Bersim Care Ltd Office

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. This is the first assessment for this service. This key question has been rated 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 systems of governance and oversight of 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 service was led by a passionate leadership team who cared about the service they were providing. The ethos and culture of the service was widely understood, and staff knew how this related to their role. Staff spoke of a care service with a ‘family’ feel where every person was important. The caring and compassionate culture had been embedded across the service by the leadership team. A staff member said, “Our vision is to provide compassionate care with kindness. Our values are person-centred, kindness and family. We treat everyone like family.” Feedback from people and their relatives confirmed staff provided care in line with the provider’s aims, objectives, visions and values. People and their relatives told us the leadership team were knowledgeable, visible, approachable and responsive.
 

The provider had inclusive leaders at all levels who embodied the culture and values of their workforce and organisation. However, systems of governance and oversight did not demonstrate leaders had the skills, knowledge, experience and credibility to lead effectively.

Leaders were caring and visible within the service, but oversight needed to improve to enable them to lead effectively. Leaders were not aware of the issues identified during this inspection, which meant they had not proactively identified issues or taken action to make the necessary improvements. There was a registered manager in post at the time of the inspection who was supported by a nominated individual (NI). The NI was responsible for supervising the management of the regulated activity provided. The registered manager had received regular support and supervisions to ensure they fully understood their responsibilities to deliver good, effective and high-quality care. They had also arranged an external ‘mentor’ to support sector learning and development ideas and to provide them with support and guidance in their role.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff described an open culture where they felt enabled to speak up. They were aware of the term ‘freedom to speak up’, understood what this meant and how it applied to their role. A staff member said, “It [freedom to speak up] means I can raise a concern without being punished. I feel able to raise any concerns with either the registered manager or the nominated individual.” Support was provided to staff during their induction to support them to understand the importance of, and the process for, speaking up. A policy was in place which outlined the process and procedures staff should follow to raise any concerns within the service and externally.
 

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 told us they were treated fairly and equitably at work and were part of an inclusive and respectful work environment. A staff member said, “Morale is good within our team. There is no favouritism. I feel we [colleagues] get the same opportunities.” Staff had received training on equality, diversity and human rights and a policy was in place which demonstrated the provider had considered the requirements of relevant legislation including the Equality Act 2010 and they sought to ‘have a workforce that will be truly representative of all sections of society and each employee feels respected and able to give their best’.
 

The provider did not have clear systems of accountability, oversight or good governance. They did not always act on the best information about risk, performance and outcomes.

The provider had a quality assurance policy, which outlined the service’s requirements for, and frequency of, audits and quality monitoring checks. Although some audits were taking place, such as call analysis and auditing of daily notes, other key audits such as medicines and infection prevention and control (IPC) audits were not. This also contravened the service’s medicines policy which stated that monthly medicines management audits should be completed. No service improvement plan or action plan was in place to evidence key findings were being logged and action taken to improve the service provision. This was implemented during the inspection, following our feedback. Although the service was currently only providing care to 4 people, robust systems of governance and oversight are imperative to sustain quality and drive improvement, to ensure people receive consistently good care as the service grows. Audits had not identified the issues highlighted during this inspection, including the improvements required in care plans, medicines records and in recruitment files. The leadership team were open and transparent about their knowledge and understanding of the system. They told us they were in the process of understanding and learning the capabilities and limitations of their current IT systems.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Care plans did not always evidence that referrals to external healthcare professionals had been considered in response to people’s changing needs, to improve outcomes for people. Although some care plans included information regarding involvement of other healthcare professionals, including district nurses and physiotherapy, they did not include enough information for staff to understand how they should work in partnership with them.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Quality assurance systems were not robust and did not evidence a consistent approach to continuous improvement where the impact of change could be measured. However, leadership engaged in the inspection process and sent evidence they had already implemented measures to make improvements in line with our feedback.

We saw staff were encouraged and enabled to contribute their ideas in relation to service improvements to improve outcomes for people. Staff meeting minutes showed a staff member had led a discussion on a real case study, to enable a team approach to learning and improving care experiences. The minutes from staff meetings also showed leaders had discussed seasonal topics to ensure the service learned from and responded to any relevant issues or changes which were pertinent at the time of the meetings, for example winter preparedness and changes to employment legislation.