Bargoed Care Home
Heol Fargoed, Bargoed, CF81 8PQ.
Tel: 01443 879005
Email: manager@bargoedcare.co.uk
Contract Monitoring Report
Name/Address of provider: Bargoed Care Home
Date/Time of visit: 9 December 2021, 30 March 2022 and 5 May 2022
Visiting Officer(s): Caroline Roberts, Contract Monitoring Officer, Sherry Lewis, 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, who took over ownership of the home in November 2020. 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.
Due to the number of visits undertaken at the home, the number of residents during each visit varied.
CIW (Care Inspectorate Wales) 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 2018. During the visit, corrective and development actions were given. Due to the Covid pandemic, regular annual visits have not been undertaken.
Since the last monitoring visit, the home has been managed by a stable management team and which has made significant improvements to the running of the home; therefore, improving the quality of life for the individuals who reside at the home.
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 (2018)
Corrective
Personal Plans to be signed by the individual, to evidence they have been involved in the preparation of the Personal Plan and that their individual views, wishes and
feelings have been considered. For Moving & Handling Plans to be in place and up- dated and maintained on a consistent basis to reflect current needs. (Regulation 15, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). Outcome MET
Should an individual decline the use of equipment, their consent is obtained and documented to safeguard the individual and staff. (Regulation 15, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). OUTCOME - MET
Carers to be reminded of responsibility when managing and administering Topical medication and the medication policy. (Reg 58, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). OUTCOME - MET
For oral care to be undertaken and recorded by care staff. (Reg 21, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). OUTCOME - MET
For supervision/appraisals to be undertaken in a timely manner (Regulation 36, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). OUTCOME - MET
Where a person appointed to a post is registered with the DBS update service, the service provider must check the person’s DBS certificate status at least annually. (Regulation 35, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). OUTCOME - MET
For checks to be undertaken should employment discrepancies be identified. (Regulation 35, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). OUTCOME - MET
For an annual quality assurance report to be completed by the end of the calendar year (CCBC contract clause 42.6) OUTCOME - MET
Developmental actions
Team meeting minutes should record the names of the chairperson, minute taker and those present. It is good practice to also have a signing sheet on the back of the minutes to evidence that all employees have had sight of the matters discussed. Outcome – NOT MET. Discussed with the home Manager who advised that team meeting minutes are not signed; however, are shared with staff. The home has a process whereby a policy of the month is chosen, and this is shared with all the staff team, who must read and sign to evidence they have read the policy.
DNACPR forms to be reviewed every year and evidence of the discussions to be clearly documented. OUTCOME - MET
Findings
Documentation
Since changing ownership in 2020, the home has moved forward into electronic recording and uses a programme 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.
As part of the monitoring process, 2 resident’s files were viewed. Whilst one file had a pre-admission assessment, the second file did not evidence one had been completed.
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 being reviewed monthly, as is good practice.
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. GP, Falls Team, Opticians.
One file viewed contained a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). Whilst there was no end-of-life plan on the second file, it was positive to note that a conversation had taken place with the individual and family, and that it had been agreed for the GP to be contacted to discuss in more detail and to complete the appropriate documentation.
Both files viewed had no life history; therefore, new members of staff would not have the sense of knowing the individual.
Risk Assessments were observed for both individuals i.e. Falls, Call Bell, Waterlow, Bedrails.
Daily records were observed to have been completed, detailing when family members visit, what has been done during the day. However, the records did not refer the individual’s moods and what staff do to improve mood should it be low.
Goals and outcomes are evidenced, such as maintaining independence, promoting a calm environment for sleep, to be part of any decision-making process, promote social interaction due to low mood.
PEEPS (Personal Emergency Evacuation Plans) were observed and both files had pictures of the individuals.
Activities
The Activity Co-ordinator at Bargoed Care Home has always been observed as being full of enthusiasm. External entertainment had been put on hold due to the pandemic but during one visit, a singer visited the home and the residents, socially distanced, enjoyed an afternoon of singing. For those who are cared for in bed, the Activity Co-ordinator visits them and provides one to one interaction i.e. hand massages, chats, reading/singing etc.
Weekly activities are displayed on the notice board for all to see, along with photographs of residents enjoying the activities. The activities calendar was noted to be populated with a lot of booked activities such as performers, services, and potential day outs (weather permitting). The home is also busy preparing for the Queen’s Platinum Jubilee.
The home respects individual religious beliefs and will endeavour to make appointments with the appropriate individual to offer pray services.
