Bluebell House Residential and Nursing Home

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

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 75 (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 provider had a clear shared direction and positive culture Staff consistently described the service as well organised and well managed, with regular team meetings which enabled them to work collaboratively, share ideas and address issues as they arose.

One member of staff told us, “So far, I feel there is a culture of collaboration because my line manager always seeks my feedback if there are any concerns with residents or staff to report.” They also told us, “We also have routine general staff meetings where feedback is received from our managers and updates are shared.” Staff who had attended meetings since starting with the service described these positively. This demonstrated a culture where staff felt listened to, engaged and able to contribute to the ongoing development of the service.

One member of staff told us. "The service is well organised and well managed. We have regular meetings and work together as a team to discuss improvements and solve problems when issues arise."

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.

Leaders were described as approachable, supportive and committed to delivering high-quality care. Staff told us they felt listened to and valued, and managers were visible and accessible when needed. The registered manager had a good understanding of their regulatory responsibilities, including notifying CQC as required.

Leaders demonstrated an inclusive and compassionate approach, promoting a positive working environment where staff were encouraged to share ideas and raise concerns, which supported a culture of openness, learning and continuous improvement.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff described feeling confident to share feedback and report poor practice without fear of negative consequences. Leaders promoted openness and transparency and were receptive to challenge, ensuring concerns were listened to and acted upon. Records demonstrated when issues were raised, they were investigated appropriately, and learning was shared to improve practice. This supported a culture of continuous improvement and helped to reduce the risk of closed cultures developing.

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.

Staff described feeling supported in their roles, with access to wellbeing initiatives such as employee assistance programmes and regular opportunities for rest. One staff member told us, “I do have breaks during my shifts, there’s also staff assistance programmes to support me in my work and daily living, there’s also birthday off for staff who prefer to have it as a day off.” These approaches reflected the service which considered staff wellbeing and aimed to create a supportive and inclusive working environment where staff? felt valued.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were processes in place to monitor performance, risks and outcomes, including regular audits and checks across key areas such as care planning, medicines, infection control and health and safety.

The provider had invested significant resources into improving the environment of the home to enhance people’s comfort, safety and overall experience. Improvements to the premises supported a more welcoming, well-maintained and suitable environment for people using the service. This demonstrated a commitment from leadership to continually develop the service and ensure it remained sustainable, fit for purpose and able to meet people’s needs.

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.

Staff shared relevant information with healthcare professionals and other partners to support positive outcomes and continuity of care. Staff made appropriate referrals when people’s needs changed and followed professional guidance to deliver safe and effective support.

We found the provider maintained open communication with relatives and external agencies, helping to ensure people’s needs were understood and met in a timely way. One relative told us, “[Family member] did not seem [Themself], so the staff member called the GP and the registered manager called me to keep me informed.” This collaborative approach supported joined‑up care and contributed to improved outcomes for people using the service.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider demonstrated a commitment to learning, improvement and innovation through the use of a service development plan and by actively seeking feedback from people using the service, their relatives and staff.

Surveys were used to gather views and experiences, and this information was reviewed to identify areas for improvement.

We found feedback from people and their relatives informed the development plan and supported continuous improvement within the service.

The provider reviewed accidents and incidents to identify themes, learn lessons and reduce the risk of reoccurrence. This approach supported a culture of learning and helped to ensure that care and support were regularly reviewed and developed to better meet people’s needs.