Church View Care Home Contract Monitoring Report

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: Friday 24 March and Monday 3 April 2023
Visiting Officers: Amelia Tyler: Caerphilly CBC
Present: Tracey Webb: Home Manager, HC-One / Lisa Jones: Deputy Home Manager, HC-One

Background

Church View is a large, purpose-built care home that is situated close to the town of Caerphilly.  It is built over 3 floors and is registered to provide care for 35 people who require general support with carrying out activities of daily living and 10 people with a diagnosis of dementia.

At the time of the visit there were 2 vacancies for people with a diagnosis of dementia and in need of residential care, and no vacancies for people with general residential care needs.  9 of the current residents were self-funders.

The last formal monitoring visit to the property was completed on the 3^rd May 2022; During the previous visit there were 5 corrective actions and 3 developmental actions identified which were reviewed and these are outlined in section 2 below.

The purpose of the visit was to 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 Personal plans are to be completed prior to the resident moving into the home unless this is done as an emergency, in which case it should be completed within 7 days of the commencement of the service.  RISCA version 2 (April 2019) Regulation 15 Met.  It was acknowledged that both files viewed contained initial personal plans.

Where an individual lacks mental capacity to consent to the arrangements for their care and support, service providers follow the statutory principles and provisions of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, where appropriate. RISCA version 2 (April 2019) Regulation 29 Met. The monthly report was sent outlining the DOLS authorisation.  There were a few residents that were still awaiting a review, 1 of which had been waiting over 18months.  The manager is chasing these outstanding assessments monthly.

If a DBS certificate is returned with any spent or unspent convictions etc. the manager must take this into consideration and evidence that this has been acknowledged to assess the suitability of the employee.  RISCA version 2 (April 2019) Regulation 35. Met.  Although it was explained that this could not be evidenced, because no checks had come back with any convictions, it was stated that appropriate conversations and risk assessments would be carried out where required.

All Staff meet for one-to-one supervision with their line manager or equivalent officer, or a more senior member of staff, no less than quarterly.  RISCA version 2 (April 2019) Regulation 36 Met.  At the time of the second visit, the manager explained there was only one member of night staff needing to attend their supervision, and this was booked in that week.  There was also one member of staff that had not completed their supervision due to long term sick leave.

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. Met. The matrix evidenced all staff had received an annual appraisal, apart from the new starters, who were not due at the time of the visits.

Consideration to be given to holding agreement on file of notifying relatives of any incidents. Partially met.  The manager explained this forms part of the initial assessment, however, it was recommended that additional information be documented around different scenarios i.e. to be phoned at any time for bigger incidents such as being admitted to hospital or any falls resulting in an injury, but if there were less urgent issues such as having a suspected chest infection or a medication error, to make contact only during the day.  Where the resident has capacity, they should also sign to evidence their agreement.

The frailty team to be contacted in relation to the residents with any mobility issues   that had an accident/incident in April. Met. There was evidence provided in the first visit that referrals were being made to the frailty team where required.

The manager to contemplate nominating at least 1 dementia champion.Not met.  This had not been completed when the visits were carried out.

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.Not met. There was no evidence this had been introduced.

Any rooms with underlying malodour to be addressed. Not met.  The contract monitoring officer noted there were 2 bedrooms that had a malodour whilst walking around the home.  This was fed back to the home manager, and it was stated this would be addressed.

Findings from Visit 

Responsible individual 

Copies of the quarterly reports required by regulation 73 of the Regulation and Inspection of Social Care (Wales) Act were viewed and it was noted these were dated 29.09.22, 09.01.23 and 01.03.23.

The statement of purpose provided was last reviewed in February 2023 and it was acknowledged this had been updated to contain the name of the new manager.

All mandatory policies and procedures, such as infection control, whistleblowing, medication and safeguarding etc. were all shared with the contract monitoring officer, and all had been reviewed within the previous 12 months.  All policies contained a review date which were either one or two years, except for infection control, which was three years unless required.

Registered manager

It was noted that the Manager has only been in post since October 2022 and is still in the process of implementing some of the long-term goals.  It was explained there is no CCTV at the property.

There were no concerns raised in relation to the property, although it was explained that some work had been carried out on the lift as the weight sensor had to be repaired.

Discussion was held around the most recent CIW inspection, and it was highlighted there were no outstanding regulation 60 notifications.  Visits completed by the responsible individual are not planned and the manager explained these are normally unannounced to ensure they have a true and accurate view of how the home is run.  It was stated the responsible individual will also conduct evening visits.

The manager explained there had been two referrals to professional teams this month: one being to SALT following a choking incident and the second was to occupational therapy.

The contract monitoring officer was informed that they were up to date with their Liberty Protection Safeguards (LPS) and receives monthly updates to inform her of any that are due to expire.

Desk top audit  

The training matrix evidenced training for mandatory courses such as manual handling food hygiene, safeguarding, infection control, first aid, medication etc.  It was noted that the majority of these were within the required refresher period.

