About the service:

Paternoster House is a care home with nursing. Many of the people living at Paternoster House are living with dementia. They also support younger people with complex nursing needs. At the time of our inspection 92 people were living in the home.

People’s experience of using this service:

People living in the home received personalised care that focussed on the quality of their lived experience. Staff were kind and compassionate in their approach and we saw people were supported to maintain their identity, independence and to carry on with their interests. Visitors were welcomed into the home, which had a pleasant environment, with plenty of variety in the areas people could spend their time. The staff focussed on ensuring people had opportunities for engagement and a wide range of activities were offered that reflected people’s individual tastes and needs.

People received care from suitable staff who were supported and developed by the provider. Staff felt valued by their managers and the registered manager recognised the contribution staff made to the home.

People were kept safe by the systems in place to mitigate risks. People were supported to take risks and make their own decisions. People were supported safely with their mobility and staff ensured people were informed about what was happening to make sure they felt secure. People were supported to take their medicines and confirmed staff offered them pain relief if they needed it. Healthcare professionals told us they had strong links with the home and this was reflected in people’s experience of being able to access healthcare services easily and in a timely way.

The registered manager had developed a positive, person-centred culture in the home. Complaints and incidents were investigated in a robust way and duty of candour obligations were met. Quality assurance systems operated effectively to address issues with the quality and safety of care when these were identified.

Support for people approaching the last stages of their life was not as detailed or personalised as other aspects of care. We have made a recommendation about supporting people to prepare for the last stages of their life.

Rating at last inspection:

The service was rated Good in all areas in July 2016.

Why we inspected:

This was a scheduled inspection in line with our public commitment to return to services within certain timescales.

Follow up:

We will continue to monitor the service to ensure it maintains its good rating.

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

This inspection took place on 25 May 2016 and was unannounced. Paternoster House provides nursing care to up to 108 people who may have physical illness or disability, or needs associated with dementia. There were 94 people living at the service when we visited.

There was a registered manager who is responsible for the home. 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 registered manager had a good knowledge about the needs and preferences of the people who lived at the home. They were committed to ensuring people received the best possible care.

Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, as were risk assessments connected to the running of the home, and these were reviewed regularly. Accidents and incidents were recorded and the causes of these analysed so that preventative action could be taken to reduce the number of occurrences.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely.

There were enough skilled, qualified staff to provide for people's needs. The necessary recruitment and selection processes were in place and the provider had taken steps to ensure that staff were suitable to work with people who lived at the home. They received training to ensure that they had the necessary skills and were supported by way of supervisions and appraisals.

People's needs had been assessed before they moved into the home and they had been involved in determining their care needs and the way in which their care was to be delivered. Their consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met.

People had a variety of nutritious food and drink available to them. There were freshly made, home cooked meals from a menu that had been devised using people's likes and dislikes. The chef made regular checks that people were happy with the meals and choices provided. Snacks and fruit were also available.

The provider had systems in place to check the quality of the service and take the views and concerns of people and their relatives into account to make improvements to the service.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

The inspection was unannounced. When we completed our last inspection of Paternoster House on 25 September 2013 we found that the provider complied with their legal requirements in the areas we looked at.

Paternoster House provides personal and nursing care for up to 108 people, some of whom may be living with dementia. The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. At the time of our inspection the registered manager had been in post for three years.

People felt that they, or their relative, were safe at the home. The home had taken appropriate steps to protect people from abuse and staff were trained in procedures for safeguarding adults.

CQC is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that the service had complied with the requirements of MCA and DoLS.

The steps staff should take to manage the identified risks to people were clearly documented in risk assessments. In the case of checks of people who used bedrails these were not always followed. People were therefore at increased risk of harm because of the failure to complete the checks. This was a breach of Regulation 9 of the Health and Social Care Act 20018 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

People were supported to maintain their health and well-being. Appropriate referrals were made to other health and social care services as was necessary

There were enough qualified, skilled and experienced staff to meet people’s needs. Staff members received regular supervision and had completed appraisal interviews.

People were protected from the risks of inadequate nutrition and dehydration, although delays in serving people’s food meant that it was not as appealing to people as it could have been.

Staff were kind, compassionate and understood people’s needs. The interaction between staff members and people was positive and respectful. People’s privacy, dignity and independence were respected.

Care was planned and delivered in a way that was intended to ensure people's safety and welfare. People had been involved in the planning of the care they or their relative received. Care plans were personalised, detailed and reviewed on a monthly basis.

People who used the service were asked for their views about their care. Meetings were held on each unit of the home to discuss people’s opinions of the service. A satisfaction survey of people who lived at the home was carried out on an annual basis.

There was an effective complaints procedure and comments and complaints people made were responded to appropriately. Relatives of people who lived at the home found the manager and deputy manager to be easily accessible.

Regular staff meetings were held on each of the four units. Most staff members felt supported by the manager at the home

The provider had a system to regularly assess and monitor the quality of service that people received, although there was uncertainty about the effectiveness of this. The system included monthly provider visits and quality audits by the manager. Action plans had been produced to address areas for improvement identified during the visits and audits and following the satisfaction survey.

