Threen House Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question requires improvement. At this assessment, the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of a legal regulation relating to safe care and treatment. The provider had made the required improvements and was no longer in breach of this legal regulation.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were systems to learn when things went wrong. The registered manager investigated all accidents, incidents and concerns. They worked with external professionals and people’s relatives to help resolve concerns. Records showed learning from incidents was shared with staff. Relatives told us they were happy with the provider’s response when things went wrong. Their comments included, “I don’t panic when the phone rings because the way they approach things and talk to me is reassuring” and “We work together to resolve any problems and decide what to do.”

The provider ensured there were safe systems for transitions between services. The registered manager met people to assess their individual needs. They worked with the person, their relatives and professionals involved in their care to make sure moves to the home were successful and appropriate. Staff recorded key information about people’s needs to show to external professionals when people needed to use other services. Staff supported people with healthcare appointments and visits to hospitals. A relative explained about a situation when staff supported a person to go to hospital when the transport had not arrived, so they did not miss their appointment. Another relative told us about a situation where the registered manager ensured all the equipment and care was in place for a person returning to the care home following a hospital stay.

The provider had systems to safeguard people from abuse. Staff undertook training to understand about safeguarding. Staff were able to explain how they would recognise and report abuse. The provider worked with the local safeguarding team to help investigate concerns and put in place systems to protect people from avoidable harm.

People using the service and their relatives told us they felt the service was safe.

The provider requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. Decisions about people’s care were made in their best interests and for their safety.

The provider assessed and managed risks to people’s safety and wellbeing. They worked with the person, their relatives and external professionals to plan safe care to meet their individual needs. Risk assessments and management plans were appropriately detailed, clear and regularly updated. People told us they were supported to take risks and be independent when this was possible and their choice. Relatives explained staff were good at supporting people when they became distressed or anxious. A relative commented, “They are very good at talking through situations when [person] is distressed. Staff offer distractions and this helps to calm [person] down.”

People lived in a safe and well-maintained environment. The provider completed regular checks on the safety of the environment and equipment. They organised for external professionals to undertake additional checks. There were systems to help prevent the risk of fire. Staff completed training and information to understand how to respond in emergency situations such as a fire. Staff were also trained to understand how to use equipment, such as hoists, in a safe way.

The provider offered double rooms to people who wanted and requested this, such as couples, siblings or friends. However, at the time of our visit, everyone had their own room, and the registered manager told us double rooms were only used when this was people’s choice. This meant that a lot of the rooms were spacious. People had personalised these with their own furniture and belongings and each room looked different and reflected the person’s choices. A relative commented, “[Person’s] bedroom is amazing and the view over the park is brilliant.” Communal rooms were spacious, free from hazards, well-lit, warm and well ventilated. People told us they enjoyed spending time in the communal areas, including a summer house and the garden.

The provider deployed enough suitable staff to meet people’s needs and keep them safe. The registered manager assessed people’s needs and allocated staffing based on people’s individual needs. Staff told us they did not have to rush and there were enough of them. Comments from people using the service and relatives included, “There always seems to be enough staff” and “I think they look after everyone. I like the ratio of staff to residents.”

The provider had systems to ensure staff were suitable during their recruitment. They carried out checks on their identity, suitability, skills and knowledge.

New staff completed a range of training and an induction into the home. Staff undertook regular training updates. They had opportunities to meet with the registered manager to discuss their work. The registered manager assessed their competencies and appraised their work. People using the service and relatives told us staff were well trained. A relative commented, “I think staff are doing a great job.”

The provider had systems for preventing and controlling infection. Staff undertook training to understand about the importance of this. Staff were provided with personal protective equipment (PPE) to use when needed. The provider employed staff to undertake cleaning and laundry. The registered manager carried out audits of cleanliness. People using the service and their relatives told us the service was clean. Their comments included, “The cleaners come every morning and clean the floor”, “Everything here is always spotless” and “I see the cleaner about. It is nice and clean here.”

People received their medicines safely and as prescribed. Staff worked closely with doctors and other healthcare professionals to make sure people were prescribed the most appropriate medicines. Staff undertook training to understand about safe medicines management. The registered manager tested their knowledge and skills in managing medicines. Medicines were stored, recorded and administered appropriately. Medicines errors were investigated and learnt from. There was clear guidance for staff about how and when people should take their medicines. Staff assessed medicines risks. Staff consulted external professionals about people’s medicines care plans and risk assessments.

People told us they were happy with the support they received with medicines. A person commented, “My medicines are always given at the times they should be and there is no problem with that. Staff are all trained to do this.”