Three Sisters

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights and understanding challenges and the needs of people and their communities. The registered manager led by example to promote a culture that was open and inclusive. Staff we spoke with were passionate about promoting a positive culture that was person centred, open, inclusive, and empowering. The registered manager was passionate about improving people’s quality of life and staff we spoke with shared this vision. This helped to make sure people were at the centre of their support when decisions were being made about their lives. Relatives spoke positively about the home. One relative said, “We are always kept up to date with any plans. The staff are all very caring and will listen if we need to discuss something, no matter what we can ring any time.”

The home had inclusive leaders at all levels who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation. The provider had systems and processes in place to provide appropriate support to the people using the home, and for staff. At our assessment, we found the management team led with integrity, and openness. The management team told us they were being supported by the provider. The registered manager said the operations manager was in the home frequently. An action plan was in place to drive forward these improvements. Staff spoke positively about the management team. One staff member said, “The [registered] manager is supportive and if I have any issues, I either speak to the senior on shift or the [registered] manager.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and staff told us they would be confident to raise any concerns with the registered manager. There was a new system in place for raising concerns. This has been communicated with the team and policies had been updated to reflect the change. Staff were aware of the new system and knew they could raise concerns at any time. People and relatives were encouraged to raise complaints and concerns so they could be addressed, and the procedure and contact details were shared with them. Feedback was also sought from people during resident meetings.

The home valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider had policies and procedures in place to create an inclusive environment that upheld the principles of equality and diversity. The provider was aware of their duty as an employer, to understand and respect people’s protected characteristics and prevent discrimination. Training was provided for staff on equality and diversity. Staff spoke positively about the management team and voiced no concerns.

The home had clear responsibilities, roles, systems of accountability and good governance. The management team used these to manage and deliver good quality, sustainable care and support. A range of audits were carried out covering different areas such as care plans and medicine management. The outcomes of audits and checks were regularly reviewed to identify compliance, lessons learned and areas for improvement. Audits were also completed by the operations manager who visited the home regularly.

The provider understood their duty to collaborate and work in partnership. The home shared information and learning with partners and collaborated for improvement. Partners we sought feedback from did not raise concerns about the home and provided positive feedback. Records showed the home worked in partnership with social and health professionals to ensure people received safe and effective support. One partner told us the home engaged in appropriate forums and provider events arranged by the department for the sector and they responded to requests for information in a timely way.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. The provider made available extra training for staff to improve their skills and knowledge. Systems were in place to continuously assess and monitor the quality of care being delivered and identify areas for learning and improvement. Regular meetings were held with people, people were encouraged to share any concerns they had or any improvements they wanted to make.