Glen Court

Contract Monitoring Report

• Name/Address of Provider: Glencourt, 54 Hillside Park, Bargoed, Caerphilly, CF81 8NL
• Date of Visit: Monday 27th November 2023
• Visiting Officer(s): Amelia Tyler: Contract Monitoring Officer, Caerphilly CBC
• Present: Jacqueline Scammell:  Home Manager, Achieve Together

Background

Glencourt is a residential home for individuals with learning disabilities and is owned and run by Achieve Together, a registered provider within Caerphilly. The new contract for the provider was completed and signed in September 2022.

The previous visit was completed on the 11th October 2022 and at this time there was one corrective and five developmental actions highlighted.  These recommendations were reviewed, and the findings are outlined in the next section of the report.

At the time of the visit there were four clients living at the property, and one vacancy.  Three clients had been supported to move by Caerphilly CBC and one by a neighbouring authority.

Dependant on the findings within the report, corrective and developmental actions will be given to the provider to complete. Corrective actions are those which must be completed (as governed by legislation), and developmental actions are good practice recommendations.

Previous Recommendations

Personal plans to evidence the involvement of the individual and/or appropriate representative.  Where signatures cannot be obtained, this should be clearly recorded on the document.  RISCA version 2 (April 2019) Regulation 15 Partly met. One of the personal plans had been signed by an appropriate representative, the second one did not evidence why the person was unable to sign or if anyone else had been asked to sign on their behalf.

Consent forms to agree to the taking and sharing of resident’s photos and signatures to be obtained from appropriate representatives, or refusals clearly documented. Not met.  Consent forms were seen following the visit and although these recorded that the individuals were unable to sign and had been dated, there was no evidence of appropriate representatives being asked or if advocates had been asked to sign on their behalf.

The doorbell to the property to be repaired or replaced. Met.  This was working at the time of the visit.

It was recommended the manager chases up her electronic registration with Social Care Wales. Met.  It was noted that the manager was on the Social Care Wales register but was down under a different authority.  It was recommended that the manager chases this up to ensure she is registered under Caerphilly.

The manager to consider implementing DisDAT (Disability distress awareness tool) to assist staff in recognising any signs that the client may be in pain. Not met.  It was stated that the manager has not implemented the DisDAT as the information was already held on the PRN protocol which outlines any signs that support staff need to be aware of that may indicate the individual may be in pain or discomfort.  Copies of the PRN protocol were shared with the contract monitoring officer following the visit.  This action is no longer required as the information is available on file.

Agreement to be implemented with relatives about being informed of any incidents. Partly met.  There was an agreement in place on one file stating that the relative should be contacted in any event.  It was explained that this needed to be more specific i.e. would they want to be contacted at any point during the night if the person had a fall?  The form must clearly stipulate the circumstances and when they would want to be notified and be signed and dated by the relative.  It was observed that the second resident didn’t have a next of kin and the duty team would need to be informed. 

Findings from Visit

Desk top audit

There had been one concern raised within the past six months which was in relation to a medication error.  This had been appropriately reported, investigated, and addressed by the provider.  The last inspection carried out by the Care Inspectorate Wales was on the 19th September 2023 and no priority action notices were given and the areas of improvement identified were around personal plans not being reviewed every three months and no there being no evidence of involvement in the production or review of risk assessments and personal plans.

It was reported that no complaints had been received by the provider or commissioning team apart from the issue mentioned previously.  There wasn’t a service user guide at the home but there was a service user agreement which contained pertinent information.

As previously mentioned, the home manager is registered with Social Care Wales.  The appraisal matrix was provided which evidenced that one support staff was on maternity leave and there were four new starters that were not yet required to complete this.

At the time of the visit resident files were being held securely in the office which is kept locked when not in use.

Responsible individual

The quarterly regulation 73 reports were last carried out on the 28th April and 28th July 2023 and these recorded efforts made to speak to members of staff and relevant stakeholders.

A copy of the statement of purpose was seen that was last reviewed on the 28th July 2023 and it was acknowledged that this hadn’t been updated to reflect and increase in the number of beds available to five.  It was also noted that although this must be reviewed at least once a year, the next planned review date wasn’t noted; it is recommended this be added to the document to highlight that regulatory requirements are being met.

All mandatory policies and procedures were seen such as referral, admission and discharge, safeguarding, infection control, medication, whistleblowing, and client finances.  All policies and procedures were clearly dated on the electronic system and documented the next date for review.  Two were to be reviewed every four years and the others were every three years.  The manager explained these ae completed by a central team.

