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Frenchay Brain Injury Rehabilitation Centre Good

Inspection Summary

Overall summary & rating


Updated 16 June 2016

We rated Frenchay Brain Injury Rehabilitation Centre as good because:

The centre was set out in a way that patients with high dependency needs were closest to the nursing station. The area was clean and staff had ensured equipment was maintained appropriately. Two of the patient bedrooms were adapted to reduce ligatures and staff assessed patients risk and allocated rooms accordingly. The centre had nurses from a variety of specialties and had a large pool of bank staff to cover shifts if need be. Staff had completed physical health checks and all of the eight care records we reviewed contained up to date risk assessments. Staff were aware of what incidents to report and prior to inspection we saw evidence that they had acted in accordance with their duty of candour.

In the eight care records we reviewed, we found that staff had put in place holistic and patient centred care plans. These care plans had clear goals and were recovery focused. Patients had access to a variety of different therapeutic professions and had access to psychological therapies recommended by the Nation Institute for Health and Care Excellence. The centre had been involved in a national research project. Staff had access to external, specialist training and reported receiving regular supervision, and when we reviewed the records 90% of staff had received regular supervision and an appraisal. The use of the Mental Health Act was limited at Frenchay Brain Injury Rehabilitation Centre and there was no-one detained under the Act at the time of inspection. Staff held appropriate multidisciplinary meetings and also had strong links to local healthcare providers.

We observed staff treating patients with kindness and respect and all of the 17 comment cards we collected had a positive comment about the service. Staff were praised by patients and carers for being caring and supportive. Patients had access to advocacy and held patient forum meetings where they could share their concerns, although there had been gaps in the frequency of the meetings previously.

Due to the nature of the service and the funding by NHS England, there were clear discharge pathways and the hospital had an average bed occupancy of 100% in the 6 months prior to inspection. Patients had access to facilities such as a hydrotherapy pool to aid their recovery, as well as private spaces to meet their family. The building allowed access for people in wheelchairs and mobility aids and there was information available for patients on how to access advocacy or make complaints. Patients had access to meals that could meet their dietary requirements and staff facilitated access to spiritual support.

Staff at the centre were aware of the organisations vision and values. We found that there were appropriate governance systems in place to ensure that actions were taken following incidents and that the majority of shifts were covered. We found that staff had the chance to feed back to the service and suggest improvements and that the provider had set up a reward scheme to recognise staff achievements. Staff morale was high and staff we spoke with spoke highly of the service and their colleagues. The service had engaged in national research and also tracked their performance via a national clinical outcomes group they participated in.


We also found that staff had stored equipment in the patients bedroom corridors due to the building work that was ongoing. This had not been risk assessed and could have formed a trip hazard. We informed the manager of this at the inspection and they had arranged the risks to be assessed and a plan to be put in place to manage them. We also found that the space where patients may have been restrained and de-escalated (should they become a danger to themselves or others) was visible from the corridor and this could have impacted on the patients privacy and dignity. We raised this with the manager at inspection and they arranged for a privacy screen to be put in place.

Inspection areas


Requires improvement

Updated 15 January 2019

Are services safe?

We rated safe as requires improvement because:

  • Equipment and substances were not stored securely. We found substances hazardous to health, sharps and oxygen cylinders unlocked and accessible to patients and visitors.

  • Resuscitation equipment was not checked in line with policy.

  • No registered nurses were trained in immediate life support.

  • Records and other patient confidential information was not secure. We found unlocked and patient records in unattended areas.

  • Patient risk was not always identified. National early warning scores were not all recorded and acted on.

  • Staffing levels did not always meet national guidance.

  • There was a high reliance on bank and agency staff.

  • Some patient identification bands were so worn they did not contain any patient identifiable information.

  • Standards of cleanliness were not regularly reviewed and we saw evidence of poor practices to prevent the spread of infection.

  • Feedback from incidents was varied. It was not clear if learning from incidents was always embedded throughout the workforce.


  • Staff spoke positively about mandatory training and being provided the time or paid for overtime to attend.

  • There was a good awareness of safeguarding roles and responsibilities.

  • Staff spoke of being supported to raise all incidents including near misses.

  • Medicines were ordered, transported, disposed of safely and securely.



Updated 16 June 2016

We rated effective as good because


  • Patients told us that they were involved in designing their care plans, and although we could not find evidence they had signed the plan in their notes, we found that care plans reflected the individual needs of the patient.

  • Patients had access to psychological therapies in line with guidance from National Institute for Health and Care Excellence.

  • Staff monitored clinical effectiveness by conducting audits.

  • There was a full range of multidisciplinary team members to meet a range of patient needs.

  • Staff worked well with local healthcare providers to ensure that patients’ needs could be met.

  • Staff could access advice and support about the Mental Health Act.

  • Staff had undertaken the providers Mental Capacity Act training and held best interest meetings when appropriate.


  • We could not always find documentation that demonstrated that staff had assessed an individual’s capacity to make specific decisions.



Updated 16 June 2016

We rated caring as good because:

  • Staff were praised in the 17 comment cards we collected as being caring, cheerful, and supportive and for treating patients with dignity and respect.

  • Patients and a carer we spoke with reported they felt involved in their care

  • Patients could feed back to the service in patient forum meetings. This had been occurring monthly in the four months prior to inspection.



Updated 16 June 2016

We rated responsive as good because:

  • Patients’ family members or care co-ordinators were involved in the patients care.

  • Patients had access to facilities that could meet their support needs, including a self-contained flat to help patients prepare for discharge from the service.

  • Staff helped patients to access religious support and catered for their dietary needs.

  • Staff learned from complaints and made changes to improve the service.


Requires improvement

Updated 15 January 2019

We rated well-led as requires improvement because:

  • Systems did not keep patient information secure.

  • There was no consistent vision for the service and the strategy to achieve the different visions were limited.

  • Data was collected, however it was not always used to drive improvement or shared with staff.

  • The audit programme did not take local issues into account.

  • The risk register did not reflect the risks expressed by staff.


  • Staff spoke of a change in culture which supported raising concerns.

  • Staff reported leaders were visible and approachable.

  • The organisation actively engaged with patients and their relatives to seek their opinions.

  • There were collaborative working relationships amongst all staff who were driven to provide good care to patients.

Checks on specific services

Services for people with acquired brain injury


Updated 16 June 2016

Medical care (including older people’s care)

Not sufficient evidence to rate

Updated 15 January 2019

Medical care services were the main hospital activity.

We rated this service as requires improvement in the safe and well led domains. We did not inspect the effective, caring or responsive domains.