Millbrook Residential Home
Gelligroes Road, Pontllanfraith, Blackwood, NP12 2JU.
Tel: 01495 225861
Email: milbrookhouse@googlemail.com
Contract Monitoring Report
Name/Address of Provider: Millbrook Residential Home, Gelligroes Road, Pontllanfraith, NP12 2JU
Date of Visit: Friday 17th November and Tuesday 21st November 2023
Visiting Officer(s): Amelia Tyler, Contract Monitoring Officer / Caroline Roberts, Contract Monitoring Officer
Present: Claire Porter, Registered Manager
Background
Millbrook is a two-storey home located in Pontllanfraith that is registered to provide care for a maximum of 38 residents (25 with general care needs and up to 13 with a cognitive impairment). At the time of the visits there were 35 residents, 10 of which were funding their own care.
The previous visit was completed on the 8th August 2022 to work through the monitoring template and review previous recommendations made during the last visit. At the time of the last visit there were three developmental and one corrective action identified; these were checked and the outcome highlighted in the section below.
Dependant on the findings within the report, corrective and developmental actions may be given to the provider for completion. Corrective actions are those which must be completed as governed by legislation and regulations. Developmental actions are those which are deemed to be good practice.
Previous Recommendations
If there is no existing pre-assessment in place, the provider must ensure this is carried out prior to agreeing to provide a service. This assessment should include health, personal care and support needs, any specialist support required, communication, emotional, educational, social cultural religious needs and establish their personal outcomes and aspirations. RISCA version 2 (April 2019) Regulation 14. Met. There were pre-assessments held of each of the files viewed that had been completed prior to the residents moving to the property. It was noted that one of these had not been signed.
Ensure there are no gaps in mandatory training. RISCA version 2 (April 2019) Regulations 34 and 36. Not met. The training matrix provided evidenced gaps in mandatory training; there were 17 staff yet to complete food hygiene training, 8 to undertake safeguarding training, 7 to do infection control, 3 to do first aid and 27 yet to complete medication training. It is recommended that if staff are not required to complete this training as part of their role that this is highlighted on the matrix.
Initial assessments to be in place. RISCA version 2 (April 2019) 34 and 15. Met. There were pre-admission assessments on both files viewed that had been completed prior to the individuals moving to the home. It was noted that one of these had not been signed or dated by the person completing the assessment or the individual (or appropriate representative).
Agreement forms for notifying relatives of any incidents should be on all resident files and to record the name, relationship, signature, and date the form was completed. Not met. It was acknowledged that agreement forms were in place to inform staff of who and when to contact family members in the event of any incidents. The contract monitoring officers noted these had not been signed by the resident to confirm their awareness and agreement of the form or by the relative.
Findings from Visit
Responsible individual
Copies of the quarterly regulation 73 visits carried out by the responsible individual were provided and it was noted these had been completed in February, May, August, and November 2023. These reports included conversations held with staff, residents, and any visitors during the visit.
The statement of purpose was provided, and this had been reviewed 25th July 2023. The document must be reviewed every year and to evidence compliance with this regulation, it is recommended that the date of the next review is recorded.
It was explained that if the home manager and responsible individual were both unexpectedly absent at the same time, that the deputy manager would oversee the home in the interim with support from the senior staff. It was stated that there is also another manager in a sister home within the borough that would be able to offer support and it was suggested this be included in the statement of purpose.
All policies and procedures including commencement of service, client finances, staff development, complaints, infection control, medication etc had all been reviewed in either April or March 2023 and all recorded that the next review date would be in twelve months’ time.
Registered manager
The contract monitoring officers were informed that there was CCTV in operation outside the property and in communal areas of the home. Although it was acknowledged this is recorded in the statement of purpose, there was no sign informing visitors to the home. It is recommended that a notice be put up by the visitors’ book in the foyer.
At the time of the visit there were no ongoing concerns in relation to the building, but work was being carried out on the lift and it was pre-planned that the work would be ongoing for several weeks and appropriate risk assessments and safety measures had been implemented.
