Church View Care Home

13 St. Martins Road, Caerphilly, CF83 1EF.
Tel: 029 2085 2951
Email: Churchview@hc-one.co.uk
Website: www.hc-one.co.uk

Contract Monitoring Report

Name/Address of Provider: Church View Residential Home, 13 St Martins Road, Caerphilly, CF83 1EF
Date of Visit: Wednesday 13th March and Monday 25th March 2024
Visiting Officers: Amelia Tyler: Contract Monitoring Officer, Caerphilly CBC
Present: Lisa Jones: Home Manager, HC-One / Ellen Smith: Turn around manager, HC-One

Background

Church View is a large, detached, purpose-built care home located very near to Caerphilly town. It is built over three floors and registered to provide care for thirty five people who require general support with carrying out activities of daily living and ten people with cognitive impairment and dementia.

At the time of the visit there were four vacancies: two for people with a diagnosis of dementia and in need of residential care, and two for general residential care needs. There were seven people that were self-funding their placement.

The last formal monitoring visit to the property was completed on the 24th March and the 3rd April 2023. At this time there were thirteen actions identified (six corrective and seven developmental). These were reviewed and the findings are outlined in the section below.

The purpose of the visit was to review the previous requirements, complete the monitoring template and to speak with staff, relatives, and residents to gain their views of the service.

Depending on the findings within this report, the Manager will be given corrective and developmental actions to complete. Corrective actions are tasks which must be completed (as governed by legislation etc.) and developmental actions are those deemed to be good practice.

Previous Recommendations

Initial assessments and personal plans to be clearly signed and dated. RISCA version 2 (April 2019) Regulation 15. Partially met. Only one of the two files seen contained an initial assessment. The one that was on file had been signed and dated, but it wasn’t clear who it had been signed by.

Dementia training to be provided that is fit for purpose and supports the staff to carry out their role effectively. RISCA version 2 (April 2019) Regulation 21. Not met. It was noted on the training matrix that there were several staff that had not completed the two day Tier 2 dementia course.

Where people are cared for in bed, they must have access to a call bell, where this isn’t possible or appropriate, a detailed risk assessment is to be completed outlining how their safety will be maintained. RISCA version 2 (April 2019) Regulations 43 and 44. Met. It was explained there was only one resident that was cared for in bed due to pain caused by Osteoarthritis and was only able to sit in a chair for short amounts of time. It was acknowledged that they spend a lot of time with their relatives, but they always had access to a call bell to be able to get assistance if needed.

All staff files to contain detailed application forms, birth certificates and a recent photo. RISCA version 2 (April 2019) Regulation 35. Partially met. There was a birth certificate missing from one of the staff files and no explanation was provided. If a member of staff has lost their birth certificate or unwilling to provide this, then a file note should be held on file.

Personal plans to be developed to outline specific outcomes, rather than general goals. RISCA version 2 (April 2019) Regulation 14. Not met. This still needs to be developed as the outcomes seen were quite generic and repetitive.

The manager to discuss with staff the safe administration of medication and not sign the MAR chart until they have seen the medication has been taken. RISCA version 2 (April 2019) Regulation 58. Not met. There was no evidence in the minutes of the team meetings to show that medication had been discussed. It was noted that there had been a change of manager since the previous visit and there had been no reported medication errors within the previous two months.

The manager to contemplate nominating at least one dementia champion. Not met. There was no dementia champion at the home at the time the visit was carried out.

Consideration to be given to holding agreement on file of notifying relatives of any incidents. Met. On both files seen it was noted that the next of kin wanted to be contacted at any time or day or night if there had been an incident.

Consideration to be given by the manager and activities coordinator to look at activities for relatives to do with residents when there are no organised events taking place such as board games, word searches, gardening, puzzles or colouring etc. Partially met. The manager explained there had been activities where relatives had been involved, such as gardening, or attending birthday parties, but there hadn’t been any progress in providing things for visitors to do with the residents when coming to see them.

Any rooms with underlying malodour to be addressed. Met. There was no odour noticed when walking around the home during either visit.

