Three Sisters Care Ltd

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.

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 129 people were using the service. Most people who used the service resided in the London Boroughs of Redbridge and Barking and Dagenham, with approximately 20 people living in other local boroughs. 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.

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

People and their relatives mainly spoke positively about the quality of the service and how care staff supported them. However, the relative of one person told us their care staff did not have appropriate training and knowledge for their roles.

People and their relatives said they were offered choices about how they received their care and support.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.

People were supported to receive safe care as risks to their safety were assessed and staff were provided with risk management guidance.

People were consulted by the provider about their needs and wishes and this information was used to develop their individual care plans.

People were safely supported with their medicine needs.

Systems were in place to audit the quality of people's care and support and the provider acted on their findings to make improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk;

Rating at last inspection

At the last inspection the service was rated as requires improvement ( published 20 November 2020). We issued a Warning Notice in relation to the repeated breaches of regulations 11 (Need for consent) and 17 (Good governance). We also found a breach of regulation 12 (Safe care and treatment). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

At this inspection enough improvement had been made and the provider had met the Warning Notice and the breach of regulation.

Please see the safe, effective and well-led sections of this report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Three Sisters Care Ltd on our website at www.cqc.org.uk.

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 270 people were using the service within the London Boroughs of Tower Hamlets, Redbridge and Barking and Dagenham. 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.

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

People and their relatives where applicable spoke positively about how care staff supported them, including their respectful and reliable approach. However, the provider had failed to make satisfactory improvements in relation to how they monitored the quality of the service.

People and their relatives also spoke positively about how staff consulted them about how they wished to be supported on a daily basis. However, as the provider did not assess people’s mental capacity we could not be fully assured that people were supported to have maximum choice and control of their lives and whether staff supported them in the least restrictive way possible and in their best interests. The provider had not implemented and embedded policies and systems in the service to support this practice.

People told us they felt their care staff were trained and supported to properly meet their needs but this was not always demonstrated when we looked at safeguarding concerns and quality issues. People said they felt comfortable about making a complaint if necessary.

The provider was in the process of introducing some useful changes to how the service operated, such as the revised induction training and refresher training for all staff. However, these strategies to improve the quality of the service were implemented shortly before this inspection visit and therefore had not yet achieved the intended positive impact on the competency and confidence of care staff.

People told us they felt safe and comfortable with care staff. People received their care from a limited number of regular staff and got to know their regular care staff. Systems were in place to safely recruit staff who were suitable to work with people using care services. However, we found that people's care plans did not always contain sufficient information and guidance to enable staff to consistently promote people's safety and wellbeing.

Although systems were in place to protect people from risks to their safety, risk assessments were not always sufficiently robust. Improvements were needed to how the provider monitored the completion of medicine administration records to promote people’s safety.

Staff told us they felt well supported by the provider particularly during the acute period of COVID-19 and enjoyed their roles supporting people. Care staff described how they reported any concerns about people’s safety and welfare to their line managers.

Audits were taking place to identify areas for improvement. This included an audit of care plans which showed some improvement since the last inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk;

Rating at last inspection

At the last inspection the service was rated as requires improvement ( published 6 June 2019). There were repeated breaches of regulations 11 (Need for consent) and 17 (Good governance). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

This service has been rated requires improvement for the last three consecutive inspections. At this inspection enough improvement had not been made and the provider was still in breach of regulations 11 and 17.

Why we inspected

We received concerns in relation to the safety and quality of care and support provided to people who used the service. We additionally received information of concern about how staff maintained professional boundaries. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained requires improvement. This is based on findings at this inspection.

Enforcement

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.

We have identified a continued breach in relation to how people’s capacity to make decisions about their care and support are recorded by the provider, including clear information about whether relatives or the Court of Protection has authority to make these decisions on people’s behalf. We have also identified a continued breach in relation to how the service is managed. We have issued a Warning Notice for the repeated breach of regulation 17 (Good governance) which includes the repeated breach of regulation 11 (Need for consent). We have also found a breach of regulation 12 (Safe care and treatment) as people's risk assessments were not sufficiently detailed.

