You are here

Inspection Summary

Overall summary & rating


Updated 21 July 2018

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 responsi

Inspection areas



Updated 21 July 2018

The service was safe.

Risks had been assessed to protect people whilst enabling them to be independent.

The management of medicines was safe and people received their prescribed medicines when they needed them.

Staff understood the safeguarding procedures to protect people from the risk of abuse and how to make a referral if they had any concerns.

There were sufficient staff employed to provide the support and care people needed. Robust recruitment procedures ensured only suitable staff worked at the home.

The home was well maintained with effective policies to keep people safe from the risk of infection.



Updated 21 July 2018

The service was effective.

Staff had received relevant training and provided appropriate support to meet people�s needs.

Staff had completed training for Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and had a clear understanding of current guidelines and their responsibilities.

People were supported to have a healthy diet, choices were provided and staff assisted people as required.

Staff ensured people could access to healthcare professionals when they needed to.



Updated 21 July 2018

The service was caring.

People were supported to be actively involved in decisions about their care and make choices about all aspects of their day to day lives.

Staff knew people very well and communication between people, visitors and staff was friendly and relaxed. People were treated with respect and support was provided in a kind and caring way.

People were encouraged to maintain relationships with relatives and friends and visitors were made to feel very welcome.



Updated 21 July 2018

The service was responsive.

People�s needs were assessed before they moved into the home and they received support that was personalised in line with their wishes and preferences.

People decided how and where they spent their time and range of group and one to one activities were provided for people to participate in if they wished.

People and visitors knew how to make a complaint or raise concern.


Requires improvement

Updated 21 July 2018

The service was not consistently well-led.

Quality assurance and monitoring systems were used to identify areas to drive improvement. However, there were areas where further improvement was needed to ensure changes were part of day to day practice.

Staff were aware of their roles and responsibilities and felt all of the staff worked well together as a team.

Feedback about the service provided was consistently sought from people, relatives and staff.