Margaret Thatcher Infirmary

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

People knew how to give feedback about their experiences of care and support and were able to raise any concerns or issues in a range of accessible ways. People and their family or friends felt confident that any complaints would be listened to and taken seriously, without fear of repercussions. People were kept informed about any action taken as a result of their feedback. Learning from complaints and concerns was seen as an opportunity for improvement and staff gave examples of how they incorporated learning into daily practice. People felt their experiences of discrimination and inequality were listened to and acted on to improve care. The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Person-centred Care during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Providing Information during this assessment. The score for this quality statement is based on the previous rating for Responsive.

People benefitted from having opportunities to speak up and have their voices heard. People we spoke to said the staff were very good at listening and keeping them informed of any changes.

Staff told us people using the service were supported to make a complaint if needed and confirmed that complaints were listened to and responded to appropriately. The manager and NI confirmed that complaints were listened to and always taken seriously. They said they ensured the complaints procedure was followed appropriately and the complainant was responded to and informed of any action taken. They also confirmed ‘learning from experience’ was embedded in the service and action plans were drawn up and changes were made, as necessary, to help prevent any recurrence. The NI also explained how they used complaints as opportunities for learning and improving.

There were effective processes in place, including a complaints procedure, to help ensure people could express their views and have their voices listened to. Complaints records showed how complaints had been responded to, as well as the action taken to resolve any issues. People living in the service were actively involved in regular meetings, such as ‘Messing Meetings’ and ‘Sounding Boards’. Some people acted as representatives for others, by attending these meetings, where they could raise and discuss issues and also share information. Minutes of staff meetings demonstrated that people’s comments and views were listened to. These minutes also detailed the actions that had been taken to make improvements wherever possible.

We did not look at Equity in access during this assessment. The score for this quality statement is based on the previous rating for Responsive.

People living in the service benefitted from an inclusive and accessible environment, which enabled them to live their lives without prejudice or discrimination. People were encouraged and supported to follow their own religious and spiritual beliefs and had their human rights respected.

The NI told us how the service is continually reviewed, to ensure all the people living in the service are fully and equitably supported, regardless of ability or disability. The NI told us in information submitted to CQC prior to this assessment that, in addition to an on-site chapel, there was also a non-denominational prayer room/quiet room. They explained how this provided people, who were not of a Christian faith, with a place to reflect and pray away from the ‘hustle’ of the building. This room was also used by people with no faith, when they wished for a quiet place for personal reflections. The NI also told us that they continued to revise their policies and ensured they took into account people’s protected characteristics. They also continued to reinforce the service’s core values, so that people living in the service and staff shared the common goals of ‘Respect, Pride, Belonging and Enjoyment’. Staff understood that people’s human rights must be observed, including their right to be treated with dignity and respect. Staff recognised and understood people’s diversity and consistently treated them with compassion and kindness. Staff demonstrated a good understanding of people’s spiritual and religious needs, wishes, and cultural heritage and respected them fully.

There were effective processes in place to ensure people's physical, mental, and social needs were holistically assessed. People’s care and support was delivered in line with legislation, standards, and evidence-based guidance, including the National Institute for Care and Excellence (NICE) and other expert professional bodies. The service had an Equality Diversity and Inclusion (EDI) officer who was helping to develop systems and practices, to embed inclusive principles throughout the service. All staff completed mandatory training for Equality Diversity and Inclusion, for which records showed full compliance in respect of completion.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.