Bersim Care Ltd Office

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. This is the first assessment for this service. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 63 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them, but recording needed to improve to ensure key records reflected people’s holistic needs.

Although care plans evidenced people’s holistic needs were assessed, including communication and emotional needs, they did not always include detailed guidance for staff to follow to ensure people’s assessed needs were met. A care plan stated that a person experienced some anxiety, but there was no further information about how this presented for the person or any strategies for staff to follow to support in reducing their anxiety. As outlined in the involving people to manage risks section of this report, care plans also included conflicting information in some areas. Despite this, people and their relatives felt staff understood their assessed needs and told us their needs were fully met. They told us there had been an assessment of needs when they started to use the service. Care plans were regularly reviewed and included dates to prompt future reviews and people’s feedback confirmed this. Where people were also supported by unpaid carers, we received feedback that staff were considerate of the health and wellbeing needs of these carers. A relative told us, “They [staff] come in and ask how I am. We recently managed to get to church, they said “get [Person’s] shoes, we will put them on, so you don’t have to do it.”
 

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Records such as care plans and assessments utilised national tools to assess people’s risk of common concerns including malnutrition and pressure injury. Organisational documents including policies and service user guides referenced national guidance including National Institute for Health and Care Excellence (NICE) guidance. NICE provide evidence-based recommendations for the health and social care sector. People’s feedback, along with daily notes evidenced people were receiving care that focussed on what mattered to them. A person said, “They make me feel like an individual who knows my own needs and wishes, but they are there to support.”
 

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff told us they felt there was effective communication and coordination within their own staff team to enable them to plan and deliver people’s care and support. A staff member said, “In our own team, we communicate via the [electronic care system] app, where we put and view handover notes and tasks. We also have a WhatsApp group chat with no client identifiable details, and we can call, text or meet when necessary.” Relatives told us communication and information sharing with the service was simple and effective, enabling them to stay informed and involved in people’s care. A relative told us, “They have given me a link to the app so I can see who’s coming and when they’re coming. I can tell [person] who’s coming and can give [person] their medicine, as [they need these so [they] can walk. I’ve got a complete link with them.” Although the service currently had limited working relationships with any external services, a person told us about how the service had worked proactively with them and emergency services to prevent the need for admission to hospital following a recent deterioration in health. They told us “The ambulance said I would need to go to hospital if nobody could come to support me. I called Bersim and they agreed to come back. They started care that day. The paramedics wanted to be sure someone was coming back.”
 

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People were empowered to manage as much for themselves as possible to promote and encourage their independence. They were supported to manage their own health needs as much as possible, for example by administering their own medicines and personal care. A relative told us how staff had supported their relative to be actively involved in managing their own personal care routine.

Staff understood people’s health care concerns and what action to take if they noticed any deterioration, including for urinary tract infections and pressure injury. However, as outlined in other section of this report, guidance in care plans needed to improve, including for management of health conditions.
 

The provider did not always routinely monitor people’s care and treatment to continuously improve it. Although they ensured outcomes met the expectations of people themselves, they did not evidence how they were monitored to ensure they consistently met clinical expectations.

Where care plans included information about people’s history of medical conditions, there was not enough information provided to guide staff in monitoring these conditions to improve outcomes for people.

The registered manager engaged regularly with people and their relatives to check care and treatment continued to meet their expectations and people told us they were satisfied the care provided had improved their lives. The registered manager completed an audit of the daily notes recorded by staff to ensure standards of care were consistent.
 

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

As outlined in the safeguarding section of this report, care plans did not evidence that people’s capacity had been robustly assessed in line with the Mental Capacity Act 2005 (MCA). As a result, information did not support staff in understanding how people would consent to elements of their care and treatment. A care plan included a list of people who could be consulted around decision making for the person, but there was no information about how the person themselves could be supported to make their own choices on a day-to-day basis. Another care plan described a person as having ’capacity to make some decisions’ without any description about how the person would give consent. Despite these findings, staff told us they had received MCA training and always sought consent before completing any task.