Bluebird Care (Bristol, Bath & N E Somerset)

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 last assessment we rated this key question good. At this assessment the rating has remained 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 86 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. The provider’s organisational values were in alignment with CQC’s, ‘Right support, right care, right culture’ guidance. The culture was embedded in the feedback we received from people and relatives using the service. During induction, staff received a training session on the organisation’s direction and culture. Staff demonstrated an understanding of the organisation’s values, aims and visions. Staff also told us they had opportunities to progress in their roles and when training requests had been made the provider was responsive to this. Leaders told us they “had focused time, energy and resources to ensure staff had the right training and skills set so they were able to deliver on the next steps of the strategy.” The provider had a clear strategy plan which outlined areas such as quality, compliance, staff and people’s care and support.

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 aware of the issues and priorities for the service and were working towards delivering on the next phase of their strategy. The was a strong leadership structure in place to support the delivery of the service. The service had dedicated care managers working within designated areas who managed a team of staff and who were the point of contact for people, relatives and professionals. There was a quality and compliance manager available to oversee and develop quality management systems, complete audits and ensure staff and leaders were adhering to regulations and company policies. The intended registered manager had recently been recruited into the service in January 2025 and was going through the registration process with CQC at the time of our onsite visit. Plans were also in place to recruit another registered manager for the service, to support the delivery of the service across the Bristol, Bath and North-East Somerset areas. The manager told us about the support they had received from the leadership team across Bluebird Care to help support them in their role. Staff told us that leaders were proactive and present for any concerns they might have and were able to lead effectively. Staff told us the management structure in place was very good compared to other services they had worked in. One staff member told us, “The new manager seems to have a lot of knowledge and experience which can be transferred over to staff.” Since this inspection, the manager had been registered with CQC in April 2025.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they had opportunities to speak up and have their voices heard during supervisions and team meetings. They felt able to approach leaders outside of scheduled meetings to discuss any concerns they had. Leaders told us they shared contact details with all staff and were involved in group chats to encourage open communication and promote an open culture.There was a whistleblowing policy and procedure in place which staff had access to. Supervisions showed staff were regularly able to have their voices heard.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. Staff were highly complementary about the way the service led on workforce equality, diversity and inclusion. One staff member told us, “They treat everyone the same, so we all feel involved and have access to the same information.” Another staff member told us about the reasonable adjustment made to support them to stay employed in their role. Discussions with leaders showed a high level of empathy towards staff and their individual backgrounds and how these may impact on their working and daily lives. There was an emphasis on supporting staff to receive support and training in areas to up-skill them in areas such as information technology (IT) and changing staff rotas to fit in with individual needs.

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. Internal governance systems were in place with a range of quality monitoring systems and audits. These had helped identify where actions were required and areas for improvement. There was oversight from the franchiser on the governance procedures.

However, we found audits had not proactively identified the concerns we found in relation to staff recruitment practices and a risk assessment not being in place for a person on blood thinning medicine. The provider was immediately responsive to the concerns raised and then put additional governance oversight measures in place to prevent future occurrences.

The provider understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. People told us the service worked with professionals on their behalf. Professionals confirmed the service worked with them to develop and improve care for people. The service organised an annual summer fun day for people, relatives and staff to support people to access their local communities in a safe and supportive environment. One staff member told us, “Staff can ensure people are supported to integrate within the wider community, for example, by accompanying them and taking them to and from community groups. This can help the person feel less isolated.”

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 overarching Bluebird Care franchise assesses services under an award scheme which looks at 30 areas of quality and best practice in line with National Institute for Health and Care Excellence (NICE) guidance. The service had undergone the assessment and achieved a score of 99%. Where concerns had been identified, the provider investigated, completed lessons learnt analysis and changed their processes to ensure they mitigated any future risks. For example, where concerns had been raised about the service, leaders had developed a reflective practice form to help them understand the context of the concerns raised and the people affected so they could take appropriate action. The service shared lessons learnt with the Bluebird franchise about the delivery of the live-in service so other services had the opportunity to change their practices to strengthen their approach and ensure people were not harmed. For example, leaders told us, “During a complaint about the live-in service we found failings with regards to the care and care plans not being followed nor updated, we found key themes, disseminated extra guidance and put in thorough processes to review all the people receiving care through the live-in service. This was shared with the Bluebird care franchise.” The person who made the complaint was kept fully informed during the process and was satisfied with what Bluebird care had put in place as a result of the complaint made. The service was in the process of delivering on their strategy to provide clinical service to people in the communities in which they worked and had recruited a prospective registered manager with clinical qualifications. They had built on staff training to ensure they were ready to deliver on their strategy for clinical services and consulted with other services to understand the context in which they will deliver the care in the future.