Archived: Threeways Dom Care

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was in breach of legal regulation in relation to mental capacity.

This service scored 25 (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 did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Relatives told us they were not involved in the creation or reviews of their family member's care plans. One relative told us, “I’ve not been shown [their] care plan, never offered, I wouldn’t mind seeing it." We did observe relatives had signed care plans suggesting they had seen them, but there was evidence to demonstrate relatives had not been involved or listened to in the process of building the information within their family member's care plan. For example, one person’s care plan stated that they were allergic to certain foods. When we asked a staff member why the person could not eat these foods, they told us, “I don’t know why. I just know [they] can’t have it.” However, when we asked the person’s family member about this, they told us, “They say [they are] allergic, [they aren’t] allergic, it just makes [them] high. They don’t give [them] any. I think [they] could have a little.” There seemed to be a suggested culture within the service that valuable information relatives could provide to ensure a person’s support plan was holistic and included details of their background was unnecessary. One staff member told us, “Relatives can suggest anything, they have an important role, but they can’t change the care plan.” Another staff member told us, “They are getting as much care and quality of life as per their care plans.” This demonstrated there was not an effective reviewing system in place that looked to build upon the basic information of a person’s care needs.

Staff members told us they were given opportunities to read people’s care plans to acquaint themselves with people’s needs. However, staff were not able to tell us what people’s needs were or what their health diagnoses were. Both people at the service had a diagnosis of autism which was confirmed in their care plan. However, a staff member told us they did not. One person’s keyworker was unable to tell us the person’s background or where they had moved into the service from. Relatives felt staff did not always understand people’s needs, with one relative telling us, “Maybe not all but some do [understand their needs].”

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Providers who support people with a learning disability must follow the guidelines of Right Support, Right Care, Right Culture (RSRCRC). This ensures people with a learning disability living in a care setting lead as normal life as any other person in society and has the same opportunities. We identified staff were not following the principles of RSRCRC. When we asked one staff member if they could tell us what RSRCRC meant, they told us, “It sounds familiar.” However, they were not able to expand on this. Another staff member said, “Sorry? I don’t know what it is.” Staff members and the registered manager confirmed staff worked across both the supported living service and the provider’s other residential service. This left people at risk of staff not consistently delivering a supported living model of care and therefore not meeting the principles of RSRCRC. The model of care being delivered did not maximise people’s choice, control and independence. The values, attitudes and behaviours of leaders and care staff did not ensure people living at the service lead inclusive and empowered lives.

We identified one person had put on a large amount of weight since moving into the service. Their current BMI identified they were obese. Despite this, there was no Malnutrition Universal Screening Tool (MUST) in place. A MUST isa five-step screening tool used to identify adults who are malnourished, at risk of malnutrition, or obese and consequently help staff to support the person by monitoring and improving the person’s weight. When we asked a staff member if they had used a MUST, they told us, “I’m not aware of them in all honesty.” This left people at risk of evidenced based care delivery not being utilised to improve their life and wellbeing.

The provider did not work well across teams and services to support people. They did not share an accurate assessment of people’s needs when moving between different services.

The provider had hospital passports in place for people. These documents should contain vital information about a person’s needs which can be transferred with them when they move into or use a hospital setting. However, we identified the information within hospital passports did not correspond with the information in people’s care plans. For example, one person’s hospital passport stated the person slept well. However, their care notes suggested they were awake during the early hours of every night. Their hospital passport also stated they required low sugar drinks due to dental issues. However, there was no mention of this in their care plan.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

One person’s recent dental appointment had identified they had multiple dental issues. A staff member told us to aid this they ensured “he doesn’t have sugar in drinks or in Weetabix and porridge.” However, receipts for their purchases identified they were frequently being supported to buy high sugar foods such as sweets. We also observed them eating sweets during our onsite visit. This could result in the person’s dental health deteriorating further and require invasive treatment.

We identified there was a lack of fresh food at the service on both of our visits which meant people would not be able to have a home cooked meal. However, we identified multiple frozen ready meals. When we asked a staff member when the last time people had a home cooked meal, they told us, “Sometime last week.” This demonstrated that people were not routinely having freshly cooked meals prepared for them. Furthermore, we identified that 36 packets of crisps were purchased on 2 July 2025. A further 30 packets of crisps were purchased one week later on 9 July 2025. This demonstrated people were not being supported to eat a healthy diet with nutritious snacks.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

One person had moved into the service from a residential care setting in order to promote their independence. The registered manager told us, “Here [Person] can prepare meals with staff, [they] go to restaurants, have takeaway, go shopping. [They] can’t prepare meals at the residential home.”

However, the person’s eating and drinking care plan stated, ‘[Person] has a permanent cognitive impairment which means that [they] cannot prepare [their] food or drink.’ A staff member confirmed, “[They don’t] get involved with food prep.” Furthermore, a recent social worker review record documented ‘Currently all food preparation is carried out by staff.’ Therefore, no additional support was being given to the person to help them achieve the goal of becoming more independent whilst living in a supported living setting. Furthermore, contrary to the information from the registered manager, there was also no evidence to demonstrate the person was being supported to go to restaurants.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

Despite it being confirmed that people lacked capacity to consent to their care, people had signed their care plans.

Staff’s knowledge around mental capacity was poor. One staff member said, “It’s been a long time. I’m not sure about that.” Another staff member said, “Oh god, my head’s gone. It’s about ensuring equal rights and how to treat people who may or may not have mental health problems.” This was incorrect.

The registered manager’s knowledge of mental capacity was also limited. We identified that people were taking it in turns to pay in full for a badminton session for other people at the service and the provider’s other service. However, people did not have capacity to consent to this use of their money. When we asked the registered manager if there was a mental capacity assessment around this decision, the registered manager told us, “There is no capacity assessment in relation to payment for use of hall for badminton. The [people] enjoy playing badminton as it is good for their health and well-being. Each person pays in turn.” Therefore, their lack of knowledge around consent and mental capacity meant people’s money was being spent in an inappropriate manner.