Try-Celyn Court

New Bryngwyn Road, Newbridge, Gwent. NP11 4NF
Tel: 01495 246622
e-mail: Karen.thomas@wellcomecarehomes.com

Contract Monitoring Report

Name/Address of Provider: Try-Celyn Court, New Bryngwyn Road, Newbridge, NP11 4NF
Date Of Visit:  6 June 2023
Visiting Officer(s): Amelia Tyler:contract monitoring officer, CCBC Caerphilly CBC
Present: Karen Thomas: Home manager

Background

Try-Celyn Court opened 19 December 2016 and is owned by Wellcome Care Homes Ltd. It consists of two separate two storey buildings which are registered to provide care for a total of 51 people with residential care needs and/or cognitive impairment. 

It was explained that one of the buildings was still under refurbishment and there were 20 vacancies at the time of the visit.

The previous formal monitoring visits to the home were completed on the 19 and 29 May 2022 and at this time there were 11 actions identified (7 of which were corrective and 4 developmental). These were reviewed as part of this visit and the findings are outlined below.

Dependant on the findings within this report, the home may 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

Staff files to contain full interview records birth certificates, passports and signed contracts of employment and proof of Social Care Wales registration (from October 2022).  RISCA schedule 1 regulation 35 (1) and schedule 2 Regulation 59 (8)

Partially met.  One of the files viewed did not contain a copy of the employee’s passport or a contract of employment.

Personal plans are to record details of anyone involved in completing the document.  RISCA Regulation 18

Not met. There was no evidence on either of the files viewed of involvement from the individual or any external parties in compiling or reviewing the personal plans.

A contingency plan to be formalised if the responsible individual is unexpectedly absent.  RISCA version 2 (April 2019) Regulation 10, part 3

Met. The manager showed the contract monitoring officer a copy of the contingency plan dated 07.06.23.

Service providers have a written policy in relation to the use of CCTV both by the service and by individuals, families, and staff. RISCA version 2 (April 2019) Regulation 43 and 44

Met.  This was viewed during the visit and had been reviewed 07.06.23 and it was highlighted on the document that the next review date was May 2024.

All staff to receive mandatory training on a regular basis and for this to be reflected in the training matrix.  RISCA version 2 (April 2019) Regulation 26

Partially met. There were some gaps identified in the mandatory training.  The manager explained that this was partly due to turnover of staff.

Individual outcomes to be identified and recorded.  RISCA version 2 (April 2019) Regulation 14

Not met. There were no agreed outcomes/goals for people to aim for on the files seen.

End of life wishes to be held on file or where the individual is not able to or does not wish to discuss, this should be clearly dated and recorded.  This is also to be discussed with the relatives where appropriate.  RISCA version 2 (April 2019) Regulation 21.

Not met. There were no records on file relating to any discussion around their wishes for their end of life.  One file did contain a DNR dated 09.01.23 but this did not evidence any discussion with the individual, her family or anyone close to her.

The supervision matrix to run consecutively rather than year-on-year to make it easier to confirm these were being held every quarter.

Partially met.  Discussion was held with the manager about the format of the supervision and appraisal matrices, and it was stated that the current layout works better for the manager and the responsible individual.

It is recommended that ex-members of staff are removed from the matrix and new starters are clearly highlighted to record when their first supervision/ end of induction session of due.

Partially met. Ex-members of staff had not been removed but had been highlighted to show that they are no longer with the company.  New starters had the start date recorded on the training matrix and the date they completed their induction.

Radiator covers to be adjusted to ensure the thermostat is accessible.         

Partially met. The contract monitoring officer was told that the maintenance man still had some rooms to complete.

All appraisal forms to be clearly signed and dated.

Not met. The two files viewed were for new starters, so there were no appraisals carried out as they were no due.  An appraisal form viewed for another member of staff was provided and it was noted this had not been appropriately signed and dated by the staff member and manager.

Findings from visit

Responsible individual

A copy of the most recent quarterly report completed by the RI was provided and this was dated 31st December 2022.  There were also reports for the period ending March 2023 (dated 03.05.23) and 30th September 2022.

