Care Home: Margaret Thatcher Infirmary - The Royal Hospital Chelsea

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What the care home does well We spent a lot of time talking to residents, relatives and staff, all were very positive about the Margaret Thatcher Infirmary stating it is a very good home and people liked living there. Staff were extremely positive telling us that they enjoyed working at the home and they were proud to be part of the homes uniqueness. The people living at the Margaret Thatcher Infirmary have access to multi-professional health care on site. There are rooms available for rehabilitation that provides people with support to become independent and enables them to go to their own homes or back onto the long wards in the old building. We looked at 6 residents files and each contained an assessment for the mental capacity of each individual, showing clearly that they had liaised with the resident on this very important area of health and social care provision when living in a care home. One resident who is diagnosed with dementia had a full assessment for Deprivation of Liberty that showed lack of capacity, the assessment had been signed by the registered manager and a senior nurse. This individual is supported and supervised at all times in the home. There are advocates working at the home that are available at anytime for residents to talk to or represent them. Also a solicitor visits on a weekly basis for any resident to discuss any legal issues they require assistance with. We discussed recruitment with the registered manager and spent time in the Human Resources department looking at 6 staff files. All of the 6 staff files had all of the relevant information in place including enhanced CRB records, two or more references that had been checked for validation, passport details and all relevant information for staff working on work permits. The food provided is of a good standard with a choice of options available to all residents. We spent time on the first floor having lunch with residents and all were very positive about the food served. There is a daily menu given to all residents, one of the residents sitting on the dinner table had a specialised diet, we were told that he is happy with the meals provided. We spent time in the kitchen with the head chef and one of the chefs who is in charge of the Infirmary kitchen who told us that they provide cultural and religious meals if required and that specialised diets are also provided as requested. We looked at staff rotas and the staffing levels are good on all floors. We were told by the registered manager that each resident is assessed for their care need requirements and the staffing levels meet the needs of each person. We were told that more staff would be used if any risk was identified. What has improved since the last inspection? This is the first Inspection of this new home. What the care home could do better: We looked at the assessment records, care plans and risk assessments of 6 residents. The assessments and care plans did work in conjunction however some entries were minimal in information. We looked at the risk assessments and not all worked in conjunction with the care plans, were risks had been identified there was no action to show what procedure staff should follow to minimize or eliminate the risk. We looked at medication records in all 4 units. The he correct quantity of each drug was in safe storage in each of the 4 units. The registered manager must put in place an up to date medication policy and procedure regarding when a pensioner is out for the day or when self medicating. The overall outcome of the pharmacy inspection was very positive. We looked at daily care records on all floors, all staff must be aware of the appropriate language when writing records as some entries were not acceptable.The registered manager and senior staff must also make sure that all records are completed thoroughly with a date and signature by the person who completed the relevant record. We looked at the health care plans of 6 residents in two of the care plans it was stated that the weight of the resident should be monitored and nutrition and fluid intake was a risk area, we did not see any records for food or fluid intake on either file and the weight of the resident was not recorded as regularly as required in the care plans. We spent time looking at the financial procedure with the almoner. The procedure has to be up dated and a more structured procedure must be put in place that shows how the home is protecting the residents when they are looking after their finances. We spent time discussing training with the registered manager and a senior nurse who is at this present time delegated to making sure that all staff are attending relevant up to date training. We were given the training programme for all staff that shows that all staff are attending training, there are areas of training that some of the staff have not had as yet, however we were told that all staff be provided with all relevant training. There are new staff employed at the new Infirmary that are being provided with a full induction training programme that is in line with Skills for Care. We were told that some training providers have let the home down by not providing training that was booked, however alternative training providers have now been found and staff booked on the relevant training. All staff have attended POVA training that was provided by the Royal Borough of Kensington and Chelsea. The registered manager told us that staff are very positive about the training and any specialised training recognised will be provided to staff. We spent time talking to nursing staff, care staff, domestic staff and all were very positive about the training being provided. We spent time with the lead therapist who is the Manager of the physio services and a trained Occupational therapist, this individual has taken the lead in putting into place an activities programme for the home. We were told that a new training coordinator was starting on 