Plas Hyfryd
74 Ffordd-y-Maes, Caerphilly, CF83 2BH
Accomodation profile: 49 self-contained 1 and 2 bedroomed flats
Care provider: Pobl
Manager: Linda Craven
Tel: 02920 849452
Email: Linda.craven@poblgroup.co.uk
Contract Monitoring Report
- Name of Provider: Pobol
- Name of Extra Care Service: Plas Hyfryd
- Date of Visit: 10 October 2023
- Visiting Officer: Caroline Roberts, Contract Monitoring Officer
- Present: Rhiannon Rogers, Scheme Manager, Hayley Wheeler, Team Leader, Linda Craven, Registered Manager
Background
Plas Hyfryd is a large scheme situated in Caerphilly, near the town centre; therefore, allowing the tenants access to the local amenities. The landlord at Plas Hyfryd is United Welsh and whilst there are 49 flats, 29 tenants are in receipt of support, providing 335 hours of support.
The range of care and support tasks undertaken by Pobl under the contract includes personal care (e.g. assistance in bathing, washing, dressing, medication intake, toileting), nutritional care (e.g. assistance with eating and drinking, food and drink preparation, and food and drink intake monitoring), mobility care (e.g. assistance with getting in and out of bed, general movement), and domestic care (e.g. assistance with cleaning, shopping, other housework, arranging appointments). Staff are on site at all times, and people living at Plas Hyfryd are able to contact them at any time through the use of Tunstall.
Dependent on the findings within the report, the provider will be given corrective and developmental actions to complete. Corrective actions are those which must be completed (as governed by the Regulation and Inspection of Social Care (Wales) Act or the CCBC contract), and developmental actions are good practice recommendations.
Previous Recommendations
Corrective
If the full amount of time for the call is no longer required, the Manager must contact the relevant team to inform them that a review is required to reduce call times (Extra Care Service Specification) Timescale – MET and continues to be ongoing
Three monthly reviews to be undertaken or sooner if there is a change in an individual’s needs. For the reviewing officer to evidence that the tenant and/or representative and any other appropriate professional is involved in the review and signs and dates the documentation. (RISCA Reg 16.) Timescale – immediate and ongoing - MET
For every effort to be made to ensure consistency with care support staff. (RISCA, Reg 22 and Service specification for Provision of an Extra Care Service) Timescale – immediate and ongoing – NOT MET, see main body of report.
To encourage tenants, wherever possible, to engage with activities and make new friends (Extra Care Specification) Timescale – immediate and ongoing. MET but remains an on-going action.
Records with regards to achieving outcomes, and the health and well-being of people must also be evidenced and monitored formally - RISCA Regulation 14 and Service specification for Provision of an Extra Care Service - MET
The service must prepare a plan for the individual which sets out the steps which will be taken to identify risks to the individual’s well-being and how this will be managed i.e. Epilepsy Risk Assessment - RISCA Regulation 15 - MET
Service provider review and update the statement of purpose at least annually or when changes are being made to the service provided. – RISCA Regulation 7
Developmental Actions
That all care staff enter the actual in/out times on the rota’s provided for internal/external audit purpose. A new Daily Log Sheet was presented as a result of this feedback and will now be use. MET
All staff to be mindful of the terminology used when recording daily records. MET and remains ongoing
For staff to be available to respond to Tunstall contacts. – remains ongoing
Management
The Scheme Manager advised that the Responsible Individual (RI) last visited in June 2023 and the next visit is expected in July 2024. However, the Manager advised that should it be required, they are able to contact the RI at any time.
Support is also provided to the manager by Ms Craven and also, Mr Hart, Assistant Director – Care.
Should the RI and Registered Manager (RM) be absent, Mr Hart as the Assistant Director of the area would cover parts of the RI role with support from Pobl’s Safeguarding Lead. If an RM were to be absent, other RM’s in the area would be requested to support.
Policies and Procedures were shared with the Monitoring Officer as part of the monitoring process. They were observed to be dated; therefore, evidencing when last reviewed.
The last 3 Quarterly Quality Review Gwent Partnership Area Reports were shared with the Monitoring Officer. These are reports that are completed by the Responsible Individual by carrying out visits to the premises, meeting with tenants, staff, management and carrying out observations. The reports outline the RI’s findings and an action plan for any improvements required.
