Threen House Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of a legal regulation relating to good governance. 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 was a positive, person-centred culture at the service. People living there, relatives and staff were happy and felt the service was well-managed. Staff and relatives referred to the service as a “family.” Relatives told us they were well informed, involved and always welcome to visit. Comments from people using the service and relatives included, “They have taken the stress off my shoulders”, “Staff are so kind and the way they manage is amazing” and “They are very good at what they do, very hard working and really kind. Staff care about the residents.”

Comments from staff included, “It is a happy place, and everyone is like a family” and “I love to care for the residents and to hear their life stories.”

Leaders were capable, compassionate and inclusive. The registered manager was a qualified nurse and experienced care home manager. The service was owned by an individual who worked at the service each day. Both the owner and registered manager kept up to date with best practice guidance. People using the service, relatives and staff told us the management team were responsive and accessible. Their comments included, “[Management team] are excellent”, “They work long hours and are here every day”, “[Management team] spend time chatting with residents and providing care” and “They go above and beyond. They spend more time at the service than their own homes. They genuinely care. It is a passion not a job.”

The provider had procedures for staff to speak up if they had concerns or anything was wrong. Staff told us they felt comfortable raising concerns with the management team. They knew they could use the provider’s procedures to speak up anonymously if needed. People using the service and relatives explained they knew how to raise concerns and felt confident doing so.

The provider supported workforce equality, diversity and inclusion. The provider ensured staff were supported through recruitment processes and their policies and procedures.

There were effective systems for governance. The provider and registered manager worked together to carry out audits and checks on all aspects of the service. They made improvements when these were needed or when concerns were identified.

The provider worked in partnership with external professionals. They had regular meetings with social care and health professionals to discuss people’s needs. The local authority visited the service and had made recommendations where they identified improvements were needed. The provider had acted on these and liaised with the local authority to let them know the action they had taken.

Relatives told us they were involved and welcome at the home. A group of relatives had formed a charity who organised and facilitated social and leisure activities for the service.

The provider had systems for learning and making improvements. Staff explained they took part in regular training, meetings and supervisions with the management team. We saw policies and procedures were regularly reviewed and discussed with staff to help make sure they understood these.