Chislehurst Neuro 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open and fair culture.

We rated well-led as good. This meant the service was generally well managed and leaders promoted a positive culture that supported person-centred care.

Leaders were visible and approachable, and staff described a positive culture in which they felt able to raise concerns. The service worked with healthcare and social care partners to support coordinated care and rehabilitation. Systems were in place to review incidents, share learning and monitor aspects of quality and performance.

However, some governance arrangements required strengthening. Governance systems had not consistently identified, monitored and addressed some concerns relating to supervision, specialist training compliance, clinical documentation and the completion of actions arising from incidents. Formal local governance meetings were not established, and team meetings had not taken place in March and April 2026. While these issues reduced assurance regarding the consistency of governance oversight, leaders were aware of the concerns, had begun taking action to address them, and were able to demonstrate that care delivery remained safe, person-centred and focused on achieving positive rehabilitation outcomes.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed a good standard. Staff shared a commitment to person-centred rehabilitation and promoting people’s health, wellbeing and independence.

Staff described a positive and improving culture. They spoke about an increased focus on healthier lifestyles, wellbeing and meaningful engagement for people using the service.

Staff demonstrated a person-centred approach and worked collaboratively across professional disciplines. They understood people’s individual needs and described a shared commitment to providing caring and respectful support.

The provider’s values focused on being kind and honest, listening, learning and acting, and being fair and inclusive. These principles were consistent with the positive interactions observed and with feedback from people, carers and staff.

The evidence showed a good standard. Leaders were visible and approachable and understood the service and the needs of people receiving care.

Staff spoke positively about local leaders and said they felt comfortable raising concerns and discussing matters affecting people’s care. Leaders had developed working relationships with staff and relevant external professionals.

Leaders understood the main areas requiring improvement and had identified actions to strengthen governance and oversight arrangements.

The service did not have a registered manager at the time of the assessment. However, the leadership team continued to oversee the service, and staff described local leaders as accessible and supportive.

The evidence showed a good standard. The service promoted an open culture in which staff felt able to raise concerns.

Staff said they felt safe to speak up and could raise issues with leaders without fear of reprisal. They described leaders as approachable and receptive to concerns.

The provider had speaking-up and whistleblowing arrangements. Information about the Freedom to Speak Up Guardian was displayed within the service, giving staff information about an additional route for raising concerns.

Staff could contribute to discussions about the service through direct engagement with managers, flash meetings and team discussions.

The evidence showed a good standard. The service promoted an inclusive culture and supported staff to understand equality, diversity and individual needs.

Compliance with equality and diversity training was high. This provided assurance that staff had received training intended to support inclusive and non-discriminatory practice, both in relation to their peers and colleagues and the people they provided care and treatment to. Staff demonstrated an understanding of people’s different backgrounds, communication needs and preferences. They adapted care and sought interpreting or advocacy support when required.

The evidence showed some shortfalls. The service had systems to monitor quality, safety and performance, but some governance arrangements did not provide consistent oversight and assurance.

The provider collected quality and performance information and had organisational arrangements for reviewing incidents. The Safety Incident Oversight Panel reviewed care-related safety incidents each week, and learning was communicated through newsletters, flash meetings and staff discussions.

However, there was no formal local governance meeting structure, and team meetings had not taken place in March and April 2026. This reduced opportunities for leaders and staff to review performance, monitor improvement actions and maintain a clear record of decisions and accountability.

Governance oversight of workforce development was not always consistent. Records showed inconsistent supervision. Some staff had received fewer than the provider’s required 4 supervision sessions during the previous 12 months, and some newly appointed staff reported limited professional support.

The service’s oversight of clinical documentation also required improvement. Some multidisciplinary records did not provide sufficient detail about people’s rehabilitation progress and the outcome of reviews. Records did not always provide a clear audit trail showing how actions arising from incidents had been assigned, monitored and completed.

Access to governance information was restricted in some areas. The clinical lead could not always access incident reports they had not submitted, and some complaint records could not be readily accessed. This limited leaders’ ability to maintain complete oversight of incidents and complaints.

Despite these shortfalls, leaders had access to quality and performance information and were able to identify many of the issues we found during the assessment. Staff described leaders as visible and approachable, incidents were reviewed through established organisational processes and there was evidence that learning was shared and acted upon. This provided some assurance that governance systems were operating in several areas, although they were not consistently effective.

Leaders were aware of the concerns within the service and had begun implementing improvements such as revising supervision arrangements. However, improvements were not fully embedded, and the service could not yet demonstrate that the revised arrangements had resulted in sustained improvements.

The evidence showed a good standard. The service worked with healthcare, social care and community organisations to support people’s care, rehabilitation and future needs.

Staff obtained input from GPs, psychologists, physiotherapists, speech and language therapists, social workers and advocates according to people’s needs. Relevant recommendations were incorporated into care and treatment.

The service worked with external professionals in relation to Mental Capacity Act assessments, best interests decisions, health needs and future care planning. Staff described being able to access specialist support when people’s needs changed.

People were supported to maintain links with their communities and participate in meaningful activities.

The evidence showed a good standard. The service demonstrated a commitment to learning and improvement. Staff were encouraged to reflect on incidents, share learning and make improvements to care and rehabilitation.

The provider had systems to support organisational learning, including a lessons learned bulletin that shared information relating to incidents, themes and safety updates across the organisation. Risks, incidents and learning were also discussed during daily flash meetings, helping staff remain informed about current issues and emerging themes.

Leaders and staff demonstrated an awareness of learning from incidents and were able to describe examples where learning had informed practice.

Staff also described examples where learning from medicines incidents had resulted in changes to practice. This demonstrated that learning was not limited to discussion but had informed improvements to the way care and support were delivered.