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Inspection carried out on 10 November 2020

During an inspection looking at part of the service

About the service

Cloisters Care Home is a care home with nursing for up to 58 older people. At the time of our inspection 55 people were living at the service. There were two units. One unit was designed for people living with the experience of dementia. The other unit was for older people with nursing needs. The provider also offered care and support for people at the end of their lives and those receiving palliative care.

People’s experience of using this service and what we found

People using the service and their relatives told us they were happy and felt safe. They liked the staff and felt their needs were being met. Some relatives told us people's health and wellbeing had improved since they moved to the service.

Risks to people's safety and wellbeing had been assessed, planned for and monitored. There was equipment designed to keep people safe and staff were appropriately trained to use this. We saw people being supported in a safe way. There were systems to learn when things went wrong, for example following accidents and complaints. The staff made changes to help keep people safe from further harm and minimise risks.

People received their medicines as prescribed from trained staff. The staff worked closely with other health care professionals to monitor people's needs and respond to changes in their health and wellbeing.

There were enough staff working at the service to keep people safe and meet their needs. The provider had systems for safe recruitment and training staff. The staff explained they felt supported and had the information they needed to care for people.

The environment was suitable. It was clean and there were systems for managing infection control and prevention. These had been updated in 2020 due to the COVID-19 pandemic. The staff wore personal protective equipment (PPE) and made sure they followed procedures to prevent the spread of infection.

People were cared for by staff who knew them well. Their needs were assessed and recorded in care plans. The staff had consulted people about their care plans and the review of these to make sure their choices and views had been captured. People were supported to take part in a range of different activities and events. There had been changes to visiting arrangements in 2020 due to the pandemic, but relatives we spoke with were happy with the arrangements and told us they had opportunities to see their family members. Care was provided in a personalised way, taking account of people's individual needs, such as their religion and cultural needs.

The provider offered care to people at the end of their lives. This meant sometimes people moved to the home from hospital for a short time before they died. The staff worked with palliative care teams and other professionals to make sure people were safe, comfortable and pain free during this time.

The registered manager was supported by a team of senior staff. They had regular meetings and discussions to help make sure they had a consistent approach and provided coordinated care. There were effective systems for monitoring and improving the quality of the service, including making changes following adverse events, such as complaints, falls and safeguarding alerts. The staff worked closely with other stakeholders and consulted people using the service and their representatives so they could make improvements based on their feedback.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (Published 10 March 2018).

Why we inspected

The inspection was prompted in part due to concerns received about people's care and safety. A decision was made for us to inspect and examine those risks.

As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key

Inspection carried out on 12 February 2018

During a routine inspection

The inspection took place on 12 February 2018 and was unannounced.

The last inspection was on 20 June 2017 when we rated the service Requires Improvement overall and in the key questions of Safe and Responsive. We did not find any breaches of Regulation, but we found that the provider needed to make improvements in order to achieve a Good rating overall.

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.

Cloisters Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Cloisters Care Home is registered to accommodate up to 58 people in one building. The building has two units. The ground floor is for people living with the experience of dementia who may also have physical healthcare needs. The first floor is for people whose primary needs are physical healthcare needs, including people who are being cared for at the end of their lives. At the time of our inspection 54 people were living at the service.

The provider, Advinia Health Care Limited, is part of the Advinia Healthcare Group, who manages 16 care homes in the United Kingdom.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People were happy living at the service. They told us their needs were met and they were treated with kindness and respect. Visitors explained they thought the service was well run and met people's needs. People were involved in planning their own care and were able to make choices about this.

The staff were happy working at the service. They felt supported. They had the training and information they needed to carry out their roles and responsibilities.

People received their medicines in a safe way. The risks to their safety and wellbeing had been assessed and planned for. The provider learnt from incidents and accidents and had made improvements at the service following these.

The environment was safely maintained, suitable and comfortable. The staff carried out checks on safety and on equipment being used.

There were procedures designed to protect people from the risks of abuse. People knew how to make a complaint, they felt the registered manager and provider listened to their concerns and took action when needed.

People were cared for in a way which met their needs and reflected their preferences. The staff worked alongside other professionals to make sure healthcare needs were being met. People had enough to eat and drink. They were able to participate in a range of social activities. There was evidence that some people's health and wellbeing had improved since they had lived at the service. People receiving care at the end of their lives were treated with dignity and respect.