We have additionally found a breach in relation to the quality of the risk assessments about people's needs and circumstances.

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

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service and return to inspect if we receive any concerning information. We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety and 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.

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 www.cqc.org.uk

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.

Enforcement:

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.

At the previous comprehensive inspection on 22 June 2016 breaches of legal requirements had been found, which included safe management of medicines and support of staff, in regards to staff supervision and training. The service was rated overall as Requires Improvement. Following the inspection, the provider had written to us to state what actions they would take in order to meet the legal requirements in relation to the breaches.

We had subsequently carried out a focused inspection on 14 February 2017 to check the provider had followed their plan and to confirm that they had met legal requirements. We had found that although some improvements had been achieved, the provider had not satisfactorily met the breaches for safe management of medicines and support of staff. It had been noted that although staff were now in receipt of appropriate supervision, there were shortfalls in terms of staff receiving suitable training to meet people’s needs. We had issued two Warning Notices for the two breaches of legal requirements and had received an action plan from the provider to explain how they would address the issues within the Warning Notices.

A focused inspection was undertaken on 25 April and 15 May 2017 to check that the provider had adhered to their action plan and to establish if they now met legal requirements. We had found that the provider had achieved the required improvements and concluded that the legal requirements had been met.

Three Sisters Care Ltd is a domiciliary care agency, which provides a personal care service to older adults and younger adults, including people living with dementia and people with a physical disability, learning disability and/or sensory impairment living in their own homes. Most of the people who use the service live in the London Borough of Tower Hamlet, and other people reside in nearby boroughs including Haringey, Islington, Hackney, and Barking and Dagenham. The registered manager informed us that the majority of the 140 people using the service at the time of the inspection received the regulated activity of ‘personal care’. The Care Quality Commission only inspects the service being received by people provided with ‘personal care’; for example, care and support with maintaining personal hygiene, continence, moving and positioning, and eating and drinking.

There was a registered manager in post at the time of our inspection, who was present on each day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The registered manager contacted us and local stakeholders shortly before the final day of this inspection to inform us that she had submitted her resignation to the provider.

We found that the provider’s recruitment practices did not always show that all the required checks were in place to ensure that people were supported by suitable staff.

People expressed that they were happy with how they were assisted with their medicines. The provider carried out monthly audits to protect people from the risk of unsafe medicine practices; however, staff needed better defined guidance about how to support people with their medicines.

Risk assessments had been developed to identify and mitigate risks to people’s safety and wellbeing. However, these assessments needed a more detailed approach to address people’s individual needs, for example guidance for staff about how to support people with behaviours that challenged.

Staff understood how to protect people from the risk of abuse and the provider reported any concerns to the appropriate authorities. They were given safeguarding training and written information about how to whistle blow.

Some care files clearly demonstrated that people were able to make their own decisions and other care files stated that a relative held the legal authority to make these decisions. However, we saw that some people’s files did not demonstrate that the provider consistently worked in line with the Mental Capacity Act 2005, as care staff did not have clear information as to whether relatives or other individuals had the legal authority to make decisions about people’s care.

People who use the service and their relatives commented favourably about the skills and approach of their care workers. Staff were supported with training, supervision and group meetings; however the frequency of supervisions and appraisals were not being delivered in accordance with the provider’s own policy for staff development.

Where people were being supported to meet their nutritional needs, staff provided support that met their individual wishes, dietary requirements and cultural needs. Staff understood how to support people to meet their health care needs, for example one person told us that their care worker assisted them every morning to apply prescribed stockings to reduce the complications of poor circulation.

People using the service spoke positively about the caring and pleasant attitude of care staff, and their willingness to make sure that people received a good standard of care. Care staff knew how to meet people’s needs in a respectful manner that upheld people’s dignity and self-esteem.

The provider enabled people to receive care and support in a way that suited them and met their choices.

We found examples where people had started receiving care and support before the provider had drawn up a care plan that reflected their wishes and their assessed needs. This meant that staff did not always have a formally written plan to follow to ensure people’s various needs were addressed.

