Inspection Report - CQC

May 29, 2013 - take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in ...
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Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Margaret Thatcher Infirmary Royal Hospital Road, Chelsea, London, SW3 4SR Date of Inspection:

29 May 2013

Date of Publication: June 2013

We inspected the following standards as part of a routine inspection. This is what we found: Consent to care and treatment

Met this standard

Care and welfare of people who use services

Met this standard

Meeting nutritional needs

Met this standard

Supporting workers

Met this standard

Assessing and monitoring the quality of service provision

Met this standard

Complaints

Met this standard

| Inspection Report | Margaret Thatcher Infirmary | June 2013

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Details about this location

Registered Provider

Royal Hospital Chelsea

Registered Managers

Mrs. Susan Mary Williams Dr. Fergus Stephen Jonathon Keating

Overview of the service

The Margaret Thatcher Infirmary (MTI) has been open since 2009.The MTI is a unique home that it is owned by the MOD and only admits Chelsea Pensioners into the Infirmary. All of the pensioners are former enlisted soldiers that are known to the Royal Chelsea Hospital, that is they have used the services of the hospital, gone through an assessment and at some time stayed because of illness or post hospital convalescence. The service also provides a domiciliary care service to the main Hospital.

Type of services

Care home service with nursing Domiciliary care service Diagnostic and/or screening service

Regulated activities

Accommodation for persons who require nursing or personal care Diagnostic and screening procedures Personal care Treatment of disease, disorder or injury

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Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page Summary of this inspection: Why we carried out this inspection

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How we carried out this inspection

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What people told us and what we found

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More information about the provider

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Our judgements for each standard inspected: Consent to care and treatment

6

Care and welfare of people who use services

7

Meeting nutritional needs

8

Supporting workers

10

Assessing and monitoring the quality of service provision

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Complaints

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About CQC Inspections

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How we define our judgements

15

Glossary of terms we use in this report

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Contact us

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Summary of this inspection

Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We carried out a visit on 29 May 2013, observed how people were being cared for, talked with people who use the service and talked with staff. We reviewed information given to us by the provider. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. What people told us and what we found The people living at the Margaret Thatcher Infirmary (MTI) known as Chelsea Pensioners reported that they were happy living at the home. Comments ranged from "very nice wouldn't be anywhere else" and "Its first class here". Care plans were written with the person that included their consent for care and support. People who lacked capacity had input from multi-disciplinary professionals ensuring the service being provided was in their best interest and their human rights were being respected. Staff had been trained in what to do in a medical emergency and would contact the emergency services if and when required. The dietary requirements for all people staying at the MTI were recorded as part of the assessment and care plan records. Staff undertook mandatory training set out in the provider's training policy on an annual basis. This included safeguarding and what to do in a medical emergency. All staff attended team meetings and received annual appraisals where their performance would be discussed and targets set for the coming year. The service conducted audits to monitor the quality of the service it was providing. Regular feedback questionnaires were completed. Records showed that there had been no incidents at the service in the last two years. We looked at the complaints log and the complaints made had been dealt with appropriately with records in place to show what actions were taken.

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You can see our judgements on the front page of this report.

More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report.

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Our judgements for each standard inspected

Consent to care and treatment

Met this standard

Before people are given any examination, care, treatment or support, they should be asked if they agree to it

Our judgement The provider was meeting this standard. Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements

Reasons for our judgement We looked at 6 care plans, information included an individual's choice and wishes in the way that care and support was provided. There were areas for staff to tick to show that the person consented to the care plan. People who lacked capacity living at the MTI had records in place to show how the staff were providing care and support that met and respected their best interests. We were informed that advocates are available to the Chelsea Pensioners if required. There was also a legal service that visited the MTI every week to provide advice and support to people if they require assistance. The registered manager told us that any family, advocates and multi-disciplinary professionals including social services are involved in supporting people with dementia in making best interest decisions at the MTI. All staff spoken with had been provided with Mental Capacity Act training and were aware of the importance of providing care in a dignified respectful way. The provider may find it useful to note that the signatures of the Chelsea Pensioners, family members or advocates were not included in the care plans to show that the care plan was agreed or completed in the best interests of the individual.

