Blue Sky Enabling

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 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.

At the previous assessment, the service was in breach of legal regulation in relation to good governance. Improvements had been made at this assessment and the provider was no longer in breach of this regulation.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The provider had strengthened their governance systems in relation to General Data Protection Regulations (GDPR) and could demonstrate that personal information was managed safely and securely. They had implemented clear processes to ensure information was shared appropriately, using secure methods rather than staff’s personal email accounts. This reduced the risk of unauthorised access or data breaches and ensured people’s information was protected. The provider had also introduced measures to obtain and record people’s consent where information sharing was required, providing assurance that this was carried out in line with best practice and regulatory requirements.

The provider continued to have effective systems and processes to support staff to perform their roles safely and in line with people’s needs. Records, including risk assessments and care plans, were clear, detailed and regularly reviewed, enabling staff to provide consistent, safe and person-centred care. Policies were up to date and provided clear guidance, supporting staff to understand their responsibilities and deliver care in line with current standards. Regular audits were carried out across key areas, including care records, medicines, risk assessments and incident reporting. These audits were structured and consistently completed, enabling leaders to identify areas for improvement in a timely way.

Where shortfalls were identified, action plans were developed and monitored to completion. Records showed that actions taken had led to improvements in the accuracy and completeness of care documentation, supporting staff to deliver consistent and person-centred care. For example, care plan audits had resulted in clearer information about people’s needs and preferences, which helped staff provide support that reflected individual choices.

Leaders maintained oversight of audit findings through regular management reviews, which ensured themes and trends were recognised and addressed promptly. For example, the registered manager noted some inaccuracies when reviewing monthly audits and took prompt action to address these. These examples provided assurance that the improvements made following the previous assessment had been embedded. The provider demonstrated that their auditing systems were effective in identifying any emerging risks or gaps in practice, and that these were acted on promptly to reduce the risk of reoccurrence. This supported sustained compliance with regulatory requirements and improved outcomes for people.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.