Frenchay 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

We did not rate safe as this was a focused assessment and we did not cover all quality statements within this key question. We found aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to consent, assessing risks, staff training, safe premises and processes and records. We assessed 5 quality statements. These were learning culture, safeguarding, involving people to manage risks, safe environments, safe and effective staffing for the safe key question. There was a positive learning safety culture and lessons learned were shared across multiple platforms. However, the information between platforms was not always consistent. There were policies and processes to keep people safe. However, most staff did not understand relevant legislation, documentation was not always clear and staff could not always locate Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. There were processes to help people manage risk and support their choices. However, risk assessment documents were not always completed for community visits. The environment was mostly safe, well maintained and met people’s needs. However, there were issues with managing the water quality in hydrotherapy and the garden fence posed an absconding risk. Leaders had staffed the service in line with the British Society of Rehabilitation Medicine (BSRM) guidelines. However, some staff felt this did not always take into account the patients’ dependency levels. Communication between specialties had improved. Training did not always meet target levels and some roles did not have competencies. Tracheostomy observations and patient care plans were not always met.

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.

Most people said they confidently raised concerns to staff about care and treatment. Some people felt staff were apologetic and tried to resolve issues. However, some people were dissatisfied with staff responses and said that not all staff listened to patients’ wishes and commented they required further training in communication and listening skills.

Staff told us they had a thorough induction; they felt training was good with yearly refreshers for certain topics and the service paid to send them on professional training. Staff said they were encouraged to share ideas and felt listened to by managers. Staff told us, following feedback from relatives and patients, a carers’ education forum had been re-started. Leaders told us the service was good at formulating ideas for improvement. Some staff told us there was a culture of improvement through aspiration for best practice. Staff knew how to raise incidents and were encouraged to do so. Staff felt supported to respond to patients concerns and would try to resolve them at the time. Staff told us that improvements were made following incidents by holding debrief meetings to discuss learning. Leaders listened to staff and responded to feedback using a “You Said We Did” process. Staff had requested more equipment which was required and 5 observation machines were ordered. Annual feedback reports provided leaders with staff views including wellbeing, leadership and teamwork. Staff feedback was mostly positive. Leaders met with teams to look at learning from staff surveys.However, staff told us maintaining improvements was challenging.

The provider had effective systems for staff to report incidents and concerns. Lessons learnt following incidents were shared and used to make improvements. However, these were not always consistent. There was a system for monitoring incidents. Learning was shared with staff via newsletters, team meeting minutes and daily safety briefings. However, staff told us they did not always have time to read newsletters. Meetings and newsletters did not always contain consistent messages. This meant there was a risk staff did not have access to all learning shared. Complaints were logged on an incident system, were reviewed at daily flow meetings and included action plans with review dates. Patient feedback highlighted that people did not know who to speak with about concerns. As a result, posters showing treatment teams for patients had recently been introduced. There was a forum for patients to give suggestions for improvements to the service. Action plans were created following learning from complaints. However, meeting minutes where complaints were discussed did not always explain learning or how to prevent recurrence. The service had an audit schedule. However, the schedule was not always followed and learning action plans were not always clearly recorded. Audit data was shared with staff at team meetings and via monthly newsletters. However, feedback to staff was not always evidenced within audit documents. Action plans around audits were not always clearly documented in clinical governance minutes. Quality improvement projects were regularly undertaken in response to complaints, patient feedback, incidents and audits. Snapshot teaching sessions were delivered when areas of poor quality were identified. However, there was no clear evidence of learning from patient outcomes. Leaders told us the use of outcomes to drive improvement had not yet developed within the service. However, therapies staff undertook a visions and values project to help with service progression.

We did not look at Safe systems, pathways and transitions during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

People’s experience of feeling safe was mixed. Some people told us they felt safe and knew who to go to for help. People felt involved in their care with clinicians talking to them about best options. Some people felt supported to make their own decisions despite cognitive issues. However, some people did not always feel safe and said communication was sometimes a problem. Some patients did not always feel supported to make decisions. Some people told us staff explained procedures before carrying them out. However, some staff did not explain intended actions to patients before carrying out care.

