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Archived: Queen Elizabeth's Foundation Brain Injury Centre

Overall: Good read more about inspection ratings

Banstead Place, Park Road, Banstead, Surrey, SM7 3EE (01737) 356222

Provided and run by:
Queen Elizabeth's Foundation

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Background to this inspection

Updated 11 July 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 8 June 2017 and was unannounced. It was conducted by one inspector, one expert by experience (Ex by Ex) and a nurse specialist (SPA) in neurological rehabilitation. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, we reviewed all the information we held about the provider. This included information sent to us by the provider in the form of notifications and safeguarding adult referrals made to the local authority. A notification is information about important events which the provider is required to tell us about by law. We contacted the local authority quality assurance and safeguarding team to ask them for their views on the service and if they had any concerns, no concerns were raised.

We asked the manager to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

As part of the inspection we spoke with eight people, four staff members, the registered manager and the nominated individual. We also spoke with the cook, the activity co-ordinator and one health care professional. We spoke with a commissioner before the inspection.

We spent time observing care and support provided throughout the day of inspection, at lunch time and in the communal areas. We reviewed a variety of documents which included people’s care plans, risk assessments, and people’s medicine administration records (MAR). We reviewed four weeks of duty rotas, four staff recruitment files, health and safety records and quality assurance records. We also looked at a range of the provider’s policy documents. We asked the manager to send us some additional information following our visit, which they did.

We last inspected the service in May 2016. At that time we found two breaches on the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had taken action to make the required improvements.

Overall inspection


Updated 11 July 2017

Queen Elizabeth's Foundation Brain Injury Centre is a residential facility providing rehabilitation and services for people with acquired brain injury and neurological conditions. People had a range of communication needs and required different communication tools such as use of electronic equipment. Different therapies such as physiotherapy and speech and language therapy are available for people to access at the service to support their rehabilitation. The service is registered to accommodate up to 28 people. Accommodation is organised across a range of buildings that include independent living facilities for the more independent person. At the time of this inspection there were 11 people living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were sufficient staff to keep people safe. There were recruitment practices in place to ensure that staff were safe to work with people.

People were protected from avoidable harm. Staff received training in safeguarding adults and were able to demonstrate that they knew the procedures to follow should they have any concerns.

People’s medicines were administered, stored and disposed of safely. Staff were trained in the safe administration of medicines and kept relevant and accurate records. For people who had ‘as required’ medicine, there were guidelines in place to tell staff when and how to administer them.

Staff had written information about risks to people and how to manage these. Risk assessments were in place, including moving and handling, personal care and skin integrity. The registered manager ensured that actions had been taken after incidents and accidents occurred to reduce the likelihood of them happening again.

People’s human rights were protected as the registered manager ensured that the requirements of the Mental Capacity Act 2005 were followed. Where people lacked capacity to make some decisions, mental capacity assessments and best interest meetings had been undertaken. Staff were heard to ask people’s consent before they provided care.

Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People had sufficient to eat and drink. People were offered a choice of what they would like to eat and drink. People’s weights were monitored on a regular basis to ensure that people remained healthy.

People were supported to maintain their health and well-being. People had regular access to health and social care professionals.

Staff were trained and had sufficient skills and knowledge to support people effectively. Staff received regular supervision and an annual appraisal.

People were well cared for and positive relationships had been established between people and staff. Staff interacted with people in a kind and caring manner.

Relatives and health professionals were involved in planning people’s care. People’s choices and views were respected by staff. Staff and the management knew people’s choices and preferences. People’s privacy and dignity was respected.

People received a personalised service. Care and support was person centred and this was reflected in people’s care plans. Care plans contained information for staff to support people effectively. Improvements could be made with regards to ensuring that nursing plans are more personalised and contain consistent information. We have made a recommendation.

There were mixed views about activities. Improvements had been made since the last inspection. There was an activity programme in place. The registered manager recognised that further work needed to be done in this area.

The home listened to staff and people’s views. There was a complaints procedure in place. Complaints had been responded to in line with the provider’s complaints procedure.

The management promoted an open and person centred culture. Staff told us they felt supported by the management. People told us the management was approachable.

There were procedures in place to monitor and improve the quality of care provided. The management understood the requirements of CQC and sent in appropriate notifications.