25th May 2009 looking at the activity programme for group activity`s and also one to one activity`s. The lead therapist is very experienced in looking at the relative activities necessary linking into individuals person centred care. We were told that the lead therapist has completed a lot of work in putting together a programme that will be implemented in June 2009 to August 2009 and audited in September 2009 looking at how they can provide an activity programme that meets the needs of all residents.We were given a copy of the activity programme `Activity provision: Benchmarking Good Practice` that has a plan to formulating a good activities programme. We discussed staffing levels in the activity team and it was established that more activity staff will be required to meet the needs of all residents. We were told that all staff will be included in the activity programme and training will be provided. Key inspection report Care homes for older people Name: Address: Margaret Thatcher Infirmary - The Royal Hospital Chelsea Royal Hospital Road London London SW3 4SR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jackie Derbyshire     Date: 2 0 0 5 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) 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. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Margaret Thatcher Infirmary - The Royal Hospital Chelsea Royal Hospital Road London London SW3 4SR Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Laura Bale Type of registration: Number of places registered: care home 125 Margaret Thacher Infirmary - The Royal Hospital Chelsea Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 125 Date of last inspection Brief description of the care home The Margaret Thatcher Infirmary is the new Infirmary that was registered and opened in January 2009. The Infirmary is now a seperate building from the Royal Chelsea Hospital, however is is situated very close to the old building so that pensioners living in the Infirmary have easy access to the old building to visit their collegues and be involved with social Care Homes for Older People Page 4 of 37 Over 65 125 0 Brief description of the care home activities. The Margaret Thatcher Infirmary is registered for 125 residents, there are currently 86 pensioners living there including 2 women as the regulations changed and women are now be eligible to live there. The Margaret Thatcher Infirmary premises are excellent with lots of communal areas for pensioners to meet with visitors, all rooms are spacious with an en-suite in each room. There is a medical centre on the ground floor that all pensioners have access to with 2 GPs available and a team of multi- disciplined professionals. There are 4 units currently being used the 5th unit is not yet open. The 4 units are Jones and Campbell wards that are for nursing care and Paget and Nicholson ward that are for residential. Externally the Infirmary has gardens all around that are very attractive, all pensioners also have access to the sixty-seven acres of gardens that surround the Royal Chelsea Hospital. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means that the people using the service receive a good service. Throughout this report the word we will be used as meaning the Care Quality Commission CQC. This unannounced inspection took place on the 19th and 20th May 2009; we spent 22.00 hours visiting the new home.The Inspector was assisted on the 20th May by Tony Lawrence a Regulation Inspector and Jane Shaw a Pharmacist Inspector. We spent time talking to people living at the home, their relatives, the registered manager, the deputy manager, care staff, nursing staff, domestic staff and one of the maintenance officers. We checked the care records of 6 residents, the medication records in the 2 nursing units and the 2 residential units. The finance records of all residents were looked at and the procedure discussed with the almoner. We spent time with in the Human Resources department looking at 6 staff recruitment records. We had a full tour of the new home and 12 bedrooms were looked at and all Care Homes for Older People Page 6 of 37 communal parts of the home. The home provides an excellent standard of accommodation, the home was very clean and tidy on both days. There were 86 residents currently living at the home. We received 11 residents surveys, 1 health care professional survey and 2 staff surveys, we also spent time talking to 2 residents relatives. Comments from the surveys will be included throughout this report. We will make reference to the Annual Quality Assurance Assessment AQAA throughout this report. There is no charge for The Margaret Thatcher Infirmary as this is a unique home that is it only admits Chelsea Pensioners into the Infirmary. All of the pensioners are former enlisted solders that are known to the Royal Chelsea Hospital, that is they have used the service of the the hospital, gone through an assessment and at some time stayed because of illness or post hospital convalescence. The Margaret Thatcher Infirmary also has on site a medical center that works extremely close with the Infirmary to provide residents with a high standard of primary health care. There are a lot of health professionals that all Chelsea Pensioners have access to including 2 GPs, Physiotherapists, chiropodists and practice nurses. All residents are offered a quarterly health check MOT to assist in monitoring any changes in their health. