Threen House Nursing Home

Updated 14 April 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by one inspector.

Service and service type

Threen House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Threen House Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. This included information about incidents the provider had notified the CQC about. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, the provider, a chef, a care worker, a senior care worker and a nurse. We observed people being supported in the communal areas. We viewed a range of records relating to people’s care and the management of the service. This included three people’s medicines support and care records and three staff files in relation to recruitment and supervision. We viewed a variety of records relating to the management of the service, including audits, maintenance records and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We also requested more evidence about the management of the service, including staffing and premises maintenance records. We spoke with two relatives, a local priest and a healthcare professional who had visited the home regularly.

Updated 14 April 2022

About the service

Threen House Nursing Home is a nursing home in a converted, detached property. The service provides personal and nursing care and accommodation for up to 26 adults. At the time of our inspection there were 16 people using the service.

People’s experience of using this service and what we found

There were arrangements in place for preventing and controlling infection but these were not applied consistently. Some records regarding the management of the service and staff employment had not always been kept up to date. The systems in place for monitoring the quality of the service and making improvements were not always effective as they had not enabled the registered manager to take timely action to address the issues we found.

Relatives and visitors spoke positively about people’s care and the atmosphere of the home. One relative told us, “They really seem to care.”

There were enough staff to meet people's needs safely. There were recruitment processes in place to help make sure the registered manager only employed suitable people. Staff liked working at the home and felt supported by the registered manager and provider.

People were supported to take their medicines safely, although the registered manager could not always demonstrate they had ensured staff remained competent to provide this support.

The service worked together with other health and social care professionals to meet people's needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 16 May 2018).

Why we inspected

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. This included checking the provider was meeting COVID-19 vaccination requirements. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service. We inspected and found there was a concern with IPC practices so we widened the scope of the inspection to become a focused inspection to include the key questions of safe and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Threen House Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.