This inspection took place on the 11, 12 and 14 June 2018 and was unannounced.

We carried out an inspection at Threeways Nursing Home on 11 and 13 August 2015 where we found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not met the regulations in relation to safeguarding people from abuse and improper treatment and, had not ensured complete and accurate contemporaneous records in respect of people needs were in place.

At the last inspection on 13 and 14 December 2016 we found the provider had taken action and had met the regulations in relation to safeguarding people from abuse and improper treatment. However, they had not addressed the breach in relation to ensuring complete and accurate contemporaneous records in respect of people were available.We also found a new breach of regulation. The provider had not ensured safe care and treatment for people. We took enforcement action for these breaches.

We found a third breach in that the provider had not ensured that staff had the information required to meet people’s individual needs and we asked the provider to send us an action plan to inform us how they would meet the regulations. The provider sent us an action plan to advise they had met the regulation.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and confirm that the service now met legal requirements. We found improvements had been made and the provider had met the legal requirements. Although, we identified some areas that needed time to be embedded into day to day practice the overall rating had improved to Good.

Threeways Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home is registered to provide nursing and personal care and accommodation for up to 45 older people and people with disabilities. At the time of the inspection there were 41 people living there. Some people required continual nursing care due to complex health care needs; including end of life care. Other people needed support with personal care and assistance to move around the home safely due to frailty or medical conditions, such as diabetes, stroke and Parkinson’s and, some people were living with dementia.

The registered manager was present during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The quality assurance system had been reviewed and areas for change had been identified and prioritised to drive improvement. The care planning process had been changed and a new care plan format had been introduced. Nurses were responsible for reviewing the care plans and daily records and, although some of these were up to date with clear guidance for staff we also found information that was not clear or had not been updated. Staff were aware records were not consistently up to date and the changes in the care planning process would take time to be embedded into day to day practice.

From 1 August 2016, all providers of NHS care and publicly-funded adult social care must follow the Accessible Information Standard (AIS) in full, in line with section 250 of the Health and Social Care Act 2012. Services must identify, record, flag, share and meet people’s information and communication needs. Staff were not fully aware of what these changes meant.

We recommend that the provider seek advice and guidance from a reputable source, about Accessible Information Standards (AIS) to ensure staff are aware of their responsi

We carried out an inspection at Threeways Nursing Home on 11 and 13 August 2015 where we found the provider had not met the regulations in relation to safeguarding people from abuse and improper treatment and completing accurate and contemporaneous records in respect of people.

We undertook an unannounced inspection on 13 and 14 December 2016 to check that the provider had made improvements and to confirm that legal requirements had been met.

At this inspection we found the provider had taken action to meet the breach in Regulation 13 of the HSCA Regulations 2014, however they had not addressed the breach in Regulation 17 of these Regulations.

Threeways Nursing Home provides nursing and personal care for up to 45 people. At the time of our inspection 35 people were living at the home. People had various long term health care needs including diabetes, dementia type illnesses and other conditions which impacted on their mobility.

Threeways Nursing Home was on two floors with bedrooms and bathrooms on both floors accessed by a lift. The ground floor included a kitchen, laundry room, dining room, a main lounge and offices.

There was a registered manager at the home. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Although staff knew people well and had a good understanding of their individual needs and choices there were inconsistencies of detailed written information which could leave people at risk of receiving care and treatment that was inappropriate or inconsistent. This had not been identified through the quality assurance system.

Three people told us they were not supported to be involved in the assessment and planning of their care and treatment. Changes to people’s needs were not always reflected in their care plans.

The audit systems had not ensured that actions identified at the last inspection had been addressed. The systems to assess the quality of the service provided were not always effective and had not identified the shortfalls we found.

Aspects of medicine management needed to be improved because guidelines in relation to the administration of some medicines were not clear.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found appropriate policies and procedures were in place. The registered manager was familiar with the processes involved in the application for a DoLS, and had made the necessary applications to the authorising authority. Although there was some improvement in relation to staff understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards people’s rights to take risks had not been taken into account. These issues in relation to MCA and DoLS require improvement.

People told us they felt safe living at Threeways Nursing Home. There were sufficient levels of staff to protect people’s health, safety and welfare. The provider had improved staffing levels based on the dependency of people’s needs.

People were provided with a choice of healthy food and drink ensuring their nutritional needs were met. Staff encouraged and supported people to eat and drink well. One person said, “The food is fresh and well presented.”

Training schedules confirmed staff had received training in safeguarding adults at risk. Staff knew how to identify if people were at risk of abuse or harm and knew what to do to ensure they were protected. Staff had received regular supervisions with their manager to discuss additional training needs and development. Staff were encouraged to attend further training, with the majority having achieved the Care Certificate.

Robust recruitment and selection procedures

During our inspection we spoke with five people who used the service and three visiting relatives or friends. We also spoke with seven staff members; these were the manager, a registered nurse, the activities co-ordinator, the chef and three care workers.

The people we spoke with told us they were happy with the care they had received and with the staff team. One person who used the service told us “Yes I’m very happy here, I have no complaints”.

Staff we spoke with said that they had undertaken safeguarding vulnerable adults training, and people we spoke with told us that they felt safe and knew who to talk to if they had any concerns.