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: We looked at the assessment records, care plans and risk assessments of 6 residents. The assessments and care plans did work in conjunction however some entries were minimal in information. We looked at the risk assessments and not all worked in Care Homes for Older People Page 8 of 37 conjunction with the care plans, were risks had been identified there was no action to show what procedure staff should follow to minimize or eliminate the risk. We looked at medication records in all 4 units. The he correct quantity of each drug was in safe storage in each of the 4 units. The registered manager must put in place an up to date medication policy and procedure regarding when a pensioner is out for the day or when self medicating. The overall outcome of the pharmacy inspection was very positive. We looked at daily care records on all floors, all staff must be aware of the appropriate language when writing records as some entries were not acceptable.The registered manager and senior staff must also make sure that all records are completed thoroughly with a date and signature by the person who completed the relevant record. We looked at the health care plans of 6 residents in two of the care plans it was stated that the weight of the resident should be monitored and nutrition and fluid intake was a risk area, we did not see any records for food or fluid intake on either file and the weight of the resident was not recorded as regularly as required in the care plans. We spent time looking at the financial procedure with the almoner. The procedure has to be up dated and a more structured procedure must be put in place that shows how the home is protecting the residents when they are looking after their finances. We spent time discussing training with the registered manager and a senior nurse who is at this present time delegated to making sure that all staff are attending relevant up to date training. We were given the training programme for all staff that shows that all staff are attending training, there are areas of training that some of the staff have not had as yet, however we were told that all staff be provided with all relevant training. There are new staff employed at the new Infirmary that are being provided with a full induction training programme that is in line with Skills for Care. We were told that some training providers have let the home down by not providing training that was booked, however alternative training providers have now been found and staff booked on the relevant training. All staff have attended POVA training that was provided by the Royal Borough of Kensington and Chelsea. The registered manager told us that staff are very positive about the training and any specialised training recognised will be provided to staff. We spent time talking to nursing staff, care staff, domestic staff and all were very positive about the training being provided. We spent time with the lead therapist who is the Manager of the physio services and a trained Occupational therapist, this individual has taken the lead in putting into place an activities programme for the home. We were told that a new training coordinator was starting on 25th May 2009 looking at the activity programme for group activitys and also one to one activitys. The lead therapist is very experienced in looking at the relative activities necessary linking into individuals person centred care. We were told that the lead therapist has completed a lot of work in putting together a programme that will be implemented in June 2009 to August 2009 and audited in September 2009 looking at how they can provide an activity programme that meets the needs of all residents.We were given a copy of the activity programme Activity provision: Benchmarking Good Practice that has a plan to formulating a good activities Care Homes for Older People Page 9 of 37 programme. We discussed staffing levels in the activity team and it was established that more activity staff will be required to meet the needs of all residents. We were told that all staff will be included in the activity programme and training will be provided. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 37 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. The guide details what the prospective residents can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff. Evidence: Comments from residents and their relatives. The standard of care is first class, service delivery excellent, all delivered in a helpful cheerful way. It is the only establishment that has improved my health, mobility and maintained a high standard of my faculties. My relative is looked after by top class staff. This is the best care home in the country. Care Homes for Older People Page 12 of 37 Evidence: We looked at the homes statement of purpose and service user guide that are up to date and relevant. There is a lot of information about the different levels of health and social care provided at the Margaret Thatcher Infirmary. A copy of the statement of purpose and service user guide was in the reception area for people to look at. In discussion with the registered manager all prospective residents are given a copy of both documents.The certificate of registration with the CQC was displayed in the registered managers office. We were given a copy of the the insurance document that is supplied by the MOD. We discussed contracts with the registered manager and because of the eligibility criteria of the Margaret Thatcher Infirmary, that is it only admits Chelsea Pensioners into the Infirmary. The pensioners do not receive a contract however all are informed of the terms and conditions of the eligibility to move 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 service of the the hospital, gone through an assessment and at some time stayed because of illness or post hospital convalescence. All residents and representatives are aware of the eligibility criteria. We discussed assessments with the registered manager all prospective residents have a full assessment and make sure that the service can meet their care needs before they move into the home. We looked at 6 residents files and each contained a full health and social care assessment. The assessments are comprehensive and include Barthel, Waterlow and Activities of Daily Living. We spent time discussing the care provided by the home with the registered manager, residents, relatives and staff. All of the people we spent time talking to were very positive and demonstrated that all residents needs however complex are at this present time being met. Relatives of residents spoken to told us that the care is