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 looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we did not rate this service. At this assessment we rated the service as requires improvement.

This meant 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.

This service scored 56 (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. The service had a proactive and positive culture of safety based on openness and honesty. Concerns were listened to about safety and the service investigated and reported safety events. There were mechanisms for sharing learning, including safety briefings, handovers, governance forums, and organisational communications such as newsletters.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. Staff understood their responsibility to report incidents.

Staff involved in incidents received individual feedback from investigations and attended incident debriefs. However, team meeting minutes we reviewed did not show any discussion of learning from incidents. We spoke with 14 staff about learning from incidents. Not all staff were able to describe how they received learning from incidents. Leaders told us lessons learned were shared in a monthly newsletter and we reviewed examples. However, only 2 members of staff were aware of the newsletters. Three members of staff told us there was no shared learning or feedback from managers that they were aware of.

Most staff felt there was an open culture. However, some staff felt concerns were not always heard by leaders and safety was not always a top priority

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Patients care was discussed with the multidisciplinary team (MDT) and planned to ensure all needs were met. Each ward had a weekly meeting and daily meeting to discuss patient care needs and therapy session. These would be discussed with the patient and family.

All new admission were assessed to ensure they were appropriate for the unit. Staff meet with families after 5 days of admission to understand their lifestyle, what is important to them and discuss expectations.

Discharge coordinators were involved in the discharge process for patients as well as mental health teams and local integrated care boards. There was a checklist and pathway for patients being discharges, this included equipment supplied, medication, information on support for mobilisation, communication and behaviours, as well as contact details for staff involved in care after discharge such as GPs and community services.

There was a medical emergency policy which included responsibilities and procedures. In the event of an emergency staff would commence first aid or resuscitation and call 999. Resuscitation trolleys were maintained and checked daily. There was information available on specific emergencies such as emergency tracheostomy management, seizures and hypoglycaemia (low blood sugar).

Most care plans were accurate and complete, with appropriate care plans in place for epilepsy, diabetes, and tracheostomy care.

Staff would identify sepsis using the NEWS2 chart and scoring which would alert them when to raise concerns and seek medical help.

The evidence showed some shortfalls. The service worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, staff were not always clear of the legal frameworks they operated within when caring for patients who may have restrictions. Accountabilities and responsibilities for assessing patients’ mental capacity were not always clear and understood.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. The service had a Safeguarding Adults policy.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In hospitals, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Some staff now had a greater awareness of mental capacity with more details around capacity documented in some daily care plans.

However, capacity assessments on admission still lacked detail and learning was not yet fully embedded. Staff did not always carry out capacity assessments before carrying out care and some documentation lacked detail. Most nursing and Rehabilitation Assistant (RA) staff we spoke with could not identify which legal frameworks they were acting under when supporting people whose liberty was restricted. Nursing and RA staff were not fully aware of what DoLS meant and were not able to ensure patients understood their rights. Some staff had not accessed the extra training or support available in relation to the MCA or DoLS. However, staff had completed their mandatory training. Nursing staff saw capacity assessments as a role to be carried out by doctors. However, therapy staff were now confident in their use of capacity assessments.

Positive Behaviour Support (PBS) plans did not include capacity assessments in relation to care. Plans did not include information around consent and had no reference to capacity assessments, best interest decisions or legal frameworks to work under. This meant there was a risk of physical abuse to patients’ who had capacity to consent if the plan was viewed in isolation during an incident. Care plans showed evidence the service continuously sought less restrictive alternatives when restrictive practice was required.

While improvement had been made since the last assessment to improve staff understanding and application of MCA, further work was required to embed all legal frameworks in practice across all disciplines.The provider had an action plan to embed the application of the legal frameworks and had recently implemented processes for staff to follow

Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were now in place for all patients, and the service was no longer in breach of regulations relating to ReSPECT forms.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

There were monthly safeguarding meetings that discussed, safeguarding referrals, concerns, training and lessons learnt. Lessons learnt included training and audits.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff made sure that people understood the care and treatment that was being provided.

We saw risk assessments such as risk of falls, skin integrity, wound care, nutritional needs, oral hygiene, and pain management were assessed daily, we saw evidence these were assessed and documented daily.However, we saw gaps in and confusion over where to document information due to having both paper and electronic patient notes.

Various members of the MDT were involved in patients’ care, including medical and nursing staff, therapy staff, physiotherapy, psychology and discharge coordinators.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Most areas were visibly clean and well maintained. Although, we did see some dusty areas in Hawthorne dayroom and on the windowsills. Areas that needed repairs were taken out of service to ensure they were fit for purpose. The service had made improvements to policies and processes to monitor water quality in the hydrotherapy pool, and the service now had the correct height garden fence, therefore were no longer in breach of regulations. This meant risks relating to patient safety from the pool water and to absconding risks at the fence were mitigated.

