Bluebird Care Exeter & Teignbridge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated Outstanding.

This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 96 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider demonstrated an exceptional and proactive approach to assessing people’s needs before support began through the dedicated Customer On-Boarding Team, customer enquiry process and customer screening tool. The provider arranged for assessments to take place during different times of day and days of the week to suit the person.

Assessments were not only thorough, consistent and holistic but also highly personalised, reflecting each person’s background, communication preferences, strengths and long-term goals. The team gathered detailed information from people, their relatives, and met with a wide range of external professionals, including GPs, community nurses, and specialist teams. People commenced support with full written confirmation and knowledge about what to expect and what was realistic.

Their assessment process included a review of previous critical incidents or care delivery failures in the past and led to thorough risk assessments and care plans that really captured people’s priority needs. For example, the complex care team involved the person and provided a bespoke staff team who were trained to meet specific needs. One package of care had been particularly successful, with the person continuing to expand their vocabulary and communication skills. This was achieved through careful pre-assessment, communication training and consistency throughout the team.

Bluebird offered emergency care support where staff worked with the hospital to enable people to return to their own homes as quickly as possible. This meant the person and their relatives were fully supported by a seamless service, right across health and social care.

Leaders demonstrated an excellent understanding of the Accessible Information Standard (AIS), ensuring all information was provided in formats that genuinely enabled people to understand and participate in decisions.

Overall, the provider’s approach to assessing needs was exceptionally person-centred and inclusive, placing people firmly in control and ensuring their care was designed around what mattered most to them.

People and their relatives told us assessments and care plans were regularly reviewed and they always felt involved. The provider used an electronic care planning system which was accessible to people and their relatives. They could view and interact with these records, adding their own comments or asking for revisions. This was in line with Bluebird’s Participation policy.

All staff were trained to ensure people were involved in decision making at all levels in a person-centred way. For example, one person’s care assessment stated, “I like all my communication to go through my friend” and this was respected. People and relative comments included, “Even though my mother has Alzheimer’s and very little speech, they [staff] seek to involve her in decision making and find ways to understand her preferences”, “I am fully involved through access to detailed care notes” and “We are listened to about changes to care needs, they [staff] take time to go through the care plan and make sure we are all on the same page.”

The provider always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

The provider demonstrated a culture where staff adopted innovative and evidence-based approaches to providing care so that people had good outcomes. The provider had strong partnerships with external professionals, including hospital discharge teams. Through these partnerships they ensured clinical recommendations were incorporated into care plans and staff followed these. With an in-house paramedic clinical lead, recommendations were overseen, implemented and carried forward. One care package was particularly complex. Staff had worked together to complete twice daily sensory circuits with the person, created a self sooth kit and a collage wall whilst following a complex communication approach. This had resulted in clear positive outcomes in the person’s wellbeing. An external professional commented, “I have found the team at Bluebird Care to be professional, responsive, and person-centred in their approach to care delivery. Communication between your staff and our service has been clear, timely, and supportive, which has enabled effective joint working to meet the needs of individuals.”

Managers and staff undertook training and followed best practice for supporting people living with dementia. The provider supported relatives to understand the condition and discussed individual challenges with people and their relatives to include in care plans. For example, staff supported a spouse living with dementia when their loved one had to go to hospital. They sourced local dementia clubs and support and let the person in hospital know their spouse was safe at home. Staff were trained in any relevant specialist need such as stoma and catheter care. Staff enjoyed learning and often chose to take more advanced external courses, sharing their learning with the team and the training academy.

The provider ensured people experienced good outcomes and found ways to overcome barriers. One person had lost their mobility unexpectedly through a medical condition. Staff had worked closely with the hospital on discharge. For example, a person had begun their rehabilitation in bed and was now able to walk slowly independently to the kitchen, which was one of their goals. Staff had learnt about the person’s condition and moved mobility goals slowly forward. The person told us, “The carers not only help me physically, they empower me and make me believe in myself again. The care and support is second to none.”

