they monitored the frequency of 'when required' medicines. We could not be assured that there was effective oversight of the management of patients with long-term conditions.

There was a process for staff to order and receive medicines from the pharmacy, and patients' medicines were reviewed by clinical teams. There was also a process to ensure patients received their medicines when on leave from the service, with staff checking and recording what patients had taken upon their return.

The service had appropriate emergency medicines available, and these were checked daily.