excellent,one relative told us that they are so pleased that their relative is living at the Margaret Thatcher Infirmary as it is the best care home in the country and their relative is looked after by very competent, caring staff. Residents told us they are happy with the care provided. Staff were seen providing care in a manner that was respectful and was asking residents what they required and assisting them to be as independent as possible. We looked at the training records for all staff that demonstrates that all staff have a continuous training programme to enable them to meet the changing needs of residents.We were given a lot of information about the specialised care provided at the home including rehabilitation, dementia care and end of life care. We were told by the registered manager that they are looking to register a domiciliary care provision on the ground floor for pensioners that are independent but Care Homes for Older People Page 13 of 37 Evidence: require some support. The change will show how the Infirmary is promoting an enabling programme, providing general support to providing full nursing care. There is a rehabilitation programme at the Infirmary for pensioners that require support in becoming independent after illness or having had a stay in hospital. We spent time talking to one resident who was having rehabilitation in the Infirmary. We were told that he is happy with the support and will be moving back onto the long ward imminently. There is a multi professional team based in the medical centre that residents have access to including GPs, Physiotherapists, Occupational therapists, chiropodists and clinical nurses. Care Homes for Older People Page 14 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plan is a working document reviewed regularly involving the person and their representatives as appropriate. Reviews take place monthly focusing on what has worked for the individual. Risk assessments are completed, some work is required for the records to work in conjunction with the assessment and care plan records. Evidence: Comments from residents and their relatives. The medical support is first class. There is a GP on site that makes it so much easier when I am not feeling well. The nursing care is exceptional. I am able to do most things myself, staff assist me when I request their help they are very helpful and always consider my dignity. Care Homes for Older People Page 15 of 37 Evidence: We looked at 6 residents files and all had a care plan in place. The care plans looked at were informative showing all areas of the individuals health care and social care needs. The care plans did work in conjunction with the assessments however the risk assessments were not as informative, there was no action plan in place for all of the risks identified in the assessments and care plans .We spent time discussing residents with complex needs including those diagnosed with dementia, the registered manager told us they are looking at providing a specialised dementia unit in the near future that will have specialised trained staff and provide a high standard of care. There are currently 10 residents that are diagnosed with dementia, one of the care plans looked at was for a resident who has diagnosed dementia. The care plan was informative showing what care was being provided and actions to take if the individual became agitated. We spent time in all 4 units and met one resident that has dementia, a member of staff was talking to the resident in a calm reassuring manner. The registered manager told us that all staff are trained in dementia care, we looked at the training programme that shows staff are attending dementia training. All of the residents care plans and risk assessment records looked at had been reviewed in the last month. We looked at the health care records of 6 residents including 2 that have complex needs. All of the residents have access to the two GPs based in the medical centre on the ground floor. The health care is very good as there is a team of multiprofessionals working at the medical centre. We saw lots of residents attending daily surgerys on both days of this inspection. We spent time talking to both GPs who were very positive about the home and stated the health care is very good. We spent time talking to residents and relatives who all commented that the health care provided at the home is excellent. We inspected medication management in four units in the Infirmary. We looked at the medication policy and procedures, the medicines GP computer system and met the manager,deputy manager and nursing and care leads. We also met the residents GP and two pensioners who were able to self administer their medication. The Infirmary medicines policy and procedures was available in each unit together with the Royal Pharmaceutical Society guidance on Handling Medicines in Social Care. We noticed that there were no local procedures for handling medicines when pensioners went away or out for the day, and also how any medicines errors were managed and reported. We discussed the management of waste medicines and clarified the regulations with respect to the residential units. We noticed the good practice of reminder instruction cards for administering eye drops,ear drops and creams. We observed medication being administered in one of the nursing units and noticed that the nurse followed procedures and gave it with gentle encouragement and Care Homes for Older People Page 16 of 37 Evidence: explanation. We inspected the recording of receipts, administration and disposal of medication in the nursing units and noticed that overall the records were good. We counted several medicines in their original dispensed packs and with the exception of one course of nitrofurantoin were able to reconcile the quantities with signatures for administration.This means that overall we were satisfied that pensioners were receiving their medication as prescribed. We noticed that warfarin and blood tests were generally managed well but that in one nursing unit the instructions on the