Archived: Threeways Dom Care

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

This is the first assessment for this service. This key question has been rated Inadequate.This meant services were not planned or delivered in ways that met people’s needs.

The provider was in breach of legal regulation in relation to delivering personalised care.

This service scored 29 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People were not encouraged to be involved in personalising their home. The environment was sparse with a lack of personalisation. There were no pictures of people who lived at the service hung around the service to make it feel like a home. People’s rooms had plain walls, and neither contained a bedside lamp. When we asked one staff member why people’s rooms did not include a bedside lamp. they responded, “They don’t really care.” The registered manager later informed us there were no bedside lamps due to safety reasons, but staff responses demonstrated a lack of understanding of people's needs and the need to make the building feel like a home.

Care plans contained little information about people’s life history and backgrounds. A staff member who was a key worker for one person told us they did not know anything about the person’s life history. This was despite their relative being happy to share details of this with us when asked. This demonstrated a missed opportunity to ensure care records and care delivery was person centred.

A relative told us staff had not respected their family member’s important possessions. They explained staff had thrown away a sentimental object which had caused both the person and them a lot of upset.

One staff member told us a person, “like[s] to watch TV too, especially sports like football.” During our onsite assessment, the person requested to watch football on the TV. However, the staff member ignored their request and put a film on instead.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

The provider and registered manager were aware of the need for a smooth transition for people between services. The registered manager told us, [Both people] came from broken placements so it’s been a gradual improvement. The team works hard. The transition time was difficult. [Person’s] transition was very gradual.” Despite this, following our assessment, the provider announced that all people living at the service had been given 28 days’ notice to find alternative care and 2 months notice on their seperate tenancy due to the provider’s retirement. This demonstrated a lack of compassion for the people who would now have to be found a new home with less than a month’s notice. The local authority asked the provider to increase the notice period so that transitions to new services could be smoother for people, but at the time of writing this report, the provider had declined.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Easy read versions of the provider’s policy were available for people who used the service. These included pictorial aids to support the person to understand the context of the document. However, the information within these documents were not always followed, as demonstrated earlier in this report.

However, relatives told us the staff were not forthcoming with sharing information with them. One relative told us, “I usually have to ask for updates.” This meant those who were important and integral to people’s care were not always involved.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

Staff told us they listened to and involved people. One staff member said, “We have to listen actively to every individual. If they have any wishes, we are promoting them, understand them and find solutions.”

We identified ‘service user meetings’ were occurring. However, some of the minutes recorded from these meetings were repeated on a monthly basis, and did not demonstrate how staff tried to communicate with people to gain their feedback on the service. For example, the meeting minutes from January 2025, February 2025, March 2025, April 2025, May 2025 and June 2025 all stated, “[People] said they were happy with the food and treats.” There was no information as to how this feedback was gained, and whether any additional feedback was sought from people in this area. Furthermore, the meetings were attended by 5 to 7 staff members each time, meaning that was an overly heavy presence of staff for a service user meeting for 2 people who lived at the service. This could lead to people not feeling comfortable to share their honest feedback in such a large group setting.

The registered manager told us, “[People] have their own keyworkers. If they need any improvements, they can tell the staff.” However, other than the ‘service user’ meetings, there were no other formats of meetings or key worker sessions for people to be asked to share their feedback on the care they were receiving.

The registered manager told us people were involved in meal planning for the week ahead. However, when we reviewed the meal plans for the previous 4 weeks, we identified they were identical. Therefore, we could not be assured that people’s opinions and wishes regarding their meals were being explored and respected by staff. Furthermore, the meals on each week’s meal planner were repetitive. For example, pasta with minced meat appeared 3 times each week. Roast chicken was on the menu for every Sunday and Monday. This meant people were being encouraged to eat the same meal two days in a row and may not be having their wishes respected.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it.

One person had their own disability car. We were informed this car was only used to transport that person to [their] badminton, shops and appointments and was not for anyone else’s use. However, their relative told us, “Sometimes the car isn’t there, it’s at [the provider’s residential service] as there is more space for it.” This meant the person did not have free access to their car when they wished to use it.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

Staff stuck rigidly to supporting people to go on walks, to the shops and to badminton, but did not work with people to understand how to increase the opportunities in their lives. We spoke to one person who told us they liked planes, trains and helicopters. However, opportunities were missed to investigate how these interests could form part of the care the person received, such as utilising local museums and aerodromes. One person’s relative told us, “[They] go for lots of walks, [they] like to be outside. I think [they] would enjoy music shows. There are pantomimes [they] might like.” However, this feedback had not been sought from the person or their relative so that their access to experiences and quality of life could be improved.

Another person’s care plan stated they enjoyed going to a farm, to the pub and to discos. However, we identified none of this was occurring and again the person was only being supported with walks, shopping and badminton. This meant the person was at risk of facing inequalities in their life due to not receiving the appropriate support from staff to expand their world and thrive.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Despite people having various comorbidities, end of life care plans were not in place to advise how staff should support people in their final days. This meant people’s final wishes may not be known in order to be fulfilled.

Despite the provider planning to close the service due to retirement, only 28 days notice had been given to people and their relatives. This meant people and relatives were not supported to plan for important life changes and were instead surprised to be told this without any future warnings or discussions around retirement plans.