Partnership of Care

Contract Monitoring Report

Name/Address of Provider: Partnership of Care, Alexander House, Colliery Road, Llanbradach, Caerphilly, CF83 8QQ
Date of Visit: Wednesday 20th and Tuesday 26th March 2024
Visiting Officers: Amelia Tyler: Contract monitoring officer, CCBC
Present: Janine Darling: Responsible individual, Partnership of Care

Background

The Partnership of Care has been providing supported living services within Caerphilly Borough since 2006. The organisation offers tenancies in twenty three different properties throughout the borough (three of which provide respite care). The properties accommodate individuals who have learning disabilities and/or mental health difficulties.

Some of the properties did not have any tenants funded by Caerphilly CBC or were funded through the local health board. Individual reports are complete for each property at least every two years and the main office in Alexander House every year.

The last visit to the main office was completed on 23rd March 2023 and at this time there were fourteen actions identified: eight corrective and six developmental. These actions were reviewed, and the findings are outlined in section below.

Depending on the findings within this report, the provider 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

Service plans to be signed by the tenant or representative. If the tenant is unable to sign, the reason for this should be clearly recorded. RISCA version 2 (April 2019) Regulation 35. Partially met. One of the plans had not been signed by the tenant or representative and there was no explanation on file for this.

The registered manager to ensure a policy is in place in relation to staff discipline. RISCA version 2 (April 2019) RISCA regulation 14. Met. This was seen as part of the visit.

Mandatory training to be up to date for all employees and the matrix updated accordingly (RISCA regulations 35 and 36). Met. Although there were some gaps identified, all mandatory training had been completed on the matrices provided.

Positive consideration to be given to involving people using the service in the recruitment process RISCA version 2 (April 2019) regulation 35. Partially met. It was explained that this has been considered and is encouraged where possible, although some clients are reluctant to be actively involved and other clients are unable to verbalise their questions. There was no evidence of these conversations being held.

Birth certificates to be held on file for all members of staff. RISCA version 2 (April 2019) Regulation 59 and Schedule 2, part 1 (8) b. Met. These were seen on the files viewed.

To evidence the 'active offer' all tenants and/or representatives are to be given a copy of the survey asking which language they would like to converse in, and this be retained on file. RISCA version 2 (April 2019) Regulation 24. Not met. There was no evidence seen that clients had been asked their preferred language / method of communication.

The incomplete reference should be addressed to ensure fitness of staff. RISCA version 2 (April 2019) Regulation 35. Met. It was noted that there was a full reference held electronically for the member of staff raised during the previous visit.

Policies to be put in place for commencement of service and staff discipline. RISCA version 2 (April 2019) Regulation 12. Met. These were provided as part of the monitoring process.

Training matrix to use consistent format to record full dates training was provided. Met. It was acknowledged that this had been implemented since the previous visit.

Where possible, interviews to be carried out by two senior members of staff. Met. One of the staff files viewed evidenced that the staff member had been interviewed by two senior members of staff and it was stated that this is implemented where practicable.

It is recommended that personal plans provide detail around what level of support is required to provide personal care. Partially met. One of the personal plans explained what the gentleman was able to do independently, but it was highlighted that a new starter would not know whether to leave the bathroom, wait outside or support them throughout their routine.

Staff to ensure outcome focussed documents are clearly signed and dated on completion and each review. Partially met. Two outcome focussed reports were seen and one had ben signed by a service manager for the period February – April 2024. The contract manager advised that reports should not be signed ahead of time and should date the document on the date of completion rather than just the period it refers to.

Compliments to be clearly dated and the relationship with the person being supported. Not met. It was not possible to evidence this during the visits.

Contracts of employment to be signed by manager and employee. Met. These had been signed by the new member of staff and administrative officer.

Desktop audit

There had been five referrals to safeguarding over the previous six months and the contract monitoring officer acknowledged these had been appropriately addressed and raised with the required teams, investigations carried out where required and any necessary action taken to minimise risk where possible.

No concerns or issues had been raised by the care management teams and no enforcement notices issued by the Care Inspectorate Wales. The last inspection carried out by the Care Inspectorate was in November 2023, and at this time there were no areas for improvement identified.