MAR (medication administration record) did not correlate with what was being given and the blood test result. We looked at the regular medication audits being carried out in the residential units and the draft procedures for giving household remedies. Medication was well organised and records generally good.We audited several packs of medication and found that balances were correct. Two residents had received their medication the morning of the inspection though, but the MAR had not been signed. We noticed the good practice in three units of keeping the handwritten Mediform MAR, used for short stay pensioners, separate from the printed MAR for permanent pensioners. We found it confusing in one nursing unit when both charts were in use for a pensioner and questioned why one system could not be used to prevent error. We looked at the storage and records of controlled drugs and noted that balances were correct and storage safe. We pointed out that there did not need to be a separate entry for each new supply and that a running balance should be recorded. We noticed that many of the pensioners were administering their own medication and that risk assessments had been carried out and consent obtained. We visited two pensioners who were taking their own tablets and they were able to explain what they were taking and where they kept their medicines. Neither of the pensioners visited used the lockable cupboards provided and we were concerned that the temazepam prescribed for one could potentially fall into the wrong hands. One pensioner also appeared to have a significant amount of medicines in his drawer. Several pensioners were able to maintain their independence by visiting the medical centre to order their repeat prescriptions. Overall therefore we were pleased with the progress made in establishing good practices for handling medicines safely at the Infirmary. There is still work to do with the new pharmacist supplier is getting permanent pensioners onto the same medication cycle.This will aid ordering processes and prevent medicines running out and also prevent stock piling.There is also further work to do in ensuring that error is minimized by establishing safe systems for record keeping for long and short stay pensioners.The storage of medicines and review of pensioners who are self medicating also requires further work. We looked at the training records for all staff, included in the homes induction programme training is that the residents privacy must be respected at all times. All Care Homes for Older People Page 17 of 37 Evidence: staff also complete training in equality and diversity. We spent time in all 4 units and observed staff working closely with residents supporting them in a courteous respectful manner. All personal care tasks will take place in a residents own room or in the privacy of one of the numerous communal bathrooms. We discussed end of life care with the registered manager and was told that staff are attending training in this area as this is part of the aims of the home to care for an individual providing dignity and respect and following the individuals cultural and religious wishes. We looked at the care plans of 6 residents and each contained information on end of life care with their requests recorded. Care Homes for Older People Page 18 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans identify the individuals interests, there is a need to make sure that the the work being implemented by staff in putting in a structured person centered activity plan is supported by the management board. Menus are varied and a wide choice of dishes is available at each mealtime. Evidence: Comments from residents, their relatives and staff. We need to supply more activities for the residents. There is activities provided but I am quite happy working in the rose gardens, I really enjoy that. I would like to see more varied activities provided, there are some however my relative does not like joining large groups and a more one to one would benefit him more. We looked at 6 residents assessments and care plans, each care plan had information on the likes and dislikes hobbies and leisure interests of all residents. We spent time Care Homes for Older People Page 19 of 37 Evidence: with the lead therapist who is the manager of the physio services and a trained Occupational therapist, this individual has taken the lead in putting into place an activities programme for the home. We were told that a new training coordinator was starting on 25th May 2009 will be looking at the activity programme for group activitys and also one to one activitys. The lead therapist is very experienced in looking at the relative activities necessary linking into individuals person centered care. We were told that the lead therapist has completed a lot of work in putting together a programme that will be implemented in June 2009 to August 2009 and audited in September 2009 looking at how they can provide an activity programme that meets the needs of all residents. We were given a copy of the activity programme Activity provision: Bencmarking Good Practice that has a plan to formulating a good activities programme. We discussed staffing levels in the activity team and it was established that more activity staff will be required to meet the needs of all residents. We were told that all staff will be included in the activity programme and training will be provided. We discussed one-one activities and was told by the lead therapist that all residents will have an activity plan that meets their social care needs. There are gardens situated all around the Infirmary with sixty seven acres of attractive areas that all residents can enjoy. Residents were seen to be enjoying walking around and sitting in the sunshine, we were told that some of the residents enjoy gardening and get involved in planting and looking after the garden. We spent time talking to residents who told us that they enjoy participating in activities, we went into a pottery class and was told by residents that they enjoy this class that is