Threeways Nursing Home

Updated 9 April 2021

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.

As part of CQC’s response to the COVID-19 pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 25 March 2021 and was announced.

Updated 9 April 2021

This inspection took place on the 11, 12 and 14 June 2018 and was unannounced.

We carried out an inspection at Threeways Nursing Home on 11 and 13 August 2015 where we found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not met the regulations in relation to safeguarding people from abuse and improper treatment and, had not ensured complete and accurate contemporaneous records in respect of people needs were in place.

At the last inspection on 13 and 14 December 2016 we found the provider had taken action and had met the regulations in relation to safeguarding people from abuse and improper treatment. However, they had not addressed the breach in relation to ensuring complete and accurate contemporaneous records in respect of people were available.We also found a new breach of regulation. The provider had not ensured safe care and treatment for people. We took enforcement action for these breaches.

We found a third breach in that the provider had not ensured that staff had the information required to meet people’s individual needs and we asked the provider to send us an action plan to inform us how they would meet the regulations. The provider sent us an action plan to advise they had met the regulation.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and confirm that the service now met legal requirements. We found improvements had been made and the provider had met the legal requirements. Although, we identified some areas that needed time to be embedded into day to day practice the overall rating had improved to Good.

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

The home is registered to provide nursing and personal care and accommodation for up to 45 older people and people with disabilities. At the time of the inspection there were 41 people living there. Some people required continual nursing care due to complex health care needs; including end of life care. Other people needed support with personal care and assistance to move around the home safely due to frailty or medical conditions, such as diabetes, stroke and Parkinson’s and, some people were living with dementia.

The registered manager was present during the inspection. 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.

The quality assurance system had been reviewed and areas for change had been identified and prioritised to drive improvement. The care planning process had been changed and a new care plan format had been introduced. Nurses were responsible for reviewing the care plans and daily records and, although some of these were up to date with clear guidance for staff we also found information that was not clear or had not been updated. Staff were aware records were not consistently up to date and the changes in the care planning process would take time to be embedded into day to day practice.

From 1 August 2016, all providers of NHS care and publicly-funded adult social care must follow the Accessible Information Standard (AIS) in full, in line with section 250 of the Health and Social Care Act 2012. Services must identify, record, flag, share and meet people’s information and communication needs. Staff were not fully aware of what these changes meant.

We recommend that the provider seek advice and guidance from a reputable source, about Accessible Information Standards (AIS) to ensure staff are aware of their responsibilities.

Staff were supported to develop their knowledge and professional practice through regular supervision and yearly appraisals. Relevant training had been provided, including safeguarding, fire training and medicines, Staff knew how to protect people from harm and what action they would take if they had any concerns.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The management and staff had attended training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and were aware of current guidance to ensure people were protected. DoLS applications had been when requested to ensure people were safe and the registered manager was waiting for a response from local authority.

Risk had been assessed and people were support to the independent in a safe way, with appropriate walking aids and assistance from staff to support people to move around the home. Staff were aware of their roles and responsibilities and followed the provider’s infection control policies to protect people, visitors and staff. The home was well maintained with regular environmental checks and emergency procedures were in place to support people if they had to leave the building.

People were encouraged to make decisions about the care provided. Staff had a good understanding of people’s needs and enabled them to be independent and make choices. There was a choice of food and drinks throughout the day and people were supported to eat a nutritious diet and drink enough fluids. Staff monitored people’s health and ensured people could access healthcare professionals and services, to maintain their health and well-being.

A range of group and one to one activities had been developed with the involvement of people living in the home and, feedback was consistently sought from people and relatives about the services provided. Through monthly meetings and day to day conversations.