The most recent quarterly report completed by the responsible individual highlighted that 6 members of staff were to be enrolled on the level 2 QCF training.  The contract monitoring officer requested evidence that this has been done and the manager explained that all had since left the company.  The report also stated that advanced dementia training had been sourced, however, this wasn’t reflected on the matrix.

It was acknowledged that the quarterly report included lots of evidence of discussions held with residents, family members and staff.

A copy of the most recent statement of purpose was provided which had been reviewed in Spring 2023., and this outlined that the core values are centred around the residents and the Daffodil building is still undergoing refurbishment and is expected to be completed in summer 2023.           

All mandatory policies and procedures were viewed, including safeguarding, use of control or restraint, infection control, and medication and it was noted that these had been reviewed within the past 12 months, with the exception of staff discipline, which was due in April 2023 and restraint which was planned for 5th June 2023.

Registered manager

The manager explained there is CCTV in use for the corridors and outside the buildings: this is included in the service user guide.  One of the files viewed contained a completed consent form, but the second file only had a blank form in place.  All files must contain completed forms, and if the resident is unable to sign, this should be completed by an appropriate representative.

There were no concerns raised in relation to the fabric of the building or equipment i.e. the lift and sluice were working well and there were no issues with the temperature of the running water in the rooms.  As highlighted previously, there are some rooms that still needed adjusting to ensure the thermostats on the radiators are accessible.

It was explained there were no outstanding regulation 60 notifications to be forwarded to the commissioning team at the time of the visit and the manager was not overseeing more than one service.

Visits carried out by the responsible individual continue to be completed approx. fortnightly and the contract monitoring officer was told these are normally unannounced.  Additionally, the manager explained there are also virtual manager’s meetings every Monday with all the Welcome Home managers’ and the responsible individual.  The manager said she felt supported by the responsible individual and was easy to contact when needed.

It was discussed that there were five Liberty Protection Safeguarding referrals that were waiting to be assessed by the LPS team and are waiting on the outcome. The manager showed the contract monitoring officer the spreadsheet containing the information about when the referral had been made.

Discussion was held about when the last referral had been made to a professional team, and the manager stated this was in February 2023 when a resident had been referred to the occupational health team as they weren’t holding their own weight.   

Staffing and training

A copy of the training matrix was provided, and it was acknowledged that this contained all mandatory training such as manual handling, food hygiene, safeguarding, first aid, administration of medication etc.  The matrix identified some gaps in training: There were 2 care staff that did not appear to have completed safeguarding training and 6 additional staff that had also not completed this course.  It is noted that it can be difficult getting spaces on this course due to high demand.  There were 2 care staff that needed to complete manual handling training plus an additional 1 that was on maternity leave.  It was acknowledged that it isn’t possible to source training for less than 5 members of staff.  The manager also explained that 2 ancillary staff have also completed a 1 day all-wales passport.  There were 11 members of care staff that didn’t have a date recorded next to first aid and administration of medication training.  This training must be sourced as a priority and once completed, be reflected on the matrix.  As with the other courses, if the training isn’t required as part of their role, this should be noted.  It was concerning that on the matrix, 1 of the 3 kitchen staff had not completed food safety training and none had attended food safety awareness or diet and nutrition training.

Although there were only a small number of staff recorded as having attended, there were non-mandatory courses that had been completed around epilepsy, stroke awareness, end of life, istumble, and sexuality. 

The contract monitoring officer was informed there were 39 care staff employed at the home in addition to the manager and deputy manager who are supernumerary.  It was noted that there is also an activities co-ordinator at the home who works 30hours a week.  The home doesn’t use any agency staff to maximise consistency for the residents.

Training courses are a combination of on-line and classroom based: it was felt that some courses, such as manual handling, fire marshal training, evac chair and first aid are all very practical sessions and therefore need to be delivered in person. The manager also mentioned that medication training had been booked in for the following week for senior carers and emergency first aid at work was planned the week after that.

The quality of training is assessed primarily through evaluation forms used by some trainers, discussions at team meetings, supervisions, and annual appraisals. It was stated that there are no staff regularly working more than 48 hours a week.

It was mentioned that there was one resident that speaks Welsh as she worked as a Welsh teacher.   The active offer is implemented as much as possible, and there are two members of staff that can speak conversational Welsh.  The contract monitoring officer was also told that efforts are made to answer the phone and end emails in Welsh and English.

