PC Cymru Care Ltd
Contract Monitoring Report
- Name/Address of Provider: PC Cymru Care Ltd. Supported Living Service.
- Date Of Visit: Friday 8 March, 2024, 10.00 a.m. – 1.00 p.m. / Thursday 28 March, 2024, 10.00 a.m. – 12.30 p.m.
- Visiting Officer(s): Andrea Crahart, Contract Monitoring Officer, CCBC
- Present: Pamela James, Registered Manager / Carl Potts, Responsible Individual (8 March, 2024 visit)
Introduction
PC Cymru Care provide a ‘shared supported living’ service, where staff support a small number of people in a home environment, who hold their own tenancy agreements. Some of the areas that people are assisted with include household management, finances, skills/independence and community participation.
The property where people reside is in a pleasant neighbourhood and is close to local amenities. There are currently no vacancies as 4 people are supported by the staff team.
There have been no known concerns or safeguarding issues over the previous year reported to the Caerphilly Commissioning or Safeguarding team.
The service’s Statement of Purpose and Service user Guide were provided. Some slight amendments were required to bring the Service User Guide up to date.
Dependent on the findings within the report PC Cymru Care will be given corrective and developmental actions to be completed. Corrective actions are those, which must be completed (as governed by legislation etc), and developmental actions are those, which are deemed good practice to be completed.
Previous Recommendations
Corrective action
Training for staff to be arranged by prioritising mandatory training initially, and any other training that staff would benefit from. Timescale: Within 2 months. RISCA regulation 36. Action met.
Staff files – DBS certificates to be removed from files and only limited information retained. Contracts of Employment to be issued and to include reference to the probationary period, and signed up to by both parties. Interview question and answers to be captured, scored answers to indicate suitability to the role and signed/dated by interviewer. Timescale: Within one month and ongoing. RISCA regulation 35. Action met.
Bathroom door lock to be repaired to ensure people can easily open and close it without any issues. Timescale: Within 1 month. RISCA regulations 43 and 44. Action met.
All Personal Plans (Service Delivery Plans) to be made more detailed and person centred to reflect the person’s care and support more fully, and provide more information for staff to follow. All plans to be signed up to by stakeholders. Timescale: Within 2 months. RISCA regulation 15. Action met.
Fire safety to be improved in terms of recording who is present during fire drills, length of the drill, areas discussed, any issues/any actions for improvement. Timescale: Within 6 months and ongoing. RISCA regulation 57. Action met.
Quarterly reports written by the Responsible Individual to include further analysis of findings and feedback from people supported, staff, relatives and other stakeholders. Timescale: Within 3 months and ongoing. RISCA regulation 74. Remains ongoing.
Quality of Care Review to be completed at regular 6 monthly intervals to report on the services quality and performance. Timescale: Within 1 month. RISCA regulation 80. Action met, but further development required.
Infection control policy to be updated to reflect the service being delivered and to include how people are supported where/if there are outbreaks of Covid-19. Timescale: Within 2 months. RISCA regulation 79. Action met.
Developmental Actions
Training matrices to be brought up to date by removing out of date information, and to consider merging all information onto one matrix to make it easier to view. Timescale: Within 3 months. Action met.
Daily routines to be captured via the Daily Notes so that more detailed information can be recorded and in more of a person centred way. Timescale: Within 3 months. Action met.
Responsible individual
Within the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA), which governs how care and support should be delivered there is an expectation that the Responsible Individual (RI) belonging to the service will visit the service regularly and produce reports relating to the quality and compliance of the service. It was evident that the RI for the service had completed quarterly reports over recent months, however some further development is recommended to ensure further information is captured and feedback is sourced from individuals using the service, family and staff members.
Policies and Procedures were requested regarding key mandatory areas e.g. safeguarding, medication, infection control management etc. It was evident that the vast majority had been reviewed in the previous 12 months, however one had not been reviewed since October 2022 and another was stated for reviewing in 10 years time.
Induction and training
PC Cymru Care Ltd. continue to use electronic training matrices to record the training that staff have attended. It was evident that staff had attended key training over the previous year e.g. safeguarding, medication, autism in maturity, fire awareness etc. It was pleasing to learn that the provider had invested in an on-line training package (Care Skills) that staff were using and the RI could see the difference it had made. Face to face training is also accessed via the Workforce Development Team (Blaenau Gwent/Caerphilly) when required.
Staff employed at PC Cymru Care have achieved an QCF level 2, 3, 4 or 5 in Health and Social Care.
The manager is aware of the new All Wales Induction Framework which has been introduced by Social Care Wales (the workforce regulator). This framework provides an induction for new carers/support workers, whilst also working towards a qualification in social care.
Supervision and appraisal
It was evident from the matrix that supervision and appraisals had been held with staff on a one to one basis at regular intervals (i.e. 3 monthly and annually, as appropriate).
Staff Documentation
A staff file was viewed for the latest appointed staff member who had been employed on a casual basis. The file contained an index and dividers and information contained on the file included e.g. a support worker job description, application form, 2 written references which had been verified, interview record which had been scored by 2 members of staff, a contract of employment which had been signed by both parties, and DBS information. Information that had been omitted included identification (birth certificate, passport or valid driving licence) and a recent photograph of the support worker.