Any actions resulting from resident’s meetings to be clearly recorded and shared with the manager (if not present). Not met. The activities coordinator had not arranged any residents’ meetings. To ensure meaningful and proactive meetings are held, it is essential that open discussion is documented with clear objectives and who is responsible for carrying these out.

Staff files to record if DBS certificate was clear or if risk assessment is required. Met. Both staff files had evidence of DBS checks, and both recorded these were clear.

Where possible, interviews to be conducted by at least 2 members of staff. Met. Although one staff member had only been interviewed by two senior employees, the other had only been interviewed by one.

Findings from Visit

Responsible individual

Copies of the regulation 73 and 80 reports were shared, and these were dated the 20th and 27th July, the 18th October, and the 4th November 2023. The reports evidenced conversations with staff, residents and family members and any outcomes/actions required following the conversations and observations from the visit. One of the actions was for the activities coordinator to record activities and interactions for individuals rather than an overall record of events. There was no evidence of any visits being carried out by the responsible individual in 2024. It is required that these are completed every three months.

The statement of purpose had been reviewed in October 2023 and needed to be updated to record the name of the deputy manager. It is recommended that the manager considers adding the next annual review date on the document to act as a prompt and to evidence compliance.

If the responsible individual was absent for 28 days or more, a regulation 60 notification would be submitted to the care Inspectorate Wales and shared with the commissioning team. Where the home manager and responsible individual were both absent at the same time, there would be support from the deputy manager, regional operations manager, and turnaround manager in addition to the other managers in the local area.

All the mandatory policies and procedures were seen including safeguarding, personal allowances, restrictive practice, staff discipline, complaints, medication, and whistleblowing etc. All policies had been reviewed within the previous twelve months and contained the due date for the next review.

Registered manager

There is CCTV at the property that covers the garden and front of the building. It was noted that there was a notice in the foyer area informing visitors this was in situ.

The manager explained there were no concerns regarding the fabric of the building i.e., the lift, sluice, boiler etc. The contract monitoring officer was told that residents can control the temperature in their rooms as the thermostats on the radiators are accessible and the windows can be opened (window restrictors in place to maintain safety).

It was discussed that the regulation 60 notifications that are submitted to Care Inspectorate Wales were not being shared with the commissioning team inbox; the manager explained that these would be sent through for the previous six months and going forward. These had been received prior to this report being completed.

The manager explained they didn’t manage any other services and the responsible individual completes the regulation 73 visits quarterly and these are pre-arranged. The manager said they felt supported by the responsible individual and the area director if there are any queries or concerns.

Referrals are made to the appropriate teams where necessary, and the contract monitoring officer was told the most recent referral was the previous month to occupational therapy through the GP. It was noted that the home was up to date with DOLS (Deprivation of liberty safeguards) applications and there are systems in place to ensure renewals are submitted in a timely manner.

Desk top audit

A copy of the supervision matrix was shared with the contract monitoring officer for the current calendar year, and this recorded planned and actual dates of the supervision sessions. For 2024, it was reflected that all care staff had attended a supervision meeting, which is in-line with the quarterly requirement. It was noted that the matrix stated that formal supervisions should be held twice a year; it is a legislative requirement that these are done every three months and it recommended that this be updated. There was no evidence of annual appraisals being carried out.

The training matrix was also provided before the visit, and this highlighted that 84.5% of staff had completed all mandatory training. Mandatory training included manual handling, food hygiene, safeguarding, infection control, medication, and first aid. There were gaps noted, such is 12% of staff yet to undertake safeguarding, 9% to participate in a fire evacuation, 25% needed to complete catering safely, and 4% to complete basic life support. The training matrix also showed that 23% of the fire training had expired. The manager is to address this with the team and ensure all mandatory is up to date.

Non-mandatory training is also provided that includes data privacy, choking, nutrition and hydration, the mental capacity act and deprivation of liberty safeguards, and the promotion of healthy skin and wound care.

It was observed that the service user guide was dated 7th March 2024, which was the date it was printed rather than the date of review and it wasn’t possible to determine whether the information was still up to date.

The contract monitoring officer was aware the manager is registered with Social Care Wales.

