Three Sisters Community Care LLP

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. At our last assessment we rated this key question as good. At this assessment the rating has remained as 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 71 (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, engagement, and understanding challenges and the needs of people and their communities.

Staff described a supportive culture and a shared focus on people. One staff member said, “They actually care and treat staff well, fair with hours.” People and relatives repeatedly described the service as family-oriented and accessible.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had governance systems in place and managers had clear responsibilities. However, these systems were not always effective in identifying areas where improvements were needed.

Although the provider had systems in place to check the quality of the service, including regular audits, these were not always effective in identifying gaps in record keeping. For example, the provider monitored when risk assessments needed to be reviewed, and we found that initial reviews had been completed. However, some follow-up actions had not been recorded as completed within the timescales set out in the provider’s policy.

We determined this was a documentation issue rather than a risk to people, as there was no evidence that people’s care or safety had been adversely affected. The provider was receptive to feedback.

Staff described accessible managers, electronic care records, spot checks and regular oversight. One staff member said managers were, “Always available” and would arrange cover and check in.

Feedback from people was mostly positive about the accessibility and responsiveness of the management team. One relative described, “Excellent record taking with constant updates,” and people said concerns were acted on. However, engagement through reviews and surveys was less consistent, with one person stating, “We have done reviews and surveys but not recently.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.