Bosun Care Limited

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• 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 of the provider’s previous registered location, we rated this key question requires improvement. At this assessment the rating has remained requires improvement for the assessment of the provider’s homecare service. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider had a clear shared vision, strategy and culture about the homecare ‘live-in’ care service which was based on transparency, equity, diversity and inclusion; this was not fully known by the registered manager who had legal accountability for people who received personal care in the community.

The provider had employed a homecare manager to oversee the homecare service. The provider stated they had regularly supported the homecare manager through weekly discussions and supervisions; however, records of these conversations were not kept. The provider acknowledged the need to develop a system to document the supervision and support of the management team to demonstrate and promote their vision for the homecare service moving forward.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Whilst the provider had employed a homecare manager to oversee the live-in care service; the registered manager who was accountable for the regulated activity of personal care had not been fully involved in the service to ensure the service met the provider’s legal registration requirements. However, since the departure of the homecare manager, the registered manager and deputy manager were taking steps to understand the homecare service and address any shortfalls. The managers shared with us the action plan they had developed as a result of their initial assessment of the homecare service and the actions they had taken to address any significant and immediate concerns. The provider was taking action to review their polices and processes as part of their on-going improvement plan of the homecare service.

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

Staff felt there was a positive culture in the service. They said they were confident in raising any concerns with the management team and felt that they would be listened to.

There was a complaints process and policy in place. We were told no complaints had been received by the service. The provider was working on updating the ‘welcome pack’ to ensure people were aware of the provider’s complaints processes and on-call contact details.

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 felt supported and raised no concerns about how they were treated. They told us they felt supported and were treated fairly and equally without discrimination.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Improvement was needed in the governance and management oversight of the service. Whilst a homecare manager had managed the service, the provider had not ensured the registered manager had maintained oversight of the homecare service as required legally as a registered manager. This meant the registered manager did not fully understand the running of the service in line with the provider’s policies and evidence-based practices when running a homecare service.

Comprehensive records of the provider’s systems to monitor the service had not been maintained. Effective governance, including assurance and auditing systems or processes to drive improvement in the quality and safety of the homecare services needed to be strengthened.

Complete and contemporaneous records had not always been maintained in relations to the management of people’s support needs, medicines and consent to care. Staff recruitment and development records needed to be more detailed to demonstrate that people were being by staff who safely recruited, trained and supervised.

The provider had not ensured their registration accurately reflected the service being delivered. Not all significant events had been appropriately notified to CQC.

The provider had not ensured their policies had been updated to reflect the homecare ‘live-in’ service and current practices.

However, the provider and registered manager had taken immediate action to strengthen the governance and leadership of the service and was responsive to our assessment’s findings. Since our assessment, the provider has submitted a comprehensive action plan which reflects the actions needed to drive improvement.

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.

People said staff supported them to access services and be part of the community. Staff explained how they had worked in partnership with people, their families, and relevant healthcare professionals. However, records of changes in people’s care needs or referral and outcomes of professional involvement were not always clearly recorded.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcomes and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Since our assessment of the service and the departure of the homecare manager, the provider, the registered manager and deputy manager were working collaboratively to assess the homecare ‘live-in’ service and to strengthen and develop their systems and protocols to manage the service safely. However, further time was needed to fully embed and assess the effectiveness of the provider’s action plan to drive improvement.