Staffing and training

Staffing levels at the home were seven care staff including a minimum of two senior staff during the day and six care staff at night (including one senior member of staff and one who is trained in administering medication).

The contract monitoring officer was told the manager is contracted to work 40 hours a week supernumerary and the deputy manager also works supernumerary two days a week.

It was pleasing to note that there is an activities coordinator that works 40 hours a week and works midday to 8.30pm on a Thursday as some residents don’t wish to take part in many activities before lunch and can be quite lethargic. It was also explained they work alternate days every weekend.

During the meeting, the manager highlighted that they don’t use any agency staff unless necessary and this hadn’t been required in the past four months.

The manager confirmed that she was on the distribution list from the workforce development team within Caerphilly CBC and can access these courses as they become available. Classroom based training is provided for manual handling, safeguarding, diabetes, and first aid. It was explained that there is an internal trainer within HC-One that presents these courses. Medication training is also accessed via Boots the chemist. Additionally, there is also electronic on-line training around the mental capacity act, deprivation of liberty, nutrition and hydration, fire safety, and catering safely.

Any gaps in training are identified by the training stats and if there are courses that need to be completed, this can be sent to the staff team or individuals on the messaging system ‘Deputy’. The manager will discuss training with staff as part of their supervision and request any outstanding topics are carried out. The manager also completes/attends the same training to be able to identify any areas that aren’t covered as part of the course. The contract monitoring officer was told there are end of course tests for electronic learning to confirm the level of understanding and this is also discussed when needed at team meetings.

It was stated that no staff are regularly working more than forty eight hours a week and the longest contract is forty four. It was explained that staff are not able to work both day and night shifts at the same home in the same week. Although it was noted that staff can pick up additional shifts in other homes within the area, it would be highlighted by payroll if they were working excessive hours.

At the time of the visit it was explained there was one resident that speaks a little bit of Welsh and one member of staff that can speak Welsh. The statement of purpose states that HC-One adopt a pro-active approach to supporting people in their preferred language and all documentation is available in Welsh on request. There is also a form in their personal plans that records their preferred method of communication, and this is asked during the initial assessment.

Two staff files were seen for staff that commenced employment in 2023. Both files contained a personal reference and one from their previous employer (both of which were in the care sector). Both files contained job descriptions, application forms, interview records with a scoring mechanism, full employment histories, copies of their passports and photographs. As previously mentioned, both files also held evidence of DBS checks.

One file contained a signed contract of employment, and the second file held a bank worker letter of understanding that had also been signed and dated. There were no training certificates on file or documentary evidence of any relevant qualifications. It is a regulatory requirement for these to be in place. Neither file contained evidence of meaningful induction and it is good practice to have a booklet or checklist that is signed off by a senior member of staff to demonstrate the completion of their induction and competence.

Supervision and appraisal

As mentioned previously, it was noted that supervisions had been carried out in 2024 for all care staff, but it wasn’t possible to evidence if these had been held every three months as this is recorded by the calendar year.

The contract monitoring officer was told that supervision sessions are held as formal, confidential, 1:1 meetings where the staff member is expected to contribute meaningfully to the process. It was explained that all staff had registered with Social Care Wales apart from the new starters that have six months to register from the commencement of their employment. Registration numbers are recorded on the front page of staff files where this has been completed.

File and documentation audit

As highlighted in section 2.1, both files contained initial personal plans, however, only one had been signed and dated to evidence this had been completed within the appropriate time frame, any member of staff carrying out an initial assessment to ensure that it is done fully.

The 2 personal plans seen were personal centred and provided some detailed information i.e. They like pasta and Italian food but dislike any green veg. Another plan explained that rather than having large meals, the person preferred to eat little and often, needs a plate guard, likes to drink squash, and looks forward to fish and chips on a Friday. It highlighted that they benefit from a calm and quiet environment and has a spray of old spice when getting dressed in the morning. Both plans had been reviewed at the beginning of March.

Some of the reviews were not meaningful and did not provide a true reflection of the previous month i.e. one of the residents had a fall 27.02.23 and this had not been updated as the most recent review had been completed 15.02.23. There was also a bladder and bowel plan that had not been reviewed since 06.11.22.

