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

People were not always safe because risks were not always assessed, monitored or managed. Accidents, incidents and other adverse events were not always investigated or learnt from. Medicines were not always safely managed. There were processes for identifying and responding to safeguarding concerns and these were effectively implemented. However, the provider had not always safeguarded people against the risks of inappropriate use of covert medicines. People lived in a safe and generally clean environment. However, some improvements were needed within the environment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Before the inspection visit, some staff and relatives had raised concerns that their complaints were not always listened to and acted on. During the visit, some people and relatives also voiced concerns about this, with one person telling us, ''When we had a problem with a care worker, my friend made a complaint. It took a while for them to do anything about it. It was awful.'' However, other people told us they felt they could raise concerns.

The operations director told us they recognised there had been problems with timely responses to some complaints and concerns. This was in part due to changes in the management of the home and senior line management. They explained they aimed to address these issues and improve the response to complaints and other adverse events.

There were systems for staff to record all accidents, incidents, and adverse events. However, these systems were not always followed. For example, records were not detailed enough, contained generic information, and did not analyse what had gone wrong. These records had not always been reviewed, assessed or seen by managers. Actions to make improvements had not always been recorded or taken. For example, a recent accident report showed that a person had fallen from their wheelchair. There were no details to explain what had happened, no analysis of why this had happened and no plan to prevent reoccurrence. There were not always lessons learnt or follow up actions for complaints which had been received. Clinical risk meetings had not always taken place and staff had not had regular supervision to help them learn and improve practice when things went wrong. This meant that systems were not always effectively implemented to monitor and improve quality of care or to mitigate risks.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The staff understood about safeguarding procedures and whistle blowing. They explained they had undertaken training about abuse and knew how to recognise and report this.

There were procedures for safeguarding people. When there had been allegations of abuse, the provider had worked with the local authority to investigate these. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

People using the service and their relatives told us they felt safe. One person explained, ''I feel safe. The staff are always there for you if you need them.''

Risks to people's safety and wellbeing had not always been assessed or planned for. For example, some people became physically or verbally aggressive. Assessments and plans about how to support them were incomplete. These did not give enough guidance for staff to help keep them safe. Staff did not always record incidents of aggression, why these had happened or how they supported people. Charts designed to help monitor people's needs were not completed accurately and therefore staff were not able to develop plans based on people's experiences. Staff did not always follow plans to help keep people safe. For example, a number of people needed support to change positions in order to prevent skin damage. Records showed that people had not been supported as often as they needed. This meant people were placed at risk. Some risk assessments were not accurate and did not reflect people's needs. For example, assessments for people who had diabetes did not always record best practice for keeping people safe and managing the risks associated with this. One person had a very low body mass index indicating they were at nutritional risk. Their care plan did not contain a detailed or personalised risk assessment relating to this. Information about their nutritional needs was inaccurate and did not highlight the level of risk. The staff had not escalated the concerns relating to a sudden change in body weight to appropriate medical professionals to help mitigate risks for this person. Assessments and care plans did not always link information or give clear guidance on how risks should be managed. The risk rating assigned by staff when assessing risks was not always accurate. For example, one person was at risk of harm to themselves and others. However, the staff had rated the risk as low in their assessment. Failure to assess, monitor and mitigate risk meant that people did not always receive safe care or treatment.

Risks to people's safety were not always well managed because these had not been fully assessed, planned for, or understood by trained staff. Some people living at the service had dementia, some people had other mental health needs and some people expressed themselves through agitation. The staff did not have the right skills or understanding about their needs. They did not provide proactive strategies to help people feel safe and secure. Whilst their responses were kind and well-meaning, they did not always mitigate the risks for people's safety and wellbeing. Therefore, people's experience was that risks were not always well managed.

During our visit we saw that some people were left unsupervised for long periods of time. Whilst staff were available within the units, people did not have the right support when they became distressed. We observed some people becoming agitated with each other. Staff intervened to stop physical altercations, but there were no proactive strategies to mitigate the risk of this happening again. When one person expressed distress, staff offered to put the television on and then left. The person remained distressed afterwards and was left without supervision or support. This meant people were at increased risk of harm and their needs were not being met.

