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Three Sisters Care Ltd Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 6 June 2019

About the service:

Three Sisters Care Ltd is a domiciliary care agency registered to provide personal care to people living in their own homes. At the time of our inspection approximately 360 people were using the service. Of those 360 people, 329 received personal care and the remainder received domestic assistance only.

For more details, please see the full report which is on the CQC website at

People’s experience of using the service:

Where consent to care forms and other documents were signed by relatives or friends, it was not always clear whether they had the legal authority to do so.

People told us they felt safe with staff. People reported that staff were reliable, caring and respectful. Some people and relatives found that members of the care staff team did not have satisfactory English language skills. Structured staff recruitment processes were followed, however the provider needed to check that all criminal record checks were valid.

Risk assessments were in place to reduce risks to people, but sometimes lacked relevant details.Staff had received training to administer medicine, but some staff needed further guidance to correctly complete medicine administration records.

People’s care plans identified the tasks that needed to be carried out but did not demonstrate an individual approach that reflected people’s preferences and personal circumstances that were important to them.

People’s entitlement to confidentiality was promoted and the provider supported staff to meet people’s diversity needs. People and their relatives knew how to make a complaint and thought the provider would respond professionally to any concerns they raised.

Staff generally reported they felt well supported by the management and received the training they needed to carry out their roles and responsibilities.

Positive links had been established with local organisations with similar aims to support the local community. Systems were in place to monitor the quality of the service, which did not always ensure that areas for improvement were addressed in a timely manner.

Rating at last inspection:

At the previous inspection the service was rated as requires improvement (23 Feb 2018). The service was rated as requires improvement at the two previous inspection and continues to be rated as requires improvement.

Why we inspected:

This was a planned inspection based on the previous rating.


We found two breaches of regulation in relation to consent and good governance. Please refer to the ‘action we told the provider to take’ section at the end of full report.

Follow up:

We will ask the provider to inform us how they will make changes to make sure they improve the rating of the service to at least good. We will continue to monitor information and intelligence we receive about the service until we return to visit in line with our re-inspection scheduling guidelines for services rated requires improvement. We may inspect this service sooner if we receive any concerning information.

Inspection areas


Requires improvement

Updated 6 June 2019

The service was not always safe.

Details are in our Safe findings below.


Requires improvement

Updated 6 June 2019

The service was not always effective

Details are in our Effective findings below.



Updated 6 June 2019

The service was caring

Details are in our Caring findings below.


Requires improvement

Updated 6 June 2019

The service was not always responsive

Details are in our Responsive findings below.


Requires improvement

Updated 6 June 2019

The service was not always well-led

Details are in our Well-Led findings below.