The responsible individual visits the home at least every three months to carry out the regulation 73 visits and the auditor also visits to ensure that the documentation is updated appropriately.  If the responsible individual and home manager were both absent unexpectedly for a period it was stated that major incident protocol would be implemented, and the tasks would be carried out between the deputy manager and regional manager.  It was stated that this arrangement is outlined in the major incident protocol.

File and documentation audit

The contract monitoring officer was told that all client files are stored securely as the office is kept locked when not in use.  There were no initial assessments on either of the files seen, but it was explained that the two residents had lived at the property for many years, and these would be completed for any new admissions.

Personal plans were held on each file, and these were personalised and contained detail to ensure all staff are aware of the needs and preferences of the people they support.  The contract monitoring officer noted that under sexuality it recorded ‘not applicable’.  The contract monitoring officer explained that the staff should record what they know e.g. have they previously had any relationships?  If this isn’t known and they haven’t expressed any tendencies, this should be documented.

Appropriate risk assessments were seen on file that related to the person’s needs such as bathing, finances, self-harm, keys, medication, accessing the community etc.  It was acknowledged that these had been carried out every three months and the previous ones had been completed in July and September 2023.  These were outcome focussed on what the provider calls the wheel of engagement and refers to personalised goals and ambitions.  There were a lot of photos to evidence various activities and events and meeting up with other clients from other properties.  The contract monitoring officer noted that one of the risk management plans was referring to another resident rather than the person who’s file was been looked at; it appeared the information had been cut and pasted.  Staff to be mindful that all the information recorded in the review refers to the correct individual.

It was discussed that the outcomes must be developed to focus on what the objective is and how the client should be feeling, and this should be aligned with the National Outcomes Framework

There was evidence of referrals being made to medical professionals when needed such as a medication review being carried out for one lady to remove any medication that was no longer required, dental and podiatry appointments etc.  It was noted that the previous month’s reports were considered when completing reviews.

Staffing and training

It was noted that a member of the bank staff had failed to turn up on the day of the visit which left the team short.  It was noted that there were two support staff and the manager on duty.  Staff absences are covered by a pool of staff within the company and in an emergency they can contact the on-call duty manager for the house.  

The manager reported that they rarely use any agency staff, and they hadn’t needed to utilise this since the beginning of the year.

Training is primarily e-learning from within Achieve Together although face to face training is provided around first aid, manual handling, and positive behaviour strategies.    It was explained that the quality of training is evaluated through questionnaires and evaluations.  Training is also assessed through spot checks, medication competency assessments, recordings, observations, and supervisions.

At the time of the visit there were no staff that regularly worked more than 48hours a week.

Discussion was held around the Welsh language and the active offer to ensure everyone is given the opportunity to speak Welsh; the manager stated that all residents are asked during the initial assessment which language they would like to converse in or be spoken to.  This could not be evidenced as these weren’t available on the files viewed.  The contract monitoring officer was informed that there were two staff members at Cwm Hyfryd that could speak some Welsh and there is a small Welsh saying handbook in the manager’s office that is accessible to staff.

The electronic records showed that the competency of training around safeguarding, first aid, medication awareness, fundamentals of care, challenging behaviour, dementia, and autism were all 100 %, Manual handing was 80%, food hygiene was 91%, and infection control was 91%.  It was acknowledged that this was mainly due to two members of staff being on maternity leave and the new starters.  Overall, the manager said that the home was 95% compliant with the service specific training.  The manager will ensure that all staff are up to date at the earliest opportunity.

Non-mandatory training was noted to include asbestos, diabetes, prevention of over medication, oral health, nutrition, and legionella.

Two staff files were seen, and these contained at least two references, one of which being a professional reference.  Application forms, job descriptions, interview records, birth certificates and passports were also present.  It was pleasing to note that the interview records evidenced that both staff members had been interviewed by two senior staff.  The gaps in employment had been explained and there were also photographs available as required.  One file contained a signed and dated contract of employment, but the second one had only been signed by the HR department; it is good practice to ensure all documentation is clearly signed and dated by both parties.

There were valid DBS checks available and it was noted that these were all clear and there were also completed induction checklists that had been completed in 2022.

Training certificates were not held on file, but these were stored electronically

Supervision and appraisal

There were four new starters that had not yet had their annual appraisal and there were two that were on maternity leave, but all other staff were recorded as having completed this on the matrix.

