CQC report explained · a nursing home
What the CQC found at Threeways Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2021
Inspected but not rated; inspectors were assured that infection control arrangements were in place.
This was an announced, targeted inspection on 25 March 2021. It focused on how the home prevented and controlled COVID-19 infections.
Inspectors found PPE, COVID-19 training, staff competency checks and cleaning schedules. They were assured that the home was managing visitors, admissions, testing, social distancing and infection outbreaks safely.
The home had experienced a high number of COVID-19 cases among people and staff. Inspectors found that people's care needs continued to be met, despite staff sickness and the need for some extra shifts.
The home was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating.
Infection control guidance
The home had PPE, COVID-19 training, competency checks and cleaning schedules. Guidance on putting on and removing PPE was displayed for staff.
“The registered manager had followed current guidance in relation to infection prevention and control.” from the report
Care continued during the outbreak
Although a number of staff were off sick, the home continued to meet people's care needs. Existing staff covered extra shifts and some housekeeping staff helped with non-clinical tasks.
“Despite a number of staff being off sick, the home had managed to continue to ensure people's care needs were met.” from the report
Safe visiting arrangements
The home had arrangements for visitors, including temperature checks, lateral flow testing, PPE and social distancing.
“Visiting protocols were in place to facilitate safe visiting to the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How are PPE training and staff competency checks kept up to date now?
- 02What arrangements are currently used to test people, staff and visitors for COVID-19?
- 03How would you manage staffing if several staff were off sick during an infection outbreak?
- 04What are the current visiting arrangements, including PPE, testing and social distancing?
- 05How do you identify and manage each person's risks from infection, including underlying health conditions?
This was a targeted inspection of infection prevention and control under the Safe question; the service was inspected but not rated and the other four questions were not covered. This explanation was written from the published report of 9 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2018
Rated Good overall; inspectors found safe, kind and responsive care, but well-led was Requires Improvement because records were not always up to date.
This was an unannounced, comprehensive inspection on 11, 12 and 14 June 2018. Inspectors spoke with people living in the home, visitors and staff. They observed care, checked the premises and medicines, and reviewed care plans, staff files, complaints and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines systems, suitable training, support with food and healthcare, respectful care, personalised plans and a choice of activities.
The home was rated Requires Improvement for Well-led. The provider had improved its checks and care planning, but some records were inconsistent or had not been updated when people's needs changed. Staff generally understood people's needs, so inspectors judged the immediate impact to be low.
The overall rating improved to Good after earlier inspections found legal breaches. The report says the provider had met the legal requirements by this inspection, although some improvements still needed to become part of everyday practice.
Safe medicines and risk management
Inspectors found that medicines were given safely and records showed they had been administered as prescribed. Risk assessments and guidance had also improved since the previous inspection.
“There were safe systems in place for the management of medicines.” from the report
Kind and respectful care
People were involved in their care and supported to make everyday choices. Staff protected privacy and dignity and treated people in a friendly, caring way.
“People were treated with respect and support was provided in a kind and caring way.” from the report
Personalised support and activities
Care planning had been changed to reflect people's preferences and support independence. People helped choose activities, including group and one-to-one sessions.
“A range of group and one to one activities had been developed with the involvement of people living in the home” from the report
Food and healthcare support
People were offered choices of meals and drinks, including food adapted for swallowing needs. Staff arranged healthcare support and followed professional advice.
“People were supported to eat a nutritious diet and drink enough fluids.” from the report
Care records were not always clear or current
needs fixingSome care plans contained conflicting information or did not clearly explain how a person should be supported. Inspectors said the immediate impact was low because staff knew people's needs, but the records still needed improvement.
“We found some of the information was not consistent and had not been updated promptly when people's needs changed.” from the report
Staff knowledge about communication standards
minorStaff were not fully aware of their responsibilities under the Accessible Information Standard. The provider was asked to seek advice and guidance so staff could better support people with communication needs.
“However, staff were not fully aware of what these changes meant.” from the report
- 01How do you make sure care plans are updated promptly when a person's health or support needs change?
- 02How do you check that staff follow the correct guidance when someone needs help to transfer, including whether to use a stand aid or hoist?
- 03What training have staff had about the Accessible Information Standard and supporting people with poor eyesight, dementia or other communication needs?
- 04How do you monitor medicines, including patches, creams and medicines given only when needed?
- 05How do you make sure people who prefer to stay in their rooms receive meaningful one-to-one activities and help to go outside?
This was an unannounced comprehensive inspection covering all five key questions and both the premises and care provided; inspectors reviewed four care plans and a range of other records. This explanation was written from the published report of 21 July 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Threeways Nursing Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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19 live-in carers within about an hour of East Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
“When he point blank refused to go into hospital for a life saving blood transfusion she talked him through the situation and agreed to go in the ambulance with him and stayed until he was settled.”
“Una felt safe, secure and loved in her time with Debbie which is a gift that I am eternally grateful for.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.