CCTV is insitu at Plas Hyfryd; however, it is not in place within individual tenant’s flats.
The service has six staff members who are fluent Welsh speakers. All tenants receiving support from Pobl have the option of receiving their documentation in the medium of Welsh. At the time of the visit, the Team Leader was in the process of arranging basic Welsh lessons for staff and tenants. Therefore, the provider is complaint with the Active Offer.
Documentation
During the monitoring visit, three tenant files were viewed. All three received various amounts of care and support.
Two out of the three files viewed did not hold a pre-admission assessment. However, a reason for the pre-admission not being on file was recorded. All three files were observed to be organised and information easily located, with an index at the front.
Information is shared with the scheme, via the Local Authority and is known as a Care and Support Plan. The plan describes what the individual will require assistance and support with i.e. mobility, personal care, medication. Their likes and dislikes are also noted. It will also include personal information about the individual including life history etc.
All three files were observed to have had the information from the Local Authority Care Plan transferred over to Pobl’s Personal Plan. The information was detailed and written in the first person, with individuals signing the plan to evidence that they had taken part its development.
Each tenant receiving care and support had signed an approximate call time sheet, evidencing that their agreement with the call times Pobl are able to provide.
The files continue to hold a document titled ‘A Little About Me´ which provides the reader with a quick synopsis of the individuals likes/dislikes, favourite memory, pets, information about their parents/siblings/family, where they were born, employment. Such information would be beneficial to any new carer providing assistance and support, and also to any professional visiting as a prompt for conversation and engagement.
All three files held information as to what was important to the individuals, how Pobl can best meet their needs and what they would like to achieve.
The files held information as to what documentation played a role in the 3 monthly reviews and during a discussion with the Scheme Manager, the visiting officer was advised that they use the opportunity to review all documentation; therefore, providing accurate and up-to-date information. Once the review has been completed, the tenant is requested to sign the reviewing sheet, evidencing that they have taken part in the review and agree with any changes that may need to be recorded and acted upon.
Appropriate Risk Assessments were observed to be in place depending on the requirements of each individual. Moving and Handling plans were also observed should an individual require assistant with transfers etc. via a hoist.
Should individuals decline support, a discussion should take place with the tenant and/or representative to identify the reasons why the tenant has refused such support. Such discussions should be documented. This can assist the scheme with monitoring any trends and should a trend be observed, this can be discussed further in order to seek an appropriate outcome for the individual concerned.
The monitoring officer read two weeks of daily records for all three tenants. It was positive to note that the daily entries they had improved. They were observed to be more detailed, and terminology had improved. It is important that staff remember that individuals may wish to view their documentation and read information pertaining to themselves.
Improvements were observed with regards to staff signing in and out of calls – no gaps were observed during this monitoring process.
The collection of the daily records has been changed from weekly to monthly and the Scheme Manager advised that this appears a more productive way. When audited the Scheme Manager signs the front of the documentation and any actions identified are noted and acted upon.
Handover logs are used to outline any issues/concerns by staff. The documentation notes the staff member going off shift, handing over to those who are undertaking the next shift. It is the staff member’s responsibility to ensure that all appropriate information is contained within the handover documentation.
Medication
Some individuals are assisted with medication. Whilst viewing the MAR chart for one individual, no gaps were observed. Assistance with medication is also noted within the daily records, as are any refusals.
Call Monitoring
There have been no missed calls during the last twelve months.
The provider uses a system ‘Care Free’ which allows staff to communicate any problems and this is accessed by the Scheme Manager, Out of Hours and any Manager covering On Call.
Tenants are able to access support at any time of day by using the telecare system (Tunstall).
A member of staff is on site at all times, including a sleep-in shift at night.
Whilst viewing the three daily logs, it was noted that a varied amount of support workers attended the calls. It is important that consistency is maintained.
Staff Files
Two staff files were viewed during the monitoring process, both were observed to hold the appropriate documentation. An individuals Contract of Employment is held at Head Office within the Human Resources department; therefore, these were not observed by the monitoring officer. The files held photographs of the individual staff members and some training certificates viewed; however, these are held by the HR team and retained electronically.
