CQC report explained · a nursing home
What the CQC found at Cloisters Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2020
Cloisters Care Home rated Good; inspectors found safe, kind and personalised care, with no evidence of harm from the concerns that prompted the inspection.
This was an unannounced focused inspection on 10 November 2020. Inspectors reviewed Safe, Responsive and Well-led. They spoke with people, relatives, staff and health professionals, observed care, and checked care records, medicines records, staff files and quality checks.
The home was rated Good overall and remained Good for Safe, Responsive and Well-led. People and relatives said they felt safe and were happy with the care. Inspectors found suitable staffing, safe medicines systems, detailed risk plans, clean premises and infection control measures that had been updated during the COVID-19 pandemic.
Care was described as personalised. Staff supported people's communication, activities, cultural and religious needs, family contact and end-of-life wishes. Inspectors also found that managers used complaints, accidents and other events to make improvements.
This was not a full inspection of all five areas. Effective and Caring were not inspected during this visit, so their previous ratings were used in the overall rating. The report says no evidence was found that people were at risk of harm from the concerns that led to the inspection.
Safe staffing
Inspectors found enough staff to keep people safe and meet their needs. Call bells were answered promptly, and extra one-to-one support was arranged for people at particularly high risk.
“There were enough staff working at the service to keep people safe and meet their needs.” from the report
Personalised care
Staff knew people well and took account of their choices, communication needs, cultural background, religion and personal preferences.
“People's needs were met in a personalised way.” from the report
Infection control
The home had updated infection control procedures during the pandemic. Inspectors saw cleaning, personal protective equipment and waste arrangements in place.
“There were systems to help prevent and control the spread of infection.” from the report
Quality oversight
Managers used audits, meetings, complaints, accidents and safeguarding events to identify improvements. They also worked with families and other health professionals.
“There were effective systems for monitoring and improving the quality of care.” from the report
Staff breaks
minorOne staff member said they did not feel they had adequate breaks. The manager said breaks were allocated and agreed to discuss this again with all staff.
“One member of staff said they did not feel they had adequate breaks.” from the report
- 01What action was taken after the inspection to make sure all staff receive adequate breaks?
- 02How are visiting arrangements currently managed, and what alternatives are offered if visits cannot take place?
- 03How does the home check that the risk plans for falls, choking, nutrition, hydration and skin care are followed?
- 04How are medicines given covertly reviewed, and how are families involved in best-interest decisions?
- 05How does the home support people receiving end-of-life or palliative care, including their religious and personal wishes?
This was a focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 2 December 2020 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, March 2018
Cloisters Care Home was rated Good; inspectors found kind, safe and responsive care, with improvements since the previous inspection but some medicines and record-keeping issues.
This was an unannounced, comprehensive inspection on 12 February 2018. Inspectors spoke with people living there, visitors, staff and managers. They observed care, checked the building and equipment, and examined medicines, care plans, staff records and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe care, suitable training, kind treatment, personalised support and effective management systems.
The home had improved since the previous inspection in June 2017, when it was rated Requires Improvement overall and in Safe and Responsive. Inspectors found that the necessary improvements had been made.
There were still some weaknesses. One person's pain-relieving patch had not been given when due, records about medical patches were incomplete, and some care records were not easy to use. Managers took action during or after the inspection.
Kind and respectful care
Inspectors saw staff treating people kindly and respectfully. People and visitors said care was compassionate and their privacy was respected.
“People were treated with kindness, respect and compassion.” from the report
Improvement since the last inspection
The home had acted on the areas for improvement identified at the previous inspection. Its overall rating and all five key-question ratings had improved to Good.
“At this inspection we found the provider had made the necessary improvements and we have rated the service Good in all key questions and overall.” from the report
Trained and supported staff
Inspectors found staff had the skills and knowledge needed for their roles. Staff described receiving induction, ongoing training and support from managers.
“People were cared for by staff who had the skills, knowledge and experience required to deliver effective care and support.” from the report
Personalised support
Care plans included people's preferences, interests, culture and religion. People were offered choices about daily care, meals and how they spent their time.
“People received personalised care which was responsive to their needs.” from the report
Active quality monitoring
Managers used audits, meetings, surveys and action plans to identify issues and make changes. The provider also reviewed incidents and shared learning.
“The provider had effective systems for assessing risks, monitoring quality and making improvements.” from the report
Medical patch error
seriousOne person had not received their most recent prescribed pain-relieving patch. Staff also did not record where patches were applied or when they were removed. The provider investigated and introduced stronger monitoring systems.
“We found that this person had not been administered the most recent patch.” from the report
Care records were not always clear
needs fixingSome daily care records and care plans were unclear, making it harder to find information about people's current needs. The manager knew about this and was working to improve record keeping.
“Some of the records of care provided and the care plans were unclear and it was not always easy to access information about people's current needs.” from the report
Concerns about risks from other residents
needs fixingSome visitors were worried that their relatives might be at risk from other people living in the home. The manager had identified the issue, arranged extra supervision and was working with the commissioning authority to reassess people's support needs.
“Some visitors told us that they were concerned that their relative was at risk from other people who lived at the service.” from the report
- 01How are prescribed medical patches checked, recorded and followed up if a dose is missed?
- 02How will you make sure care plans and daily records clearly show each person's current needs?
- 03What extra supervision is provided for people whose behaviour may cause anxiety or risk to others?
- 04How are staffing levels reviewed when people's needs change or there are falls and other incidents?
- 05How will the home show families that actions from audits, complaints and incidents have been completed?
This was an unannounced comprehensive inspection covering all five key questions, and the home and the care provided were both looked at. This explanation was written from the published report of 10 March 2018 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 Cloisters Care Home
8 rated inspections over 5 years: the service has improved, from Inadequate to Good.
- December 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2017Requires improvementstayed Requires improvementSafe: Good
- June 2016Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- November 2015Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015Inadequatestayed InadequateSafe: InadequateEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 1 March 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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