Margaret Thatcher Infirmary

What inspectors found

From the Care Quality Commission's assessment published 10 September 2024 (assessment visit 20 June 2024). Quoted under the Open Government Licence.

1. Safe

   GGood Good

   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.

2. Effective

   OOutstanding Outstanding

   People understood their rights regarding consent to the care and treatment they were offered. People’s views and wishes were taken into account when their care was planned. There were effective systems and practices to help people understand the care and treatment being offered and people were supported to make informed decisions. People were provided with information about their care and treatment ways they could understand. Staff understood the importance of ensuring people understood anything they were consenting to and also the importance of obtaining people’s consent before they delivered any care or treatment. People's mental capacity was assessed and their ability to consent was taken into account. People using the service, or a person lawfully acting on their behalf, were involved in planning, managing and reviewing their care and treatment.

3. Caring

   OOutstanding Outstanding

   People were supported to have choice and control over their care and to make their own decisions regarding their care, treatment and wellbeing. People were supported to understand their rights by using different ways to communicate. People were supported to maintain relationships and networks that were important to them. People had access to their friends and family while they were using the service. People had access to activities and the local community, which helped promote and support their independence, health and wellbeing. There was a range of appropriate equipment to help maximise people’s independence.

4. Responsive

   OOutstanding Outstanding

   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.

5. Well-led

   OOutstanding Outstanding

   Senior management and leaders ensured there was a shared vision and strategy and staff in all areas knew, understood and supported the service’s vision, values and strategic goals. Staff and leaders ensured the service’s vision, values and strategy were developed in collaboration with people who used the service, staff and external partners. Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. Staff at all levels had a well-developed understanding of equality, diversity and human rights, and they prioritised safe, high-quality, compassionate care. Equality and diversity was actively promoted and the causes of any workforce inequality are identified and action is taken to address these. There were clear and effective governance, management and accountability arrangements. Staff fully understood their roles and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. Notifications were being submitted, as required. There were effective systems in place to ensure confidentiality was maintained. Information was used effectively to monitor and improve the quality of care.