Bluebird Care (Wolverhampton)

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 newly registered service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment and the management of medicines and staffing.

This service scored 50 (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 did not always ensure there was a proactive and positive learning culture.

The nominated individual told us, and we saw there was a system in place which recorded when incidents had occurred. We saw up until June 2024 these incidents had been reviewed and analysed and learning had been identified from these incidents. However, since then there was not always a review of the information, so it was unclear what action had always been taken or how this information had been used to make improvements to the service.

However, other information such as behaviour monitoring charts, were reviewed to ensure care that was delivered to those people was effective and up to date.

The provider did not always work well with people to establish and maintain safe systems of care.

There was a process in place that ensured peoples needed were assessed and considered before they started using the service.

People and relatives felt initially involved with this process, although some confirmed they did not always have access to any records or care plans.

As people and relatives raised concerns about the turnover and skills of the staff team, we could not be assured there were always safe systems in place that ensured the care that was delivered was effective and continuous.

The provider did not always ensure staff had adequate awareness of safeguarding procedures.

Staff told us they were aware of safeguarding and how to report concerns, they also told us they had received training in this area. However, staff were not always able to demonstrate they understood this. One staff member told us, “It is using a hoist.” Whereas another staff member was able to explain signs of abuse and the action they would take.

We viewed the training matrix; this showed us that some staff had not received up to date safeguarding training.

Most people felt safe being supported by staff, however 1 person did share with us some concerns about when they did not feel at ease.

When concerns had been identified there were systems in place to ensure these concerns were reviewed and investigated.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe.

We received mixed feedback from people and relatives about how their risks were managed. A person told us about an incident where they had to intervene as staff were about to apply incorrect cream to their sore skin. A relative described the care as, “Haphazard” and gave examples of how they felt their relations risks had not been safely managed. However, another relative told us the care their relative received in an emergency situation was, “Effective and helpful”.

There was a system in place to ensure people had care plans and risk assessments that were reflective of their needs. These plans considered people’s mobility needs, health conditions and any known risks and they were reviewed when changes had occurred. However, we could not be assured these plans were always followed and understood by staff as people and relatives did not always feel their risks were managed safely.

The provider detected and controlled potential risks in the care environment.

There were processes in place to ensure environmental risks in people’s homes and surrounding areas had been considered. We saw people had individual risk assessments in place that related to their environment. Staff were aware of these plans and any risks they needed to be aware of.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

People and relatives, we spoke with raised concerns around the care calls that were delivered. A relative told us, “It’s become intolerable. [The timing of the calls] Sometimes they’ll contact me to say they’ll be late but 1 day my relation lay in bed for 6 hours before anyone came, and I had to give the medication”. They went onto comment, “I don’t know who’s coming through the door”. Another relative told us, “Timekeeping can be a bit of an issue and there have been occasions when 1 carer has turned up but not the other.”

People and relatives also raised concerns around the high turnover of staff, the inconsistency of the staff team and they did not always feel staff had the skills and knowledge to support them. One person said, “I am promised the same carers, and I get used to someone then they move on”. They went on to tell us that a lot of the carers hadn’t done care before and weren’t trained properly. They said, “They can’t read what’s written on packets and have made serious errors”. A relative told us how their relation chose to communicate. They went on to tell us that the carers kept changing and this wasn’t good as they had to keep getting used to new carers. They explained they would have to repeat the training for the carers so they could communicate with their relation.

We viewed the training matrix which confirmed staff had not always received up to date training in areas such as safeguarding, first aid and the Mental Capacity Act. Despite this, staff we spoke with were able to tell us how they supported people and how to deal with emergency situations.

There was a system in place to plan for people’s care and the records we viewed showed people had care delivered to them, mostly as planned for. However, the provider did not complete audits of people’s care calls, therefore we were unable to confirm people consistently received their care calls at the correct time.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

The provider did not always ensure infection control procedures were followed.

We received mixed feedback on how infection control was managed in people’s homes. One person raised concerns with us around how staff cleaned their equipment and the poor hygiene standards of staff. They told us, “Carers often don’t wear gloves or have any.” The person told us they had shared theirs with them. A relative also confirmed they had to prompt staff to wear Personal Protective Equipment. (PPE). Other people and relatives raised no concerns. A relative said, “They always wear the correct PPE”.

Staff told us they had received training in infection control, and they were aware of when they needed to use PPE. Although there was an infection control policy in place the systems in place to monitor or check how staff implemented IPC practices in people’s homes were not always sufficient. The spot check completed by the provider did not provide sufficient detail to ensure IPC procedures were always implemented by staff.

The systems in place to manage medicines were not effective.

The nominated individual told us there was a concern with the electronic medicine’s records, (EMAR) they had contacted the company to resolve this and there was a system in place to ensure people continued to receive their medicines.

They told us, “The system does not always work, medicines are not always showing. If this happens, they [staff] ring office to alert us. We confirm what they have, they administer, and we sign the chart.”

This had resulted in several gaps in people’s EMARs, meaning there was no records to show what had been administered. Where there were gaps, it was assumed this was due to the system error without any checks to confirm if this was accurate. We saw instances where office staff had signed the EMAR and had not administered the medicines. It was also documented in some people’s notes staff had administered medicines, without any details as to what these were. Therefore, the system in place to administer medicine was not effective and we could not be assured people had received their medicines as prescribed.

We asked the provider to take action to resolve this. After our site visit, we received reassurances that they had, we will check this as part of our next inspection.

We received mixed feedback with how people’s medicines were administered. One relative said “My relation has medication. Some carers won’t give it and say it isn’t on their rota, so I have to give medication”. Another relative told us, “The carers also suggested getting pills in blister packs and keeping them in a safe place.”

Staff administering medicines had completed training and had received a competency check in this area. However, we could not be assured staff were competent to administer medicines as they were not following safe processes to administer and record the administration of medicines.