It was explained that there had been no formal complaints made, but the responsible individual said that any smaller issues that weren’t put in writing were dealt with as quickly as possible and resolved within the home.

The training, supervision and appraisal matrices were all provided upon request. The findings are highlighted later in the report. The staff rota for one of the properties was provided for a two week period for one of the homes and this evidenced there were a minimum of seven staff on duty during the day and five waking night staff.

Responsible individual

Quarterly regulation 73 reports were seen during the visit, and it was noted that due to the number of properties, this is a big task for the responsible individual to carry out. It was acknowledged that efforts are made to speak to the clients, staff, and relatives as part of these reports, however, it was also observed that the responsible individual is approachable and present within the service and staff and clients see her informally on a regular basis and wouldn’t wait until the formal meeting to raise any concerns or issues.

A copy of the six monthly regulation 80 report was also provided for June – December 2023 and this documented that twenty three compliments and one complaint had been received and whilst these weren’t elaborated on, it was noted that these were incorporated into the areas for development at the end of the report.

The statement of purpose was provided which was dated 2024 and included the name of the new service manager that started in December 2023.

It was noted that there is a strong management team within Partnership of care and if the responsible individual was absent for more than 28 days, the Care Inspectorate Wales and the commissioning team would be informed via a regulation 60 notification. The contingency plan if one of the managers was absent at the same time as the responsible individual, the role and necessary duties would be undertaken by the remaining four service managers and seven deputy managers with support from the administrative officer.

All policies and procedures were seen, including admissions (suitability of the service), safeguarding client finances, restraint, staff training, staff discipline, infection control, medication, complaints, and whistleblowing. It was observed that the suitability of the service policy was last reviewed on the 22nd April 2022 and documented the planned review was within twelve months. The training policy was also overdue as the policy reflected the review was due on or before the 17th January 2024.

Tenant information

The responsible individual explained they are both landlord and care provider in all properties, but the people being supported are not contractually obligated to the provider as part of their tenancy agreement. If any clients expressed a wish to have a different provider support them it was stated that a referral would be made to the appropriate assessment care management team to look as sourcing another organisation.

Individuals are only referred to the provider through the care management team and the tenancy selection process includes reading through the care plan from the local authority, completing an initial assessment with the person, and carrying out introductions and compatibility assessments with staff and the other tenants living at the property.

It was noted that there is a six week transition period after which a review is carried out to consider how the placement is going. The contract monitoring officer was informed that client and staff files are held securely at the office, there is a lockable cupboard with a key code for client files and staff files are held in a lockable cabinet. Discussion was held around the documentation, and it was stated that they are in the process of going digital which will reduce costs and enhance security and accessibility for support staff.

Personal plans

Two files were looked at during the visit and it was acknowledged that neither contained initial assessments. Both files contained care and support plans and reviews that were reflected in the personal plans.

It was acknowledged that the personal plans were person centred and outcome focussed. There were goals outlined including doing household tasks without prompting, walking more, and what their likes and dislikes are. The personal plans included activities they enjoy and what is important to them. It clearly outlined what they were able to do independently and what support they need from staff. There were monthly quarterly outcomes reports on file, and as previously mentioned, these should not be completed ahead of time.

Risk assessments were available around topics such as epilepsy, activities, behaviour, and house keys. The contract monitoring officer noted that there was a risk assessment in place for not understanding what is real or imaginary, however, this was not included in the personal plan. The second file also had a risk assessment for arthritis and mobility, and this had also not been included in the plan.

There was evidence that personal plans had been coproduced; one had been signed by the person as they had capacity to understand and agree to the contents, and although the second plan had not been signed, it did record that the gentleman had been involved in compiling it along with the service manager and staff team. It was suggested that an advocate be considered for this gentleman if there are specific decisions to be made.

