Frenchay Brain Injury Rehabilitation Centre, our neurological rehabilitation service in Bristol, is celebrating its reaccreditation to Outstanding as a Headway-approved provider.

The service operates across two sites, providing expert assessment, rehabilitation, support, and care for adults aged 16 and over with acquired brain injuries or complex neurological conditions.

Patients, their families, commissioners, and other stakeholders face many options when deciding the right service for their needs. The Headway Approved Provider scheme provides an accredited symbol of excellence to aid decision-making.

The reaccreditation process is driven from the individual/carer perspective and encompasses evidence-based practice, good governance, and an outcome-focused approach.

As part of the accreditation process, the Headway AP (Approved Provider) assessors met with the Frenchay Brain Injury Rehabilitation Centre Head of Occupational Therapy/Head of Therapy, Matron, Clinical Psychologist, members of the Speech and Language team, Rehabilitation Assistants, and patients and family members.

Below are some of the highlights taken from the reaccreditation report:

Culture

The report found the service to have a clear service philosophy (the Active Care Group behaviours) and purpose. During the visit, the Headway AP Assessors met various members of staff, patients, and family members. From their discussions, the assessors observed that staff took great pride in their work and that of their colleagues, and strived to provide a high-quality, individualised service to every patient.

Throughout the day, the assessors observed staff enabling patients to maintain their maximum possible level of independence, choice and control whilst maintaining their privacy and dignity.

The assessors noted that staff sensitively support patients in making their own choices as much as possible during activities of daily living and, within the limits of the service, encourage patients to practise their religious faith (including the multifaith area) and personalise their environment.

The service was also commended for its diverse workforce and its active Equality, Diversity & Inclusion (EDI) group.

Systems and Processes

The assessors confirmed that staff are trained in the Mental Capacity Act through face-to-face training every three years, followed by an annual e-learning module. Further e-learning on the Mental Health Act and DoLS has been noted as completed.

The consultant was noted to assess the capacity to consent to treatment on the day of admission. Capacity related to specific issues is routinely considered and assessed, e.g., consent to medication and assessment in relation to wider life decisions are taken in consultation with Psychology, Speech and Language Therapists, and the wider multidisciplinary team.

Policies and procedures for safeguarding are available online and displayed around the service, as observed by the assessors. Documentation about Whistleblowing is also on display.

Each patient room has a notice listing who to contact with any concerns, along with the CQC contact number. This information is also contained in the service information booklet.

Workforce Development

The assessors found that new staff receive a comprehensive induction programme relevant to ABI (Acquired Brain Injuries) and the service’s patients.

The assessors discussed recruitment and induction in detail with the Nursing Manager and the Head of Therapy. Induction includes a shadowing period and a six-month probationary period. All the mandatory e-learning must be completed within six weeks of starting the job. The report confirmed that the training coordinator manages all staff training, and the Learning Pool system tracks online and in-person training to maintain high levels of compliance.

The assessors also noted that staff have been assigned a supervisor, are aware of who their supervisor is, and receive regular supervision, with nursing staff receiving supervision every two months, a minimum of six times a year.

Service Delivery

The assessors found that Frenchay Brain Injury Rehabilitation Centre operated a communicative environment for all patients, and they had the opportunity to meet with team members, patients, and their family members.

Family members were consulted regarding interests, previous communication preferences, and social activities. Families will often provide photos and life history information to help individualise communication passports.

There is a strong interdisciplinary approach to communication, supported by regular staff training and clear communication guidelines from the SALT (Speech and Language Team). The Headway AP Assessors met with members of the SALT, Occupational Therapy, and Psychology teams and outlined their joint approach.

Each new patient had their communication needs assessment completed on the day of admission.

The report also noted that Activity Organisers arrange both supported and informal social activities, including trips outside the unit, as opportunities for communication. The protected mealtimes were found to support social interaction, and great efforts are made to maximise social communication opportunities throughout the day in the dining room and in the patient lounges.

Governance, Leadership & Management and Quality

The assessors confirmed that a Quality Assurance Framework is in place, externally monitored, and supporting the Service Improvement Plan, which is reviewed weekly by the Quality Team.

The weekly Service Improvement Plan logs performance against areas identified for development, e.g. CQC, Safeguarding, NHSE, etc. The Improvement Plan is also updated during regular meetings, e.g., team meetings, health & safety meetings, and clinical governance meetings.

Feedback on services is obtained through patient and family surveys, monthly patient forums, family forums, a suggestion box, and key worker sessions. The report confirmed that the surveys are analysed by the team at Frenchay Brain Injury Rehabilitation Centre, and an action plan is generated.

Robust recruitment measures are also in place to ensure that all staff have the qualifications required for the roles they have been recruited to.

Environment

There are large, airy communal lounge areas and dining rooms in both buildings, and these are well decorated, including large, colourful, and striking photographs that help soften the clinical environment. Corridors are wide and uncluttered.

During the visit, assessors observed many patients and family members sitting in the garden with tables, chairs, and areas of shade. All new patients have a risk assessment and PEEP added to their notes, and these are reviewed weekly and updated as required.

Frenchay Brain Injury Rehabilitation Centre also has a locked-door policy, as explained in notices posted next to the front door.

The reaccreditation reflects Frenchay Brain Injury Rehabilitation Centre’s commitment to improving people’s lives. Hospital Director Suzanne Moss is delighted with the praise from Headway AP Assessors:

We are very proud not only to be reaccredited but also to have achieved an Outstanding rating as a Headway-accredited service. The rating is a testament to the work the staff at Frenchay have done to ensure the success of this accreditation. As Hospital Director, I am proud of our colleagues and this achievement.

To learn more about Frenchay Brain Injury Rehabilitation Centre, click here.