Regulation 60 notifications were forwarded to the Care Inspectorate Wales and copied into the commissioning team inbox. The manager stated there were no outstanding notifications. The home manager manages the one service and told the contract monitoring officers that she was supported by the responsible individual, and they attend the home most days. When they aren’t present within the home, they are available over the phone or email.
There was evidence of referrals being made to external professionals and it was highlighted that the most recent one was a referral to the physiotherapy team on the 16th November. It was also explained that three applications had been made for deprivation of liberty safeguarding assessments.
Desk top audit
As mentioned previously, there were gaps in mandatory training and there were instances where training had not been recorded since 2017. The matrix did evidence service specific non-mandatory training such as iStumble (falls awareness and prevention), vital signs, stoma and catheter care, skin integrity and oral care.
The manager explained that the protection of safeguarding adults incudes the different types of abuse, the mental capacity act and liberty protection, different scenarios, the responsibilities of staff to look out for and report any signs of abuse and what actions may be required.
Staffing and training
It was reported that there are seven members of staff on duty during the day with a minimum of one senior and four on duty from twilight and throughout the evening. It was noted that there are occasions where the home has three carers on duty during the night if they need to attend training. The activities coordinator, home manager and deputy manager are all supernumerary.
The activities coordinator works 30 hours a week (7.30am – 4.30pm) and it was also stated there is a carer that works a shift on a Wednesday with a focus on activities.
Training is evaluated through observations of the manager and senior staff. The manager said that they would not ask their staff to do anything they would not do themselves and attends the same training sessions. Additional training is provided for staff that it is felt would benefit, particularly overseas staff.
At the time of the visit, it was only the manager that was regularly working over 48 hours a week and it was highlighted that most staff have signed the working time directive.
The active offer in relation to the Welsh language is discussed and recorded in the initial assessment and the contract monitoring officers were told there were three carers that were able to speak Welsh if any of the residents stated they wanted to converse in Welsh.
Two staff files were viewed, and both contained two written references; on one of these it wasn’t clear if the references were personal or professional, however, the staff member had been employed at the home for several years and it wouldn’t be beneficial to seek this information retrospectively.
Both files held job descriptions, detailed application forms, full employment histories where any gaps in employment were explained, signed employment contracts, birth certificates, photographs, and induction. DBS checks (disclosure and barring service) were evidence on a separate matrix which was shared with the contract monitoring officers and evidenced all staff had a valid certificate within the past three years. It was noted that the matrix did not state whether the check was clear or if an appropriate risk assessment was required. The manager agreed to add this to the matrix.
Only one of the files contained a passport; it is a regulatory requirement that a copy of this is held on file (if available) it is good practice to hold a statement on file if this isn’t obtainable and signed and dated by the manager and member of staff.
Supervision and appraisal
Supervision sessions are held every three months on a formal 1:1 basis. The template provides prompts such as ‘did the staff member understand the task? Were they competent? Is any training needed?’. There is also a comment box on the template to provide any additional information. It is recommended that there is more evidence of a two way conversation to highlight that supervisees are expected to contribute; do they have any issues in relation to the home, their role, anything around their wellbeing that the supervisor may need to be aware of etc.
There were some instances where the gap was slightly over the three month period, but this can be due to annual leave, sickness, shift patterns etc.
File and documentation audit
Two resident files were seen during the visit; it was noted that both contained pre-admission assessments. One of the assessments had been completed by the deputy manager but hadn’t been signed by the assessor or the individual moving into the home (or appropriate individual).
Both files contained person centred personal plans which contained likes/dislikes, routines, and any specialist heath needs (such as diabetes). The plans were written in the first person which helps the reader in focussing on the person and their abilities rather than simply what they as carers need to do. It was acknowledged that one of the residents needs the support of one carer in the bath but didn’t elaborate i.e. do they just need assistance in and out of the bath? Does the carer need to stay present? Etc.
There were individual handling plans on file and one of the files contained a MUST (malnutritional screening tool) but there were no other risk assessments on file. The manager is to consider implementing any risk assessments where appropriate to evidence a pre-emptive approach and highlight how they are supporting individuals to maximise their independence. Assessments to be considered around mobility, accessing the community, communication, etc.
