Margaret Thatcher Infirmary

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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.

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.

The NI explained how they ensured there was a shared vision and strategy and that staff, as well as people living in the service, knew, understood and supported these. The NI shared his ‘Health and Wellbeing Manifesto/Vision Statement’ in which he detailed the 4 core values that underpinned the ethos of the service. These were to Respect Individuals, Nurture Belonging, Encourage Pride and Enjoy Life. The NI’s manifesto also explained the service’s mission as being, “To deliver and improve current services and life opportunities, develop and offer new services and opportunities for the IP community [In-Pensioner/people living in the service], monitor and improve quality in order to enable IPs to live their best lives and demonstrate to the Country that the IPs are being cared for in the way that the Nation demands. The NI stated that, with regard to ‘Multi-Disciplinary Team’ working, the key to success was by the people living in the service also actively being part of the team. The findings from our site visit, which included observations and discussions with people living in the service, staff and management, assured us that the vision, values and strategy had been developed through a structured planning process, in collaboration with people who used the service, staff and external partners. A member of staff told us, “This place has a friendly, community feel where everyone respects each other, like a family within professional boundaries.”

The service had effective systems in place to ensure everybody understood and promoted the service’s vision, values and strategic goals. We observed and the NI provided evidence, which demonstrated how staff and leaders embodied a positive, compassionate, listening culture. We saw that this culture promoted trust and understanding between staff, leaders and people using the service and was focused on learning and improvement. Minutes from meetings, which had included people living in the service as well as staff, showed that discussions had been held in respect of dignity, respect, human rights, inclusiveness, equality and non-discrimination. We saw these areas were continually monitored and there were effective processes in place to address any issues or shortfalls, quickly and appropriately.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Throughout this assessment, the NI and the new manager consistently demonstrated that they had the skills and knowledge to continue providing a well-led service. They had a clear understanding of their responsibilities and were familiar with guidance for providers on meeting the regulations and the CQC five key questions. The NI reiterated that ‘good governance was all about improving performance’ and we were assured by our findings that this ethos had been fully adopted. Staff told us they felt the service was very well run. A senior member of staff described some of the audits that were completed on a regular basis, such as dependency levels, health and safety, infection control, pressure care and ensuring equipment was safe and well maintained. One member of staff told us some of the best things about the service were that the care standards were very high, people were well looked after and had dignity, respect and comfort. They said it was a unique service, which had everything anyone needed on site.

We saw the service had clear and effective governance, management and accountability arrangements in place. We were assured that staff understood their roles and responsibilities and the management team could account for the actions, behaviours and performance of staff. We saw there were effective quality assurance processes in place. These included feedback from people and were used to help continue driving improvement within the service. The NI and the manager were aware of their responsibilities regarding duty of candour. They were open and honest with people living in the service and their relatives when things went wrong with their care and support and provided them with an apology. We saw the management reporting structure was transparent, and both the manager and the NI made themselves available for support to the people using the service, relatives, and staff. The service had a confidentiality policy and procedure, which staff understood and followed. Confidentiality was included in staff’s induction, on-going training and also contained within other written information. We saw that care records were kept securely and access was limited to those with responsibility for the day-to-day care of the people using the service. The NI provided a satisfactory explanation in respect of a ‘glitch’ that had resulted in a temporary delay of statutory notifications being submitted to CQC. The NI and the manager took appropriate action to ensure statutory notifications continued to be submitted without delay, as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.