Bikur Cholim Ltd

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 service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

Staff reported a culture of collaboration, where they felt listened to and open communication was encouraged. A member of staff told us, ‘’Yes, they have an open-door approach to staff and therefore readily available to attend to staff issues.’’

Leaders at every level were visible. Staff reported they had felt supported by leaders, who had maintained a visible presence within the service. Staff reported that leaders acknowledged service-related issues as well as concerns that could impact their health and wellbeing.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt supported and encouraged to speak up. They were able to raise concerns with the manager or, where appropriate, with other relevant external agencies. There were policies in place, and these were in line with best practice guidance on freedom to speak up, whistleblowing, and complaints.

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.

The provider did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. For example, the provider’s governance systems for auditing the service were not effective in identifying or addressing areas for improvement to ensure that people were not placed at risk of receiving unsafe and inappropriate care.
The provider’s systems to ensure staff were appropriately trained and supported were not effective. Some members of staff had not received mandatory and refresher training to ensure they had the necessary skills and knowledge to care for people safely.
Care plans and risk assessments were not consistently recorded to reflect people’s health and communication needs, which may impact the quality and continuity of care.
The systems to ensure people always received their medicines safely were not effective, as we identified shortfalls with the way the provider was managing people’s medicines, which placed people at risk of unsafe care.
There were no effective recruitment checks in place to ensure staff had met the required employment standards before starting their roles.
However, the provider had a business continuity plan in place to help ensure the service could continue running during and after any significant disruptions.
 

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information with relevant agencies and health care professionals to support service improvement and achieve better outcomes for people.

The service did not always focus on continuous learning and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. For example, there were no effective processes to ensure that learning took place when things went wrong, or to capture and share learning from examples of good practice. Learning from complaints and safety events was not viewed or used as an opportunity for improvement.