Evergreen Care
Contract Monitoring Report
- Name/Address of Provider: Evergreen Care Wales, Hebron House, Libanus Road, Blackwood, NP12 1EH
- Date of Visit: Tuesday 6th February 2024
- Visiting Officer(s): Amelia Tyler: Contract Monitoring Officer, Caerphilly CBC
- Present: Chris Davis: Responsible individual, Evergreen Care
Background
Evergreen Care is a registered domiciliary care provider based in Blackwood. They currently provide a supported living service in five properties in the Caerphilly borough.
The purpose of the visit was to complete the monitoring tool, view staff and resident files and to look at the policies and procedures. Separate visits are also planned to be carried out to the individual properties over the coming months.
This is the first monitoring visit to the head office since the 25th October 2022, and at this time there was one corrective action and five developmental actions highlighted. These actions were reviewed, and the findings are outlined in the section below.
Dependant on the findings within the report, corrective and developmental actions may be given to the provider to complete. Corrective actions are those which must be completed (as governed by legislation), and developmental actions are good practice recommendations.
Previous Recommendations
If an employee is not able to provide a copy of their passport, this should be clearly recorded and dated. RISCA version 2 (April 2019) Schedule 2, Regulation 59, part 1, 8 (b). Met. Two staff files were viewed, and it was noted that both contained copies of their passports.
The matrix to be updated to record refresher periods, or full date the training was completed. Met. The matrix had been updated to record the frequency that training needs to be refreshed and the expiry date for the most recent course.
Consideration to be given to adding the date the policy / procedure was last reviewed to the document. Met. All the policies and procedures were shared with the contract monitoring officer, and it was observed that the review date and future planned review were recorded.
It is recommended that staff be more pro-active in recording positive feedback. Met. It was acknowledged that staff are more practical and forthcoming with the recording of compliments and this is expanded on later in the report.
Where possible, interviews should be completed by two senior members of staff. Not met. The contract monitoring officer was told that it isn’t possible for two senior members of staff to conduct interviews due to resources, but it was explained that once a candidate has been recruited, they commence a probationary period of one month.
Staff to be mindful of recording emotional wellbeing as part of the daily records. Met. Following the visit, the responsible individual shared examples of daily records for two tenants which prompted staff to document whether the person had needed any emotional support; one commented that the person appeared low in mood, and they had discussed what was worrying them with the staff on duty and the other mentioned that the tenant had appeared upset but seemed happier once they chatted with staff.
Findings from Visit
Documents obtained prior to visit
No complaints had been raised with the commissioning team in relation to any of the homes in the borough since the previous visit. There had been a safeguarding concern reported and this had been appropriately documented, shared with the appropriate teams, and investigated. The contract monitoring officer was made aware that action had been taken following the referral and the manager adopts an active approach to any feedback as an opportunity to develop the service.
The previous Care Inspectorate Wales review had been carried out in December 2022, and at this time there were no priority action notices or areas for improvement identified. The training matrix, supervision and appraisal matrix, and the two weekly rota was provided ahead of the visit. The rota did not provide the full names of all staff and it is recommended that to ensure accuracy and transparency the full second names of all staff are recorded as good practice. There were abbreviations noted such as 7S, WN, 8S and it is also suggested that a key is provided at the bottom of the rota to ensure there is no confusion.
Responsible individual
A copy of the most recent quarterly report completed by the responsible individual was provided that was dated 5th October 2023, so was just over the three month timeframe. The report gave detailed information obtained from meaningful conversations with the staff on duty and the people living at the property.
The statement of purpose was seen and had been updated to include the new contact details for the complaints and information team in within Caerphilly CBC. There was a clear summary of the changes made and it was acknowledged that the document had been reviewed on the 18th March 2023 and was planned to be reviewed again on or before 18th March 2024.
If the responsible individual and the registered manager were both unexpectedly absent for twenty eight days or longer, it was explained that a regulation 60 notification would be submitted to the local authority and CIW. It was explained there were two deputy managers and four directors that would support the service and ensure the continuity of service.
