Archived: Threeways Dom Care

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.

This is the first assessment for this service. This key question has been rated inadequate.This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, staffing levels, and safeguarding people from abuse

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The registered manager told us, “We have reflective practice sessions and debriefs so we can talk through start to finish what happened, what we felt, and if necessary, we will arrange training.” However, we identified incidents were not always documented appropriately, which led to missed opportunities to identify shortfalls and make improvements where required.

For example, a person at the provider’s other service had endured a seizure in 2024.Staff involved also worked at Threeways Dom Care. One staff member told us, “Most staff hadn’t seen a seizure before. We all met and spoke for 10-15 minutes to get any concerns out. Staff have had epilepsy training.” People supported at Threeways Dom Care were known to have a history of seizures. Whilst there was a section in their care plan confirming this, there was no information confirming what type of seizure people suffered from, any known triggers, if they were on any emergency medicines for this, and how to support them while they were having a seizure. This led people at risk of staff not having sufficient knowledge and information to be able to provide safe care in the event of a seizure.

A person was known to have heightened anxiety episodes which could result in physical and verbal aggression. A staff member told us, “[they are] calmed and settled. [they are] used to the staff more.” The registered manager added, “We’ve had no recent incidents here as they’re all really settled.” Despite their behaviour chart confirming the person had displayed these behaviours 484 times in April, 518 times in May and 484 times in June, there were no reports regarding these incidents, stating what happened, what was the trigger and if any lessons needed to be learnt. When we asked the registered manager about this, they told us, “Most of these were attempts and not anything that warranted an incident form to be completed. Any low-level ones would be written in [their] care notes.” However, these were not recorded in the person’s care notes, and examples of episodes recorded in their behaviour chart were ‘self-harming’, ‘swearing at others’ and ‘throwing objects’, all of which did not indicate that these were just attempts. Furthermore, as best practice, any attempts should be recorded so that any patterns in triggers could be identified, such as the person not liking a certain member of staff supporting them.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Transition care plans were not robust. One person had moved to the service after being at their previous home for 10 years. Their transition plan did not contain information on how they would be introduced to their new home, the frequency of visits in the lead up to them moving in, and how the service had prepared them for receiving a supported living model of care instead of the residential care they had received for 10 years.

Furthermore, the transition plans for both people were very similar and lacked personalised information regarding their individual needs. For example, both plans stated, “Reinforce positive things with [Person] and go with [their] flow”, “[They are] hyperactive/impulsive and move suddenly from one place to another”, and “Encourage [person] to attend to [their] personal hygiene and to support [them] with [their] bath when [they] get up in the morning.” This meant there were not adequate personalised plans in place to manage people’s anxieties around moving home and how they would be introduced gradually.

The provider had an on-call system so that staff could contact a senior member of staff in the case of an emergency or for advice. However, the on-call system at the service was ineffective. The registered manager was the on-call manager on the day of our second onsite visit. A staff member attempted to contact them on 3 occasions during our visit, but the registered manager did not answer. This meant staff members were at risk of not receiving emergency support from the management team.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Staff told us they were aware of their responsibility to safeguard people. One staff member told us, “If I thought it was happening, I would report it immediately to the manager and the provider. I could raise it with you, the council or police. Two of us check their money and medication.” Another told us, “If I saw anything like that, I would follow the safeguarding policies, I would ensure the person is ok and safe, I would report it to the management straight away. If necessary, I would report it to the CQC or the Local Authority.”

However, we identified concerns with how people’s money was being managed. For example, the registered manager told us each person contributed £50 a week from which food was brought together for the service. However, we identified occasions where £146.40 had been spent on groceries in one week, and £126.34 another week. This exceeded the money identified for food with no rationale on why the costs were so high, . Additionally, we identified that 28 pints of milk had been purchased over the course of one week for the 2 people living at the service. As staff members did record what people had eaten and drunk in care notes, we could not be assured that people were the only ones consuming the food and drink that was purchased from their money.

One person’s behaviour chart stated they had made over 79 ‘false allegations’ each month. When we asked a staff member how they could be certain every allegation was false they told us, “There is always a member of staff with them so that is how they know they are false. [They] say everybody has hit [them].” However, this had not been recorded in any records to demonstrate that staff had considered the allegation and provided evidence to ensure that it was false and no harm had come to the person. This left the person at risk of abuse.

People were at risk of being unlawfully restricted of their liberties. Best interest meeting discussions were not recorded to ensure any decisions were the least restrictive option.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

One person had been receiving regular blood tests due to having an issue with their platelet count. However, there was no information regarding this in their care plan, or the symptoms the person may experience due to this health need. When we asked their keyworker about the reason for the regular blood tests, they told us this was due to a high white blood cell count. Therefore, staff were not aware of the reason for the recurrent blood tests and how this may impact the person’s health. This left people at risk of not receiving appropriate care if their symptoms were to worsen as staff were not aware of the risks involved with a high platelet count.

One person was at risk of constipation. However, there was no bowel monitoring chart to ensure the person was eliminating regularly, or any guidance for staff on the action they should take if the person had not. The registered manager told us that any bowel movements would be recorded in their care notes. However, we found no evidence of this.