Care workers told us that they felt valued and supported and that their training needs had been met. We looked at staffing rotas and observed levels of staffing. We saw that the service had sufficient numbers of suitably qualified staff to support people. We found care plans, staff records and other records relevant to the management of the home were accurate and fit for purpose.

Sound arrangements were in place for the safe ordering, storage, administration and disposal of medicines at the service. Staff had a good understanding of their responsibilities in relation to the safe administration of medicines.

We also saw that the service had quality assurance systems in place to monitor the quality of the service provided. However we did identify non-compliance in respect to the analysis of accident and incident recording.

We spoke with five people to hear their views and experience of living in the home. One person said that they were “well cared for” and “didn’t see anything to complain about.” Another person spoken with also said that staff looked after them well. Three people said that they had to wait too long when they used their call bell to request assistance. We spoke with the matron who confirmed that she had monitored response times to call bells and that there had been improvements in this area.

We found that care plans had been reviewed to show the needs of people and how they should be met. The provider had introduced new systems to monitor and improve the service.

The inspection team was led by a CQC inspector who was joined by a second inspector and an Expert by Experience (people who have experience of using services and who can provide that perspective).

We spoke with ten people to hear their views and experience of living in the home. We also spoke with two visitors to the home and both were happy with the care provided. One person said “I don’t think they (the staff) could be better”. However, seven of the ten people spoken with regarding staff response times to call bells said that they had experienced delays.

Five people said that they “could do with more staff” during the day. People said that there was a lot of agency staff at night. One person said “you get used to it”. Another person said “some are very good, some not good”.

People told us what it was like to live at Threeways Nursing Home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an Expert by Experience (people who have experience of using services and who can provide that perspective) and a practising professional.

We spoke with 11 of the 39 people living there at the time of the visit.

People said that staff called them by their preferred names and that they always knocked before entering their rooms. “The staff here are very good especially the older staff, they are more aware of closing curtains and doors when they do things to help me”.

One person said “There are more choices at breakfast and supper but at lunchtime you really get what is prepared for you. If you don’t like it you can say and they will give you something else”. This comment was echoed by other people spoken with.

The people we spoke with said they were happy living there, were well cared for and felt safe.

Five of the 11 people spoken with raised concerns about poor response times to call bells. In relation to two of these people we noted that their call bells were not in reach.

Threeways Nursing Home is located in Seaford with parking on site and nearby on the road. The original building has been extended to the side, there are communal rooms on the ground and first floor; lifts enable people to access all parts of the home, and there are large accessible gardens to the rear.

The home provides support and care for up to 45 people with nursing and personal care needs. There were 38 people living at the home at the time of the inspection. Some people had complex needs and required continual nursing care and support, including end of life care. Others needed support with personal care and assistance moving around the home due to physical frailty or medical conditions, and some were living with dementia.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

This inspection took place on the 11 and 13 August 2015 and was unannounced.

There were systems in place to manage medicines, but guidelines for some medicines were not clear, which meant medicines may not have been given to people in a safe or consistent way.

People were assessed before they moved into the home to ensure staff could meet their needs, and care plans were developed from this information. However, care plans were not focused on each person’s preferences and choices, and guidance for staff to follow when planning and providing care was limited. Although staff knew and understood people living in the home and were able to plan their care delivery in line with their choices

People felt staff took a long time to answer the calls bells at times, and this had not been identified by the management as an area for improvement. People also felt there were enough staff working in the home and that staff provided the support and care they needed.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The management and staff had an understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, but had not followed current guidance to ensure people were protected.

A safeguarding policy was in place and staff had attended safeguarding training. They had an understanding of recognising risks of abuse to people and how to raise concerns if they had any.

Risk assessments had been completed as part of the care planning process, with guidance for staff to follow to reduce the risk of harm.

Recruitment procedures were in place to ensure only suitable people worked at the home. Staff said they were supported to deliver safe and effective care, and demonstrated they knew people well and enabled people to maintain their independence.

New staff were required to complete an induction programme in line with Skills for Care, and the ongoing training programme supported staff to meet people’s needs. The registered nurses attended fundamental training and additional training to ensure their nursing competencies were up to date.

People told us the food was very good. Staff asked people what they wanted to eat, choices were available for each meal, and people enjoyed the food provided. People told us they decided what they wanted to do, some joined in activities while others chose to sit quietly in their room or communal areas. One person said, “I know there is an activities programme and I could join in if I wanted to, it is up to us really.”

People had access to health professionals as and when they required it. The visits were recorded in the care plans with details of any changes to support provided as guidance for staff to follow when planning care.

A complaints procedure was in place. This was displayed on the notice board near the entrance to the building, and given to people, and relatives, when they moved into the home. People said they did not have anything to complain about, and relatives said they were aware of the procedures and who to complain to, but had not needed to use them.

People, relatives and staff said the management were very approachable, and were involved in decisions about how the service developed with ongoing discussion on a day by day basis and during residents meetings. In addition feedback was sought from people, their relatives and other visitors to the home through satisfaction questionnaires.

The registered manager had quality assurance systems in place to audit the support provided at the home. These included audits of care plans, medicines, menus, accidents and complaints.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.