People and their relatives were provided with information about how to make a complaint. The complaints log showed that complaints and concerns were responded to, apart from one complaint we looked at. The provider had also received compliments from people and their representatives.

People were positive about the quality of care and support to meet their health care needs and were pleased with how the service was managed.

Although positive achievements were demonstrated such as the high level of satisfaction by people and relatives, the provider needed to address shortfalls in the quality of the service. This included the need to ensure that prompt care planning was in place and improvements to staff support, medicines guidance and risk assessments.

There were systems in place to monitor the quality of the service. This included feedback from people who use the service, their relatives and other stakeholders. We had received information of concern from anonymous sources prior to the inspection. We also identified certain broad themes that were brought to our attention by the anonymous source. For example, the busy atmosphere at the main office and how it could impact on individual staff who need a quiet environment to discuss any concerns.

The provider appropriately informed the Care Quality Commission of notifiable incidents, as required by law.

There is a recommendation for the provider to improve the scrutiny for ensuring all recruitment files demonstrate safe recruitment. We have issued two breaches of regulations. The first is in regards to the lack of information within people’s care files to confirm the details of the individual who holds legal authority to make decisions about their care and the second is in relation to the need for the provider to ensure that all persons receiving care and support have an individual care plan produced when they begin using the service.

You can see what action we told the provider to take at the end of the full version of this report.

This focused inspection was undertaken on 25 April and 15 May 2017 to check that the provider had adhered to their action plan and to establish if they now met legal requirements. We gave the provider short notice of our intention to conduct this inspection, as we needed to ensure that key staff would be available to access the information we required. This report only covers our findings in relation to safe management of medicines and support of staff. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Three Sisters Care Ltd on our website at www.cqc.org.uk.

Three Sisters Care Ltd is a domiciliary care agency located in the London Borough of Tower Hamlets. The agency provided personal care to people living within the borough and other London boroughs. At the time of the inspection 145 people were receiving personal care services; however, there was a structured plan in place for the agency to steadily increase the number of people using its services in line with new commissioning arrangements within Tower Hamlets.

There was a registered manager at the service. 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. The registered manager was present during this inspection.

At this inspection we found that the provider had achieved significant improvements. There were systems in place to ensure that the provider had clearly documented and up to date records in relation to people’s medicine needs. Staff had received medicines training and the staff we spoke with understood how to safely support people to take their prescribed medicines. The registered manager audited people’s medicine administration records every month and staff’s ability to adhere to the provider’s medicines policy and procedures was monitored by field supervisors during ‘spot check’ visits at people’s homes.

The gaps in staff training had been addressed and there was a robust structure in place to ensure that staff adhered to the provider’s training programme. Care staff told us that the management team and senior staff highlighted the necessity to attend mandatory training during their one to one supervision meetings and staff meetings. We received complimentary comments about the quality of the training from staff, and people who used the service and relatives remarked that staff appeared to be suitably prepared and trained for their duties. The provider showed us the plans they had developed in order to ensure that staff transferred from other agencies received an appropriate induction to the values of their new employer in addition to a mandatory training programme.

Following this inspection, we concluded that the provider had met the legal requirements of the two Warning Notices.

We undertook this focused inspection to check they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Three Sisters Care on our website at www.cqc.org.uk.

There was now a registered manager at the service. 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.

At our previous inspection we found that the provider was failing to obtain references for staff before they commenced work and was failing to assess people’s capacity to make decisions about their care. We found that the provider was now meeting these requirements. The provider had obtained references from staff before they started work and these were checked by the registered manager to ensure they were correct. The provider carried out quarterly audits of staff files to ensure that records were complete. The provider was now carrying out assessments of people’s capacity to make decisions for themselves, although it was not always clear whether relatives were signing people’s care plans in a legal capacity or to reflect their agreement that the provider was acting in the person’s best interests.

At our previous inspection we found that care plans did not accurately reflect the care that people received. We found that the provider was now meeting this requirement. Care plans had been reviewed and the registered manager carried out quarterly audits of care plans to ensure that these were accurate.

