Bluezone Care Ltd

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service. This key question has been rated 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 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The management team took a ‘hands on’ approach, which involved working alongside staff and delivering care. The registered manager told us they needed to understand all aspects of the business in order to provide the best possible care for people. Staff told us there was a positive culture at the service and they were happy with the support they received from senior staff. People and relatives told us senior staff were approachable and responsive. The registered manager had considered how to grow the business sustainably, without compromising on quality, safety or the values of the service. They had completed market analysis, to learn more about how equivalent care services operated within the local area. The registered manager had recognised the challenges in sustainably growing the size of the business. This included identifying the need to improve systems and processes in key areas. For example, reviewing and refining auditing systems, clearly defining roles of senior staff and improving the functionality of the electronic care planning system. Work in these areas to was ongoing at the time of our inspection.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager was experienced, suitably qualified and knowledgeable in their role. They understood their regulatory responsibilities and had submitted statutory notifications to CQC, as required. Senior staff had obtained relevant qualifications and were undertaking further professional training relevant to their role. The registered manager had identified key roles for each senior staff member to be responsible for. They told us these structures were yet to be formalised, but changes would help them maintain oversight of tasks delegated to senior staff. This would be specifically important if the size of the business grows as planned.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt comfortable raising issues or concerns to the management team. They told us the registered manager had an ‘open door’ policy and always encouraged them to air their views and feelings.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had policies and procedures in place around workforce equality and diversity. The leadership team had made sustained efforts to support staff around their own individual circumstances. This included facilitating access to external resources to promote staff wellbeing at work. The provider sought feedback from staff through supervision, team meetings and appraisals. This helped to ensure there were mechanisms in place to capture staff feedback and listen to their concerns.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Internal monitoring systems were effective and sustainable in relation to the size of the service and the number of people the provider supported. Individual senior staff had knowledge around key areas such as, systems to monitor staff availability, staff exclusion, client prioritisation and maintenance of care equipment. However, information was not formally documented and therefore, information sharing systems were not fully effective. The provider was aware of this shortfall and was in the process of changing and improving the governance systems. For example, they were currently using a dual paper and electronic system to manage people’s medicines and record administration. The registered manager told us they were working towards an exclusively electronic system. This would promote improvements around eliminating duplication of records, live monitoring of administration and responsiveness to changes in people’s prescribed medicines. However, measures were still in progress, so their effectiveness could not be determined at the time of our inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The registered manager had fostered positive working relationships with hospital discharge teams. This included joint working around reassessing people’s needs before discharge into the community after hospital admission. This helped to promote effective communication and joined up working around safe discharges.

The provider focused on continuous learning, innovation and improvement across the organisation. The registered manager promoted a positive learning culture at the service, which focussed on how to make improvements and strengthen the quality of the service. There were action plans in place from March 2025, highlighting key areas where there were opportunities to improve. These actions were around auditing, communication and staff timekeeping. For each action, there was evidence the provider had started work to address each issue. At the time of our inspection, some actions around communication and timekeeping were ongoing. The provider had worked with the developers of their electronic care planning system to improve the functionality of the system. This helped senior staff when planning and rostering care visits. The registered manager shared plans for future development of the electronic care planning system. They told us the developers were open to this collaboration, which would help further improve the effectiveness of this system.