The registered manager and provider's representatives were visible and well known. They operated effective systems for monitoring the quality of the service and making improvements. These systems included asking people using the service and other stakeholders for their views and opinions.

Inspection carried out on 20 June 2017

During a routine inspection

The inspection took place on 20 June 2017 and was unannounced.

The last comprehensive inspection of the service took place on 17 May 2016 when we found breaches of Regulation in relation to person-centred care and privacy and dignity. At the inspection of 20 June 2017 we found the provider had taken action to meet these breaches. We carried out a focussed inspection on 28 February 2017 to look at the way in which medicines were managed. This was following an incident relating to medicines management which was also investigated under the local authority safeguarding procedures. At this inspection we found that the service was managing medicines safely. We found this was still the case during our inspection of 20 June 2017 but we found that medicines were not always being stored at safe temperatures.

Cloisters Care Home is a nursing home for up to 58 older people. The ground floor is for people who are living with the experience of dementia and also have nursing needs. The primary needs of people living on the first floor were nursing needs, although some people also lived with the experience of dementia. The majority of people living on the first floor had complex needs with a variety of different medical conditions. Some people were being cared for at the end of their lives. At the time of our inspection 53 people were living at the service. The home is managed by Advinia Healthcare Limited, a private company who are part of a group which manage 16 residential and nursing homes and home care services in England and Scotland.

The registered manager had been in post since February 2017. They had previously worked at and managed other residential and nursing homes. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Some of the records at the service were not up to date and did not accurately reflect changes in people's needs. We discussed this with the registered manager who was aware of the situation and was in the process of addressing this issue. We found that despite some records not reflecting the most up to date needs of people, the staff were aware of their needs and met these.

We found some aspects of the service were not always safe. For example, we observed an incident where a member of staff almost gave someone a drink which was not safe for them. We also found concerns about medicines storage temperatures and the provider had not sought assurances from their pharmacy before we alerted them to do this. Some people felt that the service did not have enough staff. We found that there were enough staff to meet people's needs but at times the staff were under pressure to make sure people's needs were met when they needed. The environment was safely maintained but there was a malodour in some areas of the building.

People were mostly happy living at the home and felt their needs were being met. The staff were kind, caring and polite. They offered people choices and took account of their wishes and preferences. People's health was monitored and the staff worked closely with other healthcare professionals to meet these needs. People were able to make choices about a range of freshly prepared meals. People's capacity to consent had been assessed and the provider acted within the principles of the Mental Capacity Act 2005.

The staff were appropriately trained and supported. They worked well as a team and had the information they needed to carry out their roles.

The culture of the home was open and inclusive and people using the service, their visitors and staff were able to contribute their ideas and felt listened to. The provider had a number of audits which helped to monitor and improve the quality of the service. There had been impro

Inspection carried out on 28 February 2017

During an inspection looking at part of the service

The inspection took place on 28 February 2017 and was unannounced. The inspection was carried out by a pharmacist inspector to look at the way in which medicines were being managed at the home. This was because we had received information from the provider and the local Clinical Commissioning Group (CCG) about an incident relating to medicines which took place at the service.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Cloisters Care Home' on our website at www.cqc.org.uk.

The last inspection of the service was 17 May 2016. At this inspection we rated the service Requires Improvement because we found that people did not always receive care which met their social and emotional needs. Some of the staff did not always care for people in a person centred way or take account of their needs associated with having dementia. The staff did not always treat people with respect. The provider sent us an action plan telling us how they would make the required improvements.

The inspection of 28 February 2017 did not include a review of these previous concerns because it was a focussed inspection carried out by a pharmacist inspector to look at the management of medicines only. We will review other areas of the service at our next comprehensive inspection. Therefore we have not reviewed or changed the rating of the service at this time.

Cloisters Care Home is a nursing home for up to 58 older people with nursing needs. The ground floor was also for people who were living with the experience of dementia. The home is managed by Advinia Healthcare Limited, a private company who manage 16 residential and nursing homes and home care services in England and Scotland.

At this inspection we found that the provider had made suitable arrangements to ensure people were protected against the risks associated with the inappropriate treatment of medicines. People received their medicines as prescribed. Medicines were stored, administered and recorded appropriately.

