Bargoed Care Home
Heol Fargoed, Bargoed, CF81 8PQ
No of beds: 41 Care Home with Nursing
Category: 31 Older Person (Nursing) / 10 Older Person (Residential) / Dual Registered
Tel: 01443 879005
Email: manager@bargoedcare.co.uk
Contract Monitoring Report
- Name/Address of Provider: Bargoed Care Home
- Date of Visit: 12 May 2023
- Visiting Officers: Caroline Roberts, Contract Monitoring Officer / Jay Ventura-Santana, Lead Nurse Care Home Governance & Safeguarding, ABuHB
- Present: Kelly Whittington-Gidley, Registered Manager
Background
Bargoed Care Home is registered to provide residential and nursing care to 45 people aged over the age of 18 years. The home is owned by Omnia Care Home Group, and the RI (Responsible Individual) is Mr Tariq Mahmood Khan.
The Home Manager is registered with Social Care Wales and holds a Level 5 Leadership, Health & Social Care (Adults’ Residential Management) qualification.
CIW (Care Inspectorate Wales) last undertook an inspection in February 2022, and their report was published in May 2022, which is accessible via their website.
The last full monitoring visit undertaken by the CMO was in 2022. During the visit, corrective and development actions were given.
The home continues to be managed by a stable management team, and a stable staffing team.
The property has new CCTV installed consisting of 9 cameras externally and one in reception. All residents and family/representatives have been advised of the installation. A sticker on the front of the door on entry to the home, is displayed for all visitors to view.
A Monitoring Officer employs a variety of monitoring systems to gather and interpret data as part of monitoring visits, including observations of practice at the home, examination of documentation and conversations with staff, service users and relatives where possible.
Dependent on the findings within the report, corrective, and developmental actions will be given to the provider to complete. Corrective actions are those that must be completed (as governed by legislation); developmental actions are good practice recommendations.
Previous Recommendations (2022)
Corrective
Regular staff meetings take place (a minimum of six meetings per year), are recorded and appropriate actions are taken as a result. (RISCA Reg. 38) MET
Before agreeing to provide a service, the service provider makes an informed decision as to whether or not they can meet an individual’s care and support needs by undertaking a pre-admission assessment. This document should then be retained on file. (RISCA Reg. 14). MET
Developmental actions
Detailed life histories to be completed as fully as possible with records kept of any attempts to obtain this information from friends and family. This information is to be used to plan activities and inform relevant personal plans. MET
Findings from Visit
Documentation
The provider utilises an electronic recording programme called Eresman. The system has been developed with the involvement of the management team and staff team. The system is user friendly and records all appropriate documentation required.
Staff are provided with handheld equipment, which documents all the required support and assistance an individual’s requires through the day. Staff are required to complete the prompts and should anything be missed an alert is highlighted.
As part of the monitoring process, 2 residential files were viewed by the CMO. Both files held a pre-admission assessment.
The personal plans viewed for both individuals evidenced that the residents had taken part in compiling the plans.
Both files viewed reflected areas set out in the individual personal plans and were observed to be reviewed monthly, as is good practice. However, the date did not correlate with the personal plan dates and was found to be confusing for the reader. This was discussed in detail with the Home Manager, who agreed to look into this area further.
Whilst viewing both files, it was evident that staff are knowledgeable in respect of what appropriate professionals should be contacted should the need arise i.e. In Reach Team, Bowel/Bladder Services, GP, TVNs. Falls Team to name but a few.
Both files held a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) record and, also an Advanced Care Plan.
Both files viewed held detailed life history of the individuals, informing the reader of their backgrounds, where they grew up as children, their weddings, their family, pets, employment etc. The comprehensive details provided in the life history document, would provide any new member of staff with a sense of knowing the individual and would be able to engage in conversation with individuals they are supporting.
Risk Assessments were observed for both individuals i.e. Behavioural Charts, choking, call bell, bed rails, moving & handling, falls etc.
Daily records were observed to have been completed.
Goals and outcomes are recorded on each individual personal plan i.e. maintaining independence, independent decision making, promote social interaction.
PEEPS (Personal Emergency Evacuation Plans) were observed and both files held pictures of the individuals.
Activities
The Activity Co-ordinator at Bargoed Care Home was absent at the time of the visit. However, all staff have a duty and a responsibility to ensure stimuli is offered to all residents.
During the visit, a vocalist performed and the CMO observed good interaction between the entertainer and the residents; encouraging all to sing and dance. The staff joined in with the residents and smiles and laughter were observed throughout the performance. Once the show concluded, the entertainer remained and enjoyed refreshments with the residents, engaging in general conversation.
The home recently celebrated an individual’s 102nd birthday, and the Kings Coronation. The individual who celebrated their birthday advised the CMO that they had a good day and that they were up dancing with staff. Photographs of the celebrations were also shared with the CMO.
The home has a small garden area, which during the warmer weather residents can enjoy.
The home respects individual religious beliefs and will endeavour to make appointments with the appropriate individual to offer pray services.
