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

Systems and processes for monitoring and improving the quality of the service were not always effectively implemented. Risks were not always monitored or mitigated. The management team recognised where some improvements were needed and had started make these improvements.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt the culture in the organisation had not always been supportive or compassionate. Staff explained they had not always been listened to. Before our visit to the service, we received whistle blowing concerns, where the staff could demonstrate they had previously raised these issues with leaders within the organisation but these had not been addressed. The staff did not always have the training and support they needed to provide good quality care. However, the staff demonstrated respect for each other and for the people they were supporting. They understood about equality and diversity and wanted to provide compassionate care. Local managers had not always felt supported by senior managers within the organisation. Some of the decisions they made had not been listened to or acted on. There was an insufficient handover between managers when the new manager started meaning they did not have all the information they needed to help them safely manage the service. The previous manager for the service had carried out investigations into incidents and complaints. They had shown us records of discussions with senior managers which showed their findings had not been listened to or acted on. The operations director explained they recognised there needed to be an improved culture and support for managers and staff at the service. They had started to make changes to help the staff feel more supported and involved.

There were a range of policies and procedures that reflected regulations and good practice guidance. These were available for staff to view. However, these had not always been implemented effectively. People did not always receive safe or appropriate care which met their needs and staff did not always receive the support and guidance they needed.

There was no registered manager at the service. A new manager had started work shortly before our inspection. The operations director who was overseeing the service had started to introduce a range of changes and improvements. However, managers had not identified or mitigated some of the risks to people's safety and the quality of care.

Staff told us they felt supported by each other and they knew how to speak up and raise concerns with managers. However, they had not always felt supported by the management structure at the organisation. Staff had not yet had time to make judgements about the new management structure at the service. We found that staff had sometimes lacked direction and guidance from managers. This had resulted in a lack of consistent work and approach. As a result, some people had not received the right care and treatment when their needs changed. A lack of management oversight had led to risks for people using the service.

Before our inspection visit, we had received feedback from some staff that they were not always listened to when they spoke up about things that were wrong. We saw records which showed their concerns had not always been acted on. The operations director told us they recognised this had been an issue. They wanted to improve the way staff felt about this and to enable them to speak up.

There were polices and procedures for staff to whistle blow and people to raise concerns. The provider had recently taken steps to improve how information about these was shared with staff. Including posters and distributing information. They also created a whistleblowing email address which staff could contact anonymously if they wanted to raise concerns. However, these systems had not been embedded or tested at the time of the inspection.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff did not always feel supported by leaders or feel confident in governance processes. Some staff felt positive about support from local managers, however, they told us they had not had clear direction or support from the organisation and senior managers. The staff had not always been supported through processes such as clinical supervision and meetings to ensure they identified risks or were involved in improving quality of care.

Systems to monitor and improve quality and to monitor and mitigate risks had not always been implemented effectively. This meant that complaints, accidents, incidents, and other adverse events had not always been investigated or responded to completely. This placed people at risk of receiving unsafe care or care which did not meet their needs. The provider was not meeting all standards of good quality care including assessment and planning of risks and care needs, providing personalised care and support and deploying staff to meet people's needs. There were risks relating to medicines management and people's health and wellbeing. Therefore, people did not always receive good quality or safe care. The registered manager had left the service in 2023 and there had been several months with different temporary managers overseeing the service. This had impacted on responding to concerns, making improvements, and providing consistent quality care. There had been a lack of governance oversight and this meant that some people had experienced poor outcomes and not had the care they needed in a timely way. A new manager started working at the service in February 2024. They had not applied to register with CQC at the time of the inspection.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The operations director described recent systems they had introduced to help improve quality of care. These included senior managers carrying out audits and supporting the local management team to make improvements. These systems had not been embedded at the time of our visit. This meant people remained at risk of unsafe care or care which did not meet their needs.

The systems and processes for improving quality had not always been effective. Whilst recent audits were starting to identify problems, these had not been robust enough and improvements were still needed. People were placed at risk by risks which had not been identified or mitigated. For example, the way their medicines and health were being managed, how staff were deployed and how their care was planned.