Blackheath Brain Injury Rehabilitation Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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).

We have not awarded this service a score for Well-led.

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

Some staff feel that frustration from colleagues impacts patient interactions and team morale. Concerns were raised about a blame culture and lack of respect from senior management. Despite regular discussions on mutual respect, staff feel this is not always demonstrated by leadership. However, improvements in accountability have been noted.

Concerns have been reported through internal speaking-up channels. No evidence this was followed up robustly. There is recognition that ethnic minority staff may require more support. Some staff have highlighted the need for pastoral care, particularly for BAME colleagues who feel overstretched.

Concerns about leadership approachability were raised, with staff requesting an anonymous suggestions box. While management agreed, delays were attributed to building work, though staff believe a temporary solution could be implemented.

While some senior staff feel respected and supported, others report feeling unsupported by leadership. In 1 case, staff faced ongoing harassment from a patient’s relative, with no clear guidance or senior support on boundary setting. Staff suggested a scripted response but feared repercussions if complaints arose.
Despite these concerns, some staff feel valued, and executive teams are seen as supportive and engaged with frontline staff.

However, others felt leadership did not trust them to carry out their roles and raised concerns about the conduct of some senior managers. Staff also highlighted barriers to speaking up and a fear of repercussions. 1 staff member described instances of "victimisation and harassment" and believed raising concerns would lead to negative consequences. Since our visit, the provider has informed us of changes to the senior management structure.

Overall, 98% of staff had completed training in equality and diversity. Staff we spoke with were able to give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Some staff reported they did not feel able to be open with leaders when things went wrong, indicating concerns about psychological safety within the service. However, other staff described feeling valued and supported by executive leadership. These mixed views reflect variability in staff experience of leadership openness and suggest the need for ongoing improvement to foster a consistently supportive culture.

Some staff reported that communication from leaders could be clearer, and a small number felt excluded or de-motivated. Overall, the service had established structured communication processes, including governance meetings and lesson-learned bulletins.

The provider had a Freedom to Speak Up policy in place, and staff were aware of it. Posters promoted the speak up guardian. Staff told us they could contact the guardian by phone and through an app, which offered flexible communication options. The guardian had not visited the service in person since February 2024, but staff confirmed they could access the guardian through these channels. The monthly bulletin included a section on staff wellbeing, which promoted openness.

Staff provided mixed feedback about workforce morale during the inspection; some described it as poor at the time, while others reported feeling valued and supported by leadership. This reflects ongoing challenges as well as positive engagement efforts by executive leaders.

The provider had policies valuing diversity and promoting fair and equitable treatment of staff. Training in equality and diversity was completed by 98% of staff, who demonstrated awareness of supporting individuals with protected characteristics under the Equality Act.

At our previous inspection, the provider was in breach of Regulation 17(1)(2) for failing to ensure that systems to assess, monitor, and improve the quality and safety of the service were effective. At this inspection, we found improvements in the existing governance structure. Monthly local governance meetings continued, with a focus on areas such as health and safety, infection prevention and control, audits, and catering. These meetings now included representatives from each discipline, ensuring a more effective and collaborative approach to improvement.

The service holds monthly local governance meetings, led by a senior clinical representative, covering health and safety, infection prevention and control, audits, and catering. Representatives from each discipline attend, ensuring a multidisciplinary approach.

Sub-meetings within the organisation contribute to governance by feeding in action plans. The quality team conducts reviews using CQC methodology and reports on findings with corresponding actions. Data on physical health and challenging behaviour is processed through an internal data management system and shared at governance meetings.

Key information is communicated through team meetings and displayed on office notice boards to keep staff informed and engaged.

Managers did not have consistent quality assurance systems in place to ensure safe medicine storage and recording.

People said the service supported them to maintain links with other services and local resources.

Joint working arrangements and regular communication with partner organisations.

We observed examples of collaborative working during the inspection.

Service Level Agreement (SLA) with local GP surgery.

Staff received encouragement to learn and develop.

The provider had a lesson learnt bulletin, which was available to all staff and changed monthly. The bulletin included incidents, as well as other safety updates.