Evidence was held on both files to demonstrate that reviews of the personal plans and risk assessments are carried out at least quarterly and in some cases were completed monthly. It was recorded on one activity timetable that the person likes to go to Chapel twice a week; however the plan had left the section for his religion and the church they attend blank. The contract monitoring officer recommends these sections are completed. It was pleasing to note that it says they like attending Church for a cup of tea and to meet their friends and they would be supported to attend a christening, funeral or wedding if invited.

Manager’s questions

It was stated that medication audits are carried out every month in addition to medication counts that are completed on handover and weekly checks by the duty manager. The responsible individual said that covert medication is administered to some people they support who are funded by continuing healthcare. These are all authorised, and a plan written up which is usually by the learning disability nurse.

The medication procedure is in place to manage stock and ensure that repeat prescriptions are ordered with sufficient time. Medication training and assessments are competed by all staff prior to them being signed off as competent. Any liquids are carried out based on the size of bottle and the number of doses in the bottle to be able to predict when it needs to be ordered.

Feedback from clients and stakeholders is obtained through the regulation 73 visits questionnaires and the visitors’ books in each property. It was also observed that the responsible individual is very present at the day service and makes every effort to make herself available to the clients who often wish to talk to her as part of their routine. The service managers are also approachable and accessible and work closely together as a team.

As part of the discussion, the contract monitoring officer was told that no changes had been required as part of any feedback received, however, it was highlighted that they are looking to nominate a mental health champion for the staff team for an employee to attend a two day course and may consider implementing coffee mornings once this had been carried out.

At the time of the visit there were two people that had been appointed an advocate and these were both individuals supported by the local health board. The responsible individual also explained that the social worker for another tenant was looking into advocacy for them.

The provider owns the properties and employs a maintenance team to carry out any necessary work. Service managers complete a report every month outlining any work that is needed and this goes through to the administrative officer who then creates a job list based on urgency i.e., if there are any health and safety issues.

If a situation arose where there was a dispute between tenants, then meetings would be arranged with these individuals to investigate the concern and try to find a resolution. If the matter was more serious then consideration would be given to holding a multi-disciplinary team meeting, and as a last resort, alternative accommodation would be sought in line with the tenancy agreement.

The contract monitoring officer was told that in the scenario where a staff member was having trouble with a tenant then they would look at possible training, intervention and support and conflict resolution and if the issue hadn’t been dealt with then the support staff would be given the opportunity to work in another property.

Classroom based and eLearning is used by the provider, and it was noted that there is a large training room at Alexander House to allow numerous staff to attend the same sessions. It was explained that the trainer has a good understanding of the needs of the clients and can deliver bespoke training where needed.

The quality of the training is assessed as the responsible individual goes through the course objectives with the trainer to ensure that all topics are covered. It was also noted the responsible individual is trained to deliver training. Evaluation forms are provided to obtain feedback and there are regular manager’s meetings that are used to discuss any ongoing training.

Although there are some staff that regularly work over 48 hours a week and have opted out of the working time directive. The service managers are mindful when completing rotas not to allow excessive hours as this could impact on their wellbeing and efficiency.

There was nothing on file to evident the active offer in relation to the Welsh Language was being made available. The contract monitoring officer was told that a survey was being sent out to tenants that can verbalise their wishes to ask which language the wish to communicate in and that anyone who uses British Sign Language or Makaton will also be noted. There was nothing recorded in the personal plans to highlight their preferred language or method of communication.

Existing tenants are not always part of the recruitment process as some individual’s do not have capacity to participate, some are unable to verbalise their questions and there are also some that have declined the opportunity. It was explained that some have been involved in the interview process or been asked if there is anything they want the staff to ask the candidate. The responsible individual stated that they will continue to ask they if they would like to take part in the interview and the contract monitoring officer said that this should be recorded on the interview notes, even if the offer has been declined.

The responsible individual has a thorough understanding of the safeguarding legislation and their responsibility to report any situation where there has been harm caused or any evidence of neglect. If they were unsure whether there has been any abuse, the contract monitoring officer was told they would contact the safeguarding team for advice. If there was a serious matter, they would contact the police.