Two staff files were viewed for two of the newer members of staff: both files contained two references, one contained a professional reference and the second file only had two personal references as they left their previous role in 2015.

Both files contained a job description, application forms, birth certificates, a recent photograph, evidence of clear DBS checks and a signed induction checklist.  There were interview records present on file, but it was noted that these had only been carried out by one interviewer: it is deemed where possible, that interviews should be conducted by two interviewers for additional evidence if the outcome is challenged.

The application form did not evidence any gaps in employment because the applicants did not provide clear start and end dates, however, the contract monitoring officer saw a separate sheet detailing employment records.

It was pleasing to see clear, signed induction checklists on file which evidenced appropriate shadowing and competency assessments.

Supervision and appraisal

The supervision matrix evidenced that there were some gaps in supervisions, some of which were due to staff turnover and some staff were not yet due. The manager gave reassurances that these would be completed and was going to forward evidence of annual appraisals.

The annual appraisal matrix was viewed from 2022 and it was acknowledged that there were 4 employees that hadn’t attended: this will be addressed by the manager this year and will ensure there is active engagement from all members of staff.

It was explained that all supervision sessions are formal, confidential 1:1 meetings that require input from both sides.

Documentation

Two resident files were seen during the visit, and both contained pre-admission assessments, but the last page was incomplete: staff to be mindful of completing these forms in their entirety.

It was acknowledged that the personal plans detailed the improvement of one person’s mobility since being discharged from hospital.

Appropriate risk assessments were also maintained on file such as personal evacuation plans, call bell, bed rails, falls, dependency assessments and manual handling. It was explained that although ever effort was made to review all plans and assessments every month, one had been missed due to regular hospital admissions.  It was acknowledged that one plan around mobility had been updated 29.06.22 following a fall on the 23.06.22.  There was no evidence of any involvement from any external agencies.

One of the communication plans stated that the individual can communicate very well with no difficulties, but did not mention whether she required glasses or hearing aids, what her preferred language is etc. It was noted elsewhere that she has Parkinson’s but did not comment on whether this affected her communication or cognition.  Although it said she can eat independently, there was no detail around dislikes or preferences, whether they ate better with smaller portions, different coloured plates, if they can make their own decisions about what and when to eat.

There was a lack of evidence that outcomes or personal goals had been discussed with the individual or appropriate representative. Both files contained sheets for the wishes of individual representatives, but these had not been completed and signed. Where there are no appropriate representatives, this should be clearly recorded.

Both files contained minimal detail around the social and spiritual care plans, and one had not been updated since December 2021. The contract monitoring officer observed signs outside each bedroom which highlighted various hobbies and/or interests but this hadn’t been incorporated into the personal plans.  One file did contain a ‘this is me’ document which stated they enjoyed knitting and liked their food but could become emotional when discussing their friends and family, but there was no additional detail. This was not present on the second file seen.

As previously mentioned, only one of the files had a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation), but there was no detail of any discussions being held or and advocacy involvement.

Quality Assurance

A copy of the annual quality assurance report was given that was dated 3 May 2023; this provided an overview in terms of staffing, environment, external visits and safeguarding. The report also set out the aims for the manager and staff to focus on over the next 6 months.

Minutes of the most recent team meetings were seen, and it was noted that there were two meetings in February, one in March and two in May. Attendance varied from four staff and the chair to 8 attendees and the chair.  It was good to see that some meetings were focussed on a particular topic (such as fortifying diets), or a resident rather than a repetitive general agenda. At the time of the visit, the manager explained that staff do not sign the minutes to confirm they have read them, but copies are made available in the staff room.  It is good practice to ask staff to sign a copy of the minutes, particularly night staff, to ensure they have been made aware of what is going on in the home, and an equal dissemination of information.

Although there are no formal residents’ meetings, it was explained that the activities coordinator had lots of discussion with the residents about what they would like to do, if they are happy at the home and if there is anything that could be improved and completes weekly reports.

There are no minutes of formal relative’s meetings, however, the manager said that she prefers to do this on a more informal basis because she feels she gets better feedback in this environment. The contract monitoring officer was told that coffee mornings, afternoon teas and summer BBQs are better attended than if it were advertised as a relatives meeting.