It was acknowledged that one support staff had commenced employment on the 29th August and had not yet had a supervision and there were two gaps where supervisions had not been carried out every three months, but all other employees had attended a supervision session apart from the two that were on maternity leave.

It was noted that one in every four supervisions was observational to give the supervisor opportunity to watch the employee in practice and the fourth was their appraisal.  It was explained that the supervisions and appraisals are a two way conversation where the employee has the opportunity to reflect on their own practice and if there are any areas for the service to improve.

The contract monitoring officer was told that the supervisions for night staff were completed between the manager and deputy manager between them.

Approach to care / observations

No concerns were raised in relation to the appearance of the residents, and it was noted that one of the gentlemen was wearing a Christmas jumper.  All residents were dressed appropriately and smartly. 

All areas of the home that were seen were clean, tidy, and free from odour.  The contract monitoring officer acknowledged that no concerns were highlighted in relation to the health and safety or comfort of the property.  There was also evidence of personalisation such as furniture, photos, etc.

Three members of staff were present during the visit, and they all demonstrated a thorough understanding of the support needs and tastes of the people living there.  There was a rapport between the staff and residents and the contract monitoring officer took part in a game of catch with a staff member and resident.  The deputy also demonstrated the magic table which is an interactive projector with a resident.  The language used by staff was discussed with the manager as at times this could be viewed as authoritative when the residents became repetitive.  Staff to be mindful of their approach and terminology towards the residents.

Although there is a routine for resident’s meals, it was reported that they are able to decide what and when they want to eat and during the visit it was observed that one gentlemen was eating later than the others as they had gotten up later and often takes longer to eat his meals.

The manager reported that residents are encouraged to eat healthy, balanced meals and although they can choose what to eat, one of the ladies will often choose a salad.

It was noted that the residents are not able to help with food preparation but one of the ladies will take milk and butter from the fridge when asked.  All residents take it in turns to do the food shopping for the week with support from staff.

If there were any concerns about the needs of the residents changing, staff would refer to the care management team and speech and language therapist if needed and ensure families are informed if appropriate.

Residents can let staff know what they want to do using gestures or picture cards.  Staff use the personal plans and preferences to offer choice.  The manager explained that they often don’t mind where they go as long as they are going out somewhere and there were lots of photos available that reflected the various activities they taken part in as a home and as a larger group such as the Halloween party.

Mobility aids and equipment

There were no residents needing equipment that were waiting to be assessed to get the necessary aids.  It was explained that one gentleman has a wheelchair that was purchased by his family that is only used for long distances and the manager said the social worker was in the process of contacting the occupational therapy team in relation to their mobility.

There was no evidence seen to confirm that staff were carrying out visual checks on the wheelchair to ensure the safety of the resident.

Managing resident’s money

It was reported that two staff members sign for every transaction incoming and outgoing; if the manager and deputy manager are both on shift, it would usually be them that would sign the sheet.  If not, it would be the person handing the money in and a staff member of duty.

The home uses a ‘bag and tag’ safety system where a new numbered tag is used every time the wallet is opened, and the new number is clearly recorded on the sheet.  It was explained that any purchases other than food that is over £50 must be authorised by the manager (or deputy if the manager isn’t available).

A record sheet and wallet of personal monies was checked, and it was noted that all receipts were present for expenditure and the balance matched what was recorded.

Managing medication

Medication audits are completed every month by Boots and there are also internal spot checks.  It was explained that the home manager does monthly audits and the most recent one was on the 30th October 2023 and at this time the home was 100% compliant and there were no actions required.

No medication was being administered covertly and the contract monitoring officer was informed that one resident had to have their medication in liquid form due to difficulties in swallowing tablets.  Medication is held securely in lockable cabinets in the resident’s rooms.

Health and safety

There is no accident and incident book at the home, and it was reported this is held on the electronic Radar system which was seen during the visit.  It was noted that a near miss had occurred in July where a large branch from a tree in a neighbouring property had fallen onto the drive and was reported to the maintenance team.  There was an allegation against a member of staff by a resident in October 2023 that was investigated by the manager, and this was deemed unfounded as there were other members of staff present and no opportunity for this to have occurred.  There was an incident recorded between two residents and there was no evidence of any harm coming to either individual.  In November there was a fall by a resident where they fell over a curb and had been supported to hospital to be checked and there were no injuries sustained.

