Crown Lodge
Contract Monitoring Report
- Name/Address Of Provider: Crown Lodge, Crumlin, Newbridge
- Date/Time of Visit: Thursday 14th October 2022
- Visiting Officer(s): Caroline Roberts, Contract Monitoring Officer
- Present: Morgan Thomas, Trainee Home Manager (overseen by registered manager, Claire Williams).
Background
Crown Lodge is a small residential home for individuals with learning disabilities, which was taken over by Cartrefi Cwtch in January 2022. There is a sister home, also within the Caerphilly borough, and both homes are managed by the Registered Home Manager, Ms Clare Williams. The Responsible Individual (RI) is Ms Nichola Evans. Whilst working toward her QCF Level 5, Ms Morgan is currently being trained in order that she may take over the management role of Crown Lodge in the future. As part of the training process, Ms Morgan took responsibility for the monitoring visit at Crown Lodge.
Crown Lodge is located in Crumlin, and is a large, mid terraced property. The registration covers three adults with a learning disability. At the time of the visit, the property was fully occupied. 2 individuals are residents from Caerphilly Borough, whilst another had been placed by another Local Authority.
On the day of the visit, the monitoring officer met with the Ms Morgan, two members of staff and chatted to all 3 residents.
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), and developmental actions are good practice recommendations.
Previous Corrective / Developmental Actions
Corrective actions
PEEPS to be signed and dated by the author of the PEEPS. (RISCA Reg 57) Timescale: Immediately. MET
Staff to sign contract of employment (RISCA Reg 57) Timescale: Immediately. MET
Appropriate Risk Assessment to be put in place (RISCA Reg 57) Timescale: Immediately. NOT MET
Whilst the records indicated that a social worker had assisted with the development of Personal Plans, this must be evidence by the provider. Therefore, signatures are required to be obtained to evidence participation (RISCA Reg 15)Timescale: Within three months and ongoing. Not Met
Policies and Procedures to include a review date. (RISCA Reg 7) Timescale: Within one month. Met
For the RI’s quarterly reports to include residents/representative’s feedback. (RISCA Reg 73) Timescale: Within the next quarterly report. Met
Developmental actions
For an electronic supervision and training matrix to be devised to assist the Home Manager and professionals inspecting the service. MET
Staff to individually sign the team meeting staff signing sheet to evidence that they have read and understood the information contained within the minutes.
The Home Manager to collate any compliments received and to share them with the Local Authority. ONGOING
Any regulation 60 notifications submitted to the regulator to also be copied to CCBC Commissioning. (CCBC Contract). NOT MET
For Hospital Passports to be completed for existing residents and any new, that will support health professionals, should an individual be admitted to hospital. MET
Findings
Documentation
All documentation was found to be stored securely.
As part of the monitoring process, 2 files in respect of residents being supported by Caerphilly Local Authority, were viewed.
Both individuals have resided at Crown Lodge for a few years and therefore, no pre-admission assessment was observed. (undertaken by previous business owner). It is a requirement that a pre-admission assessment is completed prior to an individual taking up residence.
Both files held a one page pen profile, with an up-to-date photograph of the individuals. This would allow a visiting professional or new staff to have a quick snapshot of the individuals i.e. likes/dislikes, family, hobbies etc.
The files held new, detailed Personal Plans, which consisted of information that had been transferred from the Local Authority’s Care and Support Plan. The Personal Plans were observed to be detailed enough to assist the staff to provide appropriate assistance and support to the individuals residing at Crown Lodge. However, whilst the plans contained detailed information; there was no evidence to indicate who had played a role in its development as the individuals or representatives had not signed the document to agree to its content. This was discussed with Ms Morgan.
Within the Personal Plans, reference to risks were outlined, with information to evidence slow and fast triggers and resolution. However, whilst viewing the documentation, some medical conditions were noted that required appropriate Risk Assessments to mitigate risks. This was discussed with Ms Morgan.
Reviews were observed to be undertaken 3 monthly or sooner if required. However, there was no evidence to indicate who or what documentation had played a role in the review process.
Daily records were observed to be completed by staff and they recorded how individuals are supported daily. Recordings were made in respect of mood, medication, health issues, skin integrity, any visitors i.e., professionals, family. Staff are also recording outings/activities that the individuals undertake i.e. eating out, shopping, walks around the park, trips to the seaside etc. However, staff are to be mindful of the terminology used when writing daily records.
There are weekly outcomes/goals that people aim for.
The files evidenced that staff at Crown Lodge make appropriate referrals to outside agencies i.e. opticians, diabetic eye screening, dentist, SALT (Speech and Language Therapy) etc.
As recommended within the last report, Cartrefi Cwtch were advised to consider putting in place a signed agreement with family/representatives that would agree to being contacted should an emergency occur. It is noted, at the time however, that some individuals may not have representation and therefore, the responsibility will rest with the provider to undertake appropriate action should an emergency occur. Such documentation was noted for one individual who has family and for the second, the Manager would take appropriate action due to no family being involved.
Both files were observed to hold a Health Profile.
Personal Emergency Evacuation Plans were observed.
Quality assurance
The RI has responsibility of overseeing the adequacy of resources of the service and as such must produce a report at least on a quarterly basis (RISCA Reg 74). Also, the RI has a duty to ensure there is a system in place for monitoring, reviewing and improving the quality of care and support the service provides and should be reviewed as and when but at least every 6 months (RISCA Reg 80).
Copies of the quarterly Quality Assurance Reports for March, June and September 2023 were observed (in line with RISCA reg. 74). Such areas looked at by the RI were: Medication Administration, Home Security, Health Care, Finance, Staff Recruitment, and other areas. Within the reports, there was no evidence that feedback had been sought from the residents and staff members.