At our inspection in May 2013 we observed medicines being administered to people who used the service. We saw that some staff did not use the written records that told them what medicines each person should have and at what time. They did not observe to ensure that each person took the individual medicines prescribed for them. Staff later signed the records to show that people had been given their own medicines and had taken these, although they had not witnessed this. This meant that the procedures for administering and recording medicines safely were not always followed.

In June 2013, the provider sent us a written plan to tell us the actions they had taken, and planned to take, to put this right.

We inspected the service on 30 September 2013 to check that the provider had taken appropriate steps to ensure that medicines were safely administered and that this was accurately recorded. We did not speak with people using the service at this inspection. We spent time in four different areas of the home over a two hour period and observed medicines being administered.

We saw that procedures for administering and recording medicines safely were followed. Records showed that the provider had taken action to ensure that staff understood the correct procedures. They also showed that the staff understood the serious outcomes that would follow if staff did not comply with these in practice.

People told us that they experienced care, treatment and support that met their needs. They said, “I am very satisfied with the care I get here.” We found that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

People were provided with a choice of suitable and nutritious food and drink. There was a lack of clarity as to whether all of the people using the service were offered food between the evening meal at 5pm and breakfast the following morning. Overall, people were satisfied with the meals and drinks available.

People were not protected against the risks associated with medicines because the provider’s procedures for administering and recording medicines safely were not always followed.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. The provider had effective recruitment process in place. People told us that the staff were able to provide the support and care that they needed. One person said, “The staff are very good to me, very attentive and patient.”

The provider had a complaints system available. People we spoke with told us they could approach staff if there was anything that concerned them or they needed clarification on. Comments included, “I have no complaints, I could tell them if I did”, and “I have no complaints or grumbles and have never had any concerns but would feel able to ask them about anything.”

We visited Paternoster House on 21 November 2012 after several safeguarding notifications were sent to us from August 2012 to November 2012. We discussed each one individually with the management team and saw that each had been appropriately addressed, investigated and actions taken to reduce reoccurrence.

We spoke with seven people and they all stated that they felt respected and confirmed that they could make choices. Three people pointed out that it took a long time to get help from NHS services. Although care plans addressed the issues people raised with us, they were not updated. They also confirmed people’s concerns about the long time needed to resolve these concerns.

Safeguarding procedure and measures were in place and ensured that people were protected. All seven people who we spoke with confirmed that they felt safe. Two staff members also confirmed that they were aware of and confident in how to deal with any potential safeguarding issue.

The provider had a system in place monitor the quality of the service.

During our visit, on 04 July 2012, we spoke with several people using the service, and they were all complimentary about the care and service provided. A person commented, “The staff are absolutely wonderful. I am really happy here. They have helped me recover from my problem. They changed my life from despair to hope.” Another person said, “This home is very good; they are wonderful people, and it’s a wonderful place.” This was echoed by another person who commented, “They are the best workers, in my opinion. I have no complaints.”

When asked about choices, a person said, “The food is good. I can’t eat spicy food; they serve me what I like, English food. There are daily choices.” This was echoed by another person who said, “There are choices. The food is very good. The staff are very good.” Another person commented, “We have activities. Everything is very good. I just had my nails painted.”

We spoke with six visitors during our visit, and they were generally pleased with the care their relatives were receiving. One commented, “The place is lovely and clean. My relative receives very good care; staff are gentle with them.” Another said, “I visit everyday. Care is quite good. There is a review every 6 months. I attend the meeting. Staff keep me informed of any changes.” A friend of a person said, “Staff are always caring. This is an excellent home.”

People living in Paternoster House with whom we spoke told us they felt they were supported to make decisions about their care and daily life. Relatives of people recently admitted to the home praised the staff and management team for the way they were involved with helping their relative to settle into life at the home.

At our visit of 01 November 2011 relatives of people living in Paternoster House with whom we spoke told us that the activity provision had improved and was more flexible to people's needs than previously.

Relatives of people living in the home with whom we spoke told us they felt there were generally plenty of staff available to meet people's needs.

Some family members with whom we spoke said they felt comfortable to raise any concerns with the management team however others said they felt less so.

Most of the people living in Paternoster House have difficulty understanding and responding to verbal communication. A few people were able to make comments about specific issues, such as the meals; however, most of the information about people's experiences of life at Paternoster House was gathered through our observations and talking with visiting relatives of people living in the home.

We saw that staff showed respect to people. Visiting relatives with whom we spoke told us they were satisfied with the care people living in the home received. One person told us, ”Very good nursing care, (relative’s name) has improved considerably since they have been here.”

People using the service said they liked the food. One person told us, "There is a good variety, enough of it and it is well cooked." We saw that people were given the right amount of help to eat their meals. A relative of a person living in Paternoster House told us, “My relative likes the food, eats everything.”

Relatives of the people living in Paternoster House told us that they felt people were safe in the home. Comments we received included, “I feel my relative is safe here, I never go away feeling worried” and “I think (relative) is safe at Paternoster and as happy as they can be.”

People living in Paternoster House did not raise any concerns about the staffing levels in the home; however, a visitor told us they felt there were occasions when there were not enough staff available to assist people when needed.

People living in the home and visitors to the home on the day of our visit were complimentary about the staff team. Comments included, “The staff are very caring and attentive and look after people well” and “I get on well with the staff, some are exceptional.” People told us that they felt comfortable talking to the staff about any issues that they had.