Threeways

Updated 4 August 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 23 July 2018 and was unannounced. The inspection was undertaken by one inspector.

Before the inspection we reviewed the information we held about the service, including statutory notifications submitted about key events that occurred at the service. We also reviewed the information included in the provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we met the four people living there and had brief interactions with them. Due to limitations with their verbal communication we were unable to speak to these people in detail and therefore we observed interactions between themselves and staff in order to assess their views about the service. We spoke with four staff. We reviewed two people’s care records, three staff records, medicines management processes and records relating to the management of the home. After the inspection we spoke with one relative.

Updated 4 August 2018

Threeways is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Threeways does not provide nursing care.

Threeways accommodates up to six people with a learning disability and/or autism. At the time of inspection there were four people using the service. These four people were using the service at our previous inspection on 28 March 2017. At that inspection we rated the service ‘good’ overall and for four of the key questions. However, we found them in breach of regulation relating to safe care and treatment and rated the key question ‘safe’ requires improvement.

At this inspection we found the evidence continued to support the rating of good overall and the rating had improved to ‘good’ for each of the key questions and had met the previous breach of regulation. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People received personalised care that met their individual needs. Most of the people using the service required one to one support from staff and this enabled a safe, responsive service which was tailored to the individual. People’s care records were regularly reviewed and updated in line with any changes in their care. People had busy active lives. Each person had a tailored activity programme and staff ensured people were engaged in meaningful activities.

People continued to receive support with their health needs. Each person had a health action plan (HAP) which outlined their healthcare needs and how they were supported to have these needs met.

Risk management plans were incorporated into the individual care plans for people, clearly instructing staff how the person was to be supported to remain safe. People had positive behaviour support plans in place which instructed staff about how to support a person and reduce any triggers to people’s anxieties. Staffing numbers took account of the activities people had planned and enabled staff to be allocated to support people when out in the community.

Staff were knowledgeable about the MCA and adhered to the principles in the Act. As much as possible staff involved people in their care and respected their decisions in regards to daily activities and preferred routines. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

Staff had built caring, kind and compassionate relationships with people and the service had a calm and welcoming atmosphere. We observed staff speaking to people in a friendly manner and from the interactions it was clear staff knew people well. People’s relatives and those important to them were welcome to visit their family member at the service and there were no restrictions to visiting times.

Each person had a communication profile outlining how they communicated. Staff spoke gently and maintained good eye contact and appropriate use of touch to help communicate with people. Staff were respectful of people’s individual differences. Staff supported people’s privacy and dignity.

Staff continued to support people to have a balanced nutritious diet. People were involved in decisions about what meals were offered each day and were able to choose what they wanted to eat from the food supplies in the kitchen. At the time of inspection people did not have any food allergies or specific dietary requirements, however, staff told us they could cater for this should people need it.

Safe medicines management processes remained in place. We saw medicine administration records were completed correctly and upon checking medicine stocks levels we saw these were as expected indicating people received their medicines as prescribed.

People were supported by staff that had the knowledge and skills to undertake their duties. Staff told us they were required to undertake annual refresher training to ensure their knowledge was up to date with best practice guidance, and records confirmed this had been completed.

Staff continued to receive training in safeguarding vulnerable adults and the staff we spoke with were aware of the safeguarding adults’ procedures including how to report concerns to the local authority safeguarding team. Staff were aware of people’s vulnerabilities in the community and protected them from discrimination.

A clean, hygienic environment was provided. A cleaning schedule was maintained and infection control audits were undertaken to ensure best practice guidance was followed.

The complaints process remained in place which would ensure any complaints made were investigated and responded to. There had been no complaints received since our last inspection.

The registered manager had processes in place to review and monitor the quality of service delivery. This included a number of checks and audits. There were processes in place to obtain feedback from people, relatives, visitors and professionals. Staff felt well supported by the registered manager and director. They said there was a commitment within the team to continuously improve and ensure people received high quality care.

The registered manager was aware of and adhered to the requirements of their CQC registration. The registered manager had adhered to the requirements to display the rating from their previous inspection and we saw this was clearly displayed on the noticeboard in the communal lounge.

Further information is in the detailed findings below.