Review of the personal plans were detailed and meaningful and were being completed monthly which is more frequently than required and is working well within the home. It was addressed that there was a fall for one of the residents on the 6th October which wasn’t included in the monthly review, and the other resident had sustained bruising and a skin tear in March which had not been mentioned in the review. It is recommended that any incidents be included in these reviews, and record who was involved.
The professional visits log evidenced involvement from external professionals where needed such as the mental health nurse, chiropodist, GP, etc. The contract monitoring officers also acknowledged that the personal plans contained outcomes for the individuals and how this will make them feel.
It was stated that residents who need or choose to remain in their rooms are given the choice of what they would like to do. The contract monitoring officers were told that the activities coordinator will go in and assist them with their breakfast and gauge their mood and how they are feeling and sometimes play a game of dominoes or cards, offer them a hand massage, read the paper, or just sit and have a chat.
There was personalised information around the person’s life story in the ‘this is me’ leaflet, and contained detail such as where they grew up, where they worked, what they used to enjoy doing and what TV programmes they like. When talking to staff, they demonstrated a thorough knowledge and understanding of this.
The two files checked did not have do not attempt resuscitation forms in place (DNACPR) as these were not wanted by the residents, however, it was noted that there was a separate matrix in place for those that had one on file. The deputy manager also advised that there was a separate file in place for people that have a deprivation of liberty safeguarding agreement in place. There were no bed rails or lap belts in place for any of the residents living at Milbrook.
Quality assurance
The previous annual quality assurance report from September 2023 was provided and this gave a brief overview of the previous twelve months. There was a compliments and complaints book in place and a thank you card was seen from the family of a resident that had passed away and complimented staff for the care they provide and always with a smile on their face. It was pleasing to note that this information was being captured in the regulation 73 reports and shared with the team.
Team minutes were seen that had been held on the 18th November 2022, 15th March 2023 and 20th June 2023. Minutes covered topics such as uniforms, phones, personal plans, safeguarding, staff conduct etc. It was noted that there hadn’t been six meetings held within the past year as required. Staff do not sign the minutes to evidence they have had sight of the discussions; it is suggested that this is something that could be considered for the future, particularly for staff that are unable to attend.
Residents’ meetings are held every quarter, and these are chaired by the activities coordinator. These are held as an interactive discussion to try and determine the resident’s views on what activities are being arranged, what is working and what isn’t and if there is anything they want to do in future.
Meetings for relative’s are no longer arranged as they weren’t well attended and family members have reported that if they had any concerns or issues, they would not wait until a meeting to raise this. It was reported that relatives felt able to approach staff with any feedback and that this detail is better captured during informal events such as coffee mornings, parties or BBQ’s.
The accident and incident book was checked and it was observed that there had been 9 falls between 2nd October and 17th November 2023 but there were no identified trends or further action needed.
At the time of the visit there were no residents that required involvement from the advocacy service, but the manager explained they would contact age concern if there was anybody that would benefit from an external advocate.
Regular maintenance checks are carried out by the maintenance man and there is a log in place to record what has been carried out such as water temperature checks, fire alarm system, and fire extinguishers etc. There was a certificate of checks being completed for gas installation on the 31st October 2023 and emergency lighting on the 12th October 2023. It was evidenced that the last fire assessment had been completed by Fire Tower on the 12th April 2023. There were seven recommendations made and it was noted that some had been evidenced as completed and the manager confirmed that all the points highlighted had been addressed.
Resident finances were discussed with the deputy manager, and it was reported that either the manager or deputy manager signs for any incoming or outgoing monies and either by the relative bringing the money in or additional member of staff. One residents’ finances were checked and it was noted that all receipts were present apart from hairdressing as this was filed on a separate sheet. It was observed that one receipt for a purchase in The Range had been mis-filed and belonged to another resident, but the balance matched the expenditure record.
