Three Sisters

Updated 28 January 2023

The inspection

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors, a medicines inspector 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 care service.

Service and service type

Three Sisters is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Three Sisters is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

We visited the home on 12 September 2022. On 19 September 2022 we made phone calls to relatives of people using the service and met with the registered manager, quality development manager, head of behavioural support and behavioural support practitioner to get more information regarding the management of risk at the service.

What we did before inspection

We reviewed information we had received about the service since it’s registration. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spent time with people in the communal areas observing the care and support provided by staff. We spoke with 5 people who used the service and 3 relatives about their experience of care provided. We gathered feedback from 10 staff members including the registered manager, support workers and senior support workers. We reviewed a range of records. This included 3 people’s care records and 4 people’s medicines records. We looked at 2 staff recruitment files and other records relating to staff training. We reviewed a variety of records relating to the management of the service, including policies, procedures and quality assurance records. Following our site visit we met with the registered manager, quality development manager, head of behavioural support and the behavioural support practitioner.

Updated 28 January 2023

About the service

Three Sisters is a residential care home for up to 10 people. At the time of the inspection 9 people lived at the home. The service provides care, support and accommodation to people living with learning disabilities or autistic spectrum disorder.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

People were supported to have maximum choice and control of their lives. Staff encouraged people to enhance and maintain their independence and encouraged people to make decisions for themselves. Processes were in place to enable staff to support people in the least restrictive way possible. However best interest decisions were not always reviewed by relevant external representatives.

Risks to people were assessed, monitored and managed. Staff had the necessary skills, knowledge and experience to provide safe and effective care. Overall there were enough staff to meet people's needs. However we recommend the provider reviews the night time staffing levels to ensure they remain safe and appropriate to people’s needs.

People's medicine support was managed safely, and staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcomes. People had a choice about their living environment and were able to personalise their rooms. Some aspects of the home needed refurbishment and the provider was taking action to address this.

Right Care:

Care was person-centred and delivered in a way which promoted people's dignity, privacy and human rights. Staff offered people choices and involved people in making decisions about their routines and how care was provided. Information was provided in formats which met people’s individual needs. People could communicate with staff and understand information given to them because staff supported them consistently and understood their individual communication needs.

Staff worked alongside partnership agencies to assess and develop the care and support people received. This collaborative approach helped ensure people achieved good outcomes. Staff understood how to protect people from poor care and abuse and worked well with other agencies to do so.

People received care that supported their needs and aspirations and was focused on their quality of life. People’s equality characteristics were celebrated and respected. Staff identified people’s circles of support and involved them to help promote people’s wellbeing and enjoyment of life.

Right Culture:

The provider’s audit systems did not always identify and drive improvements in the quality of care. The ethos, values, attitudes and behaviours of leaders and care staff ensured people using the service lead confident, inclusive and empowered lives. People were supported to identify and develop individual aspirations. Staff adapted their support to help people pursue their interests and to achieve their life goals. Staff valued and acted upon people’s views. Staff ensured risks of a closed culture were minimised so people received support based on transparency, respect and inclusivity.

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

Rating at last inspection

This service was registered with us on 25 July 2019 and this is the first inspection.

Why we inspected

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

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Recommendations

We have made recommendations to the provider about ensuring best interest decisions are reviewed with input from external representatives and to ensure staff always have the most up to date policies. We have also made recommendations to the provider to review night staffing levels and their audit systems to ensure areas for improvement are consistently and promptly identified and addressed.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.