The outcomes and goals for people to aim for were generic and could be developed: The eating and drinking plan stated the goal was to maintain weight and this could be expanded to look at whether they would like to be involved in preparing any food or doing some baking as an activity, if there was anywhere he would like to go for a meal, whether they would be interested in trying a theme day such as Asian, Caribbean, or Italian day.

Activities were seen during both visits: on one visit there was a Tom Jones impersonator in the lounge area that was seen engaging with the residents and knew a couple of them by name, and the activities coordinator was also seen making Easter bonnets with some items the manager had purchased, however, there was little evidence of any activities or engagement for individuals that chose or needed to remain in their rooms.

File and documentation audit

Two resident’s files were seen during the visit, and both contained photographs and profiles which highlighted what is important to them and what they enjoy doing. Both files contained pre-admission assessments. The personal plans were person centred and it was acknowledged that although one of the plans for nutrition and hydration didn’t note any likes or dislikes, one did comment that they can verbalise their choices. It was pleasing to note that it highlighted they like milky coffee, lemonade and baileys and enjoy having their nails painted. The second file didn’t provide any preferences around eating or drinking, but the personal care plan noted they preferred to be supported by male carers to shower and liked to wear a shirt and trousers with a cardigan and that he was able to maintain and clean his own glasses. The contract monitoring officer felt that the box for recording the resident’s views and preferences was too small and didn’t provide sufficient space to clearly record important information.

There were suitable risk assessments in place, including choking, skin integrity, having access to their chair controls, malnutrition, and manual handling, and these were reviewed at least every three months.

It was evidenced that referrals were being made to external agencies when needed. There was a discharge note from the hospital dated 16.11.23 but there was no information or details recorded around what this was for or what the outcome was. The professional visit log highlighted the GP was contacted on the 18.11.23 but provided no detail around the issue or what the outcome of the conversation was. In the falls plan, it highlighted there had been no falls the previous month on the 27.09.23 or for the previous month from 03.12.23. When the reviews are being carried out, they should comment on the time frame between reviews.

Although the personal plans provided a section for outcomes, these were quite general and repetitive, e.g., they expect to be given options at mealtimes and for them to remain independent and safe rather than detailing individual wellbeing outcomes and goals.

Each of the files had information around their life histories and had booklets called ‘remembering together’ which provided important details i.e. one resident was one of seven children, had a cousin who was a famous poet, and worked building the Nantgarw bypass. It also recorded some of their favourite places. The other file mentioned they had worked in a local hospital as a seamstress, was born in London, but moved to Wales at a young age and attended Cwm Aber school. This also stated they enjoy flower arranging. Staff displayed a sound knowledge of the preferences of residents. One life story explained the resident was Baptist and would still like to attend Chapel; the initial assessment had been left blank around religious preferences and the wellbeing and support plan made no reference to this. It was emphasised that this should be discussed and for them to be supported if they still wish to go.

There was a DNA instruction in place on one of the files which documented that the individual has capacity to refuse intervention, and this was dated 17.12.20. It was recommended that this be discussed with the gentleman during the next review to ensure their wishes haven’t changed.

Quality assurance

There is a complaints and compliments system in place and a copy of the analysis was provided from September 2023 to February 2024; this reported eight compliments; these were primarily around staff professionalism and the high standard of care. In this same period there were five safeguarding referrals which had been appropriately reported and addressed. The analysis highlighted there had been three concerns raised and although these were dated as being closed, there was no recorded outcome or action taken.

It was explained that staff meetings are held at least every three months and copies of the minutes were provided for the previous two which were held on the 23rd November and the 6th December 2023. It is a requirement that there are at least six staff meetings a year. The list of attendees was not on the minutes, but it commented that there was an attendance sheet attached to the original. It was explained that it is good practice to record the names of those present directly on the minutes for transparency.