Oxygen was stored safely, water outlets were tested for legionella and facilities met professional standards. Resuscitation trolleys were maintained and checked daily. Ligature cutters were available.

Fire drills were carried out in line with policy and summaries of patients’ Personal Emergency Evacuation Plans (PEEPs) were kept in the fire safety file in line with policy. However, we observed not all patients had PEEPs in their individual care plans. Following our assessment, we saw up to date fire safety policies and that fire drills and evacuations were carried out.

There was a cleaning schedule in place. However, some parts of communal areas remained visibly dusty. Cleaning trolleys with freely accessible chemicals were left unattended in corridors while domestic staff cleaned patient bedrooms. Dressing cupboards on wards were left unlocked with hand gel inside. This meant there was a risk patients and visitors could access chemicals without supervision. The service took action following onsite assessment to address these immediate safety concerns.

Smoking risk assessments were present but lacked detail relating to medication risks of topical medicines which posed as fire risk. Following our assessment the provider told us risk assessment had been updated and would be monitored by the ward manager.

The service had a secure door system with door locks and exits accessed via key fobs for staff or door release via a receptionist for visitors. However, door locks could be overridden by relatives which meant there was a risk of detained patients absconding. The service still did not have signs to let patients who were under no restrictions know of their right to leave if they wished to do so. However, service leaders told us patients were informed of their right to leave through patient centred methods, such as welcome booklets. They also told us signage could cause confusion or risks

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervisionand development. They did not always work together well to provide safe care that met people’s individual needs.

At the time of inspection, the service had 193.48 Working Time Equivalent (WTE) staff members in post, with 19.07 (WTE) staff vacancies. These vacancies were either covered by locum staff or had active recruitment ongoing with new starters planned to join the service. Average turnover for the previous 12 months was 2%. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. The service had an 8% agency and bank staff provision. When agency and bank nursing staff were used, those staff received an induction and were familiar with the area. Managers had calculated the number and grade of nurses and Rehabilitation Assistants (RAs) and therapy staff required using the British Society of Physical and Rehabilitation Medicine guidelines. Medical cover was 9-5pm Monday to Friday with a Service Level Agreement with the local trust’s Hospital at Night service for out of hours cover.

There were 4 part-time clinical fellows equivalent to 3 WTE,1 specialist registrar, who worked part-time and was due to become full time, plus a specialist who was due to join the service. There were 2 consultant physicians. When consultants were on leave cover was provided from another unit.

Most staff were up to date with mandatory training with the majority of staff groups above target rates for all mandatory training. However, nursing staff were at 59% compliance for ligature training and 69% for Fire Marshall certification. Leaders told us this was due to a delay in training delivery from an external company. The training provided was appropriate for the patient group using the service. The service had made improvements to dementia training and Mental Health Act (MHA) (1983) training, and the service was no longer in breach of regulations. Ninety-four percent of staff had completed dementia training and 100% of staff had completed MCA training. The service offered care for patients with spinal cord injuries. There were competencies for both nursing and therapy staff to complete and both therapy and nursing staff had attended training to meet the needs of these patients. In August 2025, there was 97% compliance with mandatory training.

Staff had supervision sessions with senior staff. However, these were not always carried out in a timely manner and not always in a one-to-one format. This meant there was a risk that staff did not always receive consistent support to enable them to carry out their duties safely and the service could not be assured that competence was maintained effectively.

We saw staff supervision documents where staff could raise concerns about patients care, staffing, incidents, policies, safeguarding concerns and training needs. Supervision was carried out bimonthly. In July and August 2025 100% of staff had supervision, however between March and June 2025, 88% and 76% had been completed for nursing staff. Following our assessment the provider told us that Band 6 nurses had completed supervision training to increase their understanding of their responsibilities and ensure they support Rehabilitation Assistants (RAs) to get the most from supervision. Compliance with supervision was reviewed at the fortnightly ward managers meeting.

We asked staff what supervision meant to them, and responses included wanting supervision to continue, wanting to ensure they knew when supervision would take place and a wish to adapt the template to be more positive and meaningful.

There were defined multidisciplinary (MDT) teams, each allocated to support a part of the service. This had improved staff’s ability to provide person centred care. However, lack of rotation of nurses with tracheostomy competencies to the tracheostomy ward meant there was not enough opportunity for staff trained to maintain their confidence with tracheostomy care. Some staff told us they often felt unsupported working on this ward. Leaders had listened to staff concerns and there were plans to address this unintentional consequence of the move to fixed teams.

