What life is like for people using this service:

People told us they felt safe. They were protected from potential abuse and discrimination. Risks to people were identified, assessed and action taken to reduce these or remove them altogether. People lived in a clean and safe environment. Medicines were managed safely and staff provided the support people needed to take their medicines as prescribed. Enough suitably recruited and skilled staff were deployed in order to meet people’s needs.

People’s health needs were assessed and people had access to a variety of healthcare professionals to support them. People were provided with the right amount and type of food to meet their health needs. People had a choice in what they ate and drank. People’s religious preferences were being met. At the time of our visit there were no diverse cultural needs requiring support, but staff explained that this would not be a problem if there were; these would be respected and met.

The principles of the Mental Capacity Act 2005 were followed. People were supported to make independent decisions and their care was delivered in the least restrictive way possible. 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 Act 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 with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

Staff were kind and caring towards people. They maintained people’s dignity and privacy. People’s choices, preferences and wishes were known to the staff who had taken time to find these out. Relatives and representatives of people were made welcome. They were, where appropriate, able to contribute to the planning and review of people’s care. Care plans gave staff guidance on how to meet people’s needs. Further detail about people’s care needs was also communicated to staff by means of staff handover meetings and additional information kept in the care office. Information about people’s care and treatment was kept secure and confidential.

A team of volunteers, led by an enthusiastic activity co-ordinator enhanced the quality of people’s lives. They supported people with meaningful activities and gave them opportunities to mix socially. Established links with local community groups, businesses and schools supported better outcomes for people.

Staff were experienced in supporting people, at the end of their life, to have a comfortable and dignified death. Professional relationships were in place to help support this, for example, with local GPs, pharmacies and community palliative care specialists.

The home did not have a registered manager in position. 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 2008 and associated Regulations about how the service is run.

An interim manager had started working at the service in July 2018 when the former registered manager had retired. The interim manager was an experienced manager who was providing strong leadership to the staff. The provider’s quality monitoring processes had identified that some improvements were needed to the service. The interim manager had worked with the provider to achieve further action which was also planned as part of the home’s on-going plan of improvement. Staff were committed to providing people with good qual

This inspection took place on 15, 16 and 18 March 2016 and was unannounced. Paternoster House provides nursing care to up to 40 older people, some who live with dementia.

The service had a registered manager in position. 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 2008 and associated Regulations about how the service is run.

People’s safety was of paramount importance to the staff and there were good arrangements in place to ensure this remained the case. Personal, health and environmental risks were monitored, identified and managed. People received their medicines when they required them, as prescribed and safely. They were protected from abuse because staff knew how to report relevant concerns. Good recruitment practices protected people from those who may not be suitable to care for them. There were enough staff on duty to support people’s needs. People had access to health care professionals when they needed this. People received help to eat their food and drink. Where needed additional support was provided to support people’s nutritional well-being. Care and treatment was given with people’s consent and where people were unable to provide this, they were protected under relevant legislation. People’s decisions and choices were respected and met.

Staff were well trained and supported to provide very personalised care. People were very much seen as individuals both in how their care was planned and in how it was delivered. Their privacy and dignity was respected at all times. Staff delivered people’s care with exceptional kindness and compassion. Staff were exceptionally good at identifying people’s needs, preferences and wishes and providing opportunities for these to be met. People had extremely good opportunities to partake in activities which were meaningful and which helped promote self-confidence and self-worth. Where people wanted to be more independent they were supported to achieve their aspirations.

People benefitted from the service having a strong leader. The registered manager was clear in her expectations and the standard of care she wanted people to receive. Staff worked together to ensure this was achieved. They were collectively committed to the people they looked after. There were robust quality monitoring systems in place so the registered manager and provider could assess the service’s performance. Actions were taken swiftly to address any shortfalls and improvements were constantly being made to the service as a whole. People and staff contributed to the how the service was run. They had opportunities to meet together to be updated and feedback their ideas and suggestions. People had opportunities to raise areas of dissatisfaction. Complaints were listened to, investigated and responded to with a view of resolving the issue. The registered manager was keen that the service learnt from any form of feedback received. Arrangements were in place to ensure staff and practices met with best practice.