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Care and welfare of people who use services

Met this standard

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement The Chelsea Pensioners living at the MTI were known by staff and positive interactions were observed between the Chelsea Pensioners and staff. We observed people receiving appropriate and safe care. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We read six care plans including risk assessments. All six care plans were up to date and relevant. There were review records completed in all six and amendments made were relevant. Staff told us how they constantly assess the Chelsea Pensioners to ensure their welfare and safety was met. There is evidence that the care plans reflect the needs, preferences and diversity of the people. For example an individual liked to go out into the community daily. Everybody had a Health Action Plan that focused on their physical health and mental health. The MTI has its own on site registered primary health centre that includes a doctor, physiotherapist and other clinical professionals. We spent time talking to fifteen Chelsea Pensioners who were each positive about staying at the home, comments ranged from "very nice wouldn't be anywhere else" "Its first class here" "great place" and "marvellous place and lots for me to do, that's really important to me". Staff spoken with told us that they wrote in the daily records recording what e each person did throughout the day and night. Daily records looked at showed what support had been provided to each person. The MTI had registered for the Gold Standards that is a service provision following a care pathway for staff to provide end of life care. The registered manager told us that it is extremely important for the Chelsea Pensioners that if they wish to they can spend their last days in their room being provided with the clinical care and social care support that will ensure their privacy, dignity and comfort. All staff had been trained to deal with emergency procedures, clinical staff had annual updated CPR training. Training records and talking to staff confirmed that they were aware of the procedure and were aware of what to do should an emergency arise. | Inspection Report | Margaret Thatcher Infirmary | June 2013

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Meeting nutritional needs

Met this standard

Food and drink should meet people's individual dietary needs

Our judgement The provider was meeting this standard. People were protected from the risks of inadequate nutrition and dehydration.

Reasons for our judgement

The Chelsea Pensioners were able to choose their meal based on the menu available, lunchtime was a calm, social occasion and the majority of the Chelsea Pensioners told us they were happy with their meals. Some people required assistance with their meals and this was observed to be carried out in a dignified manner. The Chelsea Pensioners were given enough time to eat each course of their meal and those who wanted had more food. All of the Chelsea pensioners could choose where they wanted to dine, the majority ate with others in the dining areas on all units. Comments included "I enjoy meeting with the others at meal times and catching up" "the food is mainly good" "the food is ok" and "wonderful food, good choices I really like the soups". All of the Chelsea Pensioners in the dining rooms observed told staff what they wanted to eat and drink. Staff were seen working together ensuring everybody got the hot food they wanted in a very timely manner. Some staff were seen making suggestions as they knew what people liked to eat. Everybody was offered a hot drink at the end of their meal and cold drinks were available on every table. A range of food options were available and the Chelsea Pensioners told us that they were mainly happy with their food and the options available to them. Staff told us they record what people have eaten and their fluid intake at each meal if it was part of their care plan. Care plans evidenced that people's weight is recorded on admission then regularly. A range of beverages were available in communal areas and were replenished regularly by staff. There is a kitchen on each floor of the MTI, staff told us that the Chelsea Pensioners have access to food and drink at all times. We looked at the comment, suggestion books that included records on each of the wards evidencing people liaising with the chef regarding their meals. All entries had a response from the chef. The chef will meet with the Chelsea Pensioners on a regular basis to discuss any issues. Records of meetings were seen during our visit. The home is now involved with the Nutrition Action Committee (NAC) this is provided by Kensington and Chelsea local authority where a Public Health nutritionist has visited the MTI and completed audits in relation to the food provided. We observed the last audit from | Inspection Report | Margaret Thatcher Infirmary | June 2013

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29 May 2012 that showed the MTI was providing a good balanced diet to the people living there. Staff told us that this is a very important area and that they endeavour to make sure all Chelsea Pensioners enjoy the food provided.