Safeguarding leads said they accessed supervision at provider safeguarding meetings and all clinical staff were trained to the appropriate level. Some staff told us they had good quality safeguarding training and raised concerns internally. However, some staff were unclear who concerns should be reported to. Staff rarely reported safeguarding concerns to the local authority themselves. Safeguarding leads checked staff referrals for quality and generated referrals from internal incident reports before sending to the local authority. Staff had Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) training. Some staff were aware of Independent Mental Capacity Advocates (IMCAs). A board displayed information about safeguarding leads, IMCAs and Independent Mental Health Advocates (IMHAs). Some staff could not recall the content of, or when they last had, training for MCA and DoLS. Staff told us Occupational Therapists (OTs) carried out capacity assessments to review whether people were able to make particular decisions on admission and discharge. Most ward staff did not feel assessing capacity for day-to-day care was part of their role. Capacity assessments were only available within care plans for specific decisions around consent to treatment, information sharing and photo taking. Some staff were unclear how to approach patients’ fluctuating capacity. Staff were aware of Positive Behaviour Management (PBM) plans. However, some staff did not understand the MCA definition of restraint, or which legal framework was used when restraining patient Most staff were not clear that DoLS did not cover decision making for care and treatment. Capacity assessments related to specific decisions were not always clearly recorded. Staff reported they were able to find patients’ legal framework in handovers or patient records. However, it was not always clear that people had been notified of their rights following detention under the Mental Health Act (1983)(MHA).

Safeguarding referrals were recorded, including follow up with the local authority, actions to support safeguarding and responses to concerns. Patient capacity was assessed for limited decisions on admission. However, best interest decision making was not always clearly documented in line with the MCA checklist. Plans lacked detail around decisions and some were not written in a way that kept people safe. Assessments for different patients used similar wording which indicated a lack of person-centred decision making. Care plans showed least restrictive restraint for patients and aligned to Positive Behaviour Support (PBS) plans. DoLS applications were processed when assessments showed people did not have capacity to consent to admission. However, some applications were delayed. There had been no legal framework for 3 weeks in one case. Safeguards actioned if DoLS applications were delayed had not been clearly documented. Actions were not documented if authorisation of a legal framework had expired. Staff attempted to gain consent from patients. However, there was limited evidence of this in people’s care plans. Some staff told us they did not need to gain consent if a patient had a DoLS. This showed a misunderstanding of the legislation. Safeguarding adults training was below the service target at 75% of the 90% target. Staff training on MCA and DoLS was 94%. A comprehensive MCA policy detailed when the MHA should be used. However, it was not clear that the MHA could be used for people with a brain injury but not in relation to unconnected physical health needs. This meant there was a risk staff were unclear on this legislation. Records showed therapies staff did not receive MHA training. Patients’ Recommended Summary Plan for Emergency Care and Treatment (RESPECT) forms lacked detail and were not held for all patients. If capacity was documented as lacking on the forms, reasoning was not always recorded.

People told us that some staff communicated with patients before carrying out personal care. However, people said some staff had to be reminded as they did not always observe patient wishes or care plans. People told us time taken for staff to respond to call bells was varied. Some staff were quick to respond. However, other people waited a long time for a response and had to seek help in other ways.

Leaders told us each team carried out their own risk assessments on patient admission. Staff felt supported to manage risks such as caring for patients with complex feeding needs. Leaders told us there had been some concerns with emergency procedures. Nurses were trained in intermediate life support and learning from emergencies had been applied. However, most staff were not clear on where to find patients’ ReSPECT forms in the event of an emergency. Leaders told us managing emergencies out of hours could be improved. There were escalation processes to mitigate risk out of hours (5pm to 9am) and there was a Service Level Agreement (SLA) with the local hospital to provide on-call medical care. Recently trained staff carried out routine tracheostomy tube changes. Some of the Speech Language Therapy (SALT) team had basic tracheostomy training. Support was provided by the local hospital’s SALT team. The team contributed to discussions at tracheostomy meetings. If emergency situations occurred assistance would be requested. Staff told us there were clear pathways to follow for the escalation of seriously unwell patients. We observed the tracheostomy emergency chart which in some cases led to staff requesting ambulance transfers to the local hospital. However, there had been a recent incident when an ambulance was delayed entry due to the car park barrier not being opened on arrival. Following this, the emergency ambulance access to the building had been reviewed and new measures ensured access to the car park was timely. Staff told us the therapy team supported patients to manage a balance between risk to themselves and minimising restrictions on their day-to-day life choices. This helped people to do what was meaningful to them. Leaders told us intentional rounding (observation) charts were reviewed to assess patient care needs. This allowed patients more freedom with choices accepting a relative level of risk in line with rehabilitation guidance.

