CQC report explained · a nursing home
What the CQC found at Margaret Thatcher Infirmary
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, March 2022
Margaret Thatcher Infirmary was inspected but not rated; inspectors found strong infection control overall, but some records and mask use needed improvement.
This was a targeted inspection on 17 February 2022. It looked mainly at infection prevention and control during the COVID-19 response, and at whether staffing pressures were affecting care. The visit was announced with less than 24 hours' notice.
Inspectors were assured about most infection control arrangements. The home was clean and hygienic. Visitors were checked, testing was in place, staff understood outbreak procedures, and visits were supported safely, including essential caregiver visits.
There were some shortfalls. The home was not recording evidence that visiting professionals' vaccination status had been checked. Cleaning records were not always completed, and inspectors saw staff not following best practice with face masks on a couple of occasions. The provider acted immediately on the vaccination records and said it would address the other issues.
Safe visiting
Visitors had entry checks, testing arrangements and designated visiting areas. Relatives were kept updated and could become essential care givers.
“Relatives were supported to become essential care givers in line with current guidance.” from the report
Clean environment
Inspectors found the home clean, hygienic and without unpleasant smells. Extra professional deep cleaning had been arranged during positive cases.
“The home was very clean, hygienic and free from odour.” from the report
Staff support
Staff received regular updates and had access to wellbeing support, including an employment assistance programme, helplines and counselling.
“Staff had access to an employment assistance programme and helplines if needed, with a focus on staff wellbeing.” from the report
Visitor vaccination records
needs fixingThe home checked visiting professionals' vaccination evidence but did not have a system to record that this had been seen. The provider updated the visitors book the following day.
“they did not have a system in place to evidence they were checking the vaccination status and recording they had seen the relevant evidence.” from the report
Incomplete cleaning records
needs fixingAlthough the home was clean, inspectors found that cleaning records were not always completed. The provider said this would be addressed and new templates were being developed.
“Although there were cleaning schedules in place and the home was clean and hygienic, cleaning records were not always completed.” from the report
Some incorrect mask use
needs fixingInspectors saw staff not following best practice with face masks on a couple of occasions. Staff were reminded about wearing masks correctly.
“we observed a couple of occasions throughout the day where staff were not following best practice.” from the report
- 01How do you now record that visiting professionals' COVID-19 vaccination evidence has been checked?
- 02Are cleaning records now completed consistently, and how do managers check this?
- 03What checks are in place to make sure staff wear face masks correctly throughout each shift?
- 04What staffing pressures were present during the inspection, and what measures are in place to reduce their impact on residents?
- 05How will you show that the actions promised after this inspection have been completed and maintained?
This was a targeted inspection of infection prevention and control and staffing pressures during the COVID-19 response; the other care questions were not assessed. This explanation was written from the published report of 22 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2019
Margaret Thatcher Infirmary was rated Outstanding overall; inspectors found exceptionally caring, effective and responsive support, with safety rated Good.
This was an unannounced inspection over three days. Inspectors spoke with 27 people, five relatives and 30 staff. They reviewed care records, staff files and management records, and observed care.
The home was rated Outstanding overall. Inspectors found especially strong care, healthcare support, activities, end-of-life care and leadership. People and relatives were very positive about staff and the support provided.
Safety was rated Good. Inspectors found robust safeguarding, risk management, staffing, medicines and infection control arrangements. The other four areas were rated Outstanding.
The previous overall rating was also Outstanding. Effective care improved from Good to Outstanding, while Safe stayed Good and Caring, Responsive and Well-led stayed Outstanding.
Kind and respectful staff
Inspectors saw staff build warm, meaningful relationships with people. People and relatives said staff were compassionate and often went beyond what they expected.
“People and their relatives were extremely positive about the caring and compassionate nature of the staff that supported them.” from the report
Strong healthcare support
The home offered on-site GP access and a broad range of health and therapy services. Inspectors saw referrals and changes in care being made promptly when people's health changed.
“People had access to a vast range of healthcare services on-site to help manage their health and wellbeing.” from the report
Meaningful activities
People could take part in many activities, clubs, trips and events. The home also used art and music therapy to help people who were less socially engaged.
“People benefitted from an excellent variety of activities and events that were available across the service and made accessible to all.” from the report
Personalised care
Care plans focused on what was important to each person, including their routines, preferences and life history. Staff adapted support for dementia, communication and changing health needs.
“Care planning was based on 'What is important to me', which included information about people's daily routines, skills, preferences and what others liked and admired about them.” from the report
End-of-life care
Inspectors found detailed planning, specialist training and close work with the hospice and families. The provider had achieved the highest stated accreditation status in the Gold Standards Framework.
“The provider was externally recognised as providing outstanding care at the end of people's lives.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently make sure staffing levels remain sufficient on every ward, including when staff are covering breaks or extra support is needed?
- 02How quickly can residents see the on-site GP or other healthcare professionals when their health changes?
- 03How do you tailor activities and trips for people who live with dementia, have mobility needs or prefer quieter activities?
- 04How are families involved in advance care planning and end-of-life decisions?
- 05How do you currently monitor medicines, falls, safeguarding concerns and other incidents, and what changes have been made since this inspection?
This was an unannounced inspection of the care home, including the premises and care provided; the report also mentions a separate domiciliary care service for people living elsewhere at the Royal Hospital Chelsea. This explanation was written from the published report of 8 August 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Margaret Thatcher Infirmary
2 rated inspections over 3 years: the service has held its Outstanding rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Outstandingstayed OutstandingSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- November 2016OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Kensington and Chelsea
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,270 a week. 79 can care for a couple. 12 years' experience on average.
“The quality of life that she's given my parents has been priceless. The peace of mind she's given my sisters and I, through a very difficult time, has been invaluable.”
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