Partnership of Care

Contract Monitoring Report

Name of Provider: Partnership of Care, Alexander House, Colliery Road, Llanbradach, Caerphilly, CF83 8QQ
Date of Visit: Thursday 23^rd March 2023
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 25 different properties throughout the borough, which accommodate individuals who have learning disabilities and/or mental health difficulties.

It was not necessary to visit each property in the borough as some did not have any tenants funded by Caerphilly CBC. The office and all properties with Caerphilly tenants were visited in 2022 and it has been agreed that half would be completed in 2023 and the remaining half in 2024.

Individual reports will be completed for each property and this report will focus on the findings at the main office in Alexander House.

Depending on the findings within this report, the Manager will 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.

The previous visit to the main office was completed on Thursday 5^th May 2022 and at this time there were 7 corrective and 5 developmental actions identified: these were reviewed, and the findings are outlined in section 2 below.

Previous Recommendations

Personal plans to be drawn up with the involvement of the tenant (wherever possible) or their representative. This was originally highlighted 29.04.16. RISCA version 2 (April 2019) Regulation 35 Met. It was acknowledged that the personal plans seen were person-centred and was written in the first person with lots of ‘I’ statements. The contract monitoring officer was given a copy of an activity schedule for one of the gentlemen supported in one of the homes: this gave clear examples of what he does/not like to do, such as watching quiz shows, planning holidays, using public transport etc. It was a useful document that provided detail around where to park, if busy times of day should be avoided, what could go wrong, and what the desired outcome is. Various activities carried out during the month are then broken down into tables at the back of the document e.g., pub lunch, walking, preparing food/baking, shopping etc. to assist the keyworker to compile the monthly 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 Partially met. It wasn’t possible to evidence this during the visit to the office, as the signed copies were held at the individual properties. Further to the visit, the contract monitoring officer saw three signed personal plans, however, there were also some that hadn’t been. Where the tenant is unable to sign and doesn’t have an appropriate representative or lacks capacity, this should be clearly recorded, signed by the staff member, and dated.

The registered manager to ensure a policy is in place in relation to the commencement of a service. RISCA version 2 (April 2019) RISCA regulation 14 Not met. This was forwarded to the contract monitoring officer following the visit.

Mandatory training to be up to date for all employees and the matrix updated accordingly (RISCA regulations 35 and 36) Partially met. Training matrices were provided for two of the supported living properties: it was not possible to determine if some of the courses were still in date as the spreadsheet only recorded the year rather than the full date the course was completed. It is recommended this be updated to ensure the same format is used to record the full date. There were some gaps noted on the matrix which were mainly new starters, however there was a staff member that commenced employment in August 2022 and had not completed training around positive behaviour management (practical), autism, eating and drinking or first aid.

Positive consideration to be given to involving people using the service in the recruitment process RISCA version 2 (April 2019) regulation 35. Not met. The contract monitoring officer was told that this is carried out where possible, even if this is only a conversation with the tenants after they have met the candidate to gain their feedback. It was not possible to complete this action as there was no evidence of this being implemented.

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 Partially met. Only one of the two staff files seen contained birth certificates. Discussion was held around members of staff refusing to pay to replace lost certificates and the contract monitoring officer advised this be discussed with the support worker, recorded, dated, and signed to verify the responsible individual has taken all appropriate action.

Photographs of employee to be available on file. RISCA version 2 (April 2019) Schedule 1 part 1 (1) Met. Photos were present on both staff files seen during the visit.

In order to evidence the 'active offer' all tenants and/or representatives to be given a copy of the survey asking which language they would like to converse in, and this be retained on file. Not met. There was no evidence on file or in the personal plans that the individuals had been given the option to converse in Welsh.

Compliments to be clearly dated and the relationship with the person being supported. Not met. It was not possible to determine how many compliments were received over the past year, however, it was acknowledged in the quality of care report July-December 2022 said there had been 5 compliments but didn’t provide any detail. Following the visit, copies of 5 compliments were shared with the contract monitoring officer, primarily around the succeed of the parent’s evening held on the 30th March. None of these had been dated. Although there was a lovely compliment from an OT around the progress the person has made since being with Partnership of Care, there were no other notes on the other compliments indicting the relationship. It was agreed the template would be amended to capture this information.