The clinical lead was heading the ‘delegated tasks project’. They devised policies with the wider health professional community and trained staff to undertake delegated tasks. This meant people could receive consistent care from familiar workers reducing wait times for community services; staff could easily access clinical advice, if needed.

Multidisciplinary reports discussed whether complex needs were being met such as what activities were successful and beneficial to people. For example, one report stated, ‘Staff have encouraged [person’s name] to take the lead and guide staff which appears to promote engagement and positive interactions.” One family described access to clinical knowledge and honest communication from Bluebird as exceptional.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

The provider was extremely pro-active by reaching out to other services and health professionals for the benefit of people. The service worked very closely with the hospital discharge team to help alleviate hospital emergency discharge delays. They hoped to discuss the use of preventative technology enabled care with the hospital further and were training staff to perform delegated clinical tasks at people’s homes.

There were many examples of how the provider’s collaborative work with hospital discharge teams and therapists had led to improved care for people using the service. Preventing people having to go to hospital and returning home promptly was important to Bluebird Care and linked with the new paramedic clinical lead and complex care team. Bluebird celebrated their 15th birthday with a party visited by the local mayor, who said, “The stories shared highlight the impact of your work and the relationships, trust and continuity that makes Bluebird such a valued part of the landscape.”

Managers regularly met with staff and shared guidance and information. They held workshops and specialist meetings for groups of staff working with individual people. This helped staff to discuss what worked well and if any changes to care were needed. Multidisciplinary team meetings were held regularly for complex care packages with a range of specialist external health professionals. Minutes showed clear primary reasons for the meeting and consequent actions.

All professionals confirmed the provider worked well with them and shared information appropriately. A professional shared, “Overall, my experience of working alongside Bluebird Care Exeter [and Teignbridge] hasbeen very positive, and I would confidently describe the service as a valued partner in supporting adult social care provision.”

Staff had completed training in key areas that helped them identify and respond appropriately to people’s health needs. As a result, staff were confident in recognising when someone’s health might be deteriorating and knew how to support them to access timely healthcare intervention. There were many examples of staff being vigilant and contacting a person’s GP with consent. Regular spot checks and the weekly live in check in call also identified any issues. For example, one person’s call identified some deterioration in health and a hospital appointment was followed up by staff and brought forward. People said, “I feel reassured if my health changed, they would know and I could increase my care” and “I couldn’t stand to cook for a while, and Bluebird helped me then I could manage again.”

People and relatives gave examples of how health professionals had been consulted relating to any clinical issues. One person said, “I didn’t really notice myself, but the carers said I should get it looked at so I agreed and they sent a photo to my GP and it was sorted.” Another said, “I am getting a new frame from my physiotherapist. I know Bluebird keep in touch with them, so they know what’s what. They don’t go above and beyond because they are always excellent. I have stopped going to a care home for respite as they help me stay in my home.”

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to live healthier lives and, wherever possible, helped them to reduce their future need for care and support. They encouraged people to remain in their own homes by promoting independence and enabling people to maintain, and where appropriate, increase their daily living skills. This included people being supported to eat well, attend community clubs safely and maintain wellbeing. People talked about how staff helped with their mental health, “They always show interest in me, my health and everyday life. I really like that”, “Keeping my independence is what keeps me well and they know that. They encourage me and always start the visit by sitting down and letting me put the world to rights” and “They have been supportive with building my confidence since the fall. I am now back to walking with my stick, they want me to stay in my own home as much as I do.”

People’s assessments and care plans clearly identified their needs and provided guidance for staff to support them in maintaining and improving their health and wellbeing. People were helped to access healthcare services which would visit them at home, such as dental care, physiotherapy and other relevant professionals, when needed. Before receiving the service, people received a brochure including recommendations for trusted local resources to provide peace of mind such as a handyperson linked to Age UK, mobility services and mobile hairdressers. The provider maintained ongoing collaboration with various healthcare partners such as podiatrists to monitor and respond to health needs such as diabetes. This enabled staff to support people with evidence‑based dietary guidance and adjustments that promoted improved diabetes management.