The accident and incident book was seen and it evidenced there had been 4 incidents in May and none in June (at the time of the visit). It was reported that there are no identified trends, however, a capacity assessment had been requested for one resident.

Discussion was held around appointing a dementia champion: the manager said that primarily it would be her and the deputy manager, but it was also stated that one of the senior care staff would also be a good contact for driving forward good dementia care. It would be good practice to formalise this and to add into the statement of purpose and resident’s guide so there is an understanding of who the champions are and what this entails.

It was stated that if the manager felt a resident was being described medication that wasn’t needed, this would be raised with the advanced nurse practitioner during the weekly ‘ward rounds’. Senior members of staff keep the manager and deputy updated and this information would also be shared at handover.  The contract monitoring officer was told that medication reviews are completed with a community psychiatric nurse every 6 – 8 weeks, and if this is cancelled, the manager will chase up for an alternative date.

Home maintenance

All areas of the home were kept clean and tidy and there was no malodour. It was acknowledged that the maintenance book is kept securely in the medicine room on the ground floor and contains jobs such as swapping air-flow mattress with normal, hanging a mirror etc. As mentioned previously, there is also some ongoing work around the radiator covers. 

The contract monitoring officer noted that the toilet seat in the first floor bathroom was loose and there was a potential danger of a resident slipping to the floor. 

Over the previous 12 months the building had been fitted with a new boiler, the building that is undergoing refurbishment had been fitted with new windows, the shower room on the first floor had been fitted with new flooring and a new shower door. It was also highlighted the the path outside had been repaired and work has also been carried out on the patio.

Fire safety / Health and safety

The last fire inspection was completed 27.07.22 and this had been carried out by Prevention first fire and safety services. This report contained recommendations which the manager confirmed had all been achieved.

Fire alarm tests are completed every week and fire evacuations are completed at least every year.  It was noted that the previous evacuations had been carried out on the 12th and 19th January 2023 and a comment of the debrief was also recorded. 

Manual handling plans were up to date on the two files seen and the manager also highlighted that this is also covered as part of their pre-admission assessment.

Resident’s money

Any money that comes in/out of their personal wallets held in the main office are double signed by the manager and deputy manager; if one of them is unavailable, any other staff member can countersign to confirm that the correct monies have been received or spent.

A quick audit was done on one of the resident’s finances and it was confirmed that all the receipts were available for any expenditure, and these matched what was recorded on the balance sheet, and the amount in the wallet also tallied with the balance. There was a signature missing on the sheet for expenditure the previous week.  To safeguard residents and staff, double signatories to be obtained at the time.

Staff feedback

One member of staff was spoken to as part of the visit and they explained that they support the emotional needs of residents by spending time with them and listening to them. It was stated that because one of the Resident’s had been a Welsh teacher, she had taught the member of staff some conversational Welsh, and this had a big impact on her wellbeing and the staff member then went on to do a course.

It was stated that if they saw a resident upset, they would look to try and find out what was wrong.  They would take them to a quiet space and reassure them and look to find a resolution. The contract monitoring officer asked if they spent much time out in the community with residents, and they said not very often; sometimes they may walk to the closest convenience store and back, but nothing else. Although there was evidence of some great activities taking place within the home, there wasn’t much opportunity to do things in the local area.

The member of staff did say that they have chance to sit and chat to residents and play games such as connect 4 or stickle bricks.  If there was a quiet five minutes and there wasn’t much stimulation, the contract monitoring officer was told they would lay the table or fold napkins with residents, do some singing and dancing, look at reminiscence books or read a newspaper with them.

Discussion was held around whether they felt encouraged to make suggestions about improving the quality of life for resident and the member of staff said they were encouraged and gave an example if where they were listened to and ideas taken on board by the manager.  It was also highlighted that they felt supported by the manager and explained they had started as a kitchen at the home, and they were now halfway through their level four qualification.

Resident feedback

One resident was spoken to, and they told the contract monitoring officer that they spent their day doing normal activities and sometimes went out with her daughter.  When asked about mealtimes, they responded that it was ‘ok’, and they enjoyed mealtimes. They reported there wasn’t anything they would like to eat that isn’t on the menu.

