Frenchay Brain Injury Rehabilitation Centre

On this page

• 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

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

This key question has been rated as good. This meant people’s needs were met through good organisation and delivery.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. There was some partnership working with people, to decide how to respond to any relevant changes in people’s needs. However, the service did not always make sure people were at the centre of their care and treatment choices.

Staff told us patients and families who used the service were involved in planning and making shared decisions about their care and treatment. We saw family members involved in discussion with nursing and medical staff and 1 family member requested a meeting with medical staff. However, some patients and families we spoke with were not always informed of decisions in relation to care and treatment, and had to request a conversation with the medical or nursing staff.

Best interest decisions were not regularly led by consultants and meeting records for decision making had limited information about family involvement. Positive Behaviour Support plans did not talk about people’s capacity to consent, which was a risk to the patient if the document was viewed in isolation.

Relatives told us when looking at patient notes they saw mouth care recorded at a time that they had been visiting and no mouth care happened while they were present. They were concerned care records did not reflect the care given. On review of 3 sets of notes, we found amendments to dates that were not signed and dated by staff with a reason recorded for the amendment. The content of the care plans for these entries was also inconsistent with risk assessments kept separately for corresponding dates. This meant there was a risk records were not being completed accurately by staff.

There was lack of continuity between care plans on people’s electronic care notes, paper notes in patient’s blue folders and the care information on the boards of patients' room. This was a risk to patients as staff did not have one true source of information for each person.

Patients on 1:1 care had a member of staff assigned to them 24/7. Patients would have specific care plans for any long term medical conditions such as diabetes.

At lunchtimes we saw information was available on food allergens and intolerances for staff to access. We observed staff handing out meals and cutting food for patients when required.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity

There was no therapy available after 4pm or at weekends. Patients told us they were unhappy with this approach. Therapy plans showed patients were having therapy 3 days out of the available 5. With Rehabilitation Assistant duties not reflecting therapy skills, this meant therapy input was not always optimised.

Patients were referred to other specialities when required, such as neurosurgery, and were supported to attend any follow up or outpatient appointments they had outside of the service. Discharges were discussed at multi-disciplinary meetings with discharge co-ordinators, social workers and local integrated care board members which ensured care provision had continuity for patients. There were also close links with mental health teams where necessary. Discharges were also discussed with community support services. We observed therapy staff assisting a patient with a call from the community team to discuss an assessment of the patient’s home environment. This showed good integration between onward services after discharge.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People had access to information and advice that was accurate, up-to-date and provided in a way they could understand and meet their communication needs.

On admission patients and families were provided with a booklet about the centre which included information on staffing roles, meal times, therapy sessions, a legal clinic and educational groups.

Translation services were available for people whose first language was not English. Audio and braille and large print were available.

Two legal firms offered a free legal clinic for patients and families.

There was a patient information leaflet on prevention of pressure injuries that included information on who was at risk, prevention and skin care with contact details. There was a poster on how to quit smoking with information on how this could help people, aids available and support.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff generally involved people in decisions about their care and but did not always tell them what had changed as a result.

There was a leaflet for patients and families on how to raise concerns or make complaints. The service held patient forums to gain feedback on care.

There had been 11 complaints between June 2024 and June 2025. Complaints were in relation to communication, expectations and outcomes, including not answering call bells in a timely manner. Complaints were discussed at local governance meetings and at daily huddles.

Action from complaints included leaders visiting the wards to carry out ad hoc checks. The MDT met with families to discuss concerns and feedback was given to staff directly involved. The service met with families after 5 days of admission to get a full understanding of the patient’s lifestyle, what was important to them and discuss expectations for rehabilitation.

Some patients and families told us they were not always informed of decisions in relation to care and treatment following assessment.

The patient survey for 2025 included views from 24 patients. Results showed that 22 patients felt safe and were treated with respect and dignity, 19 patient felt the therapy was helpful. Overall 21 patients would recommend the service and 19 felt the admission was a positive step. However, 17 patients did not know who their consultant was and most said they wanted more therapy and weekend activities. Action plans from the survey included ensuring patients were aware of who their consultants were, especially on admission and during ward rounds and to expand therapy sessions.

The service made sure that people could access the care, support and treatment they needed when they needed it.

Patients could expect their care, treatment and support to be accessible and timely. It was delivered in line with best practice, quality standards and legal requirements.

There was an inclusion and exclusion criteria for admission of patients. A face to face assessment was carried out prior to admission to ensure suitability for patients and to identify any additional care requirements people may have.

There was a multifaith room that both staff and patients could access. Patients were encouraged to attend as part of their rehabilitation. However, staff and patients told us there was lack of activities for patients at the weekend.

Patients’ care needs were discussed and updated daily during doctors’ ward rounds.

Discharge coordinators were involved in the discharge process for patients as well as mental health teams and local integrated care boards.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service had processes and policies in place which ensured patients were treated in line with requirements under the NHS constitution and legal and human rights.

Staff received appropriate training in equality, diversity, inclusion and human rights. Patients’ heritage and values were reviewed during admission assessment, and the service determined any support people needed to meet their needs. This included examples of rituals relating to their faith or any specific food requirements people had. Interpretation services were available and leaders told us that medical reports could be translated for patients and their families as required to ensure equitable understanding of their care. Leaders told us the patient surveys helped them to ensure they were able to provide the same service to all patients regardless of any inequality they may have.

Therapy teams collected patient reported outcome measures to monitor the outcomes of each patients’ therapy.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Patients and families were supported to make informed choices about their care and treatment. Patients were provided with information on stopping smoking and managing their overall health.

RESPECT forms were completed and stored in the same place for each patient. This helped staff to support patients in making decisions about their future care.

On admission patient expectations and goals were discussed and plans put in place. Discharge planning was discussed with the families and community support services.