The provider’s ‘Guide for people who use our services’ stated, “Staff will never bring pets into your home.” However, one staff member told us, “My dog is an unofficial therapy dog for the guys here. I bring her in when it’s not hot. The guys love watching her mooch around the garden and [Person] gives her a biscuit. She’s 19 and has an undiagnosed tick disorder.” This therefore went against the provider’s own policy. There was also no risk assessment to ensure that people were safe whist the dog was in the premises, and what action should be taken if there was an incident which resulted in an injury to people due to the dog.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The medicines cabinet was stored in the kitchen. We asked the registered manager what the maximum safe temperature should be for storing medicines. He told us 24 degrees. However, the thermometer in the cabinet was showing 26 degrees. This meant the environment was not at a safe temperature to be storing medicines and as a result they medicines may lose their efficiency.

Staff completed a daily check of the medicines cabinet temperature. This had been completed at 6pm each day. Therefore, staff were not checking the temperature was within safe limits for medicines at the hottest time of the day, so could not be assured the efficiency of medicines had not been compromised. Furthermore, staff had consistently recorded the medicines cabinet temperature as 17 degrees each day. This was despite differences in the weather and general temperature each day. Therefore, we could not be assured that staff were recording this temperature accurately.

We identified sewing needles were being stored in a person’s bedroom drawers. This was a risk to the person who would not understand the needles were sharp and could injure them. Furthermore, the same person’s care plan stated they were known to throw and break the TV if it was not attached to the wall. However, we observed the TV in the lounge was freestanding and therefore presented a risk to the person and others in the premises.We informed staff members of these concerns during our assessment and the sewing needles were removed from the person's bedroom.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were not adequate numbers of staff to meet people’s needs. For example, one person’s care plan confirmed they required 2 staff when they accessed the community due to risks associated with running away from staff and inappropriate behaviour towards the public. The provider’s rotas confirmed only 2 staff were on shift at the service each day to support both people living there. Therefore, it did not meet the guidance in people’s care plans of needing 2:1 care to access the community.

Furthermore, on the day of our first site visit only one staff member supported the person to access the community. When we asked the registered manager about this, they told us the person and staff member would meet up with the other person and staff member who were also in the community. However, this did still not demonstrate that the person who required 2:1 care was receiving this. The registered manager then told us they would usually support as the second staff member. However, the provider’s rota confirmed they were only at the service one day a week.

The same person was supported to attend badminton sessions 3 times a week with people from the provider’s other service. A staff member confirmed to us there was one staff member for each person during these sessions. Therefore, this again demonstrated that the person was not receiving the 2:1 care they required when accessing the community. Their relatives also told us their family member only received support from 1 carer, stating, “They are on 1:1 ratio.”

Supervision meetings are opportunities for staff members and their line manager to discuss objectives, reflecting on practice, identifying areas for improvement, and staff welfare. However, staff did not receive adequate supervision meetings to discuss concerns and ongoing development. All supervision records were basic 1-page written documents which included little detail of the discussions had between the staff member and their line manager.

Staff members had not always been safely recruited into the service. We identified one staff member’s recruitment file did not contain a full working history, an undated character reference, and no evidence of their Right to Work in the UK. This staff member did also not appear on the provider’s training matrix. We asked the registered manager to send us an updated training matrix following our onsite assessment. However, when this was received it still did not include this staff member on it.

We identified the staff member delivering training to other staff had no career background in care or training. This meant training could be ineffective and not delivered in a suitable manner.

The registered manager told us that a lot of the staff came from an agency. However, they were not able to evidence they had received agency profiles for these members of staff. Therefore, the registered manager could not ensure agency staff had received the required training, were of good character, and had the skills required to care for people with a learning disability.

Despite this, staff told us they felt there were enough staff to meet people’s needs. One staff member told us, “I have never had an issue with staff levels, I think there is enough staff at the moment certainly.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

One staff member was wearing flip-flops while on shift. Flip-flops can easily track in dirt and germs from outside, potentially spreading infections in a care environment. Closed-toe shoes are crucial for maintaining a clean and sterile environment. Following our assessment, the registered manager informed us that staff had been reminded to wear appropriate footwear.

However, staff told us they had access to personal protective equipment (PPE). One staff member told us, “We have disposable aprons, which are worn for personal care, bathing, showering or toileting. We use disposable gloves for the same reasons and rubbing ointments and creams.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The registered manager informed us people had annual medicines reviews with their GP practice. Medicines administration record charts (MARs) were completed in full.

However, there were areas of medicines management which could be improved. For example, staff were not recording the remaining counts of a medicine when a tablet was administered. This meant staff would not be able to identify any medicines errors in a timely manner.This was somewhat mitigated by 2 staff members checking medicines daily.

People who were prescribed medicated creams did not have topical MAR charts in place. These documents should include a body map which demonstrates where on the body the person requires the cream to be applied. This meant people were at risk of having their medicated creams applied to the wrong area of their body. Following our inspection, the registered manager informed us topical MARs had been requested from the pharmacy.

Although staff completed a yearly medicines competency assessment, they were unable to tell us what the medicines people were prescribed were for. For example, when we asked a staff member why a person was prescribed a particular medicine, they told us, “I will be honest, I’m not 100% sure.” This meant staff were not aware of people’s medication needs.