Complaints and compliments

A copy of the easy to read tenants guide was seen which incorporated details on how to make a complaint. If one of the clients raised a concern, they would be supported by a member of staff to put this in writing to the service manager. This would be discussed with the responsible individual and a letter of receipt would be sent out within five days and a full investigation to be completed within twenty days. As with the safeguarding policy, if the matter was around anything to do with abuse or neglect, this would supersede the complaints policy.

The outcome of any complaint would be put in writing to ensure the matter had been concluded and a full audit trail is held on file with any lesson learned. If the complaint isn’t anonymous, the complainant would be written to explaining the outcome of any investigation and if this was from a tenant, the letter would be put in a suitable format and a member of staff would discuss the findings with them.

Staff are informed of any complaints as part of the manager’s meetings and staff team meetings (if appropriate). Following a safeguarding report staff were reminded of confidentiality and their responsibility to maintain the privacy of the people they support. The contract monitoring officer was told they always try to be proactive and use any concerns as a way of developing and improving the service provision.

Compliments are also shared with the staff team through the electronic system ‘deputy’ and a team nominated to be team of the month.

Staffing information

The provider uses the All Wales Induction Framework and there was a certificate in place to evidence this for one member of staff, but not for the staff member that started in 2017. As previously highlighted the training is evaluated by the staff team and the application into practice is monitored through team meetings, general observations, supervisions, and questionnaires.

All mandatory training is provided, including manual handling, food hygiene, safeguarding, infection control, first aid, medication, positive behaviour management, and communication. Additional training is also provided around autism, Buccal, mental capacity, eating and drinking.

Two staff files were viewed, and both contained two references (one of which was from their most recent employer), application forms, interview records, complete employment histories, signed employment contracts, photographs, training certificates, evidence of DBS checks (both of which were clear). Only one of the files contained a birth certificate and it was pleasing to note there was a statement in place that was signed by the employee explaining this had been lost. Only one of the files contained a passport.

The contract monitoring officer noted that supervisions were carried out at least every quarter. All staff had attended an annual appraisal and although these weren’t clearly indicated on the supervision matrix, the responsible individual said these were done every April or May. It was suggested that these be marked as being an appraisal.

Over the past year, it was stated that 94 employees had left the organisation, and this represents 29% of the whole staff team. The contract monitoring officer noted there was only one member of staff on long term sick leave. Eighteen staff had been dismissed and fourteen had found new jobs. There was also an on call duty rota in place between all senior managers and this is flexible.

Corrective / Developmental Actions

Corrective actions (to be completed within 3 months of the date of this report)

Service plans to be signed by the tenant or representative. If the tenant is unable to sign, the reason for this should be clearly recorded. RISCA version 2 (April 2019) Regulation 35.

Positive consideration to be given to involving people using the service in the recruitment process. RISCA version 2 (April 2019) regulation 35.

Initial personal plans to be completed prior to the person moving to the property, unless done as an emergency. RISCA version 2 (April 2019) Regulation 15.

Personal plans to include risks to the individual and others. RISCA version 2 (April 2019) Regulation 15.

Developmental actions

It is recommended that personal plans provide detail around what level of support is required to provide personal care.

Staff to ensure outcome focussed documents are clearly signed and dated on completion and each review.

Compliments to be clearly dated and the relationship with the person being supported.

The suitability of service and staff training policies to be reviewed in line with the provider’s requirement.

For the service manager to complete the blank sections in the personal plan for the individual that has expressed a wish to attend Chapel.

It is good practice to keep a statement on file that is signed and dated by the employee if they have not provided a copy of their passport.

Conclusion

It was acknowledged that out of the previous fourteen recommendations, only two had not been met and there were only eleven actions highlighted from this report.

The service is client led and there was clear evidence that staff had a thorough understanding of the needs and preferences of the people they support. The service is proactive is obtaining feedback and makes efforts to improve where any areas are highlighted.

There is good communication within the staff team and the managers are approachable and make every effort to work closely with the people they support.

The contract monitoring officer would like to thank the responsible Individual and the service managers for their time, assistance, and hospitality throughout the entire monitoring process.

Author: Amelia Tyler
Designation: Contract Monitoring Officer
Date: 26th April 2024

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