Frenchay 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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We have rated this as requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture which based on the provider’s overall strategy. This was aligned with the 10-year NHS plan.

The 3 year strategy included short term and long term goals, focusing on excellence, safety and compassionate care. There was a staff handbook that set out standards to be met which included behavior, learning and developments and staff inclusion.

There were mixed responses from staff, some staff felt supported to raise concerns and had opportunities for development and others felt there was disparity in how they were treated by leaders. Staff told us some employees had close relationships at various levels which caused difficulties when concerns were raised due to the conflict of interest. We discussed these issues with leaders in the service who were aware of staff’s concerns but were assured that close relationship within the service was managed in line with policies.

The evidence showed some shortfalls. Leaders understood the context in which the service delivered care, treatment and support. However, they did not always embody the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Some staff felt the leadership team were not visible and concerns raised were not always fed back to them. We observed feedback being delivered to an individual staff member involved an incident during a wider meeting with other colleagues present. This did not ensure staff’s dignity was maintained when providing feedback and there was a risk staff could feel singled out. It was not always clear how leaders ensured staff involved in incidents were addressed compassionately and how they tailored feedback for wider shared learning for the teams whilst ensuring the individual concerned was protected.

Nurses felt they were excluded from senior ward meetings when ward managers attended with therapy staff and plans were not always embedded.

Leaders told us staff worked well together and supported staff development.

The evidence showed some shortfalls. The service had a Freedom to Speak Up (FTSU) and whistleblowing policy and process.

While there were posters on FTSU displayed with the FTSU champions’ names and contact details and ways in which staff could speak up, staff did not always know how to speak up and were not always aware of who the FTSU champions were in the service.

Staff were not always clear on how they would speak up if they had concerns that were not being addressed by leaders. Very few staff were aware of who the FTSU Guardian was or how to approach them. Some staff felt the leadership team were not visible and they did not always receive feedback from the concerns raised.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a Equality, Diversity Inclusion Strategywhich included behaviours and why it matters.

Staff told us about staff awards ceremonies with prizes and gift vouchers awarded to staff and team outings. Staff completed an annual survey which included questions about equality, diversity and inclusion and the outcomes of which were discussed at leadership level and shared with staff. We reviewed the results for April 2025, which had 4 questions relating to diversity and inclusion. The results showed 65% of staff agreed that people of all cultures and background had equal opportunities; 70% felt their workplace was an inclusive place to work; 66% of staff said they were treated fairly, equally and with respect; 69% said there was a commitment to improving equality, diversity and inclusion.

The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service held health and safety meetings which included a review of risk assessments, water testing, fire, incidents, training and maintenance.

The overarching governance framework had not ensured staff were always clear on the application of the Mental Capacity Act especially when patients lacked capacity. There was no evidence capacity assessments had been undertaken when developing Positive Behaviour Plans.

Paper and digital records were not always synchronised to ensure they were accurate and there was a single version of the truth.

Rehabilitation Assistants (RAs) competencies were inconsistently recorded and some RAs were unaware the competency framework existed. Competency records showed assessment and sign off were completed by Rehabilitation Nursing Technicians with no input from nursing or therapy staff. There was a lack of oversight to ensure staff were signed off as competent by the relevant person in line with the service’s process.

Systems and process did not always ensure medicines were administered as prescribed and Venous thromboembolism (VTE) guidance contained accurate information.

There was an audit schedule in place with audits carried out monthly, quarterly and 6 monthly. These included hand hygiene, mattress audits, pressure ulcers and falls. Following our assessment the provider increased the frequency of audits and included additional information such as consent to treatment.

The service had a risk register for 2025 which included legionella water flushing, hydrotherapy pool refurbishment, review of loft space due to fire risk, boiler checks and damage to a fire door. Local governance meetings were held monthly, discussions included incidents and lessons learnt, safeguarding, audits, supervision and complaints.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborate for improvement.

Leaders told us there was good working relationship with the local hospitals and other brain injury and rehabilitation units. This supported a smooth transition for patients between services.

Staff attended weekly meetings at the local NHS trust to review potential admissions. The tracheostomy team attended a virtual tracheostomy ward round at the local NHS trust for updates and management.

Patient reviews and discharge planning involved the GP, social services, local community support and local integrated care boards (ICB). There were fortnightly flow calls with the local NHS trusts, ICB and NHS England to review capacity and bed use.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The service was participating in a project that focused on the cognitive and psychosocial aspects of recovery. The aim was to adapt and refine the rehabilitation model, target resources more effectively, and ensure pathways wereequitableand responsive to patients’ needs.

One manager told us they were proud of the team and felt they had the motivation and drive to improve the service.

Staff told us they were committed to learning and improving.

There was an anonymous box that staff could leave feedback and make suggestions in.

A staff newsletter included information on incidents, lessons learnt and updates on infection prevention and control and training. However, staff were not always aware of this.

The service had commenced an electronic referral system for patients referred to other specialities such as urology and cardiology. This had resulted in quicker referral times, ability to share test results and in some cases the prevention of unnecessary appointments. The service was hoping to expand this across local trusts and additional specialities.