All policies and procedures, including safeguarding, client finances, restraint, medication, staff discipline etc, were available electronically and these were shared with the contract monitoring officer. All policies were noted to have been reviewed within the past twelve months and the recorded date of the next planned review to be carried out by the 1st April 2024.
The complaints policy was next due for review in 2024 and it was noted that the contact information for the Caerphilly complaints team had not been updated to reflect the change of address. It is requested that this is updated to ensure accuracy and consistency.
A copy of the service user guide was seen and had been appropriately reviewed and was also available in an easy read version to assist clients in understanding the process and what to expect.
Tenant information
As previously highlighted, there are five properties within the borough with Evergreen owning three of them, the remaining two have separate, private landlords. There are long term lease agreements in place with these parties. It was explained that there are no plans at present to take on any more properties in the borough.
The responsible individual explained that if one of the clients expressed a wish to have their support delivered by a different provider, they would be assisted to find a new agency with involvement from the care management team.
Individuals are only referred to the provider through the care management teams within the local authorities. The tenancy selection process consists of reading the care plan completed by the placing authority, conducting a pre-admission assessment, reviewing assessed needs and compatibility, and deciding whether the provider can meet these needs.
It was discussed that there are trial periods and an agreed transition period, but there are no probationary periods as this is incorporated into the intermediate time prior to moving in. Once the person has moved into the property this is monitored and reviewed, but it was felt that probationary periods it could be detrimental as they may prevent the person from settling in.
File audit
The responsible individual confirmed that all client and staff records and stored securely in locked filing cabinets at the office.
Two client files were seen as part of the visit and it was observed that they both contained care and treatment plans complete by Caerphilly CBC, personal plans that had been developed by Evergreen and appropriate risk assessments.
One care plan review had been completed in June 2023 and it was noted this was outcomes focussed and highlighted achievements such as carrying out volunteer work, swimming, playing football, having a trip to Tenby, and taking part in Historical European Martial Arts (Hema). It was also documented that they had a longer-term goal of going on a cruise which they were saving for. There were likes and dislikes recorded and there was also an activity planner in place which evidenced developing skills to increase independence.
Both files contained initial assessment summaries that were clearly dated. Discussion was held around the active offer and the Welsh language, and it was explained there are no clients at present who have expressed a wish to speak Welsh. The contract monitoring officer was told there were four staff members that can speak Welsh including the responsible individual. It was explained that there is a statement on the front of the personal plans that provides evidence this has been discussed and the clients have stated that they do not wish to communicate in Welsh, however, they can consider this in future if they wish to do so.
Both personal plans reflected the information provided in the care and support plan reviews and were person centred and contained wellbeing outcomes such as getting their passport, cleaning their dishes without prompting and getting their hair cut. It was recommended that when reviews are carried out that staff clearly record what has/hasn’t been achieved. This can comment on how much they have saved towards a holiday and what their overall aim is, if they have had their photo taken for their passport, if they are washing dishes without prompting or how many times this happened during the month etc.
The contract monitoring officer noted that risk assessments were in place that were linked to the personal plans such as accessing the community, managing their finances, and having the keys to their home. It was also highlighted that the clients were appropriately referred to external professionals and there were outcome of appointment forms held on file such as waiting for the removal of a tooth and a physiotherapist appointment. The responsible individual explained that staff know the clients and monitor them for any changes in behaviour or anything that may indicate they are in pain.
It was evidenced that one client was unable to sign their personal plan and the other had refused to sign the document. There was a form in place to demonstrate coproduction and there had been involvement from the local authority and appropriate representatives. Discussion was held around formal reviews of the personal plans, and it was explained these are done at least every three months; one had evidence of these being completed in December 2023, and January and February 2024, and the other did not contain any reviews since October 2023. The manager must ensure these are completed wherever there are any changes, but at least every quarter.
One file contained a missing persons profile, and although this wasn’t in place on the second file, the responsible individual commented that the personal profile would be used.
Manager’s questions
The responsible individual stated the medication audit is completed every month by the administration and audit officer as part of her role. There was no covert medication being administered at the time of the visit.