Staffing
Staffing levels are based upon dependency levels. During the day shift, the home usually has 1 Nurse, 1 Care Home Assistant Practitioner and 8 care staff until 1:30
p.m. then there 7 carers. During the night shift, there is 1 Nurse and 4 carers. During the day, the Home Manager is present along with the home’s administrator and Activity Co-ordinator.
Staff supervisions and appraisals have improved under the stable management team and are undertaken 3 monthly, along with annual appraisals.
Agency staff are used and the Manager of the home 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 two staff files and found both files of a high standard. 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, signed working time regulations (1998). 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 required by Social Care Wales (SCW) within the defined timescale. All staff are expected to be registered with SCW by October 2022 and at the time of report writing, Bargoed Care Home has 5 staff undertaking the AWIF.
The Home Manager paid credit to her staff team for their hard work during the pandemic and 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 March 2022) was 97.37%. Staff were observed to have undertaken appropriate mandatory training i.e. Safeguarding, Moving and Handling, Infection Control, Food Hygiene and First Aid. Other training observed was Anaphylaxis, Basic Life Support, COSHH, Data Protection, Fire Awareness, Dementia Awareness, Pressure Ulcer Prevention, safe use of bed rails.
At the time of the visit, the monitoring officer was informed that staff are not working over 48 hours per week.
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, wear appropriate PPE, staff are receiving 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.
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.
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.
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.
At the time of the visit, there were no residents with the diagnosis of dementia. The home does not have a dementia champion.
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 due to Covid. Staff were observed to interact well with individuals and had knowledge of those they were assisting.
Two ladies in the lounge on the middle floor, were happy having a conversation between themselves and were happy to engage in conversation with the CMO. One lady showed the CMO the crocheted blanket that had been made by their mother, which clearly had great sentimental value. Another lady showed the pictures they had coloured on their iPad.
During one of the visits, one individual had described the lunch time meal as being cold and this was brought to the Home Managers attention, who was aware of the matter and was seeking to address it. However, other residents spoken to had no complaints about the meals and described them as “marvellous”. In the lounge area, tables were laid out for the residents to sit and enjoy their meal-time experience; however, two ladies chose to remain in their seats to dine and others ate in their rooms. The tables were laid with tablecloths and a centre piece, along with a menu. It was positive to note that individuals were given the choice of where to dine.
Family Feedback
Telephone contact was made with a family member, who explained that their relative went into Bargoed Care Home on respite. However, the decision has been made to make the placement long-term due to the resident settling well at the home.
The family member advised that the home is open and transparent and that the homes administrator has been a great help in assisting with various documentation etc.
No complaints or concerns were raised during the conversation and the family member advised that due to them living away, another family member visits twice a week; they too have no concerns.
It was stated that the home keeps the family relative updated on all things i.e. change in medication, putting a sensor mat in place for safety etc. The family member described staff as “very vigilant” and stated that their relative is “really happy there”.
The resident has advised the family relative that they get on well with the care staff and that they are really helpful.
Fire Safety/Health & Safety
An external company visits the home to undertake an annual fire assessment. One was scheduled for March 2022; however, due to Covid 19, the assessment had to be re-schedule to April 2022. Two recommendations were made from the visit and the Home Manager advised that remedial work is being carried out to meet the regulations in a timely manner.
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. The majority of the rooms had 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.
The home enjoys a garden area, where during the warmer months, residents can enjoy sitting out and enjoy a spot of gardening with the Activity Co-ordinator.
The home is supported by 2 maintenance officers, who have responsibility for checking the water, fire checks (doors, lights etc.) and general maintenance to the home.
The home implements the Active Offer (providing a service in Welsh without someone having to ask for it) and has 2 staff members that are fluent Welsh speakers. 1 resident is a Welsh speaker and sometimes choses to communicate in Welsh. Another staff member has a bite size knowledge of the Welsh language and engages with the 1 Welsh speaking resident.
The home currently has a Food Hygiene rating of 5, Very High. The home was last inspected in 2019.
Corrective and Developmental Actions
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)
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).
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.
Conclusion
The atmosphere at the home was found to be warm and welcoming, with plenty of smiles and laughter observed throughout the visits. Positive feedback was received from the residents, staff employed at the home and also family members.
Good interaction was observed with the residents, and staff demonstrating knowledge of the individuals residing at the home.
It is evident that the Home Manager and the RI have a positive working relationship; therefore, evidencing 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.
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, Contract Monitoring Officer
Dated: 25/05/22