Archived: Threeways Dom Care

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.

This is the first assessment for this service. This key question has been rated Inadequate.This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to governance of the service

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider had not included people or their relatives in conversations when making decisions in the lead up to their retirement. This demonstrated a poor culture that did not place people’s best interests at the heart of the service.

The registered manager told us, “In supported living they are doing everything their own way, they are more independent so there’s more opportunity.” However, there was no evidence to demonstrate this within the service. Furthermore, staff were not aware of how the supported living model of care differed from that in a residential service.

Despite this, staff told us they felt the culture at the service was positive. One staff member said, “The working culture seems to be very good. In my point of view everything is fine. They teach us and explain the guidelines. They always check the staff are doing their work properly.” Another staff member told us, “We need to provide a good quality service to our service users, we need to know about their likes, their dislikes. I am there for them, so I need to give them a good service.” However, this did not always occur as demonstrated elsewhere in this report.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Staff told us they felt supported by their leaders. One staff member told us, “[They are] very helpful for me and for everyone. [They are] there for me every time. If I need support for learning, [they] teach me lots of things. [They] know a lot about our service and about the sector. [They] give me a lot of challenges.”

Equally, the registered manager felt supported by the provider. The registered manager told us, “The provider gives us the deadlines, they are always approachable, they’re involved. They speak to staff and families. They speak via phone or email.”

However, we identified instances where the management team were not open and transparent with CQC. This included the communication to relatives when it was announced the provider was retiring. We were also informed by the registered manager that there was no link between the landlord of the property and the provider. We later identified that the landlord in also a registered manager of the service, which was confirmed by the registered manager in an email to the local authority in September 2024.

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

The registered manager told us, “We have a policy on Freedom to speak up, and a whistleblowing policy. staff complete their safeguarding training.” Staff confirmed they would feel comfortable to raise a concern or speak up if they needed to.

However, a recent whistleblower told us the culture was the opposite. They stated, “Management has increased the workload for certain employees and has been issuing threats, both directly and indirectly, creating a hostile and unsafe work environment. This appears to be a direct act of retaliation against staff who are suspected of speaking out.” Therefore, this demonstrated there was no safe systems in place for staff to be able to speak up without repercussion.

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.

Staff felt included and equal in running the service. One staff member said, “They are encouraging us by teaching. They are providing teaching sessions every Saturday, Sunday, Friday. They are providing extra courses about diversity and inclusion.” This meant staff had received the appropriate training in this area.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders had not ensured people and their relatives understood there was a separation between the care they received and their accommodation. The provider was the managing agent for the landlord to collect people’s rent and received a fee for this work. Therefore, there was no clear separation between landlord and care provider. When we asked relatives if they were aware that as their family member was a tenant they could have a separate care contract with another care provider, one relative told us, “No, I didn’t know that I understood it’s just the staff from Threeways [Dom Care] that can support him.” Another relative told us, “All I was told when [they] moved was that nothing would change, the same carers, everything would be normal, I was mis sold this. The house belongs to [the provider’s husband]. They make money out of the rent as well.” The registered manager was able to show us tenancy agreements for people but was not able to show us separate care contracts. This meant people and their relatives had not been informed they were able to use another care provider if they wished.

We identified staff were falsifying care documents. One person’s care notes and ‘opportunity chart’ stated they had baked cakes earlier that day. When we asked the staff member about this, they said, “[They] erm, [they] did a bit of baking whilst I was doing [their care] notes. [They] baked a couple of cakes, they didn’t last very long as [they] ate them. [They] baked the cakes before we went out, about 13.15ish. It’s in a ready mix box thing.” We then asked the other staff member what the person had baked. They told us, “We didn’t bake.” The first staff member then told us she thought the person had baked but they could be incorrect. We reminded them that they also said that they had seen the person eat the cakes. Therefore, care records were not accurate, and did not truly represent the care that people had actually received.

We observed care audits had not taken place since October 2024. However, they were not effective in their use. For example, a medicines audit dated October 2024 stated that all staff members knew why people were taking each of their medicines. However, during our assessment we identified that this was not correct. Furthermore, a care plan audit dated October 2024 stated MUSTs were being used. As described earlier in the report, we identified this was incorrect.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Feedback from professionals involved in people’s care such as chiropodists was positive. However, we identified information given to external partner was not always accurate.

One person had recently had a social work review with their care coordinator. The care review document stated the person still needed 2:1 in the community. However, this was not being delivered. Therefore, incorrect information was being given to professionals involved in people’s care when assessing their needs and the provider was continuing to receive funding for 2:1 care when this was not always being delivered.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Staff told us they were able to contribute to the improvement of the service. One staff member told us, “Every time I have a suggestion, they take it seriously. If something happens, they will take feedback from everyone and they will give us a teaching session. So we can learn and know what we need in order to improve.”

However, we identified there was no culture to encourage improvements in the service. Audits were not being used to identify areas for improvement, and staff were not effectively gaining feedback from people and their relatives to improve the quality of life and opportunities people received.