There were no recorded minutes of any resident’s meetings, and it was mentioned that there was one planned the previous week but had to be cancelled. The manager stated there are plans to form a resident’s committee. The last relative’s meeting was held on the 6th December 2023 and had been attended by four relatives and this covered staffing changes, activities, a summary of recent inspections and staffing levels.

The accidents and incidents were reviewed for February 2024, and it was noted there had been five incidents. Over the previous six months it was observed that two residents had seven accidents each and these had been appropriately addressed and referred to the relevant teams (the Parkinson’s team and frailty team).

At the time of the visit there were no advocacy services being utilised, but the manager was aware of the local organisations that could be contacted if needed. The manager said there were no concerns in relation to medication and there were no residents they felt were on medication that wasn’t required. It was highlighted that all residents have a medication review at least annually, but if there were any changes they would contact the GP or the mental health nurse to request a review sooner.

Resident finances were seen, and this is managed by the electronic Citrix system. There was a receipt book in place and when money is received on behalf of any individuals this is signed in by the administrative officer (if present) or another senior member of staff and the person depositing the money. The receipts matched the statements seen and the balance was correct. It was discussed that it isn’t advisable to have excessive amounts of cash at the home unless there was something specific they were looking to purchase.

Staff questionnaire

Two staff members were spoken to; one had worked at the home for four years and the other started nearly a year ago. Both said they were confident in supporting the emotional needs of the residents and were able to provide reassurance and support.

It was explained that if a resident was upset, they would use different techniques depending on the individual; some respond well to hugs and holding their hand, others react better to distraction techniques such as using doll therapy or singing.

Both staff said that they don’t have opportunity to spend time with people out in the community, but it was stated that there had been trips to local seaside towns in the minibus with the activities coordinator. One member of staff felt that it was sometimes the same residents that go out.

The contract monitoring officer asked about two residents and their needs and preferences and about their history and both provided detailed information such as one was very close to her husband and had regular visits with him and likes reading and gardening and the other explained that one gentleman enjoys watching game shows, had been referred to occupational health and that he used to be a scaffolder.

One individual at the home has communication difficulties and it was explained that staff speak to him normally as he can understand and that you must use facial expressions to see what he likes or doesn’t like. Staff use their knowledge of what he enjoys and what food he likes and if he doesn’t want something he won’t engage.

The contract monitoring was told that they are sometimes restricted by routine and unable to be flexible in their role or just sit and chat to the residents. It was highlighted that the medication round could sometimes take a long time and some staff are reluctant to assist on other floors which can put a lot of pressure on the staff team, especially when supporting people that require two carers. It was documented that the staffing levels were felt to be sufficient, and this was highlighted in the team meeting in November. It is the responsibility of the manager to continuously monitor staffing levels and ensure there are safe staffing levels to meet the needs of the residents.

When asked about the training, one staff member reported that the dementia training was unhelpful and repetitive. It was noted that eight staff had completed day one of the two-day tier 2 dementia course and five had attended day two. As mentioned previously, all staff must attend both days to ensure they can meet the needs of the people living at the home.

Resident feedback

Feedback was obtained from one of the residents on the first visit; they stated that they spend their day listening to music, seeing her daughter, knitting, or doing wordsearches. They said the food at the home was great and they particularly like the sandwiches. When asked if there was any food they would like that isn’t currently provided, they responded that they would like toast and Welsh Cakes; the contract monitoring officer agreed to share this with the manager.

Although the resident didn’t have much insight into why she was at Church View or how long she would be staying there for, she said she was comfortable and happy that her daughter could visit her regularly.

When asked about the staff, the lady responded that they were lovely and couldn’t do enough for her. She said that she can talk to staff about anything; the local news, tv programmes or her husband. They stated that although she doesn’t like asking for help, if she needs someone, they respond promptly. If there was anything wrong, she said her daughter would advocate on her behalf.

Relative feedback

One relative was spoken to and they fed back that they were always made to feel welcome at the home and offered a drink and a dinner if she wanted. They described the atmosphere at the home as lively. Although their relative doesn’t think of Church View as their home, they are as settled as they can be and is comfortable.