There were no trends identified or any preventative measures required, however it was noted that there was a risk management plan in place around behaviours and making complaints which had been reviewed on the 4th October 2023.  The manager emphasised that although there is a history of making allegations, all concerns are acknowledged and addressed thoroughly to safeguard the people being supported.

Evidence was provided of the last fire risk assessment being completed by a fire safety consultant Essential Safety Ltd on the 8th November and the overall rating for the home was moderate. There were twelve actions highlighted and it was stated that work has already started to complete the necessary work.

The previous fire drills were completed on the 8th September 4th October and 4th November 2023 and there recorded who was involved, target time, actual evacuation time and room for comment of how well the drill went.  The manager told the contract monitoring officer that all staff had taken part in a fire drill over the past year.

Complaints and compliments

All compliments and complaints are recorded on the electronic system and the manager audits this every month.  This information is fed back to staff in a 1:1 meeting if there was an issue raised in relation to a particular staff member or if it was a more general issue, this would be shared with the team during a team meeting and the outcome recorded on Radar.  Compliments and concerns would also be shared with the team in the communication book if appropriate and any learning opportunities are shared with the other home managers in the manager’s meetings.  If there were any safeguarding reports completed, these can also be shared anonymously between the managers.

It was explained there were no practices that had to be changed because of any issues or concerns raised.  Over the past year, the manager said there had been no compliments received, but if there were any, these would be clearly dated for the responsible individual to record in their regulation 73 report and shared with the commissioning team.

Advocacy support is available, and this was primarily sourced through a Responsible Person Representative (RPR) where there is no family input, and this is primarily around management of their finances.  The manager also explained there is support provided through the care management teams.

The home environment

There is no designated smoking room at the property, and it was stated that none of the current resident’s smoke.  Any staff that wish to smoke are expected to do so outside in a covered area at the top of the drive.

Resident bedrooms were seen to have been well decorated and contained personal items and sensory lamps.  There were photos of residents in the communal areas which made it feel more homely.

It was highlighted that there are locks on bedrooms, one of the resident’s bedrooms that has capacity to use this if desired and the downstairs toilet.  It was highlighted that the current residents do not have capacity to carry their own set of keys and there are risk assessments in place to cover this.

Over the previous year they have changed what was the activities room into a bedroom with en-suite facilities, there are trees that have been cut down and new fencing erected.  A new washing machine and tumble dryer had been purchased and the greenhouse had been removed.  It was noted that the garage roof is due to be repaired.

Staff questions

One member of staff was spoken to and they reported that they knew where all documentation was held and they were made aware of when there were any update and changes.  It was explained that the communication book was also used to inform staff of any documentation that needed to be read.

The contract monitoring officer was informed that the manager spends time with staff and residents and talks to every resident each morning.

Discussion was held around one resident, and the member of staff was asked what was important to them and what would a new starter need to know on their first day supporting this person.  It was highlighted that she had improved recently since her medication had been reviewed and her mobility had improved.  They explained that if she doesn’t like something she will show it in her facial expression and hand it back to you.  The contract monitoring officer was told that she needs to be given time and encouragement to make her own decisions.

There are people living in Glencourt that have communication difficulties and it was highlighted that it is important to get to know the people and their individual ways of making their wishes and feelings known alongside what is documented in the personal plans.  The member of staff said that they always talk throughout any personal care and tell them what they are doing at each stage and watch them for any signs such as if the water is too hot or cold.  One of the residents was described as relaxed and easy going with plans and support staff know what his preferences are when discussing any activities.

It was reported that they felt they could be flexible in their role and had chance to just sit and talk to residents, play a board game, do a jigsaw puzzle, colouring, crafts etc.  If there was a spare five minutes where there wasn’t much stimulation the member of staff said they would ask if the residents wanted to go for a short walk, get the beach ball out, or just have a chat with them.

Discussion was held around whether they were encouraged to offer suggestions about how to improve the quality of life for the people living there and they said they were and felt that residents were being supported to do a lot more now.

The staff member explained that if they witnessed any poor practice or something they felt was wrong they said they would address it with them immediately and escalate with the manager.  They demonstrated an understanding of the safeguarding policy and felt confident in being able to take this forward to the relevant team if the manager or deputy weren’t present.

They informed the contract monitoring officer that they were consulted about the general running of the home during the monthly meeting and felt that any feedback is taken on board.

When asked, the member of staff stated they were able to identify any training needs and that the current training provided is appropriate to enable them to fulfil their role.  It was commented that the only improvement that could be made to the service would be more staff.