Inspection carried out on 17 May 2016

During a routine inspection

The inspection took place on 17 May 2016 and was unannounced.

The last inspection took place 13 and 19 October 2015, when we found breaches of three Regulations relating to person centred care, good governance and the deployment of staff. At the inspection of May 2016 we found improvements in some areas, however, there were still risks that people did not receive care which was appropriate, met their needs and reflected their preferences.

Cloisters Care Home is a nursing home for up to 58 older people with nursing needs. The ground floor was also for people who were living with the experience of dementia. At the time of our inspection 52 people were living at the home. The home is managed by Advinia Healthcare Limited, a private company who manage 16 residential and nursing homes and home care services in England and Scotland.

There was a manager in post. She was in the process of applying to be registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People did not always receive care which met their social and emotional needs. Some of the staff did not always care for people in a person centred way or take account of their needs associated with having dementia.

The staff did not always treat people with respect.

You can see what action we told the provider to take at the back of the full version of the report.

People told us the staff were kind and caring. Most people felt their needs were met and people had consented to their care. We saw that people had detailed care plans which reflected their needs and preferences. Some of the care people received was kind and respectful. People were given the support they needed to stay healthy and eat well.

There were enough staff to support people and meet their needs. However, some of the time the staff did not work in a coordinated way so people had to wait for care. The staff received the training and support they needed to care for people and to understand their needs.

The service was appropriately managed and there were systems to audit and monitor the care people received. The provider responded to concerns raised by people, including taking action where we found they were not meeting the Regulations.

Inspection carried out on 13 and 19 October 2015

During a routine inspection

The inspection took place on 13 and 19 October 2015 and was unannounced.

The last inspection took place on 22 and 26 June 2015 when we found four breaches of the Health and Social Care Act 2008 and associated Regulations. We issued two warning notices telling the provider they needed to make the necessary improvements by 10 August 2015.

At this inspection we found that improvements had been made. The previous breaches and the warning notices had been met. However, we identified risks to people’s safety and wellbeing at this inspection.

Cloisters Care Home is a nursing home for up to 58 older people with nursing needs. The ground floor was also for people who were living with the experience of dementia. At the time of our inspection 48 people were living at the home. The home is managed by Advinia Healthcare Limited, a private company who manage 16 residential and nursing homes and home care services in England and Scotland.

There was a manager in post. She was in the process of applying to be registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

There were not always enough staff deployed to keep people safe and to meet their needs.

People’s capacity to consent and make decisions had been assessed and recorded. However, in a small number of cases the records relating to specific decisions did not always indicate whether there were discussions with a person who had been assessed as having capacity.

Although there was a range of organised activities, people’s individual interests, social and emotional needs were not always met.

The provider had not always identified and mitigated risks to people’s safety and wellbeing.

The provider had taken action to meet the concerns identified at the inspection of 22 June 2015 and had put in place measures to help keep people safe from harm.

We found that some people were at risk of choking and this had not always been managed appropriately, however, during the inspection the provider took action to remedy this and produced clear information and guidance for staff to ensure that people always received the individual support they needed.

Improvements had been made to the way in which people’s medicines were managed so they received their medicines as prescribed.

Improvements had been made to risk assessments and the way in which staff supported people to stay safe.

Improvements had been made to the maintenance and cleanliness of the environment.

The provider had appropriate safeguarding procedures and the staff were aware of these.

There were checks on staff suitability before they started working at the home.

The staff were appropriately trained and supported to carry out their roles and responsibilities.

People’s healthcare needs were appropriately assessed, monitored and met.

People’s nutritional needs were met.

Most of the staff were kind, considerate and polite towards people. They had good relationships with the people who they supported and their visitors. The provider had introduced staff training which helped them to experience what it felt like to be cared for and the staff told us this had given them a different perspective on their work.

Some staff worked in a task centred way, and although they were not unkind, they tended to focus on the task they were doing rather than the person they were caring for. The manager was aware of this and was providing more training and support for the staff to help them improve the way in which they cared for people.

The staff had assessed and planned care to meet people’s needs. They regularly reviewed these plans.

People knew how to make a complaint and felt confident their complaints would be investigated and acted upon.

There had been improvements in the care and treatment people at the home received and the improvements were continuous and ongoing.

