What the CQC found at Three Sisters

Staff supported people to make decisions and develop everyday living skills. They used the least restrictive approach and encouraged people to do things for themselves.

“People were supported to have maximum choice and control of their lives.” from the report

Staff understood people's individual needs and interests. Relatives and inspectors described caring support that promoted dignity and wellbeing.

“Staff treated people as individuals and understood and respected people's distinctive characteristics.” from the report

People and relatives were involved in reviews. Care plans were updated when needs changed and included individual communication methods and preferences.

“People told us they felt very involved in the care planning process.” from the report

Staff supported people to take part in activities linked to their needs and interests, including activities in the local community.

“Staff supported people to participate in a range of activities.” from the report

There were usually four staff on duty at night. If one person needed four staff during an emotional reaction, no staff would be available for other people unless extra help arrived.

“This meant if the person required this level of support during the night, there would not be any staff available to support other people.” from the report

Some repairs and redecoration were not completed promptly. Inspectors noted damage and problems affecting bedrooms, communal areas, the sensory room, dining room and staff toilet.

“Some areas of the home required repair and redecoration. The provider did not always ensure this was done in a timely way.” from the report

Cleaning equipment was not always stored in a way that supported infection control. Some communal areas also needed more thorough cleaning.

“The storage of cleaning equipment did not always support effective prevention and control of infection.” from the report

One best interest decision had only been reviewed by the manager. The report said there was no external scrutiny to check that the decision remained appropriate.

“This meant there was no external scrutiny to ensure the actions being taken by staff were still appropriate and, in the person's, best interest.” from the report

The home's audits did not identify all the problems found during the inspection. The provider also did not always act quickly when issues were identified, particularly maintenance problems.

“Some areas for improvement identified during this inspection had not been identified and addressed through the provider's own audit processes.” from the report