provided by one of the many volunteers that visit the home. We spent time on all 4 units on both days of this inspection, there was a lot of visitors and residents were seen to be happy meeting family and friends. All staff were seen to be very welcoming to all visitors and promoted privacy. All of the time spent on the 4 units we saw staff working very closely with residents. Staff were not telling residents what to do but were seen to be asking them or giving support to residents that required it. One member of staff was working very closely with a resident that was diagnosed with dementia, the member of staff was seen to be talking gently and reassuring the individual who was anxious. We looked at the training programme for all staff and all staff are provided with training in promoting independence and offering choice to residents. We spent time in the kitchen with the head chef and one of the chefs in charge of the Margaret Thatcher Infirmary who are very passionate about the food prepared, we discussed the menu and the variety of nutritious food that is provided. We discussed the preferences of residents and how the chefs liaised with the residents. we were told Care Homes for Older People Page 20 of 37 Evidence: that the chefs all spend time on the units talking to residents and looking how they can be more varied in the menus.Specialised diets are given to the chefs and we were told that they will endeavor to provide a variety of food for all residents. We spent time looking at the storage of all food including fresh and frozen food,all was safely stored. We spent time having lunch with residents on one unit, the menu was to start, soup, main, salmon steak or lamb, fresh vegetables were offered to all residents. The desert was cake, fruit and ice cream. All of the food tasted was good and in discussion with the residents they told us that they enjoyed lunch. The meals are served in each unit and all residents are encouraged to eat in the dinning room. There is an issue that when a care plan shows that a residents food and fluid intake should be monitored, this is not always happening. Care Homes for Older People Page 21 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of different formats, to help anyone living at, or involved with, the service to complain or make suggestions for improvement. Evidence: Comments from residents, their relatives and staff. I know who to complain to if I had something to complain about. I would speak to the matron if I was unhappy about anything. I am very happy and privileged living here everything is provided to the highest standard. We spent time discussing the complaint procedure with the registered manager and looking at the complaints procedure that is included in the statement of purpose and service user guide. A copy of the complaints procedure is also displayed in the reception area and on notice boards in all units. There have been no complaints raised at the home since it opened in January 2009, residents spoken with stated they would speak to the registered manager if they had a problem. The Margaret Thatcher Infirmary has advocates working directly with residents and Care Homes for Older People Page 22 of 37 Evidence: are available to act for any individual when required. We discussed residents that are diagnosed with dementia and do not have capacity in certain areas, we were told by the registered manager that she is liaising with RBKC to have a IMCA Independent Mental Capacity Advocate visit the Infirmary to assist with some delicate areas. We saw capacity assessments in all 6 files looked at. There is a solicitor that visits the Infirmary on a weekly basis that all Chelsea Pensioners can have access to. We looked at the safeguarding procedure that is directly linked to the Royal Borough of Kensington and Chelsea procedure as the local authority that the home is situated. The registered manager was very aware of the procedure. There have been no incidents raised at the Margaret Thatcher Infirmary, We looked at the training records of all staff and all staff have completed safeguarding training. Care Homes for Older People Page 23 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is fully able to meet the changing needs of the people who use the services,along with their cultural and specialised care needs. It is fully accessible throughout to people with physical disabilities, adaption and specilased equipment would be designed to fit in with the homely environment. Evidence: Comments from residents, their relatives and staff. Its like a 5 star hotel. Excellent environment. I lived on the long wards and thought I would not like it here in the new Infirmary, however I do and especially having my own bathroom that is wonderful. It is a fantastic home, so spacious and the decor is fantastic. We spent time in all units, looking at all communal areas including dining rooms and lounges,looking at 12 residents rooms,the standard of fixtures and fittings throughout the home is excellent. All of the 12 residents rooms looked at had personal items including pictures and photographs.There are communal bathrooms on all floors that Care Homes for Older People Page 24 of 37 Evidence: have specialist equipment in place including different types of hoists and baths. All of the residents have an en-suit bathroom that has a shower. The home has a lot of social communal rooms including a hairdressing salon and lots of gardens and residents do plant flowers and plants and spend time looking after the gardens.Residents were seen walking around the garden and sitting enjoying the good weather on seating spread around the garden. The home is very light and bright, the architecture is designed for a lot of natural light with a lot of windows throughout the home. All areas of the Margaret Thatcher Infirmary were very clean and tidy on the two days of this site visit. The home has a security system with a cameras outside the building that is linked to monitors on all floors. keypads are used to gain access onto all floors, we spent time discussing