Both files held an up-to-date Disclosure and Barring Service certificate, with no issues raised.
There was evidence of staff having a meaningful shadowing process and were observed as being signed off by the mentor. Staff members were quality checked in respect of their time keeping, uniform, interaction with tenants, Moving & Handling, Infection Control and completion of the individual daily logs.
Spot checks are undertaken on a three-monthly basis unless there are areas of concern. Should concerns be raised/highlighted, the spot checks are increased. During the spot checks uniforms, completion of documentation, IDs are observed.
Staff supervision was observed to be up-to-date and undertaken on a three-monthly basis. 1:1 supervision sessions are held with staff, during which, various topics are discussed i.e. problems with calls, annual leave, sickness, trigger points, learning and development, competency assessments, any personal issues etc.
The training matrix was observed, and staff were found to be up-to-date for mandatory training i.e. Moving and Handling, Infection Control, Food Hygiene, Safeguarding, First Aid.
In the last twelve months, seven staff member have left the organisation. Reasons for leaving the service: four staff members removed from the relief bank, one for job satisfaction and to transferred from contract to relief.
RISCA, Regulation 38 states that Regular staff meetings take place (a minimum of six meetings per year), are recorded and appropriate actions are taken as a result. Team meetings were observed to be undertaken on a regular basis, with a variety of items on the agenda i.e. medication, daily logs/recordings, time keeping, PPE, Social Care Wales registration, individual tenants if appropriate. The scheme continues to operate a read and sign approach.
Staff Members Feedback
As part of the monitoring process two members of staff were spoken to and a series of questions were asked.
One staff member has worked for the provider for ten years, whilst the second staff member has worked for Pobl for three years and advised they wished they had gone into care sooner.
Both advised that they feel supported by management and had no concerns.
The staff members both felt they were given enough time to undertake their role and provide the appropriate support required and that there was enough information available to them to provide care and support to the individuals who receive a service from Pobl.
Tenant Feedback
Three tenants were visited as part of the monitoring process and shared their experience of living at Plas Hyfryd and receiving support from Pobl. All individuals spoke positively about the care team and advised they are happy to chat and one individual advised “they have a laugh”.
No missed calls had taken place and if a carer is late, they are notified, and it is usually for an understandable reason i.e. previous individual taken poorly.
Staff always wear their ID badge and treat the tenants with dignity and respect.
No areas of concern were raised during the discussions held.
During the visit, a few individuals were spoken to after their lunch, they advised the visiting officer that “everything is fabulous here, it is fantastic”. One individual advised that the signage outside of Plas Hyfryd, should be changed to the Ritz!
General
Whilst speaking with the Regional Manager, reference was made to Plas Hyfryd experiencing some problems with regards to staff culture. This has been resolved and new staff members have been employed. It was positive to note that during the discussions with the tenants, this had not impacted upon the care and support provided and all spoke very positively about the staff team.
The environment of Plas Hyfryd was found to be inviting and welcoming. The communal areas were noted to be clean and tidy with no malodours or hazards observed during the time of the visits.
The flats visited were spacious, clean and homely. Individuals had their personal items on display i.e. family photos, individually chosen décor and some individuals displayed small ornaments on their windowsills outside in the corridor.
In the restaurant, some tenants were observed to be having lunch together, chatting and laughing and later some were observed to be gathered in the coffee area, enjoying each other’s company.
Corrective and Developmental Actions
Corrective
For every effort to be made to ensure consistency with care support staff. (RISCA, Reg 22 and Service specification for Provision of an Extra Care Service) Timescale – immediate and ongoing
Developmental Actions
None.
Conclusion
The flats at Plas Hyfryd are very welcoming and they are maintained to a high standard.
This was a positive visit, with corrective and developmental actions being undertaken. It was noted that files were laid out nicely and therefore, allowed the reader to locate easily, various documentation. Staff have improved on signing in/out and are being more mindful with regards to how they word their entries. The Contract Monitoring Officer would like to take the opportunity to thank for the staff for their hard work and for providing care and support the tenants of Plas Hyfryd deserve.
Thanks also goes to the tenants for allowing the visiting officer into their home and for offering a warm welcome.
- Author: Caroline Roberts
- Designation: Contract Monitoring Officer
- Date: 10th October 2023