Staffing
PC Cymru Care benefit from a stable staff team and where people supported have consistency of support. The majority of staff work part time hours, including some relief staff and therefore it enables the manager to have the flexibility to cover shifts more easily, when required from the existing team.
Staff were attentive to people’s needs and communicated well with the individuals that live here.
Personal Plans (Service Delivery Plans)
Personal plans were seen to be more detailed during this visit and explained more fully how to best support people. The provider had made changes to the design of the documentation and were committed to developing the plans to make them as person centred as possible on an ongoing basis.
From files viewed these contained important contact details for e.g. GP, social worker, dentist etc. Also present were Caerphilly County Borough Council (CCBC) Care Plans, CCBC Reviews etc. and Personal Plans that had been written by PC Cymru Care to guide staff in how to support the individuals concerned.
Personal Plans covered areas such as personal care, nutrition/meal preparation, activities, domestic chores, maintaining links with friends/relatives etc. The plans had been signed by the staff team to confirm that they had read and understood the content. There was reference to an individual needing to be prompted to brush his teeth twice a day and the risks of the gent using Face Book due to it being detrimental to his mental health. There was also good detail noted in relation to the times etc. that the person needed to be in work, the days/times he visits a relative and how he likes to be involved in shopping trips (e.g. how he will push the shopping trolley, how he will place items into the trolley himself and then enjoys going for a coffee when the shopping trip is done).
Personal Plans had been reviewed on a 3 monthly basis and family are invited to be part of the reviews. The manager confirmed that the information is updated more frequently than on a 3 monthly if people’s needs change.
PC Cymru Care have a ‘Daily routine’ record where staff record if certain tasks have been achieved/or not e.g. bed changes, baths, change of clothes and additional information is captured here as to the daily life of the person concerned.
The Environment
The home is very well maintained, well furnished, clean and tidy. In the previous year a new kitchen had been fitted and the contract monitoring officer was made aware that there are plans to refurbish the bathroom area.
Fire Safety/Health & Safety
There was evidence to suggest that fire drills had been undertaken at the property during 2023 and more recently in 2024. These had been attended by the staff team and service users, with no issues being identified at the time.
Personal Emergency Evacuation Plans (PEEPS) are present on files seen, with a ‘master’ copy being available for all staff to see also.
Medication
Medication records for 2 of the individuals living at the property were viewed. These included a current photograph of the individual and contact details e.g. the GP, local chemist etc.
Medication Administration Records (MAR) charts had been sourced via a local pharmacy and had been completed by staff on a daily basis to confirm that medication had been given.
PC Cymru Care hold an audit record for each person’s medication to ensure that the medication is counted on a daily basis so that any discrepancies can be identified promptly. There is also a check at the beginning of each shift.
Quality Assurance
The RI had completed a 6 monthly Quality Assurance review in February 2024 which indicated that there were no issues with the service in terms of e.g. complaints, safeguarding issues etc., there were no visits to report on from professional visits (e.g. CIW) and any improvements made since the last report were identified as the implementation of the on-line care skills training for staff. The report was however brief in content and would benefit from greater detail and analysis
General observations from the Contract Monitoring Officer
All individuals were home during the visit and were in very good spirits with lots of smiles and laughter. People looked well presented and appropriately dressed for the weather.
People were engaged in activities e.g. pegging washing out on the line, tidying their bedroom, or going out in the community. Some service users showed the contract monitoring officer pictures that they had drawn and were proud of what they had achieved.
Corrective / Developmental Actions
Policy relating to ‘managing violent incidents’ (control and restraint) to be reviewed to ensure it remains as up to date as possible and other policies to be reviewed regularly to ensure they are as up to date as possible. RISCA Regulation 12. Timescale: Within 1 year and ongoing.
Service user guide – Some slight amendments to be made (terminology and contact details). RISCA Regulation 14. Timescale: Within 3 months.
Staff Recruitment – To ensure that recent photographs and appropriate identification is kept on staff files (birth certificate, passport or valid driving licence). RISCA Regulation 34. Timescale: Ongoing.
RI reports (quarterly and 6 monthly) – To include further analysis of findings from the visit (i.e. staffing levels, any sickness, any compliments received, feedback from stakeholders etc.). RISCA Regulation 73. Timescale: Within 3 months and ongoing.
Conclusion
People living at the service are supported by suitably qualified staff who have access to an on-line training programme and face to face training to maintain and enable staff development.
Individuals are supported to meet their goals and Personal Plans are more detailed and person centred than previous. These had been reviewed on a regular basis, with involvement from family members.
The majority of recommendations that were made during the last year’s monitoring visit had been met by the provider.
RI quarterly and 6 monthly reports require further development to ensure they meet the requirements of the Regulation and Inspection of Social Care (Wales) Act 2016.
The contract monitoring officer would like to thank PC Cymru Care for their time and hospitality during the monitoring visits.
- Author: Andrea Crahart
- Designation: Contract Monitoring Officer
- Date: April 2024