The procedure for administering medication is for the staff member who administers medication to sign, a mid-afternoon count for one of the supported living properties and an evening count.
Feedback is obtained from staff and clients on a formal basis every three months as part of the responsible individual’s report and there is also a lot of informal conversations and manager’s meetings, it was also noted that clients will write to the responsible individual if there is anything they wish to discuss and will often visit the main office.
As a result of feedback received there has been 1:1 community access for one of the clients and pampering sessions such as manicure or hairdressing appointments. Additional support had been implemented around managing finances and a TV has been purchased for the hallway. The contract monitoring officer noted that the reports completed by the responsible individual include an action plan and the outcomes monitoring is carried out every month.
It was highlighted that the outcome of the quality assurance report is shared directly with the homes and if anything is raised by any of the clients, this is fed back verbally with any actions that have been agreed.
All managers are aware of how to access advocacy services if it is felt necessary and at the time of the visit it was explained there are two people that were supported by mental health first aid Wales.
During the meeting the responsible individual stated they have good working relationships with the landlords and if there are any issues, these are addressed in a timely manner.
If there were a dispute where one of the individuals being supported expressed a wish for one of the other clients to move, this would be discussed, and conflict resolutions would be sought. It was reported that disagreements are normally around heating or remote controls, and these are usually solved as they occur. Although it hasn’t happened where the matter hasn’t been able to be sorted out, it was explained that if this were to happen, that a multi-disciplinary meeting would be arranged to agree on the best outcome for the clients.
In the situation where a staff member stated they were having difficulty supporting a client, the responsible individual would discuss with the member of staff and offer training if appropriate and offer mentoring support. Depending on the nature of the concern, they would also talk to the client to get their perspective and look at what measures could be implemented. If there was nothing that could be offered or proved successful, the staff member would be given the opportunity to work in one of the other properties.
Initially, approx. 30% of training is offered on-line and this is then followed by approx. 70% of training being delivered in person. It was acknowledged that face-to-face training is more interactive and gives more opportunity to discuss specific scenarios. The contract monitoring officer was made aware that there are two trainers that are contracted internally and provide training around positive behaviour management and Autism every Monday. It was mentioned that the quality of the training used is assessed through evaluation forms and managers will also attend certain courses to ensure all areas are fully covered. This is also discussed in team meetings and manager’s meetings.
There were members of staff that choose to work more than 48 hours a week and although the standard contract is 40 hours a week, there are staff that have chosen to opt out of the working time directive and pick up additional shifts where needed. The team leaders monitor this and try to spread the shifts equally and over a larger period to reduce the risk of fatigue.
It was stated that tenants do not get directly involved in the interview process, but they would get to meet new staff members as part of the induction process. The responsible individual said they have previously been given opportunity to put any questions forward that they would like to be asked, but this is often declined.
All members of staff have received safeguarding training and are aware of what constitutes abuse and how to report this. It was explained that any issues or concerns would normally be shared with the responsible individual and if appropriate a duty to report form would be completed and shared with the appropriate safeguarding team. It was noted that there is also the whistleblowing policy that provides alternative routes if the person doesn’t wish to raise the concern internally or if they do not feel confident that the matter will be addressed.
Complaints and compliments
Tenants are supported to make a complaint if there is something they are unhappy with, and this is outlined in the easy read version of the service user guide. Honest and open feedback is sought informally daily but is captured more officially as part of the monthly reviews. Where there are communication difficulties it was shared that staff will use BSL (British sign language), PEC cards, gestures, and iPads to draw information from the client to establish if there is anything worrying them.
As mentioned earlier, there was only the one concern raised since the previous visit. Feedback is given to the complainant verbally and a written record is held on file with the outcome and any actions needed. Staff involved in the complaint are also informed formally and other staff are given anonymous outcomes with lessons learned to improve practice. The contract monitoring officer was made aware of the actions taken following the referral.