The provider to be more pro-active in getting feedback from social workers and other visiting professionals. Met. It was noted that the contract monitoring officer had been emailed a copy of the survey to request feedback on the service, and during the visits to the properties there are signing sheets for visitors in the individual properties which prompts any comments or feedback to be passed onto the service manager.

Interview records to be completed fully and contain the name(s), dates and designation of the staff conducting the interview. Met. Both interview records had been clearly signed and dated by the interviewer.

Contracts of employment to be signed by manager and employee. Partially met. One of the contracts of employment had not been signed by the support staff.

Desktop audit

It was noted that CIW had completed an inspection at the beginning of March 2023, and although the report had not been published at the time, it was stated that no concerns had been raised. The responsible individual explained that no formal complaints had been made since the previous visit.

The training, supervision and appraisal matrices were all provided upon request. As mentioned in 2.4 there were some gaps identified in mandatory training. All supervisions and appraisals were up to date for the current calendar year, with the exception of staff that were either on maternity leave or long term sick.

Responsible individual

A copy of the statement of purpose was provided which was dated 2023; this highlighted the flexibility of the packages of care offered and their core values around person-centred care. At the time the document was completed, there were 320 support workers, some of which were on part time contracts.

The responsible individual is also the registered manager of the service and the contingency plan, if they were unexpectedly absent for a longer period, would be for the five service managers to carry out the role between them with support from the administrative team.

It was acknowledged that policies and procedures were in place in relation to all mandatory areas such as safeguarding, infection control, finances, medication, complaints, whistleblowing, etc. however, as highlighted in section 2.3. A copy of the policy in place around the commencement of service was shared following the visit. There was no policy observed for staff discipline.

Tenant information

As mentioned previously, The Partnership of Care has 25 supported living properties with the Caerphilly borough and owns all of them apart from one.

Discussion was held around whether the tenants are contractually obligated to the support provider in terms of keeping their tenancy and the responsible individual confirmed they weren’t: if the tenant wanted a new support provider, they would be assisted to find another organisation.

All referrals to the provider are made either through health or social services. It was highlighted that the selection process involves reading through the referral, looking at whether they can meet their needs and then consider the vacancies and compatibility with existing tenants. Trial periods are used to introduce staff and clients and visits are gradually increased until everyone is ready for the new client to move into the property. Although there is no probationary period, the contract monitoring officer was informed there is a ‘settling in’ period.

Personal plans

Neither of the files viewed contained a compatibility assessment form, however it was acknowledged that both individuals had lived at the property for numerous years before the current legislation was implemented.

Only one of the files contained a CCBC care plan and it was explained that the other tenant’s plan would be at the property. To maintain consistency and evidence the plan written by Caerphilly is aligned with the personal plan, it is good practice to maintain a copy on the file held at the office.

The personal plan viewed was personalised and outcome focussed: there was detail on the front page of who helped to write the plan, what the client is proud of, what is important to them i.e., maintaining a clean home, having a regular staff team, having a shower every evening with support from staff. It was noted that the plan did not provide detail in relation to what assistance was required: it is recommended that detail be provided about whether this is a verbal prompt, how many staff are needed, if staff were expected to help reach difficult areas etc.

Only one of the two personal plans had been signed, but the contract monitoring officer was advised that the copy held at the home had been signed.

Personal outcomes documents were provided for two clients: These provided individual goals that are important to the person being supported such as having a varied diet, taking part in activities they enjoy but can sometimes be reluctant to participating in and for staff to be able to remove themselves once he is settled. It was noted that one of these documents had not been signed or dated and the second had been completed 16.02.23.

