Frenchay Brain Injury Rehabilitation Centre

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• 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

We did not rate well led as this was a focused assessment and we did not cover all quality statements within this key question. We found some 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 regulation in relation to governance. We reviewed the governance, management and sustainability quality statement for the well-led key question. The service had governance and risk management processes based around delivering safe care and treatment. However, risks were largely managed responsively to incidents and action to mitigate against future risk was not always clearly recorded in governance meeting minutes. Most staff said leaders had necessary skills, knowledge and integrity, and the service was well run. The structure had been changed to improve multidisciplinary working and there was a robust structure for succession. Leaders had not developed a competency framework for Rehabilitation Assistants (RAs) which could put patients at risk of harm due to unsafe care. The incident reporting system was monitored and informed improvements. The service had processes for emergencies with Service Level Agreements (SLAs) with the local hospital for out of hours medical care and a pharmacy company for medicine management. However, there had been some concerns with emergency procedures and delays to the administering of medicines due to delivery issues.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Most staff said leaders had the right skills, knowledge, experience and integrity to lead the service. Some staff told us leaders were visible, approachable and supportive. Most staff said the service was well run and leaders told us they had restructured staffing to improve visibility of leaders and ward managers. However, some staff were concerned that leaders did not always consider the staffing requirements to meet patient needs. Leaders told us that there were enough staff managing governance processes in case of sickness or absence. However, there were some challenges around whether actions had been carried out when other staff were covering this role. Some staff felt communication and patient treatment had improved with this new structure. Staff said they had regular meetings and were mostly able to raise concerns. However, some staff said they did not always receive feedback on action plans from leaders when concerns were raised. The leadership team had a robust succession plan. Staff told us the service’s vision, values and strategy was shared in monthly newsletters. However, some leaders were concerned that not all staff would engage with newsletters. Staff and leaders told us they had concerns about patient records and care plans being saved across multiple systems. This had not been reported as a risk. Staff said there had been some concerns with emergency procedures and delays to the administering of medicines due to delivery issues. Leaders said there had been some incidents, for example, regarding the timely ordering of medicines. Leaders were taking action to address these issues.

There were daily flow meetings when managers discussed patient care, staffing, feedback and urgent updates. There was a risk management policy and a risk register. Risk, patient survey feedback and issues raised in audits were discussed at monthly clinical governance meetings. However, actions to resolve issues, and who was responsible for them, were not always clearly recorded in meeting minutes. The service had a Site Improvement Plan and met weekly to discuss any new issues or progress made. Safe recruitment processes were used. Service development meetings discussed competencies for Rehabilitation Assistants (RAs). However, there was no competency framework and no formal mechanism for RAs to develop rehabilitation skills required for the role. There were effective processes with third-party care providers and a Service Level Agreement (SLA) for pharmacy management. However, there were issues with logistics of medicine deliveries. There was an SLA with the local acute NHS hospital for out of hours medical cover. A governance administrator processed alerts for changes to the service in line with safety requirements. There were processes to address concerns raised by external care providers. There was an incident reporting system for handling incidents, complaints and concerns. Themes were discussed at governance meetings and lessons learned from incidents informed improvement projects. However, systems for managing risk were largely responsive following incidents and methods for using data to mitigate future risks were not always clear. Key Performance Indicators (KPIs) data showed 100% compliance with care plans being co-produced with patients. However, care plans did not evidence shared goal setting for patients. Data was protected by a robust security policy and there were no data protection breaches recorded for the previous 12 months. There was a full business continuity plan to manage any threats to the service’s continued operation.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.