Deprivation of Liberties DOL assessments with the registered manager who told us that she is has assessed all 10 residents that are diagnosed with dementia and show that they are at risk of wandering outside of the Infirmary. Any of the 10 residents that want to leave the unit are escorted by a member of staff to protect them. We discussed residents having the numbers to the keypads to the main doors and was told that there are residents that have the numbers and have access to all areas of the home as written in their care plans. Care Homes for Older People Page 25 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service ensures that all staff receives relevant training that is focused on delivering improved outcomes for people using the service. The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people using the service. Evidence: Comments from residents, their relatives and staff. The staff are very attentive and provide good care. I have no issues regarding the staff they are very good. There are some new staff with a lot of staff having left when we moved into the new Infirmary that is very sad however I think we are all settling in very well. Some staff listen, others dont. There is always a member of staff available if my relative needs assistance with something. We have done a lot of induction training with new staff, we are very lucky with the Care Homes for Older People Page 26 of 37 Evidence: quality of staff we have recruited. I have worked here for over 20 years, its unique, theres nowhere better to work. We looked at the staffing rotas for all units for the month of May 2009, there is good levels of staffing in all units.We discussed staffing levels with the registered manager who told us that all residents needs are assessed and the staffing ratio is worked out to make sure all residents needs are fully meet. We looked at the recruitment records of 6 staff that included 2 nurses and 2 carers,one senior carer and a housekeeper. All of the recruitment records were in place with an up to date CRB disclosure for each person. The references in all 6 staff files had been validated by the registered manager who had verified that the referees had been contacted. The 2 nurses files had an up to date Pin number. The home has staff that are working on different visas, in discussion with Human Resources manager we were told that she checks with the Home Office for every individual. Visa records looked at were all in date with a relevant Home Office letter of confirmation in place.We were told by the registered manager that no staff are employed to work at the Margaret Thatcher Infirmary until all checks have been completed. We spent time discussing training with the registered manager and a senior nurse who is at this present time delegated to making sure that all staff are attending relevant up to date training. We were given the training programme for all staff that shows that all staff are attending training, there are areas of training that some of the staff have not had as yet, however we were told that all staff be provided with all relevant training. There are new staff employed at the new Infirmary that are being provided with a full induction training programme that is in line with Skills for Care. We were told that some training providers have let the home down by not providing training that was booked, however alternative training providers have now been found and staff booked on the relevant training. All staff have attended POVA traing that was provided by the Royal Borough of Kensington and Chelsea. The registered manager told us that staff are very positive about the training and any specialised training recognised will be provided to staff. We spent time talking to nursing staff, care staff, domestic staff and all were very positive about the training being provided. Staff will be sent on relevant specialised training including dementia awareness, challanging behaviour, safegaurding vulnerable adults, palliative care and nurses are sent on specialised health care training enabling them to also have a continous learning programme. We spent time discussing training with the residents and relatives of people living at the home. All comments were very positive, residents told us that staff are very competent and helpful, relatives were very complimentary about the staff and staff were all extremley pleased with the training provided. 27 care staff have an NVQ Care Homes for Older People Page 27 of 37 Evidence: qualification with 6 staff currently working towards achieving an NVQ qualification. We were told by the registered manager that NVQ training is very important for all care staff Staff are being encouraged to support and mentor eachother. We were told by the registered manager and the senior nurse that the Infirmary is promoting competent staff to do the training the trainers courses so that training can be provide in house, there are 4 manual handling trainers, and 4 senior carers completeing training in Team Leader training. Care Homes for Older People Page 28 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager has the required qualifications and experience and is competent to run the home. She works continuously to improve services and provide an increased quality of life for residents with a strong focus on equality and diversity. Evidence: Comments from residents, their relatives and staff. The manager is very good and is available to talk to at anytime. Matron is very approachable, nothing is to much trouble for her. The matron and deputy matron are always available if I have a problem. The registered manager is extremely qualified and has a Degree in Health Services Management and is also a qualified nurse. We spent a lot of time with the registered manager who is very positive about all of the staff working at the Margaret Thatcher Care Homes for Older People Page 29 of 37 Evidence: Infirmary and told us she is dedicated to providing a comfortable, warm and friendly environment making sure that all residents are cared for and the quality of service