We rated Thames Brain Injury Unit as good because:

• The management team had made improvements to the service since our previous inspection in October 2016. The maintenance of equipment and management of medicines was now safe. Staff had made improvements in care planning and learning from incidents. Arrangements for the safety and privacy of female patients had improved.

• The multidisciplinary staff team worked positively to ensure good outcomes for patients. Staff assessed and managed the care and rehabilitation needs of patients well. The service provided care and therapeutic interventions in line with good practice guidance. Staff effectively supported patients to regain their skills and independence following an acquired brain injury.

• The staff team reviewed and managed risks to ensure the safety of patients and there was sufficient staff cover to meet the needs of patients.

• Staff were proud to work in the service and reported that the management team listened to them.

• Patients told us that staff were caring and kind. They said staff had the skills to support them to recover and regain their independence.

However:

• The management team recognised that further work was required to improve clarity for staff on the location of information in the paper and electronic records.

• Staff sometimes entered patient bedrooms without knocking first.

• Although patients liked the range of food on offer, some patients said it was too salty.

• This was a focused inspection at the Thames Brain Injury Unit to follow up on areas of previous non-compliance, that not all staff had up to date Disclosure and Barring Service checks and that incidents were not being escalated or documented immediately. We looked at the following areas: care and welfare of people who use the services, cleanliness of the ward, medication management, safety of the premises, recruitment and supporting staff.
• The provider had continued to make improvements to the cleanliness, safety and maintenance of the ward environment since our last inspection. Patients were involved in their care planning and spoke highly of the service they were receiving.
• Staff felt supported and accepted that changes had needed to be made. Although there was a plan in place for all staff to have regular supervision, this plan had not been fully embedded with nursing staff who were not yet all receiving regular supervision. Staff said there had been a high turnover of nursing staff and there were still several nursing and therapy posts vacant. There was an ongoing recruitment plan to address this.
• Disclosure and Barring Service (DBS) checking for all staff had almost been completed and there was a clear process in place to monitor this going forward. A new manager was being appointed with responsibility for DBS oversight.

This was a focused inspection at the Thames Brain Injury Unit to follow up on areas of previous non-compliance. We looked at the following areas: care and welfare of people who use the services, cleanliness and infection control, safety and suitability of the premises, supporting workers and complaints.

We saw that the provider had made improvements to the cleanliness, safety and maintenance of the ward environment since our last inspection. The provider had taken action to ensure that the risk that people were not unlawfully deprived of their liberty was monitored. Most patients we spoke with were aware of their care planning, however patient’s involvement in their care plans was not evidenced in the records we reviewed. There was also a lack of evidence of mental capacity assessments in care plans.

Staff we spoke with felt supported and received regular supervision. Daily handovers, monthly staff meetings and clinical governance meetings took place to improve communication and ensure actions were follow up in a timely manner. Complaints were documented and investigated appropriately.

We found that a number of staff did not have current Disclosure and Barring Service (DBS) checks. We also found that incidents were not escalated or documented immediately.

We spoke with two people who used the service and observed the care people received who were unable to effectively communicate. People we spoke with told us they were being looked after well by the staff and they received relevant therapy in order to progress their rehabilitation. People told us the staff were good and overall they were happy living at the service. We found that staff interacted with people in a respectful way and that staff were mindful of the different needs of people who used the service.

We found that staff sought consent before they delivered care to people. People who did not have the mental capacity to make specific decisions had their capacity appropriately assessed and decisions made in their best interests where relevant. We found people's needs were adequately assessed prior to and on admission to ensure their needs were met. Staff were provided with sufficient information to ensure they knew about people's care needs. The provider acted in accordance with relevant safeguarding procedures. People who needed to be were lawfully deprived of their liberty, and the provider ensured that any physical intervention that took place was done safely and by appropriately trained staff. Staff received an appropriate induction, training and support. Appropriate records were in place to record the care people received, but some information we requested was not available during or after our inspection.

The three patients we spoke with told us about key staff members they could approach and discuss anything they needed to with. One patient told us, “they’re helping me a lot.” Another patient told us, “I go along to the activities sessions. I talk to the psychologist, the nurse and the medical team.”

Arrangements for the completion of assessments of capacity to consent to treatment needed to be improved.

There were appropriate care planning and delivery arrangements in place. Care plans were in place for patients in the service, which identified their needs and how they would be met.

The provider has taken steps to provide care in an environment that is suitably designed and adequately maintained.

There were appropriate numbers of staff on duty. However, the provision of staff supervision sessions had not improved since our last inspection

People we spoke to who use the service said that probably due to memory problems they were not aware of the details of their care plan, but that we could examine it if we needed to as part of the inspection. They said that they did speak with the staff when they need things to be done differently and that they were listened to.

Overall, the feedback we received from people who live at the home was very complimentary about the way staff respected their rights and encouraged them to get involved in the running of their home. They said that staff knew what care was needed and that they do things the way people who use the service want them to.

People told us staff listened to them and respected their privacy and dignity. Some relevant comments we received from people who use the service received were : “The staff are never rude and are always respectful to me”, “I was very depressed and disabled when I came here first, but every member of staff has always been very kind, caring and polite to me”, “I feel staff do listen and show me nothing but respect”, “The staff are very professional and have done a very good job in helping me to get better”, “I needed a lot of help when I came here first but I always felt in safe hands”.

These comments were reflective of the overall comments of people we spoke to who live at the home.

Relatives said they had no concerns about the safety and wellbeing of their family member, and that staff provided good quality care.

People that we spoke to said that they felt safe and comfortable with staff supporting them. They said that they had regularly been asked about things like what food they would like, and how they liked to be supported.

Following the most recent inspection in May 2016, the overall rating for the service has remained as requires improvement. However, whilst there is still work to do, we have seen a number of improvements. There was a leadership team in place to progress these improvements.

The ratings for the key questions of whether the service is safe and effective remain as requires improvement. We have revised the rating of the key question of whether the service is caring from good to requires improvement. We have revised the rating of the key question of whether the service is responsive from requires improvement to good. We have revised the rating of the key question of whether the service is well-led from inadequate to good.

The reasons for these ratings are as follows:

• There has been an improvement in the completion of comprehensive care planning since the last inspection, but there was still work do be done to achieve this consistently.
• Medications were not stored appropriately and the monitoring of medication management was not effective. Not all medical equipment had been routinely serviced.
• The system for nursing and rehabilitation assistant staff to learn from incidents had been updated, but was not fully embedded.
• Patient information was stored in several places meaning information could be misplaced or take staff unnecessary time to find. The system to sign off electronic notes was not effective.
• Some staff showed a limited understanding of the Mental Capacity Act 2005.
• Staff did not always consider the need to use a private space to discuss patient information. Female patients did not always have free access to the female lounge due to male patients using the room for activities and staff used the same space to facilitate meetings. The service managed this with a diary system but this meant access for female patients was occasionally disrupted.
• Male patients had to walk through female patient areas to enter or leave the ward.

However:

• The provider had taken effective action to address the requirement notices and warning notice we issued following our inspection in May 2016:
• During this inspection we found that the new hospital director and transformational change lead had introduced effective governance systems to address shortfalls and were successfully embedding them into the service. Training compliance rates and supervision levels were high and incidents were routinely reviewed in a timely way by senior staff. The activities programme had been extended to include the weekends and patients said there was plenty to do. The management team had addressed the complaints system to ensure complaints were handled effectively. Staff said there had been positive changes over the last few months and felt they could approach senior staff with concerns. Staff gave examples of actions that had been taken following feedback of their concerns.