Staff had training in wider topics such as food preparation and storage with live in staff completing an additional training day to include menu planning. They received training in the Eatwell Plate, a guide which promotes a balanced diet.

The provider routinely monitored people’s care and treatment to ensure it remained effective and continued to meet their needs. Systems were in place to review care regularly, identify any changes, and make adjustments to support positive and consistent outcomes for people.

The provider demonstrated a person-centred approach, ensuring individuals remained central to decisions about their care. People and their relatives told us staff understood their needs, reviewed them regularly, and responded promptly when any changes occurred. This was further supported by the paramedic clinical lead who was available to give staff advice. This had generated a quicker response for people if a GP was not required. This helped ensure people continued to receive care that aligned with their preferences and supported their wellbeing.

Feedback from people and their families was positive. Several described meaningful improvements in wellbeing linked to the support provided and spoke warmly about the caring attitudes of staff. Relatives told us regular staff provided consistent and reliable care. One described staff as, “Skilled and knowledgeable, they often make suggestions I act upon.” They said regular monitoring had helped them make changes, such as throwing out an unsafe old hot water bottle, get a new kettle, replaced a faulty tumble dryer and buy more comfortable clothes. The relativesaw their relationship as a partnership and co-operative relationship that improved everyone’s wellbeing. People and relatives also valued the time staff spent sitting with them, during meals or drinks, offering companionship and conversation. Staff said getting to know people well helped them know when there were any problems.

The provider demonstrated good oversight of people’s care, enabling people to receive flexible appropriate care based on their needs at the time. For example, updated moving and handling plans to reflect peoples’ progress towards independence. Key information was documented clearly, often with photographs, and staff were trained to enable them to work with each individual situation.

Information was shared where appropriate, and any concerns escalated to healthcare professionals, to ensure individuals received timely and appropriate interventions. Staff said, “I’ve yet to come across a care plan that isn’t packed full with up to date information. I feel very confident I can manage any issues that may occur.” One staff member said how they had increased support for a person when their spouse went into hospital and it had been arranged and set up in good time. Another person had had their visits scheduled around certain appointments which had eased their worries.

Staff told us about the process they followed where they recognised changes to a person’s needs and how they would work with professionals and the person to improve people’s experiences. For example, there was a clear process to follow should anyone have a fall. The clinical lead was in the early stages of setting up a dedicated falls team. This would reduce any waiting time for ambulances if an assessment could be made earlier. Staff knew how and who to contact for people and where to find information. Staff followed up after a fall, referring to health professionals and discussing future equipment needs as needed. People and families also were able to discuss any incident afterwards to see if there were any additional preventative measures they could take.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.People were supported to have choice and control, with staff working in ways that maintained independence and promoted safety without unnecessary restrictions.

The provider respected people’s preferences regarding the gender of the staff delivering their personal care. Where individuals expressed a preference for male only or female only carers, this was clearly recorded in their care plan and communicated to the staff team. These preferences were consistently upheld during scheduling to ensure people felt safe, comfortable and in control of their care. A staff compatibility register enabled people to feel confident they were listened to and that it was ok not to ‘gel’ with a particular staff member. Careful staff rotas ensured people they received support from staff they felt comfortable with.

Staff had undertaken training and understood the areas of Mental Capacity Act 2005 (MCA) that were applicable and ensured they asked for consent and offered choices to people. Where people were assessed as lacking capacity to make specific decisions, best interest decisions were carried out. These were documented in people’s care plans and showed who participated in the decision-making process and how the decision had been reached. There was clear multidisciplinary input including GPs.

A detailed Mental Capacity assessment tool was completed showing what decision was being discussed. For example, one showed details about why a hoist needed to be used and another about the risk of self-neglect and what actions were needed and when, to keep the person safe.

People told us they were always asked for consent, for example relating to any personal care. One person’s records showed clear discussion they did not want their skin checking as they could manage and understood the explanation of potential risks.