Staff told us they did not have time to effectively manage some risks. For example, staff spoke about people becoming agitated with each other and how they were not always able to prevent this because they did not feel there were enough staff to help keep people safe. This meant people were at increased risk of unsafe care and treatment. The operations director told us they were arranging for staff to have more training and support to understand people's needs and the risks associated with these.

Some of the risks within the environment were not being well manged. For example, call bells designed to be used to alert staff in an emergency were not always within people's reach and had been tied up in bathrooms so they could not be accessed. Some furniture and furnishings were stained, marked or damaged. For example, tiles in some bathrooms had cracked and were missing. Throughout the building there were some features designed to make the environment more attractive and stimulating. However, there were also areas where the décor needed replacement, renovation or improvements.

The staff and managers told us they took steps to keep the environment safe. The operations director told us they had identified issues with the way call bells were placed and they were reviewing practice to make sure call bells were accessible when needed or make alternative arrangements when people were not able to use these.

The operations director explained the organisation was in the process of agreeing a refurbishment programme which would include upgrading some of the bathrooms and other communal areas. A senior manager had carried out an assessment of the environment and was working with maintenance staff to identify and address risks. The provider carried out regular checks on health and safety. There were appropriate assessments in place, including emergency plans and procedures to safely evacuate people in the event of an emergency.

People were able to move safely around the environment. There were grab rails and specialist equipment available to support people who needed these. People were provided with specialist beds, hoists, and other equipment. There were coded doors to help restrict access to stairways and front door. The front entrance was monitored by CCTV.

People's needs were not always being met because staff deployment did not reflect these needs. The provider used a dependence tool to calculate the numbers of staff they needed. This used data from people's risk assessments. However, we identified that some risk assessments did not fully calculate the level of risk for people and therefore this could mean the tool for calculating staffing did not always reflect people's needs accurately. For example, one person who was often agitated and confrontational with others had been assessed as low risk regarding these challenges even though they and others could be placed at harm. Staff were not always supported because systems to provide support were not always effectively implemented. The provider had processes for supporting staff through regular supervision and meetings. These processes had not always been followed. Records indicated most staff had not had clinical or individual supervisions to discuss their work and reflect on practice at all, or not had this for several months. Processes to discuss accidents, incidents and complaints so these could be learnt from were not always followed. This meant staff were not effectively supported to learn from these. We identified people's clinical needs had not always been met. The provider had not always taken enough action to assess, monitor and check the clinical skills of staff or to help them learn and improve these. The staff undertook most of their training via online courses. This meant they did not always have the opportunity to support each other through shared learning experiences. Nursing staff were not always provided with regular opportunities to improve their knowledge and clinical skills. Although, the operations director told us they had started to organise extra training for nurses and other staff.

The deployment of staff did not always meet people's needs. All the care and nursing staff we spoke with told us they did not feel there were enough staff to meet people's needs. Their comments included, ''We are struggling and always short staffed'', ''There are not enough staff to help people to do the things they want to do, like individual activities'', ''We hardly have time to sit and talk with residents'' and ''Sometimes it is difficult to do our work.'' Staff were not always well supported. Staff told us they did not always get formal support from managers through supervision or appraisal. They told us they felt there was good informal support amongst colleagues, but they did not have opportunities to discuss their work and reflect on this with managers or senior staff. Staff did not always have the skills needed to provide safe care. Staff told us they had completed online training courses, but they would like more opportunities for in person training. One staff member told us, ''We asked for more face-to-face training because it is good to be interactive.'' Another staff member explained, ''I have not had training for a very long time.''

People using the service and their relatives told us they did not always feel there were enough staff to meet their needs safely and well. Some people told us staff were rushed when providing care and support. They also explained staff did not spend quality time with them. One person told us, ''They don’t spend long here really, they do what they have to do and then they are gone.'' Another person commented, ''There's no messing around, they scrub you clean, you don’t really get a say in it and it is done quickly.'' Some people told us there were not always enough staff to offer drinks when they wanted them. One relative commented that people did not always get support to use the toilet when they needed to.

