Blackheath Brain Injury Rehabilitation Centre

Our rating of this location went down. We rated it as requires improvement because:

• The service had over 360 medicine errors in the 6 months prior to inspection. The biggest themes were medicines being out of stock and recording omissions. Meeting minutes showed these were discussed at clinical governance and team meetings. Some actions were taken to address medicines being out of stock. The provider had contacted the GP surgery about the medicines being out of stock from the 19 April 2022, and was communicating with the GP surgery to address this concern. However, an incident took place in October 2022 where a patient had been left without medicine for 7 days. Actions to address recording omissions included peer reviewing records to ensure no recording omissions. However, medicine audits showed errors were still happening.
• Staff did not always discharge their responsibilities under the Mental Capacity Act 2005 in a timely way. Two patients under deprivation of liberty safeguards (DoLS) had not had a further application made after their DoLS had expired. This meant the patients were unlawfully deprived of their liberty for several months
• Although the service had governance systems to assess and the quality and safety of the service, these systems were not always effective. The service had a site improvement plan to manage any identified improvements and actions from audits. However, these did not include many of the issues we identified during the inspection. The service had a quality assurance framework to help manage their audits. However, additional audits to monitor identified areas of concern had not been done monthly, as required. The service risk register did not reflect some of the risks we identified during the inspection
• While learning from incidents was shared at morning handover meetings, in team meetings and in clinical governance meetings, the ongoing medicine errors showed this learning was not always embedded
• The service did not have a formal process to collect feedback from patients, carers and families. This meant the service was not able to use this feedback to make improvements to the service. The service had a process to obtain feedback from staff in the form of a staff satisfaction survey. The most recent survey had been completed in November 2021. The survey for 2022 had been delayed as the service had changed their methodology, and this took place in January 2023
• The occupational therapy team had 6 vacancies with only 1 rehabilitation technician and an activities co-ordinator in post. There was a risk that patients were not getting the appropriate support in this area
• A few patients told us they were not always involved in the planning of their own therapy goals, or were not aware of their discharge plans
• One patient was concerned they had not been instructed in the proper use of a mobility aid
• Not all staff knew of the accessible information standard (AIS) which is a legal standard aimed at making sure people with a disability or sensory loss are given information they can understand in the way they would like it and their communication needs are flagged on their health records
• The premises were a smoke-free environment, but patients were supported to smoke in the garden. This meant that the service was not operating within its own policy or being mindful of national public health guidance
• Some patients told us that did not like the quality of the food. One patient said the food was bland and another patient showed us a photograph of burnt food they had received
• Staff annual appraisals were not always completed on time. At the time of inspection appraisals for the therapy team were at 63%, and for non-clinical staff 54%

However:

• Staff treated patients with care and kindness and encouraged them in their rehabilitation goals
• Staff spoke highly of the managers and their team. The said there was good teamwork and support from the therapy teams and from each other
• The therapy teams developed holistic, recovery-oriented care plans informed by the initial risk assessment.
• The wards were fully staffed with nurses and doctors. Staff assessed and managed risk well
• The service was engaged in a range of quality improvement projects.