The manager and the provider regularly audited the service and had plans to make further changes to the service. People living at the home, their visitors and the staff reported the culture and the atmosphere at the home had improved and was open and inclusive.

Following our last inspection, we placed the service in special measures. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. As the provider has demonstrated improvements and the service is no longer rated as inadequate for any of the five questions, it is no longer in special measures.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 22 & 26 June 2015

During a routine inspection

The inspection took place over two days on 22 and 26 June 2015. The visit on 22 June 2015 was unannounced. We notified the provider we were returning on 26 June 2015 to gather more evidence and to feedback our findings.

The last inspection of the service took place on 20, 22 and 26 January 2015 when the service was rated inadequate and we identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and one breach of the Care Quality Commission (Registration) Regulations 2009. At the inspection on 22 June 2015 we found that the provider had taken action to meet some but not all of these breaches. There was evidence that they had focussed on improving some areas of the service. However, they had not taken enough action in other areas and we identified additional areas where people’s safety and wellbeing were at risk.

Cloisters Care Home is a nursing home for up to 58 older people with nursing needs. The ground floor was also for people who were living with the experience of dementia. At the time of our inspection 55 people were living at the home. The home is managed by Advinia Healthcare Limited, a private company who manage 16 residential and nursing homes and home care services in England and Scotland.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The staff followed practices which put people’s safety and wellbeing at risk.

Parts of the environment were not clean.

People’s medicines were not managed in a safe way.

We observed and people told us that they were not always treated with kindness and respect.

People’s privacy and dignity was not always respected.

People’s emotional and social needs were not always met. People were not always given care in a personalised way which met their individual needs.

The provider had audits and quality checks which they carried out but these had not identified areas of concern and they had not taken action to mitigate the risks to the health, safety and welfare of people who lived at the home.

Some people felt the culture of the home was not always positive, whilst others were satisfied with this.

The provider had taken action to improve some practices. For example, they had made sure call bells were accessible, they had improved the records of risk assessments and they had taken action to minimise the risks of repeated accidents and incidents.

There were procedures for safeguarding vulnerable people and the staff, people living at the home and visitors were aware of these.

The provider had improved the systems for obtaining and recording people’s consent to their care and treatment. They had assessed people’s capacity to consent.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLs). DoLS provides a process to make sure that providers only deprive people of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them. The provider was aware of their responsibilities and had acted in accordance with the legal requirements.

The staff had regular meetings with their manager to appraise and discuss their work. They had been trained to understand their roles and responsibilities.

People’s nutritional needs had been assessed and recorded. They were provided with a choice and variety of freshly prepared meals.

We observed and people told us about some members of staff who were kind and caring and who took the time to listen to people.

People’s needs had been assessed and these were recorded in care plans.

The provider had a complaints procedure and had investigated and responded to complaints which had been made.

We found four breaches of the Health and Social Care Act 2008 and associated Regulations. We have taken against the provider for the breach of the Regulations in relation to the safe care and treatment of people using the service (Regulation 12) and the good governance of the service (Regulation 17).

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 20, 22 and 26 January 2015

During a routine inspection

This inspection took place on the 20 January, 22 January and 26 January 2015 and was unannounced.

Cloisters Care Home is registered to provide accommodation and nursing care for up to 58 older people. The ground floor caters for people living with the experience of dementia. At the time of our inspection there were 46 people using the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The provider did not meet all of the regulations we inspected against at our last inspection on 16 June and 17 June 2014. During the June 2014 inspection we found the provider was not meeting the legal requirements in relation to people’s views not being taken into account in relation to how the care was provided, their end of life wishes were not identified and staff did not receive training and support to provide appropriate care.

During this inspection we saw the processes used when recruiting staff were not completely effective. We saw references and employment histories of applicants were not always checked during the recruitment process. We have made a recommendation about the recruitment process.

We saw the provider was gradually introducing a new care plan format which was more focused on the individuals wishes and needs. They were also contacting relatives to be involved in the on-going review of these plans. We have made a recommendation about the implementation of the new care plans.

We saw there was a clear process and procedure in place for the storage, receipt and disposal of medicines that had been prescribed to people using the service. We saw the majority of Medicines Administration Record (MAR) charts were completed accurately but we did see the records for one person were not clearly recorded.

Emergency evacuation plans were developed for each person using the service and were kept in each person’s room.