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Supporting workers

Met this standard

Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Our judgement The provider was meeting this standard. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Reasons for our judgement The Chelsea Pensioners interacted with staff and it was evident that all staff were known to them. Comments made by the Chelsea Pensioners included "the staff are very good here" "staff work extremely hard to make sure we are cared for properly" "the staff are trained extremely well". There was a training officer in post who assessed staff training needs and ensured these were met across the year. We saw information displayed in the staff area of training opportunities and details of upcoming training. Most training was internal but some was provided by external organisations. Staff received appropriate professional development that was arranged to fit in with their working patterns. Mandatory training included Mental Capacity Act training, equality and diversity, health and safety, fire safety and human rights awareness training. All staff were due to undertake training on dementia awareness. Training records looked at showed that training was refreshed regularly. Staff had completed relevant qualifications to ensure they were competent in their roles. Staff told us that they were happy with the training they received and could access the training they requested. We spoke with a new member of staff who was currently going through the induction procedure, and we looked at the programme of induction and what training the member of staff had completed. All staff spoken with confirmed that they had one to one supervision on a regular basis. The registered manager told us that this is an area they want to improve to ensure all staff are confident and competent in their roles. The provider funds qualifications for staff in line with Good Practice Guidelines and Skills for Care. Nursing staff are provided with on-going competency training, we were told by staff that the registered manager is very good at encouraging staff to complete training and development. We spent time in the Human Resources department looking at staff training records and discussing staff competencies. The home operates a rota so that staff will work all shifts on a specific unit ensuring continuity for the Chelsea Pensioners living there. | Inspection Report | Margaret Thatcher Infirmary | June 2013

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Staff skills are kept up-to-date by supervision, appraisal meetings and staff meetings where they are informed of any new issues. The registered manager informed us that the MTI is registered for training initiative for dementia care called 'Be Inspired'. The training is provided by an external provider. Be Inspired is being provided on Campbell unit where the MTI have a specialist dementia unit. We spent time on the Campbell unit observing staff interacting with the Chelsea Pensioners living on that unit.

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Assessing and monitoring the quality of service provision

Met this standard

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Staff told us that they regularly update information about the quality of the service being provided and discuss ways to improve the service. The MTI carries out a satisfaction survey with people who use the services and their family/advocates every year. The results from the last survey show that the Chelsea Pensioners and their families rate the MTI as providing good or very good aspects of care. The Chelsea Pensioners hold 'resident meetings' bi-monthly were they discuss what they want to improve and feed this back to staff. People can also comment anonymously by giving feedback using the comments books that are available on each floor. The MTI staff monitor the quality of the service they provide by heads of departments having meetings at least twice monthly, where they discuss critical analysis of accidents, safeguarding, weight loss/gain of people, physical changes, infections, compliments, suggestions, incidents, and complaints. Action plans are developed and implementation monitored. We spent time looking at the action plans implemented which included the laundry service where a new system has been started to help ensure that individuals' clothing items are returned appropriately. Staff explained how to report incidents and confirmed they received feedback on incidents. We looked at audits completed that showed regular quality assurance checks take place. Records looked at showed that staff identified, managed and monitored the risks to people who use the services. Staff told us that were open days at the service where all people using the service their families/carers and multi-disciplinary professionals were invited. The Care Quality Commission (CQC) had been invited to various events at the service. Records and other information looked at informed us that the MTI is providing a service that responds to people's needs.

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Complaints

Met this standard

People should have their complaints listened to and acted on properly

Our judgement The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

Reasons for our judgement We looked at the complaints log and the complaints made had been dealt with appropriately, with records in place to show what actions were taken. Chelsea Pensioners spoken with told us they would talk to the matron, deputy matron or staff if they had a complaint. Staff were aware of the procedure to follow if a complaint was raised. Staff we spent time talking to were aware of the complaints procedure and how to discuss any issues they had including the whistle blowing policy and procedure.

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About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website.

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How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected.

Met this standard

This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed

This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.

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How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact – people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact – people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact – people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.

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Glossary of terms we use in this report

Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.

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Glossary of terms we use in this report (continued)

(Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care.

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Contact us

Phone:

03000 616161

Email:

[email protected]

Write to us at:

Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA

Website:

www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

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