On the 24^th March, it was highlighted that the home was 86% compliant with their training:  11% of staff had to complete MCA training and infection control and 7% needed to complete fire safety assessment training. 

Non-mandatory courses include promoting healthy skin, International Dysphagia Diet Standardisation Initiative (IDDSI), and choking.

Staffing and training 

It was stated that at the time of the visit, there were 32 care staff and 8 senior carers at the home.  The contract monitoring officer was informed there were also 3 new members of staff starting the following week: 1 night carer, 1 night senior and 1 day carer.  During the day it was reported there are 8 members of care staff on duty, and this includes 3 senior staff (1 on each floor).  Night staffing levels are reduced to 7 including 1 senior member of staff working between the floors.

There were 2 activities coordinators at the home who are contracted to work 2 x 16hour shifts and cover alternate weekends.

E-leaning courses are the main sessions used, but TW also highlighted that induction training was being provided in one of the sister homes in a neighbouring authority and safer people handling (practical), first aid and level 3 safeguarding are all delivered in a classroom-based setting.

The quality of training is assessed through supervisions, team meetings, and observations.  It was mentioned during a discussion with a member of staff and relative, that the dementia training was not adequate and more interactive sessions using case studies would be beneficial, particularly around distraction techniques.

It was noted that the active offer was highlighted in the statement of purpose and explains that any linguistic needs are identified during the initial assessment and responded to accordingly.  The contract monitoring officer was told there were 6 staff that were able to converse in Welsh.  2 of the relatives spoken to about their loved one said that he spoke Welsh as a first language.

2 staff files were viewed for staff that had started at the end of 2022, and both contained written references, full employment histories (with any gaps explained), Interview records, signed employment contracts, copies of passports, and certificate numbers for their DBS.  The contract monitoring officer explained that it should highlight whether the DBS was clear, or if a risk assessment was required. 

Only 1 of the files contained a detailed application form, birth certificate, and recent photo.  To comply with current legislation, the manager must ensure this information is maintained on file.    

One of the interview records evidenced there had only been 1 interviewer: although it may not always be possible, it is good practice to have at least 2 interviewers should the outcome be challenged.

There was no evidence of any shadowing or induction held of file, but the manager explained this is all done on-line.

Supervision and appraisal 

As highlighted in section 2.4, It was evidenced during the second visit that there was only 1 member of staff due to complete their supervision session, and this had been booked in by the end of the week.  All other members of staff attended a formal supervision at least every 3 months.

All staff that were required to attend their annual appraisal to review their development and progression had been completed.

The manager explained that staff attend the formal 1:1 supervision session with either herself or the deputy manager.  These meetings are expected to be a two-way conversation, where the member of staff is required to contribute their thoughts and feelings about their own achievements and areas for development as well as any issues within the home.

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.

Quality assurance

A conversation was held with a visiting professional who was present during the visit: they had previous experience with the home as their grandfather had been a resident 10 years ago.  They explained that previously, the carers attended to basic needs and looked after the residents, but in his opinion did not provide a quality service.  When he started his involvement at the home, he believed it appeared a bit chaotic and staff were unmotivated, however, since the new manager has been in post there is more structure and staff are more motivated.  He had also noticed a happier atmosphere in general. The visiting professional shared that he intended to nominate the manager and a carer for good practice awards   

Since being in post, the manager explained there had been three compliments and two formal complaints that had been addressed.

Due to the pandemic, it had not been possible to hold relatives and residents’ meetings and it was explained these have now been re-started.  The next residents meeting was planned for 05.04.23 and the last relatives meeting had been held 25.01.23.

Minutes of the last residents’ meeting held 28.01.23 noted that a couple of residents mentioned the home can be noisy at night and had witnessed an increase in some residents arguing.  It was disappointing that nothing was recorded in the agreed actions relating to this, even if was just feeding back to the manager.

It was shared that there was no nominated dementia champion at the home: it is recommended that at least one member of the care staff acts as the dementia champion to share good practice, attend meetings with relatives, and contact external bodies to promote understanding and knowledge of quality dementia care.

Over the past 12 months, the contract monitoring officer was told that work has been carried out in the foyer area, a new bathroom has been fitted on the lower floor, redecoration of the ‘turn-around’ rooms, additional lighting, and new blinds and door fitted in the conservatory.  Over the following 6 months, a kitchen area is going to be installed on the upper floor and a hairdressing room.

Staff questionnaire

Two members of staff were spoken to during the visit, and both demonstrated a good understanding of the needs of the residents and the need to be patient and compassionate when providing reassurance.  They were able to reiterate what was important to specific people living at Church View.

One carer said they were able to support residents out in the community as they also have shifts as an activities co-ordinator, but the other carer said they didn’t have as much time doing activities as they would like.  This was emphasised when asked, they  didn’t feel they had sufficient opportunity to sit and chat with people or to be flexible within their role.

