Blue Fountain Care Limited

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 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 82 (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 clear shared vision, strategy and culture that was consistently understood and demonstrated by leaders and staff. There was a strong focus on person-centred care, dignity and compassion, which was embedded across the service and reflected in day-to-day practice.

Leaders clearly articulated values focused on treating people as individuals, promoting independence and respecting rights. Staff consistently described these values in the same terms and gave examples of how they applied them in practice. One staff member told us, “We treat people like our relatives. We get to know them and tailor care to the individual.” Staff demonstrated a shared commitment to quality and spoke positively about the organisation’s purpose and direction.

There was a culture of openness and accountability. Leaders were transparent when things went wrong, including self-reporting medication errors, issuing duty of candour letters and learning from incidents. This openness was reflected in staff confidence to report concerns and in the service’s approach to continuous improvement. People using the service and relatives described the service as reliable, responsive and well organised, which reinforced a strong, shared culture across the organisation.

The service was led by capable, compassionate and inclusive leaders who were highly visible and trusted by staff, people using the service and partners. Leadership was described as hands-on, supportive and values led.

Staff consistently spoke positively about the registered manager’s approachability and involvement in care. Leaders regularly visited people using the service, reviewed care records and supported staff directly in complex situations. One staff member said, “The manager is calm, compassionate and very involved in care. He checks notes and makes sure we use respectful language.” Another told us, “If you tell him something needs changing, it will be done.”

Leaders demonstrated inclusive leadership by supporting staff wellbeing and development. Staff described being supported during personal crises, offered flexible rotas, access to vehicles, interest-free loans and opportunities for progression. Several staff had progressed into senior roles, which showed leaders invested in developing people. External professionals also described leadership as accessible and reliable, noting timely communication and effective coordination of care. This strong leadership approach positively influenced morale, retention and the quality of care delivered.

The provider had created an open culture where staff felt able to raise concerns and make suggestions. Staff understood how to escalate concerns and were confident that leaders would listen and take action.

Staff gave examples of raising issues related to safeguarding, practice concerns and operational improvements, such as rota arrangements, which leaders acted upon. One staff member said, “If something is not right, I tell the manager and it gets addressed.” Staff were also clear about escalation routes if concerns were not resolved internally.

However, while the culture was open, the provider did not yet have consistent, formal mechanisms to capture and review speaking-up themes across the workforce. The feedback systems did not ensure learning from concerns was consistently shared and embedded across the service.

The provider demonstrated a commitment to equality, diversity and inclusion in day-to-day practice. Staff respected people’s protected characteristics and supported individual cultural, religious and communication needs.

Care plans clearly documented people’s preferences, communication needs, religion and routines. Staff gave strong examples of adapting care, including supporting religious practices, working with GPs to address faith-related concerns about medication, and using alternative communication methods such as sign language, writing and visual prompts. Staff from diverse backgrounds described feeling valued and treated fairly.

The provider demonstrated a strategic approach to workforce equality, diversity and inclusion. This included routine analysis of workforce data and structured Equality, Diversity and Inclusion (EDI) action planning, which strengthened oversight and supported long-term sustainability.

The provider had effective governance systems to monitor quality, manage risks and drive improvement. Audits of care plans, medication records, infection prevention and incidents were carried out regularly, with clear actions and evidence of learning.

Leaders demonstrated good oversight of risk, including responding to changes in people’s needs, reviewing staffing levels and working with external professionals. Complaints, incidents and safeguarding concerns were generally managed in a timely and proportionate way. Learning from incidents was shared with staff through supervision, memos and training updates.

While systems were effective, some quality assurance processes relied heavily on the registered manager. The current governance arrangements did not ensure long-term sustainability and resilience for the service.

The provider worked in partnership with a wide range of external professionals and community organisations to support people’s health, safety and wellbeing. This included close working with district nurses, GPs, physiotherapists, occupational therapists, local authorities, fire and rescue services and specialist services.

Partners consistently provided positive feedback about communication, responsiveness and professionalism. One external professional described the service as proactive and reliable, with regular updates and appropriate escalation of concerns. The provider also supported people to remain connected to their communities through social activities, shopping, appointments and meaningful routines.

While partnership working was effective, opportunities remained to further evidence shared learning outcomes with partners to strengthen system-wide improvement.

The provider demonstrated a commitment to learning and continuous improvement. Incidents, complaints and changes in people’s needs were reviewed, and learning was reflected in updated care plans, training and practice guidance.

Staff described regular handovers, supervision and informal learning opportunities. Leaders used audits and spot checks to identify gaps, such as infection prevention practice, and took immediate action through retraining and feedback. Innovation was evident in adapting care creatively. Staff adapted care within people’s homes to promote independence and used technology and communication tools to support people with complex needs. They used electronic care systems for real-time updates, telecare (e.g. pendant alarms) to enhance safety, and personalised communication approaches such as visual prompts and simplified language, supported by specialist input where needed.

Learning was embedded at both individual and team level. The provider had a clear commitment to continuous improvement and was actively strengthening processes to ensure learning trends were more formally analysed and consistently shared across the whole service to maximise improvement and drive better outcomes