Staff received training, supervision and support to ensure they were providing appropriate and effective care for people using the service.

Assessments of people’s needs were carried out before they moved into the home which were used to develop care plans and risk assessment. Staff completed daily records describing the care provided to each person.

Staff felt they were supported in their work and there was a good team atmosphere within the home.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to management of risk, implementing the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, communication, involving people in decisions about their care, activities and monitoring the quality of the service. You can see what action we told the provider to take at the back of the full version of this report. In regard to the breach of Regulation 16 of the Care Quality Commission (Registration) Regulations 2009, a Warning Notice was issued however the provider has now demonstrated they are meeting the requirements of the regulation.

Inspection carried out on 16, 17 June 2014

During a routine inspection

We spoke with two people using the service, three relatives, two members of staff, the deputy manager and the registered manager. At the time of the inspection there were 54 people using the service.

The inspection was carried out by an inspector over two days. This helped answer our five questions;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care plans had details of people's needs and how these were to be met. These plans were regularly reviewed by staff. Risk assessments related to the care and support being provided and were regularly reviewed to ensure people's individual needs were being met safely.

The medicines prescribed to people using the service were stored in a secure appropriate manner. We saw that the Medicines Administration Records (MAR) charts for all the people using the service were correct and information was clearly recorded.

The service had policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). This meant that the service had clear processes in place that managers and staff could follow if they were required to access the Deprivation of Liberty Safeguards.

Is the service effective?

There was no evidence that people using the service and their relatives were involved in the development and review of care plans so they could ensure that the plans were tailored to their needs.

The home did not have a system in place to identify and review people’s resuscitation and end of life plans. There were no care plans describing people’s wishes and what support they wanted at the end of their life.

Is the service caring?

We saw that staff did not always communicate and interact with the people using the service when providing care and support to them. People were not always treated with dignity and respect and were not involved in decisions relating to their daily care and activities.

Is the service responsive?

The home worked closely with the local palliative care nursing team to provide support for people using the service and their relatives.

Is the service well led?

The service had a quality assurance system in place. Records seen by us showed that any issues identified in relation to the quality of the care provided were acted on and as a result the quality of the service was continuingly improving.

Regular audits of the care plans and risk assessments were carried out and any identified actions had a completion date. This allowed staff to identify if the care provided met the needs of each individual using the service.

We saw that staff had not completed training courses or refresher training identified as mandatory by the provider. Records showed that staff did not have annual appraisals with their manager.

Inspection carried out on 13 November 2013

During an inspection looking at part of the service

At our inspection on 28 June 2013 we found that people were not always involved in planning their care and people told us they were not always treated respectfully by staff. In addition to this we found that staff had not received adequate training, supervision and appraisal and therefore were not fully supported in their roles.

Following our inspection the manager submitted an action plan telling us what action would be taken to ensure these issues were addressed. The manager told us that the home would be fully compliant by 2 September 2013.

During this inspection we spoke with the manager, two other members of staff and five people who use the service. We found that people were involved in their care planning and supported to make choices with regards to their daily routines. People told us that staff treated them well. One person we spoke with told us, "staff treat me respectfully and I respect them too." Another person said, "they're absolutely brilliant, they [staff] come and chat with me, I am happy here."

We looked at training records and saw that staff had attended training in a range of areas to support them in developing/refreshing their skills and knowledge so that they could meet people's needs effectively.

We found that systems had been implemented to ensure that staff received regular supervision and annual appraisals to monitor their performance and identify any areas for development to support them in their role.

Inspection carried out on 21 August 2013

During an inspection in response to concerns

We visited the service because we had received information that the service might not be complying with essential standards of quality and safety. In particular concerns were raised about staff practices in relation to getting people out of bed early in the morning against their will from 4:30am to ensure people were up and dressed before staff came on duty in the morning at 8am.

We carried out an early morning visit to the home. When we arrived at 5:30am we found that all of the people using the service were in their beds and most people were still sleeping. We spoke with one of the nurses on duty and two other members of staff. We also looked at three people's care records and viewed the daily progress notes for all of the people with dementia care needs accommodated on the ground floor.

The staff we spoke with told us that there were a few people who were early risers but that everybody was supported to get up in the morning when they chose to do so. Staff also told us that there had been previous discussions between the day and night staff about expectations in relation to how many people were supported to get up by the night staff to reduce the workload of day staff in the morning rather than basing these decisions on people�s individual needs. This meant that people's individual needs and preferences were not always considered in terms of staff practice discussions in the home.