The contract monitoring officer was told that there were two residents that have complex needs, and these take up most of their time, this results in people who are quieter and more independent not having as much engagement as desired.

Both members of staff were aware of the safeguarding and whistle-blowing policies and said they were confident in being able to address any poor practice: one gave an example of an incident where they had escalated a concern around a colleague.

Discussion was held around the mix of residents throughout the home and explained that on occasion, they would phone for an additional member of staff from the middle floor, and this didn’t always happen.  It was also highlighted that although there are 12 dementia courses on the training matrix, these were videos which wasn’t sufficient for their roles.  It is recommended that more interactive dementia training is sourced which allows staff to ask specific questions and give scenarios to help them support the residents.

Resident feedback

Two residents were spoken to, to obtain their views of the service (one on the middle floor and one on the top floor).  Both residents were well presented and comfortable in their surroundings and were able to express their wishes clearly.

One of the gentlemen explained that often, the care staff appeared busy in the living room, sat round the table completing paperwork and did not like to disturb them.  He had a TV in his room and stated that he gets to go out with his sister quite frequently.

Both gentlemen explained that the food was nice and didn’t have any complaints.  Neither could think of any meals they would like that isn’t on the menu.  They explained the staff were kind and friendly and were able to talk to them about anything.

When asked if there was anything that could be improved within the home, neither could think of anything and when prompted if there was anything else they wanted to feedback, they said no.

The contract monitoring officer observed evidence of personalisation in the rooms seen, such as small items of furniture, TVs, radios, photos, and soft toys.

Relative feedback

Four relatives were spoken to that were related to two of the residents: All explained they felt welcomed into the home and the atmosphere was generally quite relaxed.

It was stated that all staff at the home are approachable, and if there are any issues, this is dealt with promptly: an example was given where they asked if their father could have a haircut, and this had been done by the time they next visited.  They both said their loved ones were well presented and smart.

It was reported that there is good communication, and they are made aware of any hospital appointments or changes in their health.  Two of the relatives also highlighted that their father is much calmer and happier when being spoken to in Welsh and there was one carer that often talks to him in his first language, which means a lot to him.

No concerns or issues were raised in relation to the care provided, however, one family mentioned they felt their father was retreating into himself and did not often come out of his room due to one of the other residents and expressed concern around staff ability to meet the needs of some of the more complex residents.  They also mentioned their loved one was diabetic, so his diet is important, and rather that offering him choice, it is often more effective to put something in front of him, as if he is asked, he will just say no.

General observations

When walking around the home it was noted there was a fruit bowl in the dining room which anyone was able to help themselves to.  There was also orange juice and water available in the dining and lounge areas.

The dining tables on the main floor had tablecloths, napkins, flowers, and condiments, although it was disappointing this isn’t replicated on the other floors.

During the visit, the fire alarm was inadvertently set off, and it was noted that all members of staff reacted immediately to see what the cause was.

There were lots of Easter eggs and hampers on display in the communal area for the prizes that were available from the raffle.

One of the residents was calling out and her bedroom door was closed and there was no call bell alarm within reach.  She didn’t look comfortable and reported having pain in her leg.  There were 2 tablets on the floor and when the contract monitoring officer asked who was responsible for administering medication that morning, the carer said they didn’t know where she was.  This was fed back to the manager during the visit.

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

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

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

All staff file to contain detailed application forms, birth certificates and a recent photo. RISCA version 2 (April 2019) Regulation 35

Personal plans to be developed to outline specific outcomes, rather than general goals.  RISCA version 2 (April 2019) Regulation 14

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

Developmental actions

The manager to contemplate nominating at least one dementia champion.

Consideration to be given to holding agreement on file of notifying relatives of any incidents.

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.

Any rooms with underlying malodour to be addressed.

Any actions resulting from resident’s meetings to be clearly recorded and shared with the manager (if not present).         

Staff files to record if DBS certificate was clear or if risk assessment is required.

Where possible, interviews to be conducted by at least 2 members of staff.

Conclusion

It was pleasing to note that of the 10 previous recommendations made, 6 were met, 1 was partially met and 3 were not met.  Although the manager has only been in post for a few months, there was evidence of some positive changes and is proactive in her approach.

There were some concerns raised by relatives around the wide range of needs and complexities required within the home and this was reflected in the conversations held with members of staff.  It is believed that the home would benefit from some additional dementia training for staff caring for people in the more advanced stages.  It is recommended the manager also considers the possibility of sourcing some training for relatives from an external source such as the Alzheimer’s society.    

A lot of positive changes have already been noted since the previous visit, and the staff appeared more positive and engaged in making progressive changes within the home.  There was some lovely feedback received during the conversations held, and the hard work of the staff team was acknowledged.

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.

Author: Amelia Tyler
Designation: Contract Monitoring Officer
Date: 28/04/2023