PRESS Tir-y-Berth
Contract Monitoring Report
- Residence: 3 Woodside, Tir Y Berth
- Name/Address of Provider: Press, Festival House, Victoria Business Park (S), Ebbw Vale NP23 8ER
- Date of Visit: 20th July 2023
- Visiting Officer(s): Ceri Williams, Contract Monitoring Officer, CCBC
Background
3 Woodside is a large, detached bungalow situated in Tir-y-Berth, close to all amenities. The property is registered to provide personal care and accommodation for up to three adults with learning disabilities. At the time of the visit there were two people living at the home with one vacancy.
The previous monitoring visit had been carried out in January 2020. This is the first monitoring visit since the Coronovirus pandemic and previous recommendations have not been taken into account.
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 etc.), and developmental actions are those which are deemed good practice to be completed.
Findings from Visit
Documentation
Personal plans viewed were detailed and person centered and included sufficient detail for staff to support residents in achieving outcomes. The residents personal plan contained all the care and support needs identified in the CCBC care and support plan.
There were suitable risk assessments in place to meet individuals care and health needs. There was a particular risk assessment relating to one of the residents health needs that had been written by health colleagues. This contained detailed information regarding the risks associated with and managing the specific health need for the individual. It was recommended that a read and sign sheet be added for staff to ensure they have read and understood the risk assessment.
Documentation on file referred to specific exercises provided by Physiotherapy for one individual however, there was no reference of the exercises in the individual personal plan and no information in daily recordings as to whether they had been completed.
There was evidence of personal plans being reviewed every three months as required by legislation. However, there was no evidence of the individual being involved in the review of their personal plans. Risk Assessments are reviewed annually, as these form part of the personal plan for an individual, risk assessments should be reviewed every three months to ensure they still accurately reflect the risks associated with providing support.
Individuals are supported with routine medical appointments and evidence was also available of referrals being made to outside agencies regarding the health and well-being of individuals.
Interests, activities practical skills and details of personal care are recorded daily on ‘Keeping Track’ records to evidence resident’s outcomes are being achieved.
Activities
Activities are planned with the individual and their key worker and in consideration with personal preferences. An activities timetable is in place however, this is dependant on the individual and their choices. Evidence was available of residents regularly accessing the community for shopping, meals and activities such as attending shows and rugby matches. Staff also advised that they had recently sourced an activity that one resident used to attend before the pandemic, and they were hoping to re-start the activity soon.
Medication
Medication for all residents is kept securely in a looked cabinet in the staff office. Medication Administration records viewed evidenced that medication was administered correctly for the current month. Medications are counted daily after each administration and management carry out audits weekly.
Nutrition
The residents are involved in choosing the menu when deciding what they would like to eat are always offered a choice. All residents are involved in visiting shops to purchase the shopping for the home and are also encouraged to help with food preparation. A healthy diet is ensured by supporting the residents to choose healthy options where possible and by monitoring weight gain and loss.
Health & Fire Safety
Any accidents or incidents are recorded, and senior management informed. A number of weekly and monthly audits are carried out to ensure health and safety compliance. Evidence was available of fire drills being completed and are recorded including a list of participants.
Staff Recruitment, Supervision & Training
Two staff files were viewed as part of the monitoring visit. All necessary recruitment documentary evidence was available on file including proof of identity, references from previous employers, evidence of DBS checks, application forms and contracts of employment.
A staff training matrix was provided which evidenced that staff had received training in mandatory and non-mandatory courses. However, the majority of staff had not received training in Infection Control or Safeguarding of Vulnerable Adults.
It was also noted that the majority of staff had not received or needed refresher training in a particular medical condition which one of the residents has a diagnosis of, despite this being recommended in the risk assessment provided by the health board.
A staff supervision matrix was also provided and evidenced that staff receive regular supervision with their manager within the timescales set in regulations. Supervision documentation showed that supervision sessions were meaningful and gave both staff opportunity to discuss their role, development, progression of actions from previous sessions and any other support that may be required.
Annual Appraisals were also viewed and were comprehensive documents providing the opportunity for feedback on a range of areas related to performance and development.
Quality Assurance
The last two Responsible Individual visit reports were provided. These records evidenced that the visits to the service are being carried out by the RI in a timely manner and included feedback from residents and a number of checks carried out at the service and also any actions to be completed following the visit.
Two quality of care reports were also provided and were being completed within timescales set in regulations. The most recent report followed the template recommended by the regulator and was detailed including actions for improvement and development.
Environment
There have been significant improvements carried out within the property since the last visit, including re-decoration, new flooring and new furniture. The home is decorated in a homely manner and is comfortable and accessible for the residents that live there. Photographs of the residents enjoying activities are displayed and also arts and crafts created by them.
One of the residents bedrooms was viewed whilst visiting and was found to be newly decorated, clean and personalised. The resident told the monitoring officer that he had been involved in the re-decoration of his room choosing colours and furnishings.
The property was free from malodours and hazards throughout.
Staff Feedback
A member of staff was able to give feedback regarding working at the home during the visit. They advised that they enjoy working at the home and feel supported within their role. Staff displayed good knowledge of the residents they support. Staff advised that access the community daily with residents but also have time to sit and talk to residents, and do not feel restricted by tasks and routines. They felt able and encouraged to make suggestions regarding the general running of the home and able to identify their own training needs through supervision.
Resident Feedback
The resident spoken to for feedback advised that he was happy living at the home and got on well with staff and the other people who lived there. He advised that he was feeling well and discussed activities that he had enjoyed that week and activities that were planned for him in the future.
Corrective Actions
The Personal Plan to include all care and support needs identified and actions required to meet the individuals well-being and how they will be supported to achieve outcomes.
The Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA) Regulation 15.
Reviews are undertaken involving the individual and, where appropriate, with the agreement of the individual, their representative. RISCA Regulation 16.
Risk Assessments (as part of the overall Personal Plan) to be reviewed at least every three months. RISCA Regulation 16.
All staff to receive training in Infection Control. RISCA Regulation 56.
All staff to receive training in Safeguarding of Vulnerable Adults. RISCA Regulation 26.
All staff to receive training as specified in the risk assessment relating to an individual’s medical condition. RISCA Regulation 36
Developmental Actions
There were no developmental actions identified at this visit.
Conclusion
It was a positive visit to the home, the first after the pandemic, and was pleasing to see improvements achieved in the refurbishment of the home. The individuals living at the home were happy and content in the company of each other and staff. Staff were knowledgeable and positively interacted with the individuals they support. PRESS are encouraged to ensure staff receive the relevant core and specialist training to enable them to fulfil the requirements of their role, and meet the needs of the individuals they support, as soon as possible. The monitoring officer would like to thank residents and staff for their hospitality during the visit.
- Author(s): Ceri Williams
- Designation: Contract Monitoring Officer
- Date: 12 September 2023