The service had made improvements by introducing a RA competency framework. However, we found competencies were inconsistently recorded and some staff were not aware the competency framework existed or were not sure who had signed it off. Leaders told us competencies were signed off during induction by staff qualified in each specialism. However, we found evidence sign offs had been carried out by staff who were not qualified to do so, therefore there was a risk that the competency framework was ineffective, and some lacked detail. We observed RA staff carrying out basic therapy duties ineffectively. RA staff were supervised by the nursing team and it was not always clear how the service was assured RA competence in basic therapy duties was maintained after induction was completed.

Following our assessment the provider sent us information on how competencies would be completed and signed off by designated trained staff. They also sent up to date competencies for staff that had been assessed and signed off by relevant staff. The service told us there would be a final sign off by the education lead which would be reviewed every 3 years. Competencies were due to be reviewed at the fortnightly ward managers meeting.We were also provided with meeting minutes which showed RAs were informed of the competency sign off.

Positive Behaviour Support (PBS) and Positive Behaviour Management (PBM) training for staff was above the service’s 85% target. However, most RAs we spoke with told us there were no patients in the service with a PBS plan and PBS plans were not discussed during our observation of handovers or safety briefings. We found there were 10 patients with a PBS plan at the service during our assessment. This meant there was a risk patients who required restrictive intervention to manage their behaviour were not always cared for in line with their plan.

Leaders told us there was a strong MDT working culture to ensure a holistic approach to patient care. Team structures had improved MDT working relationships and there were many meetings which involved staff from different specialisms in patient care. Staff told us they could approach individuals working in different specialisms with concerns. However, we found nursing and RA staff were not consistently present at key meetings to discuss care planning for people. This meant care was not always joined up and there was a risk of poor communication between specialisms effecting patient care.

Staff told us that the on call nursing system worked well when patients deteriorated.

The team assessed and generally managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, not all staff followed infection prevention and control policies.

There was an up to date infection prevention and control (IPC) policy which included information on responsibilities, hand hygiene, management of waste and information on personal protective clothing (PPE). The service had an IPC lead, who carried out regular audits, including monthly hand hygiene audits. Results for July and August 2025 were 100% and June 2025 was 98%, which 1 member of staff not removing PPE correctly. This was raised with the staff member.

We saw staff had access to PPE and used this appropriately. We observed 1 member of staff not washing hands after removing their gloves following administration of a Percutaneous Endoscopic Gastrostomy(PEG) feed. We also observed staff with long hair that was not tied back and staff wearing stoned jewellery.

There was a clinical waste management policy which included information on segregation of waste and photos of different coloured bags and when to use them.

There were weekly environmental and equipment cleaning schedules and deep cleaning checklists. The monthly IPC report included checks that cleaning schedules were in place including cleaning of equipment and the environment, and waste management. Results for May and July 2025 were 100%, August 2025 was 95% with some dust identified. The provider sent evidence actions was taken as a result of the audit findings.

On admission each patient would have an infection control risk assessment completed which included details of any previous or current infections and antibiotic use.

Between January and August 2025 there were 2 cases of clostridium difficile (C.diff) reported. There were no cases MRSA bacteriuma reported.

The evidence showed some shortfalls. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, documentation revealed some inconsistencies.

The service demonstrated a structured and well-monitored approach to medicines management. There was a medicines management standard operating procedure for controlled drugs, which include information on ordering, storage and administration of controlled drugs. Medication rounds were clearly scheduled and any missed doses were reviewed daily in multidisciplinary (MDT) meetings. An electronic system was used for prescribing and administration. The service had a Service Level Agreement with an external provider who provided a weekly pharmacist visit to review electronic medication administration records and patient notes. This generated actions for staff to follow-up.

Fridge temperature, room temperature and controlled drug stock checks were routinely completed and documented. Medicine storage was safe and compliant with best practice. However, we observed one instance of an unattended drug trolley.

There was evidence of good practice in Percutaneous Endoscopic Gastrostomy (PEG) administration, insulin management, and PRN protocols. However, some inconsistencies were noted. One patient had a single dose of medicine prescribed intramuscularly but this was administered orally. Venous thromboembolism (VTE) guidance showed incorrect doses in relation to patients’ weight.

Inconsistencies were noted between care plans and electronic medication entries for some patients. Falls risk assessments were not always accurate with inaccurate recording of information around sedatives noted. For example, 1 patient risk assessment stated they were not taking any sedatives but had been prescribed these medicines.

Medical staff had access to online application that provided information and advice on drug monitoring and antimicrobial prescribing.