Registered manager questions

The registered manager said they manage the one service and that they have planned and unannounced visits that are complete by the responsible individual and the auditor.

There is no CCTV at the property, and it was stated that there are no issues regarding anything at the property, although it was felt that the new tumble dryer that had recently been installed was making a lot of noise and needed to be looked at.

It was explained that the residents don’t have capacity or ability to be able to amend the temperature in their bedrooms, so this has to be monitored by support staff.  There are window restrictors in place, but they can be opened if it is felt the rooms are becoming too hot.

It was noted that there were no outstanding regulation 60 notifications to be forwarded to the Care Inspectorate Wales, but the manager was aware that if required, these would be shared with the commissioning team.

Recent referrals had been made recently for one resident to the podiatrist and another one had ben referred for a follow up appointment with their surgeon.  It was explained that all DoLS (deprivation of liberty safeguarding) referrals were up to date, and they were just waiting for an assessment to be completed for one gentleman.

Support staff do encourage community participation, and this can be through local walks, coffee mornings, taking them to a beautician to have their nails done, hairdressers, barbers, shopping, or going out for a meal.  The contract monitoring officer was told that due to communication difficulties, it isn’t possible to involve the residents directly in the interview process with new staff, but they do get to meet the potential candidates so that existing staff can observe their interaction.

Resident feedback

The current residents at the home lack capacity to be able to understand the information requested and/or unable to give a verbal response.  It was decided that the contract monitoring obtain feedback from a relative and social worker who had been involved with the residents.  The social worker explained that the gentleman who moved into the home recently has settled in well and appears comfortable.  The family have been complimentary and there is lots of evidence of stimulation and a variety of activities.  It was reported that there are plans to go and see a pantomime in the coming weeks.  No issues had been raised with the social work team and there were no areas for development highlighted.

It was reported that even though the relative hadn’t able to visit the home recently because they hadn’t been well the home was in regular contact and had kept them updated with everything.  The contract monitoring officer was told that staff have a good understanding of the person’s need and preferences.  It was explained that their relative goes out for drives with staff but appears to feel the cold more as they are getting older.  There appears to be lots of stimulation and the relative commented they felt the individual had a good quality of life.  Discussion was held around development, and it was highlighted that they couldn’t think of anything that could be improved apart from the fact there had been quite a high turnover of staff.

Corrective / Developmental Actions

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

Personal plans to evidence the involvement of the individual and/or appropriate representative.  Where signatures cannot be obtained, this should be clearly recorded on the document.  RISCA version 2 (April 2019) Regulation 15

Personal plans not to record ‘not applicable’ under any of the headings, particularly in relation to sexuality.  RISCA version 2 (April 2019) Regulation 15

The statement of purpose to be updated to reflect the increase in the number of beds and to include the next review date.  RISCA version 2 (April 2019) Regulation 7

Supervisions to be completed every three months.  RISCA version 2 (April 2019) Regulation 36

Developmental actions

Consent forms to agree to the taking and sharing of resident’s photos and signatures to be obtained from appropriate representatives, or refusals clearly documented.

The manager to contact Social Care Wales to ensure she is registered under Caerphilly authority.

Clear agreements to be in place with relatives or representatives detailing which circumstances they would want to be informed of any incidents and be signed and dated.

Risk management plans not to be cut and pasted and be specific to the person it refers to.

Contracts of employment to be clearly signed and dated by both parties.

Conclusion

The atmosphere at Glencourt was relaxed and homely and it was noted the residents appeared content in their home.  There were some areas for improvement that had been noted internally and it was evident these were being addressed.

There were no concerns raised during the monitoring process, although the contract monitoring officer did discuss with the manager that staff are to be mindful of the terminology used towards residents and the techniques used when clients become repetitive.  All feedback received from external parties was complimentary and it was pleasing to see that they had so many events and activities available to them to encourage interaction and wellbeing.

It was observed that the staff team work closely together and demonstrated a thorough understanding of the needs and preferences of the people they support and there appeared to be a culture that wanted to provide the best quality of life for those being supported.

The contract monitoring officer would like to thank everyone that has assisted with the process and the time and hospitality shown by everyone at Glencourt.

The contract monitoring officer will follow up the recommendations informally in approx. three months’ time.  Unless it is deemed necessary to be carried out beforehand, the next formal monitoring visit will be completed in approx. twelve months.

• Author: Amelia Tyler
• Designation: Contract Monitoring Officer
• Date: 18th December 2023