Cloisters Care Home

On this page

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. 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 was a positive and inclusive culture at the service. People living there, relatives and staff expressed they were happy. An external professional told us, “There is a kind approach, and I hear good things about the nurses.’’ A relative told us, “I am very happy with how things are, they do what they can to take care of [Person]” and a staff member commented, “I love it. I am very happy here.”

The provider had clear values and aims for the service. Staff were aware of and understood these.

The service was appropriately managed. There was no registered manager at the time of our assessment. However, the manager had applied to be registered with CQC. They had experience managing other care homes and were a registered nurse. They had a good understanding about the service and where improvements were needed. People living there, relatives and staff knew who the manager was and found them approachable. Their comments included, “The manager tries [their] best to support us”, “The manager is hands on and works as part of the team”, “[Manager] is very supportive and eager to listen to us. It makes a big difference” and “The manager helps out with care when needed.” The manager was supported by a robust senior management structure and governance team who regularly visited and monitored the service.

There were procedures for speaking up and staff were familiar with these. Staff told us they felt confident speaking up.

There were procedures to help protect staff and make sure they felt included. There was a diverse staff team, and they told us the provider supported them when they needed time off or extra support for caring responsibilities, religious festivals and fasting. Staff told us they were supported to access learning and information in a format which they understood.

At our last assessment, we identified breaches of Regulations in relation to good governance. At this assessment, we found that not enough improvements had been made, and the provider was still breaching this Regulation. Whilst they had systems and processes to monitor and mitigate risk, these had not always been effective because we found improvements were needed to safely manage risk and medicines management. The provider had systems to improve quality, and these had helped them to identify where some improvements were needed. However, we found that care plans and risk assessments effective because they were not always detailed enough or updated. We also found that staffing deployment did not always safely and effectively meet people’s needs. This was a continued breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The manager had introduced improvements to governance at the service. These included improved audits and better learning from incidents, accidents and things that went wrong. The manager carried out regular checks on the service and consulted with stakeholders. The provider’s quality team had developed a new system for monitoring the service, identifying risk and planning for improvements. This system had just started to be introduced at the home and changes had not been fully embedded. However, we saw that the system would be effective once fully operational.

The provider worked in partnership with other organisations. The manager met regularly with other care managers to discuss best practice and learning from adverse events. The staff worked with other professionals to help make sure people’s needs were met. There was a network of teams within the organisation who offered support and oversight of the service. The provider also met with local commissioners regularly. At the time of our assessment, the provider had invited members of the local community to an event to discuss future planning for the service and the type of service people living locally would want.

There were systems for learning. These included regular training sessions for staff, meetings and staff supervisions. The manager discussed learning from accidents, incidents and complaints with staff. There was a service improvement plan which was regularly reviewed and updated. There was evidence of learning and improvements. The provider had responded to our last assessment and made improvements to different aspects of the service. However, further improvements were needed and some systems needed to be embedded.