Threeways 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.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The home was welcoming and staff spoke positively about the leadership in the home. Staff told us they worked together well as a team.

Management were receptive, open to feedback and transparent. There was a clear emphasis on continued development and improvement in relation to all aspects of the day to day running of the home. Management led by example, there was a clear open door policy, we saw people, relatives and staff stopping to speak to the management team. Managers were observed visiting people in their rooms and assisting at mealtimes. This ensured they were a visible face around the home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was a clear management team involved in the running of the home. The registered and deputy manager were supported by the operations consultant, compliance manager and services manager. The provider visited the home regularly and had oversight of the service.

Staff spoke highly of the registered manager telling us, “It is a nice team in charge, they are all supportive. Manager is lovely, very kind I worked with them before when they were a nurse here and now they are the manager.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Management were visible and everyone we spoke with told us they would feel comfortable going to any of the management team if they had an issue or concern.

A whistleblowing policy was in place, this included key principles of freedom to speak up. Staff told us they were aware of the whistleblowing policy and felt they would be supported if they raised any concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a robust recruitment process in place to ensure fair recruitment and selection procedures. All staff received mandatory equality training.

Staff discussed how they were supported equally. At the time of the inspection some staff were observing Ramadan. All staff had been reminded of this and steps taken to ensure staff breaks were arranged to support this and ensure staff could take a break when they needed. Practical adjustments were made for staff with disabilities or health needs by adapting roles and working environments to support staff to remain in work safely and effectively.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

It was evident that a considerable amount of work had been completed to ensure relevant information was recorded on the care system. Some areas were still being developed and the provider was working with the company providing the system to ensure that it could be utilised to the full potential. The operations consultant was supporting the registered manager to continue to improve recording and documentation overall. RN’s told us they found the new electronic care system fairly straight forward and were working hard to ensure all relevant information was recorded. The focus had been on updating documentation for those people with more complex needs. These were person centred and detailed. Further work was needed for those with less complex needs, however, staff knew people well so people were receiving safe and effective care. When gaps in recording were discussed during the inspection for example in relation to clearer recording around nutrition and preferences, and more detailed daily records to ensure these were not task based, this was responded to promptly.

There was a robust and effective quality assurance system in place completed by the registered manager, operations consultant, compliance manager and a further external consultant. Audits and quality assurance was used to identify any improvements or learning to be taken forward to facilitate ongoing improvement.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Management had established good working relationships with other health care providers and specialist teams involved in people care and nursing needs. This included GP’s, community mental health teams, SaLT and the local authority.

People were encouraged and supported to maintain relationships and connections outside the home with church involvement, local outings and activities available for people

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff spoke of an open culture within the home. When things had gone wrong there was a no blame culture. Each situation had been used as a learning opportunity to facilitate ongoing improvement. Staff had been involved in discussing incidents, reflecting, attending staff meetings and supporting each other through the process to identify areas for improvement and development.

Following the introduction of a new electronic care system management had continued to work closely with staff to ensure documentation could develop and improve. Any areas for further development were identified and discussed with staff.