We observed the facilities to be well maintained and tidy. Corridors were kept clear. We observed learning around safety of the environment being shared during staff safety briefings. The environment appeared to be clean with consistently completed rotas and infection control processes. Equipment was serviced in line with procedures. However, fridge temperatures were not always recorded consistently to ensure the safe storage of food. There was a fire door which was not fully functioning and an oxygen cylinder was not stored in line with safety requirements.” The service’s hydrotherapy pool was clean and tidy. However, it had a number of areas showing wear and tear with rusty screws leaking on the walls. This was on the service’s risk register. There was a policy for the safe management of care in the hydrotherapy unit. However, we observed staff numbers in the area did not always meet the policy for emergency evacuation. Staff using the hydrotherapy pool were all compliant with emergency evacuation training. Microbiology testing had not been carried out consistently in line with policy or with Pool and Water Testing Advisory Group (PWTAG) standards for the previous 12 months. This was an infection control risk to patients using the pool.

People told us hoists could be difficult to use within the space available. However, families found the size of the rooms accommodating to their needs when visiting. Equipment for patients’ rehabilitation needs were provided as required. People said “I like it here. It is a nice environment. Very clean.” People also told us that floors and equipment were kept clean. However, food trays were not always promptly removed.

Staff were able to provide any equipment required to support patients’ rehabilitation. Staff were assured that patient information was safely stored on the electronic systems which were password protected. Staff said infection control risks for specific patients were well documented and this was well managed. Staff said there was a hand washing audit. These were completed monthly. The environment facilitated patient recovery and outcomes, and the premises were well maintained. Staff said there was a new checklist for cleaners. However, they said there could be a better process for reporting faulty equipment. Maintenance staff told us the company who provided water testing kits for the management of bacteria in the hydrotherapy pool had not been sending them. Staff said the water had not been tested in the pool for 2 months. Attempts to address this had been made. However, there were delays in resolving the issue.

We observed the facilities to be well maintained and tidy. Corridors were kept clear. We observed learning around safety of the environment being shared during staff safety briefings. The environment appeared to be clean with consistently completed rotas and infection control processes. Equipment was serviced in line with procedures. However, fridge temperatures were not always recorded consistently to ensure the safe storage of food. There was a fire door which was not fully functioning and an oxygen cylinder was not stored in line with safety requirements.. The service’s hydrotherapy pool was clean and tidy. However, it had a number of areas showing wear and tear with rusty screws leaking on the walls. This was on the service’s risk register. There was a policy for the safe management of care in the hydrotherapy unit. However, we observed staff numbers in the area did not always meet the policy for emergency evacuation. Staff using the hydrotherapy pool were all compliant with emergency evacuation training. Microbiology testing had not been carried out consistently in line with policy or with Pool and Water Testing Advisory Group (PWTAG) standards for the previous 12 months. This was an infection control risk to patients using the pool.

The risk register listed several concerns with the environment. The height of a gate had been raised as this was an absconding risk. However, the height of the garden fence had not been resolved. This had been escalated and there was an action plan to address this but work had not been completed. The maintenance team carried out fire and mattress checks. Safety checks for the hydrotherapy pool were carried out daily. However, there were not always enough maintenance staff on site who were trained in line with PWTAG standards. This meant there was no safety net for maintaining water quality in times of staff absence. There was a hydrotherapy policy for the safe management of patients. The policy for water safety in the hydrotherapy pool stated laboratory water testing for bacteria should be done monthly. However, in line with PWTAG standards this should have been carried out weekly.

