Brainkind Neurological Centre York

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained the same.

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.

Data showed that staff did not always receive supervision or appraisals. The service used a safe staffing tool, and the wards were rarely short staffed. However, some people felt that there were not always enough staff during busy periods to ensure that people were cared for in a way that they preferred and had access to Section 17 leave. The service aimed to promote a culture where staff and people were able to raise concerns, but some staff felt managers were not proactive and didn’t respond to issues raised in a timely manner. However, safety was a priority for staff and leaders within the service, and they provided care in a way that made people feel safe. Staff told us people were actively encouraged to be involved in their care and treatment, and staff were familiar with policies and procedures used to safeguard people and ensure the environment was kept safe.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had 10 serious incidents within the last 12 months. We reviewed incidents and data and where appropriate, risks were added to the service risk register with action plans to prevent any similar incidents. Staff knew what incidents to report and how to report them. Incidents were reported through an electronic system and were reviewed by managers. Staff reported incidents appropriately and where required, actions were outlined and lessons learned were identified. Staff had a good understanding of the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service through communications from the service. Staff we spoke with told us that any incidents were discussed during handovers and in multidisciplinary team meetings (MDTs). Some staff we spoke with told us they had been involved in debriefs following incidents. There was evidence that changes had been made because of lessons learned and that there was oversight of learning from incidents.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service’s referral and admission processes ensured that all essential information about each patient was received to determine if the patient’s needs could safely be met prior to admission. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

There was a robust admission, discharge and transfer policy in place that included risk assessment, identification of needs, consideration of admission either informally or under the Mental Health Act and use of the Mental Capacity Act where Deprivation of Liberty Safeguards (DOLS) were appropriate. Staff and leaders discussed potential admissions during regular referrals meetings, and they described a collaborative approach to decision making. All admissions were planned in advance. The service used a bio-psycho-social model to determine each patient’s care pathway and how their needs would be addressed.

We scored the service as 3. The evidence showed a good standard. The service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The service promoted improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were shared quickly and appropriately. The service had a safeguarding standard operating procedure in place.

We reviewed incidents ranging from 9 March 2025 to 27 January 2026 and notifications submitted to the Care Quality Commission (CQC). Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Records showed that 95% of staff were up to date with safeguarding training and the staff we spoke with 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 and staff followed safe procedures for children visiting the service.

We reviewed 12 safeguarding incidents that were referred to the Local Authority and these showed that effective systems, processes and practices were in place to make sure that people were protected from abuse and neglect. The alerts we reviewed were detailed and submitted in a timely manner.

We reviewed reported restrictive interventions over a 12 month period for the service (January 2025 to December 2025). A total of 983 incidents were reported during the period. Of the 983 reported incidents, 223 incidents reported the use of de-escalation techniques representing 23% of all reported incidents. This included the use of de‑escalation strategies, non-contact interventions and physically restrictive interventions. In total, during the reporting period there were 44 incidents, out of the 223 incidents involving interventions, that were classified as physically restrictive. In addition, 98% of incidents involving physical interventions were recorded within the harm and abuse category, indicating that interventions were used primarily to prevent or minimise the risk of harm. Foss accounted for approximately 74% of all Maybo (de-escalation and restraint approach) use including de-escalation and self-protection approaches due to the complexity of patients. Tarn, Brook and the central unit accounted for smaller proportions.

Mental Capacity Act

The service had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Records showed that 90% of staff were trained in MCA and DOLS. Staff we spoke with were able to demonstrate a good understanding of the MCA, in particular, the five statutory principles. There was good oversight of patients who required DOLS to be in place and evidence of capacity assessments and best interest decision making.

Staff knew where to get advice from within the service regarding the MCA and had an allocated MHA and MCA lead. Audits were completed on a monthly basis by the safeguarding lead and staff took action on any learning that resulted from these. Staff took all practical steps to enable patients to make their own decisions where possible and, for patients who had impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks in terms of family involvement.

