Bluebird Care (Wolverhampton)

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

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 had a vision, strategy and culture that was not always shared with staff.

The nominated individual spoke of a culture they had created for the service and their aspirations for the service. However, staff we spoke with were not aware of this vison, and we were not provided with any further information that demonstrated this for us to consider or review.

Not all leaders understood the context in which the provider delivered care, treatment and support.

We received mixed views on the leadership of the organisation. One relative told us, “There could be improvements in the leadership. The carers are good but communication from the office could be better along with management of the carers.” Another relative felt the organisation was, “Well-led”.

There was no registered manager in place. The provider told us they had recruited a new manager who was due to start work at the service.This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. The lack of systems and oversight of the care people received demonstrated a lack of capable leaders.

People did not always feel when they spoke up their voice would be heard and action taken. When people and relatives raised concerns although they felt comfortable to do so, they felt this was not always acted upon. This meant there was a risk people and relatives would stop speaking up about the care.

Staff told us they felt confident and comfortable to raise concerns and there was a whistleblowing policy in place that staff were aware of and the procedures they needed to follow.

The provider valued diversity in their workforce.

Staff felt they were treated in an inclusive way and their needs were considered. There were policies in place to consider staffs’ individual needs and plans to ensure this was effective.

There were not always effective systems in place to make changes and identify areas of improvement.

Some audits were in place; however, they were not consistently completed or effective. For example, the nominated individual told us they completed a medicines audit. We saw this was a printout of people’s EMAR. This was not consistently completed, for example in March 2025 this had not been completed and for February 2025 it had only been completed for 1 person. Where people had not received their medicine, it was recorded as ‘system error’, and no action was recorded to show the cause and potential impact of this on people had been explored.

Essential audit systems to monitor safety and quality were not always in place. For example, there was no audit of call times to ensure people received support when needed. There was no oversight in people’s homes of how IPC procedures were implemented and people raised concerns to us about this. There was also no analysis of incidents and accidents to ensure action had been taken and trends identified.

The provider did not always work in partnership, so services worked seamlessly for people.

As part of this assessment, we asked the Local Authority for feedback, they told us they had previously received some concerns about the care people received.

Although there were systems in place to ensure the provider worked in partnership with other agencies people told us this was not always implemented into practice. One person gave an example of not being supported with their physiotherapy programme.The provider told us they took their responsibility to work in partnership seriously and have systems in place to ensure that they engage effectively with other agencies. They also provided examples of how on other occasions they had worked in partnership with agencies.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

People and relatives told us they had the opportunity to give feedback however felt this information was not always used to make improvements.There was a lack of effective systems in place to identify concerns and drive improvements, which meant learning opportunities were missed.