Staff feedback
Feedback was sought from two care staff, and both explained that when they need to support the emotional needs of the residents, they would take the time to listen and try to understand what they needed. The contract monitoring officers were told that with some residents they may need some reassurance, or it may be caused by being in pain. It was noted that different techniques work for different individuals, and this is why it’s important to spend time getting to know the people they care for.
One of the carers said they didn’t go out with residents very often and it was also explained that some residents have poor mobility and choose not to go out in the community. The deputy manager stated that she had supported a gentleman to attend an eye screening appointment as she is a registered driver, and she will also take them out shopping if they want to. It was acknowledged that most residents have family involvement and most of them will take them out but there are two they don’t have any support, so they are asked if they wanted to go out anywhere.
The contract monitoring officers asked the two staff to provide information around one of the residents at random and explain to us what is important to the individual and what we would need to know about him if we were a new starter supporting him; both commented that he likes the garden, can be quiet but often enjoys a 1:1 chat. He has three children that visit him often and are very supportive ad he also likes a newspaper and the occasional gin and tonic.
It was highlighted that they felt able to be flexible within their roles and can sit and talk to residents and if there was a five-minute window where they felt the residents needed some stimulation, they said they would play a board game from the activity area. One member of staff commented that they would have a chat with the residents or put some music on.
Both staff said they were encouraged to offer any suggestions about improving the home and improving the quality of life for those living at Millbrook. It was also noted that each member of staff was aware of the safeguarding and whistleblowing policies and explained that if they witnessed any poor practice, they would record and report to the appropriate teams, and escalate if necessary.
The contract monitoring officers asked what the home does to help maximise independence and it was explained that some residents need more encouragement than others. It was explained that the detail in the initial assessment helps to build the personal plans which outlines the individual capabilities and not to undertake tasks thy can do themselves. It is important to offer as much choice as possible an promote positive risk taking, which may be a small as making themselves a hot drink.
Members of staff reported that they share information about themselves if it isn’t something which might cause them upset. One carer said that some of the residents are wise and enjoy giving advice and reminiscing. One carer said there is a feeling of togetherness and residents respond well when the carers talk about their families and any plans they have. It was also highlighted that the manager and deputy spend time walking around the home and engage with residents and carers and can support and offer guidance if required.
Resident feedback
Two residents completed the resident questionnaire with the contract monitoring officers. One lady on the top floor explained that she normally spends her day downstairs as she felt there was more going there and has friends on the ground floor. They told the contract monitoring officer the food was excellent; they didn’t have a favourite and liked most foods. One resident said she was easy to please and the other explained if they didn’t like what was on the menu, they are always offered an alternative. During the second visit, it was observed that one of the residents changed their mind during the meal, and they were given a different option. The contract monitoring officers felt standard and presentation of the food at Millbrook was excellent.
There was nothing either resident said they would like to eat that wasn’t on the menu and one commented ‘we get everything’.
One resident commented that although they missed their home, they were happy living at Millbrook, and the other resident said they enjoyed the company and the interaction with other residents and staff. Although one of the ladies spoken to explained that her son takes her out twice a week, the other said that she hadn’t been out in the community.
When asked about their contact with friends and family, one said that she didn’t have any family but has made friends with the other residents. The other lady explained that her son lives locally who she sees every week and a daughter in Cardiff that she speaks to regularly.
Both ladies were very complimentary and said that carers are respectful, and one told the contract monitoring officer they were wonderful. One said that when they help her with the bath, they are always very kind, and it was stated that everything they do is faultless. When asked about what they talk to staff about they said they felt comfortable to talk about anything and everything with the care staff. It was mentioned that one of the residents had known one of the carers since she was a young child.
The residents reported that if they need staff, they respond in a timely manner. One stated that she didn’t need them often, but knew they are always there if she does. It was asked of there was any other feedback they would like to give one responded that everything was lovely and that they were confident if they wanted anything at all, it would be sorted and that she was looking forward to seeing her family but spending Christmas day at Millbrook.
Relative feedback
One relative was spoken to during the second visit and another relative was contacted by phone after the visits and they provided positive feedback. The hairdresser at the home was spoken to as they had a relative living in Millbrook.
