BG Healthcare Cumbria Branch

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 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 service 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.

Staff strived to provide person centred, compassionate care. One staff member told us, “I take their feedback seriously. If someone says they would like me to approach things differently, I discuss it with [registered manager] and we find solutions together. It is important we deal we these things to promote trust.”

The registered manager told us, “Our vision is to build trust, provide safe care and to support people to live at home as long as possible.”

The service had inclusive leaders 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.

The leadership team consisted of people whose skills had been nurtured and developed in the organisation. They embodied the organisation’s values and culture which was shared by staff.

The service was focussed on staff development and creating a motivated and stable team. The registered manager told us, “The staff are our greatest asset, and I believe happy staff leads to a good service. I really want to develop staff and give them opportunity to grow, learn and to lead. We are supporting senior staff to do leadership qualifications. We have seen a lot of cultural development in our staff.”

Staff felt the leadership team were approachable, inclusive and supportive. One member of staff told us, “[Registered manager] has always been very helpful. They rang me to ask if I wanted to do an [accredited qualification] in care.”

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

The service had an up-to-date whistleblowing policy which staff understood. One staff member told us, “I have seen the whistleblowing policy, and this is accessible on our handsets.” Another staff member told us, “We are always encouraged to read the whistleblowing policy. I would whistle blow if I needed to.”

Staff were able to report concerns in one-to-one meetings and could ring the registered manager any time.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. One staff member told us, “There are always other opportunities elsewhere, but I prefer to stay with Brown Glass [BG Healthcare Cumbria Branch] as [the registered manager] always handles any issues in the right way and is professional. We always find a compromise.”

Staff had completed equality and diversity training.

Overall, the service 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 generally acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service undertook regular checks on the quality of people’s care. These included spot checks of staff practice and competency, audits of incidents, visit schedules, people’s care records and regular requests for feedback from people and staff. The information gathered from these activities was used to continually improve the service and support staff development.

However, we found some shortfalls with how the service oversees some areas of care planning around people’s health needs and with people’s medicines records.

Care plan audits did not always identify a lack of detail about people’s health symptoms to guide staff how to escalate concerns effectively.

Medicines audits had not always identified recording issues with timings of medication administration, out of date information about people’s medicines in their care plans and the effectiveness of instructions on people’s medication administration records.

The registered manager acknowledged these shortfalls and was proactive in putting a plan in place to address them.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

The service worked well with health and social care partners in the area and understood their roles and responsibilities. Where required, the service shared information and sought advice and support appropriately from these services.

The service 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.

The leadership team worked well together with a focus on delivering good care and improving systems.

Where incidents led to learning in one branch, this learning was shared across the organisation to continually improve practice. The registered manager told us, “Learning is so important to us, and we share this across the organisation. As a result, our processes have improved a lot.”

Staff spoke of their confidence in the management team and their ability to continually improve the service.