We reviewed 8 care records including risk assessments and risk management plans during the inspection. All care records reviewed included robust risk management plans, which outlined how to keep people safe during periods of distress. Care plans referenced interventions, communication and the person’s individual needs, and these were accessible to staff on duty via electronic tablets. Staff knew about any risks to each person and acted to prevent or reduce risks. Managers and staff held daily handovers where they discussed the previous 24 hours on the unit. This included staffing, patient updates, incidents and environmental concerns. Any concerns around risk were escalated to the wider staff team.

There was evidence of easy read care plans in place for the 8 records reviewed and where required. The service also completed patient surveys to gain feedback on patient involvement. We reviewed the, Tell Us What You Think Survey Results 2025 feedback where 9 patients from the service participated. The results showed 5 out of 9 patients said they were involved in decisions about their care and support. 6 out of 9 people said their care and support plans included what was important to them. The report was published in an easy read version for people using the service.

Feedback from family members and relatives however, showed that they were not involved in developing care plans and had not seen care plans. Some family members relayed that they had provided useful information about their loved ones, independently of being asked, and this had not been used to assist to care for loved ones in a way which supported their preferences and interests.

Aadvocacy services were available to all patients. Some patients we spoke with found this beneficial, others told us they did not see the need for one. However, staff ensured that patients could access advocacy during their admission.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service had four transitional living apartments, 14 bedrooms with full tracking hoists in each of the four houses, including assisted daily living kitchens and laundry rooms. Each house had an anti-ligature room and two rooms with anti-barricade doors.

Within the service there was a specially equipped gym, sensory room, arts, crafts, and music activity rooms. There was also a sizeable family visiting room with games, toys and books for children visiting relatives, and a multi-faith room. Upstairs houses had access to an eco green roof space and surrounding the houses were sensory/therapy gardens to allow access to fresh air.

The layout of each house allowed staff to observe all parts of ward, including patient bedroom corridors. The nurse’s station was central to the house, with a 360 degree view of the lounge, entrance and bedrooms. Environmental risks relating to rooms off the main communal area, such as activity rooms, dining room and activity kitchen were mitigated by staff observations. The houses complied with guidance on eliminating mixed-sex accommodation, each house was single sex, with Brook and Tarn being male only, and Foss being female only. All staff had easy access to alarms and patients had easy access to nurse call systems in all bedrooms, bathrooms and communal areas.

Managers completed daily walks around the houses to ensure environmental risks were monitored. The service had monthly infection prevention and control checks in place and the domestic team completed checks on a daily basis. House managers were responsible for risk assessments of the environment, and all staff knew how to escalate potential risks. Any identified risks were documented on incident forms.

Potential ligature risks were documented within the environmental risk assessments, which were carried out on an annual basis. Each house had an anti-ligature bedroom, which included specialist cupboards, doors, curtains and ensuite bathroom. The service agreed use of the bedroom with commissioners for those who were at risk of self-harm. The service also had one room in each house that had a bedroom with anti-barricade doors. All doors fitted in the houses were alarm censored.

Patients had wrist bands that were programmed to their bedrooms and other areas of the houses and service depending on their risk assessment. This meant patients were able to move freely between communal areas and their bedrooms, which could only be accessed by staff and themselves.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. All houses had access to ligature cutters within the main office.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure there were enough skilled and experienced staff. They did not make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The sickness rate for the service was very high. This was at its highest at 7.61% in December 2025 with a staff turnover rate of 44.29% in December 2025. This was also reflected in staffs intention to work for the service in 12 months’ time within the ‘your voice survey’. We spoke to 22 members of staff, across all disciplines. The majority of staff told us there was often not enough staff and gave examples of times when patient programmes had not been met, such as outings in the community, time within the therapeutic gardens and Section 17 leave. Staff told us they did not always get breaks due to staff numbers and being required to cover therapeutic observations. Staff told us that shifts were usually filled, but that cross- ward cover was frequent. However, staff did not raise any concerns regarding meeting patients’ immediate needs or responding to incidents as a result of the staffing pressures.

