Three Sisters Care Ltd

Updated 29 November 2022

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.

Inspection team

This inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service.

Service and service type

This is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. The manager of the service was present throughout the inspection and had applied to the Commission for registration. The provider has subsequently informed us the manager has resigned and they are recruiting for a new manager.

Notice of inspection

We gave the service 2 days’ notice of the inspection. This was because we needed to be sure that the manager or another senior staff member would be in the office to support the inspection. Inspection activity commenced on 16 August 2022 with a visit to the office location and concluded on 26 September 2022.

What we did before the inspection

We reviewed the information we held about the service, for example any statutory notifications the provider is required by legislation to send to us and the last inspection report. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the manager, 6 care workers including senior care workers, a care coordinator, the office manager, an administrator, the deputy manager, the operations auditor and the chief executive officer. We also spoke with the nominated individual who is responsible for supervising the management of the service on behalf of the provider and met a group of 18 care staff attending their monthly team meeting.

We reviewed a variety of records, which included the care records for 12 people using the service. We checked 8 staff files in relation to recruitment, training, supervision and appraisal. A range of records were reviewed relating to the management of the service including ‘spot check’ visits reports, the complaints log and policies and procedures.

We continued to seek clarification from the provider to validate evidence found. We contacted 13 people and their relatives and spoke by telephone with 4 people and 4 relatives. We contacted 2 health and social care professionals with knowledge and experience of the service for their views.

Updated 29 November 2022

About the service

Three Sisters Care Ltd is a domiciliary care service providing personal care to people living in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of the inspection 120 people were receiving personal care.

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

People were provided with care and support from staff who were kind, respectful and caring.

Systems were in place to promote people’s safety and minimise any identified risks. However, the provider did not make sure that appropriate measures were in place at a time when staff needed to test themselves twice weekly for COVID-19.

People were supported by safely recruited staff who received training and guidance for their roles and responsibilities. Staff received supervision from their line managers and the provider was working towards ensuring staff received sufficient supervision.

The service was not consistently well-managed. Although people were asked for their views about the quality of their care and support and found the office team helpful when they had enquiries, people did not receive sufficient visits to their homes to check how staff supported them. The provider’s own quality monitoring systems did not always identify the shortfalls we found.

Staff received safeguarding training and knew how to protect people from the risk of abuse, harm and neglect. People received safe support when taking their medicines.

People were supported to meet their nutritional and hydration needs where this formed part of their agreed care plan.

Staff were aware of people's rights under the Mental Capacity Act 2005 and supported people to have maximum choice and control of their lives, in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and/or who are autistic.

People and/or their relatives where applicable were supported to take part in the planning and reviewing of their care and support, if they wished to. Care and support plans showed that people were consulted about their needs, wishes and aspirations.

People knew how to make a complaint and were confident the manager would act professionally and swiftly to investigate and resolve their concerns.

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 requires improvement (published 7 July 2021). There were no requirements or recommendations following the last inspection. The provider completed an action plan after the last inspection to show what they would do and by when to improve their rating. This service remains rated requires improvement. This service has been rated requires improvement for the last eight consecutive inspections. However, two of these inspections were targeted to check on whether the service had met breaches of regulation and did not permit for the rating to be changed.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Enforcement and Recommendations

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 a breach in relation to how the provider audits and monitors the quality and safety of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow-up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.