Cloisters Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. There were not enough improvements found at this assessment, and the provider remained in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to staffing. There were not enough improvements found at this assessment, and the provider remained in breach of this regulation.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were systems to help staff learn when things went wrong, such as accidents and incidents. Staff reported these on an electronic system which the managers and senior managers viewed. Records showed that appropriate action had been taken following adverse events, that these were investigated and that lessons were learnt. Actions included debriefs for staff, updating care plans and risk assessments and, if needed, retraining or supervising staff. The staff confirmed that they discussed accidents and incidents so that they could all learn from these. People using the service and their relatives told us the provider had apologised when things went wrong.

People were supported with safe transitions and pathways. Managers or nurses carried out assessments before people moved into the home and this included speaking with them, their families and professionals involved in their care. They developed profiles which they shared with other healthcare professionals to describe people’s needs, including health and communication needs. This helped to make sure professionals who did not know people had essential information. The provider had worked with hospitals and other care services to support people when they were moving between services.

People using the service and their relatives told us they felt safe. Their comments included, “They [staff] are all lovely and I feel safe’’, “It seems safe enough’’ and “It is safe. At least I think it is. They [staff] do check up on you.”

However, 2 people described incidents where a member of staff had told them to go to bed and not to use their call bells. One person explained they had reported this to another member of staff. However, the management team explained they were not aware of this. The manager told us they would investigate the concerns and address the issue with staff.

There were systems designed to protect people from abuse. The provider had procedures. Staff were trained to understand these. Staff discussed these procedures during meetings with the manager to ensure they understood how to recognise and report abuse. The provider had worked with the local safeguarding authority and others to help investigate allegations of abuse and protect people from further harm.

The provider had obtained legal authorisations regarding restrictions placed on people who lacked the mental capacity to make decisions about their safety or aspects of their care. These authorisations (known as Deprivation of Liberty Safeguards – DoLS) were regularly reviewed and monitored to ensure they remained appropriate for the person.

At our last assessment, we found that risks were not always well managed. At this assessment, we found that whilst some improvements had been made, some risks were not being safely managed. Whilst risks to people’s safety and wellbeing had been assessed, the management plans were not always detailed enough to ensure staff knew how to mitigate these risks. For example, some people became anxious and shouted or acted in a way that caused concern to others. The guidance for staff was not detailed enough and as a result they did not always know what to do or how to manage situations. Charts designed to help monitor people's needs were not completed accurately. This meant staff were not able to develop plans based on people's experiences. This was a continuing breach of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Other risks such as those relating to healthcare needs, mobility and nutrition had been assessed and planned for. Most plans were appropriately detailed and showed decisions had been made in a person-centred way to promote people’s independence and keep them safe. Staff had the training they needed to understand about safe care and treatment. We observed staff supporting people in a safe way and in line with best practice.

People lived in a safe and well-maintained environment. They liked their rooms and communal rooms. People were able to personalise their rooms and bring their own belongings if they wanted. People had the equipment they needed for safe care. This was regularly checked to make sure it was working. The staff assessed people’s individual needs to make sure equipment was appropriate and the least restrictive options for them.

Communal rooms and corridors were attractively decorated. The provider was in the process of improving signage to help orientate people. The provider had a programme of refurbishment and decoration to attend to repairs and wear and tear.

At our last assessment, staff were not always effectively deployed to meet people’s needs. At this assessment, there were still times when people’s needs were not being fully met due to staff deployment. People told us staff were often rushed and did not spend quality time with them. For example, 1 person explained that when they were being supported with medicines, they felt rushed and found it hard to swallow their tablets because they did not have enough time. Comments from people and their relatives included, “The main problem here is not enough staff. The staff are very nice but there are not enough of them”, “Personally, I think they need more staff. They don’t get a minute to themselves. I just don’t think they have the time to spend with people who have extra needs’’, “They are always short of staff. They try their best, but they don’t have much time to spend with you.’’

We witnessed times when there were not enough staff available to support people. For example, at one point a single staff member was trying to deal with a situation where several people required support. The staff member was unable to meet everyone’s needs. A different staff member commented, “Sometimes we have to leave the lounge unattended because we have to [provide] support elsewhere.’’

Staff told us there were times of the day and night when they struggled to meet people’s needs. Comments included, “I feel we need another staff [member] as anything can happen. I feel guilty because there is not enough time to chat to the residents’’, and “On this floor there is dementia and there is a risk of falls, or anything could happen like challenging behaviour could happen between 2 residents meaning they could get hurt.” The way in which the staff were deployed was not always safe and effective. This was a continuing breach of Regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were systems to help prevent and control infections. Staff were trained to understand how to apply these. There were procedures to ensure the building and equipment were regularly cleaned, for audits of cleanliness and for staff to follow good hand hygiene. Staff were provided with personal protective equipment (PPE) such as gloves and aprons. They wore these when needed. People using the service and their relatives explained the environment, including their bedrooms, were kept clean. Their comments included, “It’s cleaned every day, and a lovely lady comes in to do it. We have a chat with her we look forward to that’’, ‘’They are always cleaning here’’, ‘’When there is a mess it normally gets sorted right away’’ and “It’s cleaned well. They use gloves and masks. I am happy with that.’’ We observed good levels of cleanliness and staff following appropriate procedures to minimise the spread of infection.

Medicines were not always safely managed. The service did not always ensure topical medicines were applied in line with manufacturer’s guidance. For example, we saw application sites of medicated patches for Parkinsons not being rotated in line with guidance. This could lead to skin damage. Controlled drugs were not disposed of in line with guidance. For example, single use destruction kits for controlled drugs were used multiple times. This meant that they were not always effectively destroyed, and this presented a risk.

Care plans and risk assessments did not always include information on the risks of some medicines, such as anticoagulants (medicines used to thin the blood).

However, we found that people were receiving medicines as prescribed, including time critical medicines. There had been improvements since our last assessment, for example staff were making timely referrals following concerns about people’s blood sugar levels.

Staff were given induction, and training and were competency assessed to handle medicines safely. They told us they received further external training in complex areas of medicines and care management such as epilepsy, Parkinson’s and end of life care.

The service ensure that people’s medicines were reviewed regularly.