Both relatives were very complimentary and said they were always made to feel welcome at the home and the atmosphere is always polite and kind. It was reported that both residents thought of Millbrook as their home and one relative commented that her grandfather sometimes became distressed if the social worker visited as he was concerned he was going to be moved.
Neither relative had been invited to any relatives’ meetings but did say they had been asked to attend review meetings with the allocated social worker and they both said they are confident with joining in any activities or events going on. It was highlighted that one relative was aware of an arrangement with the home about being notified of any incidents, but the second relative wasn’t, however, they did state they were not the next of kin so this was likely to be in place for another family member. It was acknowledged that they felt there was good communication with the home.
They both felt comfortable in raising any issues or concerns but neither said they had had any reason to do so. The contract monitoring officer was told there was nothing the relatives could think of that they would change about the home and that they had been successful in providing a good quality of life for their loved ones. One commented that Millbrook had changed his whole life as he was very anxious before and is much more settled and happier now and is supported to see his wife three times a week.
It was noted that the relatives felt staff go out of their way to make the residents feel at home and examples were given that one gentleman used to be supported to a local corner shop every week to do the lottery, but since his mobility has deteriorated, staff do this for him. It was also highlighted that when one gentleman goes out to meet family, staff make sure that he is smartly dressed and cleanly shaven and reported ‘it’s amazing here!’.
General observations
The foyer at the entrance to the home had been decorated with autumnal garlands and wreaths and there was also a Christmas tree to make the home welcoming and festive. It was an area that is used for family visits or if a resident wanted to relax and watch the world go by.
Mealtimes were a social occasion with staff interacting with residents that wished to eat in the dining area and were being assisted to eat where necessary. The chef was upstairs during one of the visits, serving the food, and was getting feedback directly from residents.
There were photos in the communal areas of residents taking part in various activities, including a recent pumpkin carving for Halloween. It was noted that residents were also playing bingo during the first visit, and those that had wanted their hair done were having this done on the day of the second visit.
Corrective / Developmental Actions
Corrective actions
Ensure there are no gaps in mandatory training. RISCA version 2 (April 2019) Regulations 34 and 36.
Notification within the property to inform visitors of the use of CCTV. RISCA version 2 (April 2019) Regulations 43 and 44
The DBS matrix to state if the check was clear or any appropriate action is required. RISCA version 2 (April 2019) Schedule 2, Regulation 59, part 1, 8 (g)
A minimum of six team meetings to be held annually. RISCA version 2 (April 2019) Regulation 38
Developmental actions
Ensure pre-admission assessments are signed and dated by the person completing the form and the new resident (or appropriate representative).
Agreement forms for notifying relatives of any incidents should be on all resident files and to record the name, relationship, signature, and date the form was completed.
It is recommended where staff don’t require certain training to carry out their role this is reflected on the matrix.
The date of the next review of the statement of purpose to be included in the document.
The statement of purpose to note that the manager of the sister home would also be able to assist if the manager and responsible individual were absent at the same time.
If passport and/or birth certificate is not obtainable it is good practice to hold a signed statement on file.
Consideration to be given to updating the supervision template to fully capture input from the supervisee.
Conclusion
Millbrook continues to be a happy, welcoming home and both contract monitoring officers felt that staff and residents were content. It was nice to see the chef out in the communal area serving lunch and talking directly to residents to get their feedback.
All areas of the home that were seen were well presented and it was nice to see the main foyer decorated with festive and autumnal decorations which gives the idea of the culture and atmosphere within the home, and this was supported by the feedback from relatives, residents, staff and visiting professionals to the home.
It was pleasing to note that 3 out of the 5 previous recommendations had been met and a lot of work had been completed within the home to maintain a high standard of care. Despite the extreme challenges of the pandemic and changes to the staff team, the home appears to have come through this stronger.
Both contract monitoring officers would like to thank the manager, deputy manager and others who were involved in the monitoring process for their time and hospitality throughout. Unless it is deemed necessary, the next monitoring visit will be carried out in approximately twelve months’ time.
Author: Amelia Tyler
Designation: Contract Monitoring Officer
Date: 11th December 2023