There were fourteen compliments received across the ten properties between the 28th March and 5th December 2023. Eight of the compliments related to the properties within Caerphilly borough. It was acknowledged that these were predominantly received over the phone and are shared with the staff team through staff meetings. The compliments related to the support provision and commented on how well one client had settled into the home and another felt the individual was happy in their home for the first time in a long time. The report also highlighted that staff had made it possible for a family holiday to Tenerife.
The quality assurance report dated 30th May 2023 gave a clear action plan with deadlines and the person responsible. Surveys were sent out to family, professionals, clients and staff and it was noted that 184 were sent out and there was a 28% response rate.
Staffing information
The provider uses the social care induction framework which is incorporated into the Evergreen induction pack. Alongside the evaluation forms that are completed following any training, it was noted that end of course quizzes are also used to determine the level of understanding. Team leaders observe practice to ensure that staff are implementing the training received and spot checks are also used to ensure safe practice such as the administration of medication.
It was commented that all staff have completed mandatory training, including manual handling, food hygiene, safeguarding, infection control, first aid, medication, and positive behaviour management. Non-mandatory training is also carried out that is specific to the needs to clients and staff such as dysphagia, confidence building, British sign language, diabetes, mental capacity act, Buccal Midazolam, and epilepsy.
Two staff files were seen and both contained two references, job descriptions, application forms, interview records (scored, signed, and dated), full employment histories, signed contracts, birth certificates, copies of passports, photographs, training certificates DBS checks and induction packs that had been signed off by an appropriate senior staff member.
The responsible individual also provided evidence that all staff had registered with Social Care Wales apart from one new starter who commenced employment in January 2024.
Supervisions were up to date and being carried out at least every three months. At the time of the visit t was noted that one was due on the 12th February and there were two members of staff that work in the Caerphilly borough on maternity leave.
Appraisals had been carried out for all staff that were due and it was explained these are completed every October. Supervisions are carried out every three months and the final session is an appraisal i.e. three supervisions and an appraisal on a rolling programme.
Supervisions are held as formal 1:1 meetings that are treated confidentially and are used as a two way development opportunity and staff are expected to contribute on how they feel they are progressing as well as any suggestions for improving the service. Managers are supported by the team leaders in each property and the responsible individual who is available to speak to in the office as well as by phone or email. Support is also provided through supervisions, weekly meetings, and the managers on call.
It was explained that four members of staff had left the organisation over the past year within the borough mainly for career progression and better terms and conditions with the health board or local authority. In the same period, they had recruited thirteen members of staff. It was noted that there were no employees on long term sick, and it was pleasing to note they had not needed to use any agency.
There is an on-call system that is operated between four managers on a four-weekly rolling rota, and this is planned by the responsible individual. It is planned to ensure they are not on call if they are on leave, or it is their day off.
Corrective / Developmental Actions
Corrective
The complaints contact information for Caerphilly to be updated in the complaints policy. RISCA version 2 (April 2019) Regulation 64.
Developmental
Consideration to be given to adding the full names to the rota and a key for any abbreviation used.
When conducting the quarterly reviews, staff to provide additional detail around what has been achieved towards their wellbeing goals.
Conclusion
Through the meeting and from the information provided throughout the monitoring process, the contract monitoring officer acknowledged that the provider continues to operate an open and transparent service that encourages the input of those they support. It is positive to note that five of the previous recommendations have been met.
The files viewed were well organised and person-centred. Information was easily located and there was a clear organisational structure. The responsible individual is present in the office and welcomes interaction and feedback from the staff and clients.
There were no concerns in relation to the support provided and there was evidence of a thorough understanding of the needs and preferences of their tenants and this was reflected in the personal plans. There appeared to be a client led culture and consideration was evidenced in how to support people to achieve their wellbeing outcomes.
The contract monitoring officer would like to thank the responsible individual for their time, assistance, and hospitality throughout the monitoring process. The individual properties will be monitored (with the agreement of the tenants) in the coming months, and unless it is deemed necessary, the next visit to the main office will be completed in approx. twelve months’ time.
- Author: Amelia Tyler
- Designation: Contract Monitoring Officer
- Date: 5th March 2024