Quality Assurance
No recent quality of care review has been completed; it was discussed with the manager that these should be completed every six months as required in regulations.
There were however documented quarterly visits from the Responsible Individual, this was a detailed report monitoring the performance of the service, engaging with staff and residents and overall inspection of the premises.
There was no evidence of formal staff meetings taking place and recorded as required within regulations. The manager advised that staff are kept informed and updated of any changes by means of handovers at change of shifts and also by digital communications. The manger is visible throughout the home and approachable by staff should they require to speak to him.
A number of audits carried out at the home both internally by staff and also by external agencies such as Complex Care Pharmacist, Fire Service, Environmental Health.
Internal audits completed by the manager include Accidents, Incidents, Complaints, Medication, Food Safety, care Plans, Client equipment and the Home Environment, Maintenance Checks, Prevention of Sharps, Hand Hygiene and PPE and Satisfaction Surveys.
The home has a robust daily handover which takes place every change of shift and is attended by all staff.
All residents are discussed, and this is documented on individual daily handover sheets. A summary of daily handover is also printed off with each resident listed and any significant information recorded and provided to each member of staff
The handover also contains discussions regarding the general running of the home including staffing, any maintenance issues, messages from relatives etc.
The home employs a full-time maintenance operative and has an annual maintenance plan and schedule. Various checks are carried out weekly, monthly quarterly and six monthly. These checks are recorded and kept on the maintenance file.
A number of improvements to the environment of the home have taken place since the last monitoring visit including decoration, new flooring throughout, investment in new laundry equipment and two new large screen T.V.’s for the lounge.
The annual Fire Safety assessment for the home has been arranged. The last assessment was provided for the Contract Monitoring Officer and evidenced that there was one recommendation which had been actioned.
Evidence was available of documented fire drills which had taken place at the home and personal emergency evacuation plans for residents viewed were clear regarding the support required in the event of an emergency.
Staffing
Staffing levels are based upon dependency levels. Staffing levels are (07:30-13:30) 2 nurses or 1 nurse and 1 Care Home Assistant Practitioner (CHAP), 1 senior carer, 6 care staff. From 13:30-19:30 there are 2 nurses or 1 nurse and 1 CHAP, 1 senior, 6 care staff and then 19:30-07:30 there is 1 nurse, 1 senior and 3 care staff.
Staff supervisions and appraisals were observed to be undertaken in a timely manner, with all staff receiving their annual PDR in January 2023. Supervisions are held on a 2 monthly basis, face to face.
Should the home be required to access agency staff, the Home Manager holds responsibility for obtaining a profile of the agency nurse and ensuring they receive an induction pack. It is the Manager’s responsibility to ensure the agency nurses have valid PINs to practice.
The visiting officer viewed three staff files. Both files contained appropriate documentation i.e. completed job applications, job descriptions, interview records (score system used), signed contracts of employment, DBS checks, 2 references, photos of the staff member). The files were in excellent condition, with an index at the beginning to aid the reader.
The All-Wales Induction Framework (AWIF) for health and social care (induction framework) creates a firm basis for new workers to help them develop their practice and future careers, in and across the health and social care sectors. It also provides a clear understanding of the knowledge, skills and values that are needed to make sure new workers are safe and competent to practice, at this stage of their development. Care workers complete the relevant induction programme as required by Social Care Wales (SCW).
Out of 39 staff members, 8 are currently working toward their registration.
The Home Manager is proud of the staff team for working together to maintain the quality of care provided to the residents.
Training
Training is assessed and overseen by the Home Manager. A report is produced which identifies any overdue training or those staff that require a refresher course. Observations are undertaken of staff who have undertaken training to see how the new skills and knowledge are implemented.
The Training Matrix was observed, and training compliance (as of May 2023) varied between 91%-100%. Staff were observed to have undertaken appropriate mandatory training i.e. Safeguarding, Moving and Handling, Infection Control, Food Hygiene; Basic Life Saving (First Aide). Other training observed was GDPR, Sexual harassment, Record Keeping, COSHH, Fire Awareness and others.
Quality Assurance
The RI’s accountable for both service quality and compliance and part of the RI’s duty is to visit the service on a quarterly basis to have an oversight of the service and report on its quality. Regular visits were observed to have taken place and the Home Manager advised that the RI visits every second Tuesday of the month or as and when required. Both the Home Manager and staff team have stated that the RI is very supportive and interacts with the residents during his visit.
Should the RI and the Home Manager be absent from the home for any given reason the Deputy Manager would oversee the running of the home, along with the RI’s business partner.
The RI has responsibility of producing quarterly reports and said reports include ensuring that staff wear appropriate uniform, staff are in receipt of appropriate support from the management team, interactions with residents, observing décor inside and outside, ensuring policies are in place and that all staff are adhering to them, there are no hazards throughout the home etc. Any corrective matters are recorded and discussed with the Home Manager for action.