Inspection carried out on 28 June 2013

During a routine inspection

We spoke with the deputy manager, four other members of staff, 11 people who were using the service and two relatives who were visiting the home at the time of our inspection. We found that some people were unable to express their views about the service as they had complex needs. However, we used different methods to help us understand their experiences such as observation, speaking to people's relatives and reviewing care records.

We found that people's responses were mixed in relation to the staff working at the home. For example, one person said, "the girls (staff) are good" but another told us, "there are a few staff who are rough when they are helping me and say things like 'get over' but sometimes I am well looked after". Other people we spoke with also said that they had mixed feelings about the staff or made comments like, "they're (staff) ok I suppose, I don't like to criticise". Therefore people were not always treated respectfully and in a dignified manner by staff.

People's needs were assessed and care plans developed that took account of their likes, dislikes and preferences. Any identified risks were assessed and action taken to minimise these risks and keep people safe. People's health needs were met.

The home was clean and warm at the time of our visit and appropriate maintenance and health and safety checks were taking place to ensure that people were kept safe.

At our previous inspection staff were not receiving formal supervision. We found that a plan had been put in place and this was being addressed, however staff had not received adequate training and no staff appraisals had taken place.

Quality assurance systems were in place to monitor areas such as medication, pressure area care, nutrition and the use of bedrails. However, the records viewed did not show what action was taken to address any identified issues.

Inspection carried out on 20 February 2013

During an inspection looking at part of the service

During the inspection we talked with six people using the service, two visitors and eight members of staff to get their views about the service.

People told us they were pleased with the care they received at the home. They said staff were attentive to their needs and ensured these were met. Comments we received included, �everyone looks after me well� and �I can go home and have peace of mind that [my family member] is being well looked after�.

People�s care plans generally addressed their needs but information about their backgrounds was not always available to ensure staff understood them as a �person�. Some of the arrangements to ensure people received safe and appropriate care were not adequate to ensure their welfare and safety.

Staff were aware of the need to maintain people�s privacy and dignity and people who talked with us said these were respected. However, their care plans did not address how their privacy and dignity would be maintained, such as when they were in bed with their bedroom doors left open.

People received information about their care and were given opportunities to make choices. However, care records did not always make clear how people or their relatives were involved in the care people received.

Staff received appraisals but did not always receive training and supervision in a timely manner to ensure they were appropriately supported in their job. The manager said they had plans to address this.

Inspection carried out on 5 September 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience; people who have experience of using services and who can provide that perspective.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

People who use the service told us that staff were kind and respected their privacy. They confirmed that staff treated them with care, respect and dignity. One visitor told us �we are delighted with the care, they are very good�. Another visitor said �I�m happy with the care�. People�s comments about their experience of living at Cloisters Nursing Home included �they are very good to me� and �I�m very well looked after�. One person said "your're just told about treatment and not given any options".

We found during the inspection that, for people who remained in their bedrooms the doors were kept open and it was not clear that they had made this choice.

People confirmed they had a choice of menu and that their religious and cultural menu requirements were met. People's comments and description of the

meals included, "the food is nice", "you choose what you want." One person told us the food was "luke warm".

The majority of people indicated to us that they felt safe at the home. They told us if they had no concerns or complaints about their care but would speak with the deputy manager or the staff if they needed to. One person said �I have no worries about abuse and another said �If I don�t like anything I let them know�

Inspection carried out on 24 November 2011

During a routine inspection

The feedback we received from people who use the service was positive. They told us that staff were available when they needed them and supported them to take part in activities that they enjoyed. They said that staff treated them well and provided good care. One person told us, �I�ve got no complaints � they treat me very well. I�m quite happy here� and another said, �The staff are really good, they�re brilliant�. People also said that staff helped them get medical treatment if they needed it and helped them to stay healthy.

People told us they could choose how they spent their time and that they could have privacy when they wanted it. They said they felt safe living at the home and that they were asked for their opinions about the way the home is run and about the care they received. People said that staff were available when they needed them and responded to their needs promptly. One person told us, �When I call them, they�re with me straight away� and another said, �If I ask for something, they get it done�.