Staff told us that shifts were often covered by agency staff and skill levels across shifts varied, although there was an induction policy in place for new agency staff. We reviewed the agency use by the service and saw they had significantly reduced the number of agency workers for both nursing and recovery support workers. January 2025 to March 2025 data showed the service used agency nurses for 1600 hours and recovery support workers for 2070 hours however in December 2025, data showed agency nurses were used for 286 hours and recovery support workers for 400 hours. At the time of our inspection, the service was completing a recruitment event and this was well attended. The service was in the process of onboarding 20 new members of staff.

Managers were able to increase the number of staff required when this was indicated. In order to decrease staff numbers, this would be a wider team discussion. The service used a safe staffing tool, and the wards were staffed according to this. Data showed shifts were covered at baseline numbers at a minimum. There was a responsible clinician in post, although employed on a locum basis, who visited the service one day a week but was available to contact throughout the week. There was also a speciality doctor in post 4 days a week and an on-call system for out of hours and weekends. The service had a speech and language therapist in post, occupational therapy team, and physiotherapy team. There was also a safeguarding lead in post.

We found significant issues in relation to staff supervisions and appraisals, both from service data and feedback from staff. No staff we spoke with had received regular supervision in the last 12 months. Some staff had not had appraisals due to length of time working at the service.

Some newer staff had never had supervision. The service had a rate of 13% for completed supervisions and an appraisal completion rate of 22%. New managers were in the process of embedding systems to ensure compliance with internal targets by March 2026. Staff mandatory training targets were set at 90% compliance for all courses except for data security which was 95%. Overall training compliance was 87% at time of inspection, with the lowest numbers being for Oliver McGowan training on learning disability and autism which was 74% and data security which was 92%.

Managers told us that supervision and appraisal rates were a long-standing issue and that plans were in place to address this. Two new ward managers had recently entered posts, and a third manager was due to join the service. Plans were in place to address the current 13% supervision completion rate and 22% appraisal rate. However, staff were positive about opportunities for career progression, and this was evidenced by some staff we spoke with having progressed to more senior roles within the service.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The environment was very well maintained throughout the service. There were a dedicated team of domestic staff who completed daily cleaning. Equipment was well kept, clean and stored appropriately. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly which were also audited on a monthly basis which helped identify areas of concern. Staff adhered to infection control principles, including handwashing. Staff training in infection prevention control was 88%, and 100% in Legionella awareness. There was adequate access to hand sanitisers throughout the service. Family members we spoke to complimented the cleanliness of the service.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. We reviewed 9 patient prescription charts, sampled across the three houses and records were consistently accurate and up to date. Each house had a clinic room for storing and dispensing medication and a separate treatment room. There was no medication stored in treatment rooms.

Staff followed good practice in medicines management including transporting, storing, dispensing, administrating, medicines reconciliation, recording, disposal and use of covert medication in line with national guidance. Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. There was evidence of pharmacy involvement, supporting the wards in checking stock levels and expiry dates. Audits of medication were completed to ensure any errors were identified and resolved.

Staff demonstrated a good working knowledge of destruction, recording and removal of controlled drugs and demonstrated escalation processes being followed, as well as pharmacy oversight. Any controlled drug errors were reported through as incidents which in turn alerted the organisation’s Controlled Drug Lead. Staff also demonstrated an awareness of the ordering of controlled drugs including when to order in an urgent situation.

Each clinic room was clear and free from clutter, and each room had adequate space to prepare medication or prepare for treatment. Clinics had cleaning records which were in date. Room and fridge temperatures were recorded daily. Each house had their own observation equipment, and this was calibrated correctly with status and dates. All equipment was in good working order.

The treatment rooms were large and contained examination couches and were spacious enough for any treatment offered. Medication Administration Record (MAR) charts had patients’ photos, personal details and known allergies, minimising risks of medication errors. As required medication had specific directions and charts did not evidence any missed signatures or other issues.