It was reported that they had been invited to and attended a relative’s meeting and said they were happy to participate in any activities being carried out and it was highlighted that they were making flowers in the conservatory on the day of the first visit. They stated they had an arrangement with the home about hospital appointments or any changes to health.

The relative said they hadn’t ever needed to raise a concern but felt confident in raising this if needed. There wasn’t anything they could think of that they would change about the home apart from more fresh air and to get out of the home more. It was explained that staff were also supporting her as it was a very difficult decision to move their relative to the home.

General observations

On the first visit it was noted that the activities coordinator was singing along with some residents in the lounge and later they were making flowers in the conservatory. It was acknowledged there was an Easter Raffle and there were hampers that had been beautifully decorated in the dining area.

On the second visit, the atmosphere was quiet on arrival and there were a few residents sat in the dining room waiting for their breakfast and it was noted that the tables were decorated with a tablecloth, flowers, napkins, cutlery, and condiments.

One of the gentlemen came down to the small lounge to discuss arrangements for his birthday party the following week and an appointment with the audiologist as he was having difficulty with his hearing aid. He was very smartly dressed and very clear in expressing his wishes.

Corrective / Developmental Actions (to be completed within 3 months of the date of this report)

Corrective actions

Initial assessments and personal plans to be clearly signed and dated. RISCA version 2 (April 2019) Regulation 15.

Personal plans to detail agreed personal wellbeing outcomes and goals. RISCA version 2 (April 2019) Regulation 15.

Dementia training to be provided that is fit for purpose and supports the staff to carry out their role effectively. RISCA version 2 (April 2019) Regulation 21.

The manager to discuss with staff the safe administration of medication and not sign the MAR chart until they have seen the medication has been taken. RISCA version 2 (April 2019) Regulation 58.

All staff have an annual appraisal which provides feedback on their performance and identifies areas for training and development to support them in their role. RISCA version 2 (April 2019) Regulation 36.

Mandatory training to be completed and up to date for all care staff. RISCA version 2 (April 2019) Regulation 36.

Documentary evidence to be held on staff files for any relevant qualification. RISCA version 2 (April 2019) Schedule 1, Part 1 (Regulation 35), 6.

The service user guide to be reviewed at least annually and to be clearly dated to show this. RISCA version 2 (April 2019) Regulation 19.

Six staff meetings to be evidenced each year. RISCA version 2 (April 2019) Regulation 38.

Developmental actions

To ensure transparency and accountability, it is good practice for all documentation to be dated with the name of the person completing it.

If a birth certificate isn’t available, it is recommended that a file note is available explaining the reason.

Evidence of meaningful induction process to be held on staff files.

The activities coordinator must ensure that individual records are maintained for each resident to evidence what they have been doing (this should be supported by care staff).

The supervision matrix to be amended to highlight sessions are to be held every three months.

It is recommended that the statement of purpose be updated to include the name of the new deputy and the annual review date.

Quarterly reviews to provide meaningful overview of the previous three month period.

To evidence the residents guide is reviewed appropriately, this should be recorded on the document.

Where residents have expressed a religious preference, this should be reflected in the personal plan and evidence held of how they are supported to observe any religious practice they wish (either within or outside the home).

The activities coordinator to evidence that all residents have the same opportunity to access the community.

Feedback to be shared with the catering team around the provision of toast and Welsh Cakes.

Conclusion

From the thirteen recommendations made previously, five had been met, three were partially met and five were not met. It was acknowledged that there had been a new manager and deputy manager appointed since the last visit and they were still in the process of working on their own action plan and implementing positive changes.

Although there are twenty one recommendations made during this monitoring period, the manager was already aware of some of these areas and will work with the staff team to make these changes. It was pleasing to note that amendments had already been made since the new manager started and some positive feedback was received from the resident and relative that were spoken to as well as some good feedback received prior to the visits from a reviewing officer.

The contract monitoring officer would like to take this opportunity to thank everyone involved in the monitoring process for their time, assistance, and hospitality during the visit. Unless it is deemed necessary to be carried out beforehand, the next visit will be carried out in approx. 12 months’ time.

Author: Amelia Tyler
Designation: Contract Monitoring Officer
Date: 18th April 2024

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