The resident said they were happy there and there was lots of company and said ‘there is always someone to talk to.  It’s like being at home’. The contract monitoring officer asked if they go out often, the response was ‘not very often, only when my daughter is able to take me. The staff aren’t able to take us out’.  They commented that the staff are good as gold, and she has a laugh with them. There wasn’t anything she could think of that she couldn’t talk to them about.

It was also commented that when she presses the buzzer, the staff always come to assist her, and she doesn’t have to wait for long periods. They mentioned that they are very nervous about falling in the bathroom, so likes to have staff nearby. No concerns were raised, and no areas of improvement raised apart from external activities.

Relative feedback

A relative was observed sitting at the table with a group of residents, and was involved in a conversation with them whilst taking part in an activity (making fruit kebabs drizzled with melted chocolate). 

They told the contract monitoring officer that they were always made to feel welcome at the home and the atmosphere was always friendly. Although the resident will occasionally still ask to come home, they are settled at Try-Celyn and they feel she is safe. Although they haven’t been invited to attend formal relative’s meetings, they said they would talk to Karen if there was a concern, and there are lots of informal gatherings where they get together, such as the King’s Coronation.

The relative told the contract monitoring officer they love the Facebook page, because even if he is unable to visit, he knows what has been going on. When asked if there was anything about the home they would change, they said there wasn’t anything. It was fed-back that all the staff go out of their way to make the residents feel at home and to give them the best possible quality of life.

General observations

It was noted that the home has a level 5 food hygiene rating, which is the highest possible. There were lots of photos in the lounge of residents, making it feel homely and personal. Staff were seen interacting well with residents and the contract monitoring officer also had opportunity to play hangman with one of the ladies.

During the lunch period, residents appeared to enjoy their lunch of fish, chips and mushy peas followed by a large variety of desserts.

There was a two week activity plan in the lounge which included activities such as balloon ping-pong, armchair aerobics, music quiz, hangman etc. Although this is flexible, it give the residents some ideas of what they could do. 

Corrective / Developmental Actions

Corrective (to be completed within three months from the date of this report)

Staff files to contain full interview records birth certificates, passports and signed contracts of employment and proof of Social Care Wales registration (from October 2022). RISCA schedule 1 regulation 35 (1) and schedule 2 Regulation 59 (8)

Personal plans are to record details of anyone involved in completing the document. RISCA version 2 (April 2019) Regulation 18

All staff to receive mandatory training on a regular basis and for this to be to be reflected in the training matrix. RISCA version 2 (April 2019) Regulation 26

Individual outcomes to be identified and recorded. RISCA version 2 (April 2019) Regulations 6, 14 and 80

End of life wishes to be held on file or where the individual is not able to or does not wish to discuss, this should be clearly dated and recorded. This is also to be discussed with the relatives where appropriate. RISCA version 2 (April 2019) Regulation 21

All files to contain completed consent forms for CCTV. RISCA version 2 (April 2019) Regulations 43 and 44

Residents that wish to access the local community to be supported to do so. RISCA version 2 (April 2019) 21, 43 and 44

Developmental

The supervision matrix to run consecutively rather than year-on-year to make it easier to confirm these were being held every quarter.

It is recommended that ex-members of staff are removed from the matrix and new starters are clearly highlighted to record when their first supervision/ end of induction session of due.

The Radiator covers in the remaining rooms to be adjusted to ensure the thermostat is accessible.

The policies around control and restraint and staff discipline to be reviewed to ensure they are kept up to date.

Where possible, interviews to be carried out by two senior members of staff.

Nominate formal dementia champions, incorporate into relevant documentation and advertise to visitors in the foyer area.

Toilet seat in bathroom 1 to be fixed or replaced.

Conclusion

The atmosphere in the home was calm and relaxed and it was lovely to observe some meaningful interaction between staff, residents, and visitors. There were no concerns in relation to the care provided at the home and it was nice to see staff taking part in an activity.  The quality of the food was good and there was a large selection of desserts to choose from.

Out of the previous 11 actions 2 had been met, 4 partially met and 5 not met, however the contract monitoring officer is confident that these will be addressed by the manager and deputy within the dedicated deadline.

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

Author:  Amelia Tyler
Designation: Contract monitoring officer
Date: 2 August 2023