Bluezone Care Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. We found evidence of positive learning in response to safety incidents. For example, investigations and responses to medicines errors demonstrated the provider analysed incidents thoroughly to reduce the risk of recurrence. There was reflective practice in place with staff and leadership, through team meetings and individual staff supervision. Staff gave positive feedback about level of engagement around learning from incidents. This helped to promote improved practice and implementation of learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider had fostered positive working relationships with hospital discharge teams. This helped ensure people’s needs were assessed before discharge and appropriate provisions of care were in place. The provider ensured there were flexible arrangements around the timings and levels of care after hospital discharge. This helped to avoid risks around failed discharges due to fluctuating levels of needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately with professionals. People told us they felt safe receiving care from the provider. There were policies in place around safeguarding, which both senior and care staff understood how to follow. Senior staff had a good oversight of safeguarding concerns and alerts received. Records demonstrated they understood their responsibilities in reporting and investigating in partnership with professionals. There was evidence of reflective learning around safeguarding issues in the form of discussions in supervision and team meetings. The provider had effective measures to promote people’s safety and security. This included, non entry policies, encouraging people to change key safe numbers and procedures around handling people’s money. This helped to promote people’s safety.

The provider did not always work well with people to understand and manage risks. Systems and processes to manage risks related to business continuity needed to be clearer and more detailed to help keep people safe. There were business continuity plans in place. However, plans did not clearly document how people’s care should be prioritised in the event of an emergency or extreme event, such as severe weather. The registered manager had a good knowledge of people’s individual needs. However, this information was not accessible to all senior staff, meaning there were not clear contingency plans in place. People confirmed there had not been any missed calls and overall, the care they received was dependable. People’s care plans detailed how risks related to care were monitored and reduced. This included risks around skin integrity, dehydration, and use of equipment, such as catheters. Where monitoring was required, for example to reduce risks around dehydration, records reflected staff carried out care as planned. There was evidence the provider completed referrals to professionals where appropriate. This included referrals to community nursing teams or commissioners around mobility, falls and skin integrity. This helped to ensure people received appropriate professional input to reduce risks.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment supported the delivery of safe care. However, the provider effectively used technology to promote oversight of care. Environmental assessments of people’s home environments included limited detail around maintenance and servicing for care related equipment, for example, ceiling track hoists. Care plans did not document when equipment was last serviced and who was responsible for overseeing equipment’s maintenance. The registered manager acknowledged for ease of accessibility and clarity for staff; this needed to be documented in people’s care plans. Technology helped to promote the effective delivery of care and the safe storage of people’s personal information. For example, the provider was able to control access to electronic care planning system. For example, they were able to quickly block access to the system when staff left employment. This helped to keep people’s personal information securely stored.

The provider had enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, improvements were needed around ensuring staff arrived at agreed times and people were informed of changes to their planned care. The provider also needed to embed improvements they had recently implemented around staff recruitment processes People told us care call times could be inconsistent and they were not always informed about changes when staff were running late. The registered manager had listened to people’s feedback and had addressed issues around punctuality and communication in staff meetings from February 2025 onwards. Staff told us they had tried to make improvements to communication, by phoning ahead to people if they are not able to arrive at planned times. We reviewed 5 people’s care records from May 2025 and found although there were fluctuations in care call times, people did not experience a significant delay in receiving their care. The registered manager had recognised where their historical recruitment practices required improvement. This was specifically in ensuring they obtained a full work history for new candidates. The registered manager had implemented a staff recruitment file auditing tool, which had improved recruitment processes. They told us all historical staff recruitment files will be compliant by the end of July, as they would gather missing information retrospectively at planned upcoming staff appraisals. Staff had a high compliance with provider’s mandatory training, which was a combination of online and classroom-based learning. Staff were positive about the breadth and quality of the training and ongoing support they received in their role. One staff member told us, “The training compares favourably with other training I have received before (working for other providers).”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People raised no concerns around infection control practices. They told us staff used appropriate personal protective equipment (PPE) when supporting them with their personal care. The provider had infection control policies and procedures, which they had developed in line with best practice guidance. Staff confirmed they had received training in infection prevention and control and there were sufficient supplies of PPE in place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People gave positive feedback around the support they received from staff to manage their medicines. The provider’s medicines policies were reflective of best practice guidance. Staff had received training in medicines administration and their competency assessed by senior staff. This helped to ensure staff were following agreed procedures around medicines administration. The provider monitored people’s medicines administration via alerts linked to their electronic care planning. This helped senior staff quickly identify when planned medicines administration did not take place. We found evidence of thorough investigation and robust follow up when medicines errors occurred. This helped to identify staff training needs and reduce the risk of recurrence.