We observed people were left alone and left without staff interactions for long periods of time. Staff checked on people but did not spend time engaging with them. Some people were left without drinks and commented that staff were not available to provide them. Our observations demonstrated staff were not deployed in a way to meet people's needs. Staff interactions with people were kind and pleasant, although they were often rushed and time limited.

People told us they lived in a clean environment. They were happy with the standard of cleanliness. Their comments included, ''The cleaner does every nook and cranny. She always asks if it is ok to hoover in case it is too noisy'' and ''They are always cleaning.'' People's visitors also commented on the good standard of cleanliness.

The management team explained they carried out regular infection control audits. Staff understood about good infection prevention and control. They had training to help them understand this and followed good hand hygiene practices.

We observed staff cleaning the environment throughout the day. The living environment looked clean and smelt fresh. However, some improvements were needed to the storage arrangements in the kitchen because we found used mops stored near food preparation areas. We discussed this with the management team. They had already identified this as an issue and shared their plans for updating the kitchen environment to allow for better storage arrangements. Some of the bathrooms were used to store equipment. This meant that areas of the bathrooms had not always been well cleaned. We also discussed this with the management team who were looking at ways to address this problem.

There were regular audits of infection prevention and control. These included checks on equipment, the environment, and staff practice. Where problems were identified, action had been taken. Staff and people using the service were supported to access vaccinations against seasonal flu and COVID-19. There was enough personal protective equipment (PPE) and staff knew how and when to use this.

People did not always receive their medicines safely and as prescribed. Care plans for medicines were not always person-centred. Care plans contained generic information about medicines. For example, the care plans about medicines that were prescribed to be given when required, such as pain relief, did not always state when these should be administered or how staff should recognise when the person was in pain. The provider did not always take steps to minimise the risk of using excessive and inappropriate medicines to control people's behaviour. For example, 1 person was receiving a 'when required' medicine on a daily basis. Records did not indicate whether other de-escalation techniques had been used to reduce the need for ‘when required’ medicine. The staff were polite and caring when administering medicines. They recorded the administration of medicines in a timely manner. However, we saw staff did not follow best practice when checking high risk medicines. Staff had access to information about people's allergies and people's preferences on how to take medicines, as well as recent photographs of people to help make sure they were administering medicines to the right person. We saw staff administer medicines in a way people preferred. Areas where medicines were stored were clean, tidy and secure. However, in the medicine cupboard we found one medicine that had expired. This was highlighted to staff to be disposed.

Staff informed us they received training and had their skills, knowledge and competency assessed to make sure they could handle medicines safely. However, we saw that competency assessments had not always been completed or signed by an assessor. Concerns had been raised about the service not administering controlled medicines in line with best practice. The management team told us they were in the process of training more staff to help support nurses in administering medicines appropriately. Staff told us they had a good relationship with the local pharmacy when ordering medicines and could contact them to deliver urgent medicines when needed.

The provider had not always escalated concerns about people's health to a doctor when required. There had been instances when people who had diabetes had experienced worsening symptoms and another incident when a person had lost a significant amount of weight. The staff had not contacted the relevant health professionals to make sure these concerns were addressed and that their prescribed medicines remained right for them. This put people at risk of harm. Staff were not able to access or refer to records the visiting doctors had made about people's health conditions. Therefore, this information had not been recorded in care plans to make sure people were receiving safe and effective care. This placed people at risk of harm. The staff did not always follow best national guidance when supporting people who lacked the mental capacity to understand their medicines and who also needed medicines to be administered covertly (without their knowledge). The provider had not always sought pharmacy advice on the covert administration of medicines was being followed. In addition, some medicines were being given covertly when no agreement for this had been recorded. Medicines were not always stored within the correct range of temperatures. The staff checked and recorded the current temperature of the medicine storage room and refrigerator daily but did not record the maximum and minimum temperatures and therefore did not have a record of the varying temperatures throughout the day. Regular medicines audits had not been completed. Therefore, the provider could not assure themselves that they were delivering safe and effective care. The management team told us they were in the process of introducing new medicines audits. In the past few months the provider had been alerted to concerns about medicines management by a whistle blower. Despite these concerns, they had not effectively implemented a system of regular medicines audits in a timely manner.