The Regulation 80 report (6 monthly) was not observed during this monitoring period.
Staffing and training
Two staff members’ files were viewed, and were found to contain the appropriate information i.e., two references, birth certificate, passport, DBS, job description etc. signed Contract of Employment, staff photograph, training certificates and Social Care Wales registration.
Both staff members commenced their employment at Crown Lodge whilst under the previous business manager.
Staff receive 1:1 supervision and this is held on a 3 monthly basis. Ms Morgan advised that appraisals have yet to be undertaken and will commence in 2024. However, this matter was also discussed during the previous monitoring visit and therefore, the monitoring officer will review this area early 2024.
Since the last visit, the provider has introduced an electronic method of recording training and refresher training. Mandatory training had been undertaken, along with additional training that would assist support workers.
Staff meetings were observed to be taking place (Aug 2022, February 2023, May 2023, August 23) and covered various topics for discussion i.e. spot checks, cleanliness, shifts, documentation, items required by the residents and more. However, RISCA advises that there should be a minimum of 6 held a year.
Life at the home
On arriving at the property, the home was observed as being calm and quiet. One resident was already up, with the second being supported with personal care.
All three residents enjoy accessing the community and were planning to go out during the visit.
Positive interaction was observed, and it was evident that the residents had a good relationship with the staff members on duty.
An Activity Calendar was observed, outlining house chores, Valley Daffodils (an activity group), tea & chatter event, shopping, craft club, movie night, baking, visiting the sister home etc. Both individuals can indicate to staff what they would like or not like to do.
Individuals are offered a choice of food; however, one individual has medical conditions that the home has to take into consideration when preparing meals i.e., Type 2 Diabetes, Coeliac, a soft diet. The staff ensure the individual does not miss out on certain foods, as gluten free ingredients/recipes are sourced.
One of the residents prefers a structure to meal times, but individuals are given a choice of when they would like their meals.
Individuals are encouraged to assist with meal preparation but again, they have a choice.
As and when required, Dietician and SALT (Speech and Language Therapy) advice is sought. However, it is imperative that Risk Assessments are devised to manage potential risks associated with health conditions.
During the monitoring visit, three bedrooms were viewed. All rooms have been decorated and are personalised to each individual’s personal taste.
The home currently has no individual that communicates in the medium of Welsh (the Active Offer). When asked how the Active Offer would be implemented, the Home Manager advised that as a provider they would endeavour to learn basic Welsh to communicate with any individual who converses in the language.
Crown Lodge had their Food Hygiene inspection in July 2022 and were awarded a level 4 Food hygiene rating.
No specialised equipment is currently used.
General internal checks are undertaken by the Home Manager and staff and local electricians undertake PAT testing. Appliances are insured and therefore, should any equipment become faulty, it is replaced.
Health and Safety
It was noted that one tenant had had a fall and sustained a broken arm. Whilst a regulation 60 was shared with the regulatory authority, it had not been shared with the Local Authority.
Fire drills were observed to be undertaken regularly, with no concerns raised.
Complaints/Compliments and Advocacy
Should individuals require external support to convey their wishes and feelings, the provider will request the appointment of an IMCA (Independent Mental Capacity Advocate).
There have been no complaints received in respect of the provider in the last year.
Ms Morgan was reminded to collate any compliments received and to share them with the Local Authority.
Manager and Staff Questions
On arrival, the visiting officer observed a staff member interacting well with the residents and interaction was observed to be warm and caring. It was evident that the staff member knew the two residents well and how best to support them.
At the time of the visit, there were no concerns raised or noted regarding the property. Ms Morgan advised that they are slowly decorating the house, with input from the tenants. Bedrooms have recently been re-decorated, with the residents choosing the colour. When advising that the bathroom looked tired, Ms Morgan advised that there are also plans to improve the bathroom area, the kitchen and to make the lounge area more spacious and modern for the residents.
Ms Morgan advised that she meets with the RI every Monday.
All DoLs (Deprivation of Liberty Safeguards) renewal applications are up to date.
Policies and procedures were viewed by the monitoring officer including the providers Statement of Purpose.
Corrective Actions
Personal Plans are co-produced with the individual receiving care and support, the placing authority (if applicable) or any representative. If unable to obtain signatures, record such. (RISCA Reg 15)
Reviews are undertaken involving the individual and, where appropriate, with the agreement of the individual, their representative. RISCA – Reg 16
Staff receive appropriate appraisals (RISCA Reg 36)
Staff Meetings (Team Meetings) should be held at least 6 times a year – RISCA Reg 38.
Any regulation 60 notifications submitted to the regulator to also be copied to CCBC Commissioning. (CCBC Contract).
Developmental Actions
For consideration to be given to adding the local authority’s complaints details in the complaints policy and residents guide: Complaints & Information Team, Penallta House, 2nd Floor, Tredomen, Hengoed CF82 7WF Telephone: 0800 328 4061 or sscomplaintsandinformation@caerphilly.gov.uk
For the Statement of Purpose to be updated in respect of the recent change of address with regards to the LA’s Complaints & Information Team.
Conclusion
The home environment and atmosphere at Crown Lodge was warm, relaxed, and welcoming.
It was evident that the provider has built a good working relationship with professionals who also support those who reside at the home.
All three residents appeared to be relaxed in the company of the staff members. There was plenty of interaction, laughter and smiles.
All three residents appeared to be well, were dressed appropriately for the weather and looked happy.
The Registered Home Manager, RI and Ms Morgan are eager to continue looking for ways to improve the service the residents receive at Crown Lodge, and to improve their quality of live.
Monitoring will continue to take as planned, and the monitoring officer would like to thank all involved for the welcome given at the home.
- Author: Caroline Roberts
- Designation: Contract Monitoring Officer
- Date: 29 November 2022