We previously visited this home in April 2013. At that time we had concerns about the standard of record keeping. Although care plans were comprehensive and up-to-date, daily records of care were not sufficient detailed to evidence that care provided was consistent with the care outlined in people's care plans. Records for the most vulnerable people, to show that they received regular and frequent safety and comfort checks and support, were not consistently completed. We also found that some areas of the home were not cleaned to an acceptable standard and that cleaning records were incomplete.

We returned to the home to see if improvements had been made. We found that care records were completed consistently and to a higher standard, with greater detail, which assured us that people's needs were being met.

We looked around the home and spoke with the senior housekeeper. We found all areas of the home to be clean and free from any offensive odours. Cleaning records had been consistently completed, although weekly checks by the senior housekeeper could not always be evidenced.

We spoke with three people who lived at the home. They told us they enjoyed living at Paternoster House and spoke positively about the staff. They told us they were treated with respect and they were supported to make decisions about how they lived their lives. People said they enjoyed the activities organised by the home.

Care plans were well written and demonstrated a person centred approach to care. We saw that they had been regularly reviewed and their effectiveness evaluated. Record keeping had improved since our last visit, although daily records of care were not always sufficiently detailed to evidence that the care provided was consistent with the care outlined in people’s care plans.

At our previous inspection in July 2012 we raised concerns that the home could not evidence that vulnerable people who could not use a call bell, were receiving adequate checks to ensure their comfort and safety. We noted on our return visit that care plans had been developed specifically to address this. Staff told us that people confined to bed received regular checks and support but this was not routinely recorded.

Staff told us they were well supported with regular training and supervision, although records had not been updated to reflect this.

We found that some areas of the home were not cleaned to an acceptable standard and cleaning records were incomplete. We saw incorrect practice in relation to the disposal of contaminated waste.

We spoke to five people who lived at the home and a relative. They told us they enjoyed living at Paternoster House. They all spoke positively about the staff. One person said “they treat me with respect”. Another person told us “they are very patient". The home had appropriate recruitment and selection procedures in place to ensure that people were care for by suitably qualified and competent staff.

Care plans demonstrated a person centred approach to care but there was little evidence to demonstrate that people were involved in decision making. Where people lacked mental capacity to make decisions, processes were not consistently followed to demonstrate that people’s rights to independence, dignity and choice were balanced against potential risks.

People living at Paternoster House appeared clean and well groomed but records of personal hygiene suggested that people did not always receive the care they needed. One person told us they liked to have a bath every three to four days but was only supported to take a bath once a week. Some staff told us they felt frustrated that they did not have the time to provide the level of care people needed and told us that some people went too long without a bath. Care records did not provide adequate evidence that care provided was consistent with the care prescribed in people’s care plans and met people’s needs.

People told us that when they used their call bells to summon assistance, the staff usually responded quickly, although there were occasions when they had to wait too long. Staff confirmed that this was sometimes the case. We were concerned that there were a number of people who could not use the call bell and there was limited evidence to demonstrate that these people were receiving adequate checks to ensure their comfort and safety.

People told us that they had plenty to eat and drink, although one person said “I would like more cups of tea”. They said they enjoyed their meals and they could always request an alternative if they did not like what was on the menu. We were concerned however that people who were most vulnerable and were at risk of malnutrition, dehydration and/or at risk of developing pressure ulcers were not adequately monitored and supported to eat and drink.

Some people told us they enjoyed the activities organised in the home and outings in the community. We saw people actively engaged and enjoying bingo on the day of our visit and saw a programme of regular activities. Others told us that they were sometimes bored, especially at weekends and they did not think the staff had time to stop and chat with them. There was little evidence that people who could not, or chose not to engage in group activities had opportunities for social interaction and were therefore at risk of social isolation.

People told us that they felt safe and well cared for at Paternoster House. They said they felt able to raise any concerns with staff and confident that concerns would be acted upon. Staff understood their responsibility to keep people safe and were trained to recognise signs of abuse and how to report concerns.

The home had systems in place to monitor quality but we questioned the effectiveness of some of these systems, given the deficiencies we found.