Threeways 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Lessons learned and actions taken were recorded and accountability was demonstrated in documentation. We saw evidence of an active learning culture through team meetings and clinical reviews. Analysis of accidents and incidents was completed with observations and actions identified. Staff told us they were encouraged to report safety events and lessons learned were discussed with them to prevent reoccurrence.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Management, nursing and care staff worked with other health professionals involved in people’s care. Staff escalated concerns promptly, such as weight loss or swallowing difficulties, and worked effectively with GPs, speech and language therapists (SALT) and other professionals. Registered nurses (RN’s) told us they documented wounds or pressure area concerns. Body maps were completed and photographs taken to ensure any issues could be assessed and reviewed for changes. Care plans included essential information to guide staff, and where changes occurred, this was communicated to staff promptly.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff completed safeguarding training and demonstrated a clear understanding of actions to take to protect people from any allegation of abuse. Staff told us they would be confident to raise a concern and felt this would be escalated and responded to promptly by management.

People told us they felt safe and well cared for. Incident reporting processes ensured managers reviewed events and took appropriate action, including referral to other agencies when required.

People’s mental capacity had been considered. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We saw best interest meetings had taken place to involve relatives and relevant health professionals in decisions about people’s care.

The service was working within the principles of the MCA and if needed, DoLS authorisations were in place to deprive a person of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments were in place to support staff to provide safe and appropriate care. Care and nursing staff told us they were kept up to date with any changes. We saw examples of messages for staff following a review of safety checks and documentation. This included updates to monitoring and recording in relation to bed rail safety checks and mattress pressure settings. Changes to individuals moving and handling needs and oral care recording.

Risks to people were managed and reviewed regularly. People were supported to take positive risks to enhance their quality of life whilst balancing safety. We saw this in particular in relation to choices people made regarding what they ate. If a person had been assessed by Speech and Language Therapy (SaLT) and recommended to eat a specifically textured diet but had the capacity to make an informed choice whether or not they followed this guidance. We saw this had been discussed with the person and their family if appropriate and clearly documented, including what foods the person would particularly like to eat and foods they enjoyed. Safety measures had been introduced to ensure this person was supported throughout meals and advice in place for staff to follow should any issues arise.

People’s capacity and DoLS was reviewed to ensure any specific DoLS conditions were being safely followed.People at risk of falls had appropriate equipment in place to support their safety and mobility. People had Personal Emergency Evacuation Plans (PEEPS) in place to inform staff and emergency services in the event of an evacuation being required.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us they thought the home was clean and tidy. Feedback included, “I am generally happy with cleanliness overall,” and “On the whole the home is always clean, tidy and well maintained.” The home had designated housekeeping staff. The home appeared clean and free from odour. The home was pleasantly decorated throughout, any maintenance issues identified were discussed with management and addressed promptly by the maintenance team, when required external companies were used for specialised work.

Equipment was in place for people’s needs, including electronic hoists, assisted baths, and mobility aids. Some equipment within the home needed to be updated. This included window restrictors and some commodes. This was discussed with management during the inspection who responded promptly and devised an immediate schedule for replacement.

The service improvement plan identified the need for the registered manager to complete a daily walk around to identify any new concerns. This was being regularly reviewed to ensure this was completed and documented. Any concerns identified were added to the improvement plan and actioned promptly.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff undertook regular training updates and told us they received the training they needed to meet people’s needs safely. RN’s were supported to attend courses and training to ensure they stayed up to date with current practice guidelines and to support their professional registration.

There were clear and robust recruitment processes in place, this included relevant checks completed before people started working at the home. Staff were safely recruited and there was a stable staff team which ensured consistency. New staff completed a range of training and an induction into the home.

We observed staff were visible and did not appear rushed. People confirmed call bells were answered promptly and staff were available if they needed any help or support.

Staff told us they enjoyed working at Threeways Nursing Home. One told us, “It’s a nice management team they support us,” And “We get support if we need it, and get to attend really good courses, it is a lovely place to work.”

Staff felt they received good support from the management team and told us they could speak to the registered manage, deputy or operations consultant at any time if they had any issues or concerns. One to one and group supervision and meetings took place. The supervision matrix identified some people were late receiving their latest supervision, however, this had been identified and work was underway to catch up.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had access to personal protective equipment (PPE) and we saw staff using this appropriately. Audits and checks had been completed to ensure infection prevention controls were maintained. During a recent infection outbreak the home had taken appropriate steps to manage and report this to relevant agencies.

People told us their bedrooms were kept clean and relatives told us, “The home always appears to be nice, clean and tidy.” Minor concerns raised regarding storage of items in communal bathrooms and commodes were responded to and addressed promptly.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely. Registered Nurses (RN’s) demonstrated a good clear understanding of the medicines people were prescribed and we observed safe medicine administration practises being followed. Only staff who had received medicine training and had been assessed as competent supported people with their medicines. Electronic Medicine Administration Records (eMAR) were completed when people had taken their medicines. Some people had been prescribed medicines to take ‘as required’ (PRN), for example for pain relief. There was guidance for staff about why these medicines were needed and how they should be taken. Records were completed to show if the medicine had been effective. This was also reviewed by the clinical lead. They told us about a medicine they had reviewed. This had been prescribed for one person's anxiety. The outcome had been recorded as effective. However, it was only effective for a few hours and did not relieve the person's anxiety in the long term. Therefore, following discussions with the person and their GP a referral had been made for review by the mental health team.

Where people had been prescribed varying doses of medicine, for example for the treatment of diabetes, there was guidance in the eMAR and care plans for staff to ensure this was given appropriately, depending on the results of blood tests.

Weekly and monthly medicine audits were completed. Any issues or improvements identified had been discussed with staff and/or added to the service improvement plan.