Three Sisters Care Ltd was rated Requires Improvement overall at its August 2022 inspection, with a confirmed breach of Regulation 17 (Good Governance) due to insufficient auditing, inconsistent staff supervision and appraisals, and failure to monitor COVID-19 testing compliance. Care delivery was broadly positive, with staff described as kind and competent, medicines managed safely, and responsive, personalised care plans in place.
Concerns (6)
criticalGovernance: “The provider failed to operate a robust system of governance to comprehensively monitor the quality and safety of the service. This constituted a breach of regulation 17”
moderateInfection control: “the provider could not be assured employees were effectively protecting people from the risk of COVID-19 due to the absence of a robustly organised testing programme.”
moderateSupervision / appraisal: “appraisals were out of date and there were some gaps in the regularity of staff supervision sessions.”
moderateSupervision / appraisal: “gaps in the regularity of 'spot check' visits to people's homes, designed to observe whether care staff properly supported them.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post...the provider has subsequently informed us the manager has resigned and they are recruiting for a new manager.”
minorRecord keeping: “The minutes for some staff supervision sessions did not always demonstrate that action points from the previous meeting were followed through.”
Strengths
· People were supported by kind, respectful and caring staff, with consistently positive feedback from people and relatives.
· Safe recruitment practices were in place including DBS checks, references and right-to-work verification.
· Medicines were managed safely with a designated medicine lead auditing MAR charts monthly and staff competency assessed.
· Risk assessments were comprehensive, regularly reviewed and covered environmental and personal care risks.
· Care and support plans were personalised, considering individual routines, preferences, cultural needs and communication requirements.
Quality-Statement breakdown (24)
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood
Three Sisters Care Ltd was rated Requires Improvement overall for the third consecutive inspection, with Well-led deteriorating to Inadequate due to continued breaches of regulations 11 (consent) and 17 (governance) and a new breach of regulation 12 (safe care and treatment). Despite positive feedback about reliable, respectful care staff, the provider failed to robustly monitor MAR charts, risk assessments and care plans, leading to a Warning Notice for governance failings.
Concerns (9)
criticalGovernance: “The Registered person did not ensure a suitable system was operated to assess, monitor and improve the quality and safety of the service.”
criticalConsent / capacity: “managerial and supervisory staff did not undertake assessments of people's mental capacity to make decisions when they carried out initial assessments and subsequent reviews”
criticalMedication management: “We found gaps of recording by care staff or inconsistencies in all of the seven MAR charts we looked at.”
criticalCare planning: “The lack of sufficient information and guidance in the risk assessments placed people at risk of avoidable harm.”
criticalSafeguarding: “two people had experienced significant and detrimental risks that were not identified by the provider's own risk assessments”
criticalLeadership: “there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
moderateRecord keeping: “The daily log sheets were not always satisfactorily completed in relation to how people were supported with food preparation, eating and drinking.”
moderateIncident learning: “this approach was not implemented in a timely manner following the previous inspection and insufficient progress was demonstrated at this inspection”
moderateStaff training: “the provider's aim for improving the quality of the training and staff support was still at an early stage and had not been fully implemented”
Strengths
· Reliable and punctual service with continuity of care from regular staff
· Safe recruitment procedures including DBS checks and right-to-work verification
· Sufficient PPE and good infection prevention and control practices during COVID-19
· Positive feedback from people and relatives about staff conduct, kindness and respectfulness
· Electronic call monitoring system used to track visits
Quality-Statement breakdown (15)
safe: Using medicines safelyNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law