Bluebell Manor

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.

At our previous inspection we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation relating to good governance. Action had been taken to improve and the provider was no longer in breach of this regulation.

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 demonstrated a clear and positive culture which was understood and reflected by staff across the service. Staff spoke positively about the culture of the service and described a supportive working environment. A staff member stated, “Teamwork is strong, and overall staff morale remains very positive.”

This positive culture was also reflected in feedback from those who regularly visited and supported the home and staff. A chaplain from the local church told us, “A particularly lovely aspect is that members of staff will often join the residents in receiving Communion. Seeing staff and residents sharing this experience together is a beautiful example of the sense of community within the home.” A health and social care professional told us, “My experience with Bluebell Manor has been very positive and wonderful, from the home manager to the deputy manager and every one of the staff I have met in the course of duty.”

Feedback from people and most relatives about the culture of the service was positive. A relative told us, “Staff do appear to be happy and they're always pleasant and calm when we visit. The entertainment officer organised a party for her 60th birthday, it was a lovely party.” A small amount of feedback reflected a less positive view of the home.

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.

The service had a clear leadership structure, led by the registered manager and deputy manager, with additional provider support through operational and quality oversight. Staff spoke positively about the registered manager and the support they received. A staff member told us, “Since getting new manager I can see a big difference in the home she has pushed hard to get the home renovated and to get in extra staff. She always pushes us to strive to achieve the best we can and always makes sure that we always put the residents above everyone and everything.”

The registered manager was committed to the home. For example, despite being away from work, they attended the home during our 1st visit to provide support. Health and social care professionals also spoke positively about the management and leadership of the home. Comments included, “The new manager is lovely and keeps me updated” and “The deputy keeps me up to date with everything regarding the residents in my care.”

The provider had processes in place to encourage feedback and learning, which helped to promote an open and transparent culture where concerns could be raised and addressed appropriately.

Staff knew how to speak up and raise concerns when needed. They told us they had no concerns about practice and felt confident that issues would be taken seriously and acted upon if raised. A staff member told us, "I feel fully supported to speak up and confident that any concerns raised will be addressed promptly."

Staff meetings and supervision sessions provided opportunities for staff to share feedback, discuss concerns and reflect on practice. The provider also had a whistleblowing policy in place and staff understood how to use it. Staff had access to a confidential 'Speak Up' service and were aware of external organisations they could contact if they wished to raise concerns outside of the service.

The provider promoted an inclusive and fair workplace and supported equality and diversity within the staff team.

The provider supported staff with their individual needs, including religious beliefs and practices, and made adjustments to support staff during important religious events and observances. Staff told us they felt supported by managers and encouraged to develop their skills and knowledge through training and development opportunities. A staff member told us, "We receive comprehensive ongoing training, supervision, and clear opportunities for professional growth."

The provider worked in partnership with local organisations to support an inclusive workforce and create employment opportunities. An employability professional told us the provider had successfully supported 3 of their candidates into care worker roles during the previous year.

The provider held a certificate of sponsorship, which supported the recruitment of overseas staff and helped maintain workforce stability.

The provider had clear governance arrangements in place. Regular audits and quality reviews covered areas including medicines, infection prevention and control, and the dining experience. Oversight from senior leaders supported the monitoring of the quality and safety of the service and identified areas for improvement.

Clinical governance and care review meetings were used to review people’s health and care needs, including identified risks and ongoing monitoring. Actions arising from these meetings were added to the home improvement plan and monitored.

The provider understood their duty to collaborate and work in partnership so that services worked seamlessly for people.

The service worked with the local authority and health and social care professionals, including GPs, community health services and specialist teams, to support people's health, wellbeing and continuity of care. They also maintained links with local churches to support people's spiritual needs and connections with the local community.

The provider also worked with local organisations to promote employment opportunities and strengthen community links. An employability professional told us, “I thoroughly enjoy working in partnership with [provider] and value their commitment to creating employment opportunities for local people. Their supportive approach and dedication to both staff and service users make them a fantastic organisation to work with.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

Learning from incidents, audits and feedback was shared with staff through meetings and supervision sessions, which enabled staff to reflect on practice, develop their skills and improve outcomes for people. Staff spoke positively about the learning culture within the home. A staff member told us, "I feel supported in my role and have opportunities to develop my knowledge and skills. The team works hard to maintain good standards of care, and I feel that there is a positive culture of continuous improvement within the home."

The provider had invested in improvements to the home environment and subsequently reviewed incidents, audits and feedback to understand the impact of these changes and on people’s health and wellbeing.