Regular monthly audits are undertaken i.e. Infection, Prevention and Control, Medication and MAR (Medication Administration Record) are undertaken weekly, Health and Safety, bedrails, wound and pressure ulcers and care files. All noted to have good outcomes.
Minutes of the residents meeting were viewed and topics such as events/activities, food/menu, improvements etc. are discussed. Unfortunately, it is sometimes problematic in obtaining family members/representatives involvement. However, the home Manager operates an open door policy, which allows residents/family to discuss any concerns/issues at their convenience.
The home has an up-to-date Statement of Purpose and Service User Guide, which explains to residents the service the home offers and what they can expect from the provider. For transparency reasons, it is recommended that the Statement of Purpose is dated; therefore, evidencing its review.
Any accidents that occur within the home are Datixed and if applicable, a Duty To Report form is completed and shared with the Local Authority’s Safeguarding Team for advice. At the time of report writing, since January 2023 to date, there have been 4 DTR’s submitted by the Home Manager. 4 were closed (concluded) and 1 was not progressed. 3 out of the 4 were closed or not taken further due to the home contacting all appropriate professionals for advice and input. For the 4th incident, this progressed via the disciplinary route.
In respect of advocacy, residents at Bargoed Care Home are generally supported by family/friends; however, the Home Manager was aware of how to access advocacy for an individual should it be required.
The Manager, during the visits advised that should an individual be taking medication they may not need, she would know which procedure to follow and explained that she would request a medication review.
Discussion with staff and residents
Conversations were held with staff during the visits and staff advised that the Home Manager and Deputy Manager would assist, as and when required, sometimes covering shifts should staffing levels be depleted. Staff were observed to interact well with individuals, encouraging smiles and laughter throughout the day. It was evident that staff members had knowledge of those they were assisting and supporting.
Residents were observed to enjoying a full cooked breakfast and then toast and a cup of tea/coffee. Soft drinks were offered should a hot drink be declined. Menus were on display on individual tables. The tables were laid invitingly, with flowers, condiments, napkins and cutlery.
Individuals are offered the choice of where they would wish to dine i.e. in their rooms, at the table in the dining area or where they are sat in the lounge area.
Mealtimes were observed to be a positive experience for the residents.
Fire Safety/Health & Safety
An external company visits the home to undertake an annual fire assessment. One was scheduled in April 2022. At the time of the visit, the next scheduled inspection was for June.
The Home Manager advised that staff attend a day’s training session on fire safety, and this is provided by an external company who visit the home. During the training staff take part in a fire stimulation exercise, where smoke is used, and staff have to demonstrate their fire awareness knowledge.
Managing Residents Money
When managing money that comes in/out of the home, two signatures are obtained. This is usually the Manager’s and the administrator. Signatures are also obtained from the resident and/or family members. The Monitoring Officer viewed the appropriate documentation and electronic system used by the homes administrator.
General
Resident’s rooms were found to be decorated with personal belongings, photos of family, scatter cushions, trinkets etc. All rooms have memory boxes attached to the walls by their door, which had been hand crafted by the Home Manager. This enables the residents to easily recognise their rooms and provides staff and visitors with a prompt for conversation.
The home has undertaken some internal re-decorating; therefore, making the home inviting and warm. The foyer (middle floor) is open, bright and airy and you are greeted by the home administrator on arrival. Appropriate checks are undertaken prior to entry to the home i.e. presentation of LFD result, temperature checks etc. Comfortable chairs are situated in the foyer, should residents wish to meet their visitors there. There is an electronic system (T.V.) that sits behind the administrator’s desk, that displays staff members on shift and any visiting professionals.
At the time of monitoring, the Home Manager advised that they were experiencing difficulty in appointing and retaining maintenance staff. However, one had recently been appointed and at the time of the monitoring visit, had yet to commence their employment at the home. However, staff work as a team if anything urgent is required or alternatively, external support is employed.
The home implements the Active Offer (providing a service in Welsh without someone having to ask for it) and has 3 staff members that are fluent Welsh speakers. 1 resident is a Welsh speaker and sometimes choses to communicate in Welsh.
Corrective / Development Actions
Corrective
None.
Developmental actions
Dates of reviews to coincide with renewal of Personal Plans so that they correlate.
For the Statement of Purpose to record the date of review for transparency
Conclusion
The atmosphere at the home was found to be relaxed, warm and welcoming, with plenty of smiles and laughter observed throughout the visit. Positive feedback was received from the residents and staff employed at the home.
Good interaction was observed with the residents, and staff demonstrating knowledge of the individuals residing at the home.
The Home Manager and the RI continue to have a positive working relationship; therefore, maintaining a strong management team.
The Home Manager continues to be open and transparent and notifies the Local Authority and/or Health Board of any issues or concerns identified.
Routine monitoring will continue, and the monitoring officer would like to thank the RI, the Home Manager, the staff team, and the residents for their hospitality during the visit.
- Author: Caroline Roberts
- Designation: Contract Monitoring Officer
- Date: 19/05/2023