Trafalgar Park Nursing Home
Heol Islwyn, Pontypridd Road, Nelson, Treharris, CF46 6HG.
Tel: 01443 450423
Email: trafalgar.manager@hc-one.co.uk
Website: www.hc-one.co.uk
Contract Monitoring Report
Name/Address of Provider: Trafalgar Park Residential Home, Heol Islwyn, Pontypridd Road, Nelson, CF46 6HG
Date of Visit: Tuesday 24th October 2023
Visiting Officer(s): Ceri Williams, Contract Monitoring Officer, CCBC
Present: Joan Thomas, Home Manager, HC-One
Background
Trafalgar park is a large property located on the outskirts of Nelson. The care provider is HC-One. The home is registered to provide residential care and dementia residential care, there were two vacancies at the time of the visit.
The last CIW inspection was conducted in December 2022, no areas of non-compliance or areas of improvement were identified.
Dependant on the findings within the report, Trafalgar Park will be given corrective and developmental actions to complete. Corrective actions are those, which must be completed (as governed by legislation etc.), and developmental actions are those, which are deemed to be good practice.
Previous Recommendations
Corrective Actions
Personal Plans are drawn up with the participation of the service user and signed by the service user wherever capable and/or representative. Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA) Regulation 15. Evidence was available of individuals and their representative’s involvement in personalplans and reviews.
The Personal Plan is kept under review and is amended and developed to reflect changes in the individuals care and support needs and personal outcomes. RISCA Regulation 16. Met: Personal plans viewed were reviewed within relevant timescales and amened when necessary.
Staff training for Mandatory training courses that are overdue to be completed as soon as possible. RISCA Regulation. Not met: See body of report. There were no developmental actions in the previous report.
Findings from Visit
Two residents files were viewed during the visit. Both were clearly indexed and information was easily accessible.
Both files contained the necessary pre admission assessments for residents. Personal Plans and risk assessments were detailed, personalised, and gave a good picture of the resident and their support needs and also what could be achieved independently. Personal Plans viewed contained all needs identified on the care and support plans prepared by the local authority.
Personal Plans viewed were person-centered and contained good detail of likes/dislikes and routines and included evidence of the resident being involved in the production of the personal plan. Where the resident lacked capacity there was evidence of family being consulted regarding the residents care and support needs.
There were appropriate risk assessments in place where necessary to meet the individual’s needs.
Reviews are completed monthly which is good practice. Reviews viewed on file were completed in a timely manner. There was also evidence that residents or their representatives are involved in the review.
A number of individuals daily recordings were viewed during the visit. All contained detailed information including personal care checklists and written records included information on how the resident had spent their day and included mood and presentation.
From viewing resident’s files, it was evident that changes/deterioration relating to residents are being recorded and that the home are making referrals to the appropriate outside agencies for support with managing conditions. Referrals were seen to Dietician, G.P., incontinence team when they were required.
Daily records are audited by senior staff and management and any concerns actioned upon while also forming part of monthly reviews.
Files also included life history and individual well-being information with good levels of detail regarding the residents including family, past occupations, details of hobbies and interests and what was important to them.
Staffing
The staffing ratio of the home by day is made up of eleven care staff, two senior care staff who cover two communities. In addition to this are the Manager, Deputy Manager, administration assistant, laundry assistant, maintenance assistant, two kitchen assistants, and two domestic assistants. The night shift comprises of six carers and two senior carers. Two activities co-ordinators are also employed at the home.
Two staff files were viewed during the monitoring visit. Both files were in good order and contained all the relevant documentation including detailed application form, interview record with scoring, photographs of staff member and verified references. A database is held providing evidence of staff DBS checks.
Evidence of identity was present on both staff files which contained copies of birth certificates and passports.
Staff meetings regularly take place and are recorded, minutes are also made available for staff who did not attend the meetings.
