This inspection took place on 21, 22 and 23 September 2016 and was unannounced on the first day. We told the registered manager we would be returning over the next few days. At our previous inspection on 29 May 2013 we found the provider was meeting the regulations we inspected.The Margaret Thatcher Infirmary provides accommodation for up to 100 people who require nursing or personal care. At the time of our inspection 81 people were living in the infirmary. The organisation also provided personal care to approximately 20 people who were living in the Royal Hospital Chelsea, known as the long wards. This was through their domiciliary care service. People who use the service are known as ‘pensioners’ and they usually move into the Royal Hospital Chelsea onto the long wards. Pensioners could then progress to the four wards within the infirmary if they are assessed to need more care due to frailty and healthcare needs.
There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People told us staff were kind and compassionate and knew how to provide the care and support they required. Staff were committed and motivated, and understood the importance of getting to know people and understand their personal histories. All staff showed concern for people’s health and welfare in a caring manner, with enough time given for positive relationships to be developed.
People were spoken with and treated in a respectful and kind way and staff respected their privacy and dignity, and promoted their independence. People also had the support of Captains of Invalids, who were responsible for people’s social welfare and well-being. People felt comfortable speaking with them due to their military background. Where appropriate, people and their families were involved in decisions about end of life care and staff were aware of the importance of respecting people’s wishes and providing support at this sensitive time. Care for people at this stage of their life had been recognised as outstanding.
People had direct access to healthcare services as there was an on-site GP and physiotherapist, with regular visits from other healthcare professionals, such as occupational therapists, chiropodists, audiologists and speech and language therapists. We saw if staff had any concerns about people’s health, immediate referrals were made with appropriate follow up meetings.
People were supported to follow their interests and were encouraged to take part in a comprehensive range of activities and programmes to increase their well-being and reduce social isolation. There were a number of events held within the service along with day trips, including opportunities to travel overseas. The provider also had the use of volunteers to support people with activities and events. People were able to be ambassadors of the Chelsea Pensioners, and supported to represent them at official events throughout the world.
There was a real sense of a unique community spirit throughout the service with all the amenities, public gardens, tours and a museum that people could volunteer in that was open to the general public. The provider’s values were embedded throughout the service and understood by all.
People were involved in planning how they were cared for and supported. An initial assessment was completed from which detailed care plans and risk assessments were developed. Care records were person centred and developed to meet people’s individual needs and reviewed if there were any significant changes. People and their relatives were actively encouraged to express their views and were involved in making decisions about their care and whether any changes could be made to the support they received.
People knew how to make a complaint and were able to share their views and opinions about the service they received. The provider listened to all complaints and made sure people were confident their complaints would be taken seriously. When issues were highlighted we saw action was taken. There were also surveys in place to allow people and their relatives the opportunity to feedback about the care and treatment they received.
There were effective quality assurance systems in place to monitor the quality of the service provided and understand the experiences of people who used the service. The registered manager followed a regular cycle of quality assurance activities and learning took place from the result of the audits. Quality assurance processes included obtaining and acting on the views of people in order that their views could be used to drive improvements throughout the service.
The service promoted an open and honest culture and the registered manager and senior staff team were transparent in their discussions with us during the inspection. The registered provider focussed on their core values and staff were dedicated and knew what was expected of them, feeling privileged to be able to care for people who had served in the British Army.
Staff spoke highly of the support they received from management and were confident they could raise any issues or concerns, knowing they would be listened to and acted upon. The strength of leadership throughout the service contributed to the outstanding level of care, attitude of staff and quality of life for people using the service.
Staff were aware of people’s dietary needs and food preferences and provided support to those who required it during mealtimes. There was a good variety of choice available and people had the opportunity to feedback about the food they received. People also had the choice to visit the on-site café or licensed bar.
There was a comprehensive induction and a 12 month probation period for new staff. Staff members also took part in a training programme to support them in meeting people’s needs effectively. New staff shadowed more experienced staff before they started to deliver personal care independently and received regular supervision from management. They told us they felt supported and were listened to during the supervision they received.
People who required support with their medicines received them safely from staff who had completed in-depth training in the safe handling and administration of medicines, which was refreshed annually. Staff training in this area included observations of their practice to ensure medicines were given appropriately and with consideration for the person concerned. Staff completed appropriate records when they administered medicines and these were checked after each medicines round on the same day to minimise medicines errors. More thorough checks were carried out on a monthly basis and findings were discussed at quarterly governance meetings.
The service had a robust recruitment process and staff had the necessary checks to ensure they were suitable to work with people using the service. Sufficient numbers of staff were employed to keep people safe and meet their needs, being able to spend enough time with them to know them well.
Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff were aware of the importance of asking people for consent and the need to have best interests meetings in relation to decisions where people did not have the capacity to consent. The provider was aware when people had restrictions placed upon them and notified the local authority responsible for assessment and application.
There were robust systems and processes in place to protect people from the risk of harm. Staff were aware of different types of abuse, what constituted poor practice and the correct action to take if abuse was suspected. Appropriate safety checks of the building, equipment and maintenance systems were undertaken to ensure health and safety for people and staff was maintained.
People’s risks were managed and care plans contained appropriate and detailed risk assessments which were updated regularly when people’s needs changed. We saw accidents and incidents were closely monitored by the registered provider and discussed at quarterly meetings.