provision is very high. We were told by the registered manager that she attends training on a regular basis making sure that she is up to date with all training. The Margaret Thatcher Infirmary opened in January 2009, we were told by the registered manager that all residents are liaised with on a regular basis to make sure they are happy with the care and support provided by the home. There is a quality assurance procedure that is being implemented We looked at external audit records that the registered manager had a company complete to ascertain if they were providing a good standard of care. The outcome of the audit was good and action plans were completed and actioned for areas that required improvement. We discussed Regulation 26 visit that are happening however the registered manager told us that the records had not been fully completed as they were making sure that all areas of the home was meeting the residents needs initially. We were told that Regulation 26 records will be fully completed form May 2009.The registered manager is at this present time setting up residents and relatives forums. We spent time with the almoner who supports residents with their finances.We looked at the finances of all residents, all of the records looked at on the computer system were correct showing the items purchased with receipts in place. The residents are encouraged to keep their own money, as there are lockable draws in each residents rooms. The almoner is requested by relatives to keep money for residents if they need to purchase any personal items.The system currently used needs to be up dated with the policy and procedure up dating showing financial assessments for each resident that monies are kept for and what banking procedure is in place and used by the home. We looked at a lot of records kept at the home that are kept in files in lockable filling cabinets in the units. There are also records kept on the computer system that are only accessible by using a password. We discussed some of the language written in the records with the registered manager as some of the language used was not acceptable. We were told by the registered manager that she will liaise with all staff to make sure they are aware of the correct language to use. We discussed all staff completing records completely and was told by the registered manager that she will make sure that all staff will be liaised with to make sure they are completing records appropriately with a date and signature. We looked at the health and safety records including fire safety, fire alarm checks, gas maintenance, water temperatures, food storage, medication fridge storage, legionella Care Homes for Older People Page 30 of 37 Evidence: checks. All of the records looked at were up to date and certificates of maintenance were in place. We spent time talking to one the maintenance officers who went through the check list of all of the maintenance checks that are completed on a weekly-monthly basis. All staff are fully trained in health and safety and infection control, moving and handling and are trained on all equipment in the home. The AQAA sent to the CQC had all of the information on health and safety showing that the home is a safe environment for people to live and staff to work. Care Homes for Older People Page 31 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 13 The registered manager must make sure that all risks identified in the residents assessment and care plan have an action plan in place. To show how staff are protecting the resident in minimizing or reducing a risk area. 27/06/2009 2 8 13 The registered manager 27/06/2009 must make sure that when a specific health issue has been raised and the resident must be monitored for food and fluid intake this is carried out and records made. To protect the resident and to make sure their health is being monitored as requested in care plan. Care Homes for Older People Page 33 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 9 13 the registered manager to make sure that instructions are clear on the MAR and dosage changes are rewritten. To avoid error and that there is clarity to which MAR is in use. 14/06/2009 4 9 13 The registered manager 01/08/2009 makes sure there is a review of pensioners who are selfmedicating. So that medicines are stored securely and are not allowed to stockpile. 5 9 13 The registered manager to make sure that regular audits are maintained to firmly establish accurate recording. To make sure that all staff are recording the correct information. 01/08/2009 6 9 13 the registered manager to make sure that there are local policies in place to manage drug errors and medicines when pensioners are on holiday or out for the day. To make sure that the pensioners are receiving the correct medication. 01/08/2009 Care Homes for Older People Page 34 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 12 16 The home to recruit 27/09/2009 sufficient activity staff to provide all residents with a person centered activity plan to meet their needs. To make sure that all residents have opportunities for stimulation through leisure and recreational activities. 8 35 20 The registered manger must 27/08/2009 make sure that the policy and procedure for handling residents money is up dated. To show how the home is protecting the residents finances. 9 37 13 The registered manager to make sure that all records are completed thoroughly. For the individual that has completed a record to sign and date it as appropriate. 27/06/2009 10 37 13 The registered manager to make sure that staff do not write inappropriate information in resideents records. To make sure that all records written show that staff respect the residents. 27/06/2009 Care Homes for Older People Page 35 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 That all parties work together to establish residents and their medication on to the same medication cycle. Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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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