Training & Supervision
At the time of the visit training statistics for staff evidenced 77% of staff up to date with mandatory training courses. The manager explained that training compliance was good however, there were a lot of new staff who were yet to complete some courses and that the figures also contained staff members that had left or who are off work at the moment.
Staff are also required to complete training in non-mandatory courses in order to better understand and support the residents they care for. These included Dementia care, promoting healthy skin and wound care and person-centred care.
Evidence was provided that staff receive face to face supervision with a senior member of staff within timescales set out in regulations. An example of supervision was seen, the format included open discussion between staff and manager including any support issues or training required and also items for discussion and actions for the next meeting.
Staff also receive annual appraisals with their line manager.
Facilities & Observations
There was a warm, relaxed atmosphere in the home, and we observed positive interactions between staff and residents throughout the day. Staff were observed offering choices and going with whatever residents wanted. The home was clean and tidy throughout with no evidence of hazards or malodours. Resident’s rooms are clean, light and all have evidence of personalisation with personal effects, furniture, and photographs.
Two new activity co-ordinators have been employed by the home and are planning events based on feedback from residents and their interests.
Regular maintenance checks, such as fire alarm testing, water temperatures and CO2 measurements are conducted by the maintenance employee and recorded in the maintenance file. The manager also conducts maintenance spot checks.
The last fire safety assessment was completed in May 2023 with all recommendations completed. Fire drills are carried out regularly in line with timescales set in regulations and recorded. Personal Emergency Evacuation Plans were present on both residents files that were viewed and found to be current regarding any support needs required in an evacuation and are also reviewed monthly.
Resident & Relative Feedback
A number of residents were spoken to throughout the visit with positive feedback received. Residents advised that they were happy living at the home.Residents meetings take place regularly where residents can discuss all aspects of living at the home and are involved in the planning of events.
Relatives of individuals living at the home were also contacted for feedback.
They confirmed that they are informed and consulted on the care and well-being of their relative that reside at the home and that they are kept informed about hospital appointments, changes in health etc.
Neither relative have had cause to raise any complaints or minor issues at the home and described staff as always helpful and would feel comfortable raising an issue with any of the staff if they had to.
One relative described the care as brilliant and could not fault it, and that there are familiar faces every time they visit and described the staff as very caring.
Quality Assurance
HC-One use a number of internal Quality Assurance systems and data is collected and audited through these systems on a daily, weekly, and quarterly basis.
Daily manager walk arounds, staff meetings, relatives and residents’ meetings and annual surveys completed by stakeholders are also carried out as a means of collating information. A number of regular audits are undertaken for in areas such as medication, infection control and any falls/incidents. Evidence was available of actions identified from audits being followed up and processes put in place for further improvement.
The Responsible Individual quarterly reports were made available to the visiting officer and are undertaken within timeframes set out in regulations.They are comprehensive and evidence that feedback is sought from both residents and staff regarding living and working at the home.
Six monthly Quality of Care reports were also provided to the monitoring officer.Again, these were detailed reports analysing and reviewing the monitoring systems in place to improve the care and support provided and included actions to be taken following the findings of the report.
There is a daily handover process in place at the home which takes place at each shift change and includes senior staff. During the handover information and updates are shared about every resident, including any significant changes. There are also daily flash meetings within the home which are attended by all heads of departments.
Corrective/Development Actions
Corrective Actions
All staff to be up to date with mandatory and on-mandatory training. Regulation 36 of The Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA).
Development Actions
Regulation 60 notifications to the regulator to be copied to CCBC Commissioning Team. CCBC Contract
Conclusion
The home was calm and relaxed throughout the visit with plenty of staff presence.Staff were observed to be caring and re-assuring to individuals during their interactions.People living at the home are offered choice and are involved in any decisions relating to their care and support and are also consulted on the general running of the home.
The Contract Monitoring Officer would like to take this opportunity to thank the residents, Manager and staff for their time and hospitality during the visit.
Author: Ceri Williams
Designation: Contract Monitoring
Officer Date: 08 December 2023