Margaret Thatcher Infirmary

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

Staff in the service had a clear understanding of safeguarding and knew how to take appropriate action. People were supported to understand what being safe meant and they knew how to raise concerns if they didn’t feel safe, or were concerned about the safety of others. There were effective systems, processes and practices to make sure people were protected from abuse and neglect. Staff understood the Deprivation of Liberty Safeguards (DoLS) and these were only used when it was in people’s best interests. Safeguarding systems, processes and practices mean that people’s human rights were upheld and they were protected from discrimination. People were informed about any identified risks and were supported to keep themselves safe. Risk assessments were person-centred, proportionate and regularly reviewed with the person they related to. The service followed safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent and confident to carry out their role. Recruitment, disciplinary and capability processes were fair and ensured people were not disadvantaged due to any protected equality characteristics. Staffing levels were sufficient and there was an appropriate skill mix, to make sure people receive consistently safe, good quality care that meets their needs. Staff received training that was appropriate and relevant to their role. Staff received regular support, supervision and appraisals. Staff at all levels had opportunities to learn and poor performance was managed appropriately.

This service scored 75 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with said they felt the Margaret Thatcher Infirmary was a safe, secure place to live and they were treated with kindness and respect by staff. People told us they knew what to do and who to speak to if they had any concerns about their safety or wellbeing. People told us they had not seen or experienced any restrictive practices.

Staff told us they knew what to do to ensure people received a safe service, were protected from abuse or neglect and had their human rights promoted. Staff said they understood how to recognise potential abuse and knew the reporting procedure for any safeguarding concern or allegation. Staff said they completed safeguarding and whistleblowing training and this was kept up to date. A senior member of staff told us they provided some of the training and explained how they had recently shown a video to help teach staff how to identify different kinds of abuse.

We observed that people were at ease and comfortable in the presence of staff. Staff’s interaction with people was characterised by warmth and mutual respect. Staff spoke about people using the service in a respectful, affectionate and positive way and it was evident they were committed to the people they were caring for. Our observations of people, and their relaxed body language with staff, assured us they felt comfortable and safe. We saw people’s human rights and diversity were respected and people were treated with compassion and kindness by staff. We did not observe any restrictive practices during our visit.

We saw the service had effective processes in place to help ensure people were well looked after and kept safe from harm. Safeguarding and whistleblowing information was available for staff, service users and visitors. There was a safeguarding log, which detailed any concern, together with the action taken. Records showed that staff completed appropriate training, which was kept up to date. People’s care records were clear and detailed. They included information about how people may be at risk and explained what action needed to be taken to help them remain safe.

People told us they were supported to stay safe, without having their independence and freedom restricted. People said they were helped to understand and manage risks to their health, safety and wellbeing. One person told us they felt safe and added, “I can’t go out [alone] anymore. I get dizzy spells. I can go out with staff in a wheelchair.”

The manager and senior staff told us they ensured risks to people were assessed and their safety was monitored and managed, with minimal restrictions on their freedom. The manager told us they monitored and analysed accidents and incidents, so lessons could be learned and recurrences could be avoided. Staff told us people’s care plans were detailed in respect of individual risks and explaining how people preferred to be supported. Staff told us they knew people well, which helped them recognise changes in people’s needs and identify new or increased risks. Staff confirmed that any concerns regarding people’s safety were recorded and reported to senior staff and people’s care plans and risk assessments were reviewed and updated promptly.

We saw people were supported and encouraged to maintain their independence as much as possible. We saw staff observing and monitoring people, to make sure they were safe, without being intrusive. We saw staff involved people and worked in collaboration with them, so people could make informed choices and individual risks could be managed with their agreement and in the way they preferred. Where needed, we saw staff supporting people to eat and drink safely and also providing people with, or reminding them to use, equipment to help them mobilise safely around the environment.

The service had effective systems in place to help people understand and manage risk. Staff advised people how to keep safe and any areas of concern were discussed with them and recorded in their care plans. Risks to people were assessed and monitored. Risk assessments were incorporated into people’s care plans and included areas that were important to them, such as their individual health and daily living. People’s care plans and risk assessments were regularly reviewed and updated as their needs changed. Clinical risks were managed by nursing staff who were appropriately trained and qualified to do so. Clinical records were also regularly reviewed and kept up to date. Staff recorded accidents and incidents. These were analysed and audited on a regular basis, so any trends could be identified and action could be taken to help prevent recurrences.

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

People told us there were sufficient staff to provide a safe and efficient service that met their needs. One person said, “I love every minute of living here, the staff are so helpful, and I can’t fault anything.” Another person told us, “There are more than enough staff here, including on weekends and this enables us to do what we want to do, when we want to do it.” People said staff were friendly, supportive, and caring. They spoke positively about their experiences of living in Margaret Thatcher Infirmary and were very complimentary about how staff treated them and the polite, friendly way they interacted with people.

Staff told us there was a clear management structure and all staff knew their individual areas of responsibility. Staff said they received regular supervision and annual appraisals and staff performance monitoring was included in the supervision process. Staff told us they were very well supported. One staff member said, “From the matron down we receive the kind of support we need. There is an openness that maybe wasn’t here before the new matron [Manager] started.” Another member of staff told us, “I can ask for support and advice. We also have team meetings from time to time, as well as handovers in the mornings and evenings. Staff said they felt there were enough staff employed to meet people’s needs. One member of staff described a typical shift and added, “We all help each other.” Staff said that staffing shortfalls caused by sickness or leave were covered by other regular staff or agency staff. A senior member of staff told us the service used a dependency tool to make sure the staffing levels remained safe and appropriate. Staff told us the training provision was very good. They said they completed a mixture of online training, as well as face-to-face and practical training. Staff confirmed their training was kept up to date and refreshers were completed when needed.

We saw there were consistently enough staff to meet people’s needs. We observed a mealtime and saw enough staff were present to support people with their food and drinks. Staff responded quickly when people needed assistance and people were not kept waiting. Staff supported people in a cheerful, confident and relaxed manner and did not appear to be rushed or under pressure. Throughout our visit, people using the service and staff consistently greeted each other with a smile and a cheery hello. We saw staff enhanced their knowledge and experience of people’s likes, dislikes, and preferences by building up bonds and relationships with them. We saw this had a positive impact on people’s daily lives and emotional wellbeing. We saw there were enough staff to support people with activities and staff were competent when using equipment or supporting people. This assured us their training had been effective. We saw there were dedicated activities co-ordinators and many volunteers who also provided excellent interactions with people. We saw staff provided enriching experiences for people living with dementia. For example, encouraging people to participate and discuss things by using open ended questions, which people could respond to.

There were effective processes in place to ensure there were always enough appropriately experienced and qualified staff on shift. The management team followed safe recruitment procedures, to ensure only suitable staff worked in the service. Recruitment processes included obtaining verified employment references and completing Disclosure and Barring Service (DBS) police checks for prospective staff. Training records showed staff completed mandatory, as well as additional training and we saw training was monitored and kept up to date. Records provided evidence that staff had regular one-to-one supervisions and annual appraisals. Staff’s performance was monitored and managed well. There were effective processes and procedures in place to ensure poor performance or disciplinary issues were dealt with fairly and without discrimination.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.