Three Sisters Care Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion.

The registered manager operated an ‘open door’ policy where people, relatives and staff could speak to them at any time.

Staff told us the registered manager was approachable and was easy to talk to if they had any issues to discuss.

Staff had a good understanding of the ethos of the service and were clear about their responsibilities. They understood their roles and told us they were supported by the management team.

The registered manager understood their legal responsibility to be open and honest when something goes wrong and had responded accordingly where the duty of candour applied. They had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

The provider had inclusive leaders at all levels who understood the context in which they delivered care.

The registered manager had a good relationship with staff, people using the service and their relatives. Staff told us the registered manager was approachable and was easy to talk to if they had any issues to discuss. They were happy working at the service.

There were good systems in place for communication between staff and the management of the service through a digital application or phone calls.

Relatives told us that they were always kept up to date with what was happening with their family members.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a whistleblowing policy which gave guidance to staff about who they could speak to should they have any concerns.

Staff were encouraged to speak freely, and they felt confident to raise issues with the management team should they have any concerns.

People and their relatives told us that if they had any concerns about the service, they would speak with one of the members of the management team or the staff who visited them.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them.

The registered manager encouraged staff to be involved in how the service was run. There were regular meetings for staff where they had opportunities to discuss any issues or share any ideas.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

There were quality assurance systems in place to monitor and drive service quality improvements.

The management team undertook regular audits to monitor the quality of the service they provided. This included regular care plan reviews, medicines administration and health and safety checks audits.

There were systems to monitor care visits and processes to help make sure visits were met. This was monitored by dedicated staff in the office and this helped to ensure staff provided care and support to people to the required standard and were arriving and leaving people’s homes at the agreed times.

The registered manager identified areas for improvement and discussed them in team meetings, such as spelling mistakes when staff wrote in people’s records. They also shared important information with staff to ensure they maintained a professional approach and good standards of care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The management team worked closely with the local authority and other professionals to ensure they improved the care and support they offered to people. They recognised the importance of developing close ongoing professional relationship with individual professionals.

The registered manager kept themselves up to date with best practice as far as health and social care was concerned. They attended regular provider’s forums with different local authorities. They engaged with the local community, helping them contribute to the shaping of the service. The deputy manager had recently completed their level 5 Diploma in Leadership and Management for Adult Care.

The provider was a member of UKHCA (UK Home Care Association).

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

There were a range of monitoring and audit tools to assess and monitor the delivery of care and support to people. People felt listened to and their views were taken into account. We saw the provider had received a number of positive feedback from people who used the service.

The provider sought the views of people using the service and their relatives through different ways, which included completing satisfaction surveys, phone calls and home visits. We saw the information received was analysed so that the registered manager could use it to improve the quality of the service provided. The registered manager acknowledged and addressed any areas of improvement if needed.

The management team also carried out regular unannounced checks on staff to ensure they were providing care and support to people in a safe way. The findings of the spot checks were then discussed with staff if further action was required.