Bluebird Care (Stockport)

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

During our assessment of this key question we found the provider’s governance systems were not always effective, did not drive improvement and did not identify all of the shortfalls we found during this assessment. This has resulted in a breach of regulation relating to good governance. You can find more details of our concerns in the evidence category findings below. There was a lack of provider oversight in measuring the quality of care and support provided to people, for example there was a lack of provider quality assurance checks and audits. People’s risks were not always appropriately assessed, monitored and reviewed. There was some evidence of feedback being sought from people, however the gathering of feedback was mainly triggered by our assessment. There was no evidence of people’s feedback being continually sought, monitored and analysed, and no evidence of any learning or actions identified and carried out as a result. There was very little evidence of people, relatives, staff and partners being involved in developing the vision and values of the service. There was no registered manager in post and the provider was not consistently measuring the quality of care delivered to people. Staff meetings did not take place at regular and planned intervals, and staff supervision was not consistently completed. The provider had not ensured staff received the appropriate training to enable them to support people safely. Care plans did not contain all the necessary information to ensure people's needs were safely met. Processes in place to support learning and continuous improvement were not effective. Following our on-site assessment the provider told us about the steps they had taken to address the identified areas of improvement.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had faced significant challenges regarding the direction and culture of the service, due to management and staff changes. There was little evidence the vision, values and strategy of the service had been developed with feedback from staff, people and partners. However, the provider told us they were keen to address this and some steps had already been taken, for example by sending service review forms to people to complete. There was also evidence of an action plan being completed during this on-site assessment. Following our on-site assessment the provider gave us some evidence of improvements made, for example in the area of staff training and monitoring their competencies. Staff were also to be provided with regular supervisions and appraisals and a monitoring tool had now been put in place. The provider also told us feedback sought from people would be analysed, and people’s care plans and risk assessments reviewed.

There was very little evidence of a shared vision between staff and people. There were processes and procedures in place to support this, however, these were not effective. There was evidence of equality and diversity being promoted within the service.

Most staff told us they felt supported in their roles. One staff member said, “If there was anything I feel I would need support with I can pick up a phone anytime.” Another staff member told us, ”Since the registered manager left [nominated individual name] has always been there. However, there is still the same amount of staff; they [managers] are not learning.”

There was a management structure in place, which had not always been effective. There was currently no registered manager in place. However, the provider had employed new manager and was taking active steps to have this person registered with CQC. There was some evidence of feedback from people being gathered during this on-site assessment, however, there was no evidence of feedback being gathered frequently and any learning being identified and analysed as result of the feedback received. Following our on-site assessment the provider told us they were in the process of analysing feedback received from people. The provider also employed a consultant/field care supervisor to support with making improvements within the service. The provider told us about the steps they had taken to address the identified areas of improvement. For example, people’s care plans and risk assessments were in the process of being updated, people’s feedback was in the process of being analysed, staff training and their competencies were being reviewed and staff were to be provided with regular supervisions and appraisals. A monitoring tool had now been put in place, which better enabled oversight of staff competencies, including the administering people’s medicines. Staff were to be provided with opportunities for regular feedback. Weekly managers meetings were put in place.

Staff told us they felt comfortable in raising any concerns and they knew who to contact. However, there was no evidence feedback from people and staff was gathered frequently and any learning as a result of this being identified and analysed. There was evidence the provider gathered people’s feedback at the time of this on-site assessment, however, there was very little evidence of this being undertaken periodically. There was no evidence of staff meetings taking place. There was evidence of some staff supervision and appraisals taking place, however, this was undertaken periodically. There was no provider oversight of feedback received, and no evidence of any analysis and learning as a result.

There were processes, procedures and policies in place to support staff and people to speak up. However, these had not always been effective and had not been reviewed appropriately. There was a lack of provider oversight regarding how feedback from people and staff supported an organisational open and transparent culture. There was no evidence of any learning undertaken by the provider when feedback from people and staff had been received. Following our on-site assessment the provider told us they were in the process of analysing feedback received from people. The provider told us regular staff meetings were to take to take place and staff were to be provided with an opportunity for regular supervisions and appraisals. A staff survey was to be sent out in the near future. The provider informed us managers were now to have weekly meetings with clear actions plans in place.

Staff and leaders were representative of the local population. However, there was no evidence the provider continually reviewed and made improvements to the culture of the organisation in the context of equality, diversity and inclusion. There was evidence the provider had taken action to prevent and address bullying and harassment at all levels and for all staff.

There were processes, policies and procedures in place to support workforce equality, diversity and inclusion. The provider ensured employed staff represented people they supported. Staff told us they felt they could speak up and raise concerns.

There was a lack of provider oversight of the service. There was currently no registered manager in place. However, the provider had employed a new manager and was taking active steps to have this person registered with CQC. There was no evidence of quality assurance checks and monitoring of the service undertaken by the provider to measure the quality of care delivered to people and no evidence of any learning identified as a result of this. The provider told us steps were being taken to address this.

Governance systems in place were not effective. There was no evidence of the provider identifying and monitoring any learning and addressing this promptly and effectively. Some of the areas of improvement identified by the provider, and actions taken, were triggered by this on-site assessment

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Learning opportunities, for example, were things had gone wrong, were not always identified in a timely manner and acted upon promptly. Continuous feedback from staff was not sought and analysed. Staff were provided with training, however not all staff training and competencies were up to date. There was no evidence staff were provided with opportunities for further training and career development. Some of the provider’s policies were not continuously reviewed, were generic and lacked relevant details. The provider was keen to learn from identified areas of improvement as a part of this assessment process and there was evidence of some steps having been taken after our on-site visit.

The provider had processes and procedures in place to support learning and continuous improvement. However these processes were not effective and were underutilised. There was no evidence of the provider carrying out regular, appropriate and relevant audits to ensure people received good care. There was no evidence the provider frequently monitored and analysed the quality of care provided to people. There was no evidence of learning opportunities being identified promptly and acted upon. The provider took some action as a result of this on-site assessment and some steps had already been taken to address this. However, the provider also told us, on reflection, 'there wasn’t anything they could have done better.’ Following our on-site assessment the provider had taken active steps to address some areas of improvement as provided in our feedback. For example, the provider told us staff training was to be reviewed and staff competencies were to be regularly checked. Staff and people were to be provided with regular opportunities to provide feedback and this was to be analysed. There was evidence the provider had reflected on feedback received and was taking active steps to address some areas of improvement.