Bersim Care Ltd Office

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment, safe management of medicines and capacity and consent.
 

This service scored 56 (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 positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and reported safety events. However, recording needed to improve to ensure the service continually identified and embedded good practice.

Where safety events occurred, they were not always identified, recorded in a consistent way and investigated to ensure lessons were learned and action taken to drive improvements. Where safety events were investigated, although action was taken to improve people’s safety, records were not updated promptly to ensure lessons learned resulted in clear action to reduce the risk of reoccurrence. Where a person had experienced a fall, although an incident report had been completed which included factual details about the incident, lessons learned and actions to reduce the risk of reoccurrence, there had been no updates to key records including the care plan to ensure lessons learned drove improvement to the care provision. A tool was available to support the registered manager to analyse incidents for themes and trends across the service, however incidents that had not been formally recorded via the service’s incident reporting did not show on this tool and therefore could not feed into the overall analysis.

Staff told us they felt confident reporting accidents and incidents and escalating when needed. A staff member said, “I record accidents or incidents on the electronic call monitoring app. For anything serious and urgent I call the [registered] manager. I feel able to raise safety concerns because the [registered] manager listens to our concerns. I have never felt my concerns would be ignored if I were to raise any.”
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider ensured a smooth transition for people when they started using the service. A service user guide was available, setting clear expectations for people. This included key information such as the registered manager’s name and contact details, how to identify staff, and information about assessment of their needs.

People told us the service worked with them, and with those close to them to establish their plan of care prior to them using the service, to ensure their needs were understood and they received continuity of care. One person said, “When I started using the service again, [registered manager] came round, asked me what had happened and did an observation of what I could do. When the carers came back the next day, they knew exactly what I needed. [Registered manager] hadn’t missed a thing. I was so impressed, they are fantastic.” Staff told us people’s needs were effectively communicated with them when people started using the service. A staff member said, “When someone starts using our service, the [registered] manager gives a verbal handover, informing me about the person’s care plan. There will also be a care plan on the app. The [registered] manager also communicates via a WhatsApp group chat, and we shadow the [registered] manager on the first visit. I always get enough information to be able to support the client.”
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. People were not supported to understand their rights under the Mental Capacity Act 2005. However, staff and leaders concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, and neglect.

Care plans did not include enough detail about people’s capacity or ability to consent to or make decisions about their care and treatment. The Mental Capacity Act 2005 (MCA) is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. Although the registered manager demonstrated an understanding of the MCA, there were no assessments in any care plans we reviewed, to evidence how people’s capacity to make decisions about key decisions such as receiving support from care staff with medicines, personal and continence care, had been assessed. A care plan stated a person had ‘capacity to make some decisions’ without any further exploration or indication of what those decisions were or of any discussions or assessments that had taken place to reach this conclusion.

Effective systems, processes, and practices were in place to safeguard people from abuse. Staff had received training in safeguarding and reported feeling confident in raising concerns internally and externally. A staff member told us, “Safeguarding concerns includes abuse such as physical, emotional, sexual, neglect, financial harm or someone being left unsafe. I would report to my manager immediately and [they] would contact the local authority safeguarding team if needed. I have raised an incident with my manager. The registered manager investigated, spoke to the family, and updated the whole team.” People and their relatives confirmed they felt safe with staff. They told us they were comfortable raising any concerns and were confident their concerns would be listened to and acted on. A person told us they felt, “Really safe.”
 

The provider did not always work well with people to understand and manage risks to ensure staff could provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments included basic information about risks to people but lacked detailed guidance about how to manage assessed risks to ensure people’s safety. Some care plans included contradictory and/or confusing information in relation to risk, including where people had a history of health conditions. Although staff told us how they would monitor for deterioration in some health conditions, there was no guidance included in the care plan to support staff to manage or monitor this risk. A care plan listed a person’s current medicines under the ‘medicines allergies’ section which could lead to confusion about how to provide safe care when administering medicines. Records did not always evidence there was a culture of promoting positive risk taking to enable people to do the things that mattered to them and retain important skills. However, people and their relatives told us they felt staff were knowledgeable and understood them well, including any associated risks. A person said, “I can lose my mobility quickly. [Staff member] made a suggestion about where I left the walker. They did it in a nice way. They are really skilful.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider was not responsible for the premises because they supported people in their own homes. Risks in the home environment were generally assessed, and environmental risk assessments were in place, for example around slips, trips and falls. However, they needed more detail to provide guidance to staff to manage these risks safely. Where incidents had occurred, it had not always triggered a review of the existing environmental risk assessments despite there being new risks identified, for example fire risks due to unsupervised cooking and security/access to people’s homes.

People and their relatives told us staff were respectful or their home environment and ensured people’s equipment was used correctly to keep people safe.
 

The provider made sure there were enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs. However, recording and administration systems needed to improve to evidence staff were recruited safely and received effective support, supervision and development.

Although key documents used to evidence safe recruitment were on record such as identification, Disclosure and Baring Service (DBS) and right to work checks, we identified recruitment records where gaps in employment were not explored. Exploring gaps in employment is an essential step for safeguarding and assessing suitability of staff in adult social care. References had been received for new staff members, but they were not always from the most recent employer and there were omissions in important information such as the role of the person completing the references. The provider was responsive to feedback provided to them during the inspection and had sent us evidence they had implemented measures to improve this going forwards.

There were enough staff to meet people’s needs, and this was confirmed by people using the service and their relatives. A relative said, “As far as I’m aware they are there for the full time and they seem to be on time. If I need to speak to someone, I look at the rota, I will call and they [staff] always seem to be there when they’re supposed to be.” The provider had completed an analysis of visit data, this showed people consistently received their commissioned hours of care. Where there had been discrepancies or over delivery of care hours, we saw the provider was regularly monitoring this and taking appropriate action when needed. People told us staff appeared well trained and able to meet their needs. Staff had received training relevant to their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Systems to assess and manage the risk of infection were effective. People and relatives told us staff kept their home environment clean and tidy and used personal protective equipment (PPE) appropriately. Staff supported people to manage their hygiene, which reduced the risk of infection. A relative told us, “As soon as [staff] walk through the front door, they are putting an apron and gloves on. They check [person] cleans [their] teeth, shower [them] every day, and they clear up behind them. They even make the beds.”
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Systems needed to improve to ensure people were receiving their medicines in ways that met their needs, capacities and preferences and they were enabled to be involved in planning. Medicine administration records (MAR) are records designed to document the administration of people’s medicines. Although MAR charts were used and completed safely for oral medicines, no MAR charts were being used for external medicines including emollient creams. Although risk assessments were in place for the use of emollients, they were not person centred and required more detail to help staff to understand the associated risks (including fire risks) and how to apply these safely. Medicines care plans and skin integrity care plans did not include detailed and person-centred guidance about how these were to be used. The provider was responsive and provided evidence that MAR charts had been implemented for topical applications following our feedback. PRN Protocols are essential for ensuring that PRN (as required) medications are used safely and appropriately. Although PRN protocols were in place for a person’s pain relief, it lacked important information and clear guidance on the minimum time between doses, escalation triggers and routes, and any person-centred examples of pain experienced by the person that may have required the administration of PRN medicines. PRN protocols were not in place for the administration of topical applications for 2 people. This contravened the provider’s own medicines policy. The provider also evidenced these had been implemented following our feedback. Medicines care plans did not always demonstrate how people had been involved in decisions about their medicines support and they lacked guidance on people’s preferences, for example how they preferred to take their medicines.