Bluebird Care (Hull and Beverley)

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 changed to Requires Improvement.

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 governance at 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.

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 manager demonstrated a positive, compassionate listening culture that promoted trust and understanding between them, people, their families and the staff team.

Not all leaders understood the context in which the provider delivered care, treatment and support. Whilst they embodied the culture and values of their organisation with integrity and honesty, managers did not always have the knowledge or understanding to ensure the service provided safe and effective care in line with best practice guidance. For example, there were shortfalls around best practice in relation to care planning, assessing risk and people’s mental capacity. However, feedback was very positive about the management team and their ability to provide competent staff and manage the service. A relative added, “[service] are the third care company we have used; my [relative] has never been happier, we have had no problems whatsoever with them.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Staff told us they were confident they could raise any concerns they had. Staff were very confident they would be listened to, and their voices would be heard. A staff member added, “The atmosphere is open and supportive, so I feel at ease bringing up any concerns.” Another staff member told us, “The service focus’ on creating a positive environment where both the staff and clients feel supported to raise their concerns.” The service did not complete regular staff surveys to allow another avenue for staff to feel heard and provide feedback, however the manager was responsive to this feedback.

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 confirmed they had regular contact with the management team and praised how they were treated and the positive and inclusive work environment. A staff member added, “I truly feel valued as part of the team.”

The provider did not have clear responsibilities, roles, systems of accountability or good governance. Audits and quality assurance processes were not effective in identifying areas for

improvement. An example included people’s medicines records, with ineffective audits in place, which failed to identify risk.

Quality assurance processes were not always effective in identifying improvement with how the service sought and recorded consent in line with best practice.

Systems were not in place to identify gaps in staff training, overdue supervisions, annual appraisals, supervisions and spot checks. We saw evidence of a lack of robust systems to record probation sign off and shadow shift completion for staff. There was little overall oversight and an overreliance on a digital system.

Furthermore, care planning audits had not identified the shortfalls we found at this assessment regarding conflicting and missing information and assessment of risk within care records.

Whilst a system was in place to manage any complaints or concerns, the service did not have robust oversight to monitor safeguarding incidents and accidents, with limited evidence of review or trend analysis. Additionally, safeguarding and complaints policies were missing crucial information regarding professionals contact information and information on who to raise concerns too.

The providers service quality audits from January and June 2025 had the same outstanding actions at the time of our assessment.

We found examples of when the provider had failed to notify CQC of safeguarding incidents. Governance system had not identified this.

Whilst we found no evidence that people had been harmed, the manager acknowledged the shortfalls and told us they would look to address these immediately.

The provider understood and carried out their duty to collaborate and work in partnership, so services worked seamlessly for people. People and their families told us they received effective care.

The manager told us they worked in partnership with other organisations such as healthcare professionals and commissioners to support the care provision.

The manager attended an online franchise forum to share and improve their knowledge.

The provider did not always actively contribute to safe, effective practice. A lack of oversight and governance had impacted on their ability to do this.

Leaders understood how to make improvements but lacked a consistent approach measuring outcomes and monitoring impact. The service took all concerns raised seriously and responded to them on an individual basis. However, it was not clear if a thorough root cause analysis had been completed to monitor for patterns and trends to minimise the risk of further recurrences.

Further, people using the service, their families and carers were not routinely involved in developing and evaluating improvement and innovation initiatives. Consequently, necessary improvements were missed. There was a lack of means for people and their relative to provide regular feedback regarding the quality of the service and to complete meaningful analysis of this feedback to directly contribute to service improvement.