People told us doctors and rehabilitation staff were brilliant. However, some people said there were not enough staff to cover patients’ needs, particularly at weekends. People told us some staff were better trained than others in communication skills and medicine was sometimes given late. Some people told us staff ID badges were not always visible.

Staff told us staff retention had improved. Most staff we spoke with were very happy and felt teams worked well together. Some staff had been in post for many years and felt supported by their seniors. However, some staff felt staffing levels were not always enough to be able to provide the required care and support for the higher dependency patients and medication times could be missed. Leaders told us staffing levels were governed by the hospital’s central provider and was at 70% of British Society of Rehabilitation Medicine (BSRM) guidelines. This staffing level was higher when compared to similar services. Agency staff were rarely used with consistent staffing levels. However, short term sickness was often a challenge and the service’s own bank staff covered this. Leaders told us there were concerns that higher staffing needs for higher dependency patients impacted on the monitoring of tracheostomy patients. Leaders worked to fill previously high number of vacancies by recruiting international staff, mainly Rehabilitation Assistants (RAs) roles. There had been complaints about a lack of weekend staff. However, leaders told us this was due to the therapy teams working Monday to Friday. Leaders told us there were plans to develop a competency framework for RAs to improve therapy input 7 days per week. Leaders told us they sometimes felt stretched due to service demand but were supported to carry out their roles effectively. Duty slots allowed them to handle unexpected events and escalate concerns easily. Staff told us while access to psychologists was available, there was no formal training for therapies staff on psychological distress in patients. Staff told us the recent addition of spinal patients to the service had increased the need for psychology input. However, recent recruitment had improved the situation. Staff said communication and reflection of learning between Speech Language Therapy (SALT) and multidisciplinary teams was good.

Daily staffing rotas for all wards showed shifts were consistently filled. Clinicians followed an up-to-date Standard Operating Procedure (SOP) for the management of tracheostomy patients. Tracheostomy patients required high levels of nursing in single occupancy rooms. We observed the tracheostomy travel bag and trolley check lists. However, the checking and stocking lists were not always completed by staff. We observed a flow chart for staff to follow in the event of a tracheostomy emergency. There was an inclusion and exclusion criteria to determine whether patients were suitable for admission to the service. Patients with nasogastric (NG) feeding tubes were listed as unsuitable to be cared for in the service. However, staff said that they were able carry out NG feeding and removal of tubes. A review of enhanced care patient records showed that not all records and care plans were completed. There was a Cardiopulmonary Resuscitation policy which provided staff with guidance. We observed thorough handovers of patient care between shifts. However, when concerns were raised, staff did not always create action plans to resolve issues. Meetings between nursing and therapies staff demonstrated good multi-disciplinary working. Food and drink was discussed at these meetings.

The service had a recruitment policy setting out safe recruitment selection and responsibilities and a clinical supervision policy. There were processes to ensure staff were safely recruited and fair for people with protected characteristics. Recruitment records were held on site. However, files were not always up to date as some information was held centrally by the service provider. All staff files reviewed demonstrated suitable staff with performance managed in line with policy. Staff sickness and turnover rates were recorded as low. Staff appraisal compliance was in line with the service’s targets. The service had a mandatory training list for each level of staff and specialty. However, there were some key areas that were not meeting targets for training compliance, for example, Positive Behaviour Management (PBM) and tracheostomy. There was no mandatory dementia training and this was not monitored. Supervision targets were monitored but were not always met. The service held weekly PBM meetings which included consultant review of patient needs. There was a specialist behaviour nurse in post and 5 PBM trainers. There were Positive Behaviour Support (PBS) plans for patients. However, these lacked detail and capacity assessments and assessments for physical intervention were not always easily accessible to staff. Staff could not locate documentation to show how consent was obtained as part of PBS plans. Physical interventions were recorded on the service incident reporting system. However, risk assessments relating to PBS were not always clearly recorded. There was a policy to assure all stakeholders that doctors worked in line with their registration. Specialism specific team meetings were held. The service had recently begun receiving spinal patients. However, it was not clear whether all staff had received training to care for spinal patients. Spinal training was not included in snapshot training sessions.

We did not look at Infection prevention and control during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.