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 i

We inspected this service on 28 March 2017. The inspection visit was announced.

Threeways is a residential care home for six people who have a learning disability and autism. People have varied communication needs and abilities. At the time of inspection there were five people living at the service.

On the day of inspection we met the registered manager. ‘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.

We last inspected the service on 18 November 2015 where concerns were identified with regards to staffing levels, risk management, consent, dignity and respect, person centred support and auditing.

The registered manager had made several improvements with regards to incident reporting, consent, dignity and respect and person centred support. Despite this we still found a shortfall with regards to the management of risk while people were being supported out in the community..

Relatives felt their loved ones were safe at Threeways. Despite this we found that the registered manager did not always ensure people were support by a safe amount of staff while accessing the community. This put people at risk as their assessments indicated they become anxious and distressed while out in the community.

Further risks of harm to people were identified at the initial assessment of care and staff understood what actions they needed to take to minimise risks. Staff understood people's needs and abilities.

People were supported by staff who understood the signs of abuse and their responsibilities to keep people safe. Recruitment practices were followed that helped ensure only suitable staff were employed at the service.

People were supported by regular members of staff who supported people in a timely manner. Staff were confident and had the knowledge to administer medicines safely. They knew how to support people to take their medicines safely and to keep accurate records.

Staff felt they received the training and support they needed to meet people's needs effectively. Staff felt supported by the management team.

The registered manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff had a good understanding of MCA and DoLS. When people lacked capacity the best interest process was followed.

People were supported to eat meals of their choice and staff understood the importance of people having sufficient nutrition and hydration. Staff referred people to healthcare professionals for advice and support when their health needs changed.

Relatives praised staff for their caring nature. Relatives told us staff were kind and respected their privacy, dignity and independence. Care staff were thoughtful and recognised and respected people's wishes and preferences.

People received person centred care and people were supported with activities.

Relatives knew how to complain on behalf of their loved ones and were confident any complaints would be listened to and action taken to resolve them.

Relatives praised the quality of support offered to their loved ones and agreed that the service was managed well. The registered manager understood their responsibilities in terms of notifying CQC of significant events at the service.

The registered manager audited the care and support delivered and sort feedback from people and relatives regarding the support received. All feedback from audits and questionnaires was positive so it was hard to judge if this had been used to improve the service provided to people.

This was an unannounced inspection that took place on 18th November 2015.

Threeways is a residential care home for 6 people who have a learning disability, autism and behaviours that can challenge. People have varied communication needs and abilities. Some people are able to express themselves verbally using one or two words; others use body language to communicate their needs. At the time of inspection there were five people living at the service.

There was a registered manager in post. ‘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 is the first inspection since the provider changed its legal entity.

People were not always safe at Threeways. There were times when there were not always enough staff deployed to meet the needs of people. Some people were assessed to have 1:1 staff support. The provider told us “we sometimes do group sharing.” This means that people were sometimes grouped together for activities when there was not enough staff to provide 1:1 support.

Incidents and accidents had not been recorded appropriately. The incident and accident folder did not contain any forms; the provider stated “We do not have any incidents or accidents.”

Staff had some knowledge of safeguarding people and told us what they would do if they had a concern. They knew to report it to the registered manager or to the local authority.

Risks to people had been assessed, however one person had been identified as a risk of choking. Surrey’s choking policy had not been followed, as the registered manager had not made the appropriate referral to the Speech and Language Therapist. The provider made the referral on the day of inspection.

There were robust checks in place to make sure that staff were suitable before working in the home. Medicines were stored safely and people were given their medicines at the right time in a safe way.

We found the provider had not always met the requirements of the Mental Capacity Act. Peoples consent was not always sought about what care and support they needed. We saw staff leading people around the house by holding onto their wrists or hands.

Some mental capacity assessments had been completed regarding people being able to leave the home and accepting care and support. Relatives and relevant health and social care professionals had been consulted on these decisions.

Staff were not always sufficiently trained to support people. Most staff had not received specific training or had a refresher in current practises in working with people with autism, communication difficulties and physical interventions.

People had access to health professionals such as psychiatrists, dentists, GPs and opticians to ensure their health and wellbeing was maintained. People had enough to eat and drink, but people did not always have a choice as to when they could have it or what they wanted.

The service was not always caring. People were not always involved in making decisions about their care. People did not have individual goals to allow them to develop their skills and life opportunities. People had person centred and care plans in place.

Staff were not always interacting with people in an age appropriate manner; phrases like “good boy” were common place. People’s dignity and privacy was not always respected. Staff did not always knock on people’s bedroom doors.

People did not always receive individualised care that was tailored to their needs. People’s activity timetables were very similar and people did in house group activities together. There was little opportunity to participate in activities out in the community.

A relative told us “We are very pleased our relative is there, it is the best home they have been in, it’s family orientated.” Another relative told us “The family environment the service offers was very relaxing and had helped him in many ways.” Staff supported people to maintain relationships that were important to them.

We observed an activity outdoors; the staff member engaged with the person about road safety, nature and plans for later that day. Staff treated people with kindness and compassion.

There was a complaints policy in place; the registered manager told us that no complaints had been received by the home. However the complaints policy was not on display around the home for people or relatives.

The registered manager and the provider spent most of their working week supporting people. This does not allow them time to develop the service and to drive improvements with regards to staff practise. There were quality audits in place, but they were not always effective as they did not identify any of the areas that have been identified in the report.

Staff told us that they felt the manager was approachable. Staff received regular supervision and there were regular staff meetings.

We found 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.