At our previous inspection we found that the provider was not managing medicines in a safe manner. This was because medicines recording charts were inaccurate and incomplete and were not checked by managers in a timely fashion, and that risk assessments for administering medicines were not being carried out. At this inspection we found the provider was still not meeting this requirement. Although risk assessments had now been carried out, and records of medicines administration were being checked by the manager, we found that records were still not accurately completed and did not always reflect people’s current medicines. Staff had received training in administering medicines, but the provider had not carried out observations of staff to ensure they were competent to do this.

At our previous inspection we found that staff did not always receive training and supervision. At this inspection we found that staff were now attending team meetings and receiving regular supervision and that there were systems in place to make sure this took place. However, the provider was not meeting this requirement as a significant number of staff had still not received mandatory training in areas such as safeguarding adults, basic life support, health and safety, fire safety and manual handling. The provider had training in these areas scheduled for the coming months.

At our previous inspection we found that the registered manager was not always checking records of care provided to ensure these were accurate. At this inspection we found that the provider was not meeting this requirement. We saw that records were being checked by the registered manager, however although these had improved we found that in some cases these were still not complete, and there were not records of what action had been taken in response to errors.

We found continuing breaches in relation to the safe management of medicines, staff training and good governance. We issued a warning notice to the provider in relation to the safe management of medicines and staff training.

Three Sisters Care is a domiciliary care service which provides care to people in their own homes, including to older people and people with physical or learning disabilities and people with mental health needs. At the time of our inspection there were 31 people using the service.

The service did not have a 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. The manager of the service had been in post since February 2016 and was in the process of applying to become the registered manager.

People who used the service praised their care workers and said that they benefited from consistent staffing from staff who spoke their first language. People were treated with dignity and respect by staff. People understood how to make complaints, and we saw that complaints were handled appropriately by the provider who was responsive to people’s concerns.

Managers took steps to ensure that people were happy with their care. However, there was not enough oversight by managers to ensure that care plans and records of care were correctly completed, meaning that we could not be sure that people were receiving the care they needed.

Staff were not recording when people had received their medicines and there was insufficient information recorded and checks carried out by managers to ensure that people had received their medicines safely. Risk assessments were detailed in their scope, and risk management plans were in place, however some needed revising to ensure they accurately described how risks to people were managed.

Safer recruitment processes were not being followed, and a number of staff had been supporting people despite the provider failing to take up references and ensure that they had a complete work history for the person. Internal audits had identified and addressed this, although one person was still working with incomplete references.

Staff said they were well supported by their managers, however we found that staff supervisions and team meetings were not taking place regularly. Although a number of staff had been supported to achieve nationally recognised qualifications in care, there were significant gaps in staff training and this was not properly identified by managers.

The provider had failed to meet its responsibilities under the Mental Capacity Act (2005), by assessing whether people had the capacity to consent to their care, and frequently sought consent from people’s relatives for their care rather than demonstrating that they were acting in the person’s best interests. People were supported to maintain good health, and staff supported people to access health services as required.

We found a number of breaches of regulations relating to consent to care, support of staff, suitability of staff, person centred care, safe management of medicines and good governance. You can see what action we told the provider to take at the back of the full version of the report.

We met with the Nominated Individual and the care supervisor. We spoke to four family members and looked at seven records of those who used the service. We spoke to four care workers and looked at six staff records.

We noted that the provider made suitable arrangements to ensure that those who used the service were helped to make decisions. A care worker told us "I always do my best to engage with the person. I don't want them to feel that I am imposing something on them."

We found that people's care needs were met. We saw that each person who used the service had a care plan specific to their needs. A family member told us "They give such good care to my relative and have relieved me of all that stress."

We found that people who used the service were protected from the risks of abuse as robust safeguarding procedures were in place.

We saw that there were effective recruitment procedures in place. The Nominated Individual told us "No matter how good the references are or how experienced a new worker might be, we need to be sure they meet our standards of care."

We saw that the provider kept in regular contact with people who used their services and regularly sought feedback information. A family member told us "I am confident that any complaint I might have would be dealt with immediately."