Manager’s questions

The registered manager is also the responsible individual and they advised that they have regular contact with the staff and clients at the properties and is always available at Alexander House. The contract monitoring officer was told that feedback from clients and stakeholders is sought both formally and informally. There was a parents evening planned for the following week, and it was explained this would be used as an opportunity for parents to network, provide feedback on the service to date, and to obtain their views of the support being provided.

It was explained that the responsible individual was aware of the advocacy services available to the clients, but there was nobody that required this service at the time of the visit.

Discussion was held around the repairs and maintenance of the properties, and the responsible individual explained they have their own maintenance team that have a list of any work required at any of the properties, and if there are any issues, these are addressed appropriately. An example was provided of a conversation the contract had with one of the parents last year in relation to one of the homes that was dealt with immediately.

Although there was no evidence on file to show those being supported had been asked if they wished to communicate in Welsh, it was explained this is carried out informally. The contract monitoring officer was told there were four members of staff and one tenant that speak Welsh. One of the service managers said they try to team the Welsh speakers up with this person and text messages are also done in Welsh.

The quality of training is assessed via the evaluation forms provided by the trainer and if there were any issues, this would be highlighted in the team meeting. Supervisions are also used as an opportunity to look at any training needs and if there were any issues with the training arranged. It was noted that The Partnership of care use a consistent training company who they have worked with for a long time and work closely with to ensure the needs of the people supported are met. The contract monitoring officer was told the administrator runs end of month reports to inform the responsible individual and the service managers of any training gaps or courses due for renewal.

Complaints and compliments

It was pleasing to note that examples of compliments had been received both from family members of clients and visiting professionals. It was also acknowledged that the service is much more proactive in using this feedback to identify any areas for improvement.

As highlighted in section 2.9, staff need to ensure that any concerns or compliments are clearly dated along with the relationship to the client; this will assist the registered manager when completing the quarterly quality assurance reports.

During the visit one of the clients was observed asking to speak to the responsible individual about something that was worrying her, and this was addressed and resolved immediately. It was noted the person being supported was reassured and left the meeting feeling much happier. The contract monitoring officer was told that where possible, tenants will often approach one of the service managers or registered if there is anything they want to discuss, and there is also an easy read version of the complaint’s procedure. Staff and parents will both advocate of behalf of any individuals that are not able to express their views verbally and assist them to address any complaints.

Where appropriate, staff will be notified of any complaints during house meetings and team meetings. An example was given of ensuring the mobility car was kept clean: all staff at the home were made aware of the expectation to leave the car clean and tidy, as they would wish to find it. If there was a more serious concern, this would not be shared until any appropriate investigation had been carried out.

At the time of the visit, the contract monitoring officer was told that no practices had need to be changed because of any complaints.

Staffing information

The responsible individual stated they use the Social Care Wales Induction Framework, and this contributes to their level 2 qualification and registration, this was evidenced on the training matrix provided for Ty Nant and Pengam Road. The training received is evaluated during supervision sessions, buddy books for new starters, shadowing and shift monitoring forms which are held on file.

Due to there being over 300 support staff employed by The Partnership of Care, it was acknowledged that it is very difficult to manage, and check from an overall perspective, how many staff haven’t completed certain mandatory courses, or which are due for renewal. AT requested a copy of the report for any outstanding courses and this had not been received at the time of the report being completed.

Mandatory training has been completed by most support staff, such as medication, first aid, infection control, safeguarding and food hygiene. Catheter and stoma care training is also provided, but only for staff that work with individuals who require this support. Non-mandatory training is also held around autism, positive behaviour support, and intensive interaction.

Two staff files were reviewed that had started in November 2022 and January 2023: both contained application forms, job descriptions, interview records, contracts of employment, copies of passports, photos, training certificates, and evidence of DBS checks. There were no unexplained gaps in employment and there was a separate sheet which documented full employment history and a rationale for any breaks.

One of the files contained an incomplete reference; it is recommended that the previous employer be contacted, and a clear record held on file to ensure compliance with regulations.

It was acknowledged that both interviews had only been carried out by one interviewer: discussion was held with the responsible individual that it is good practice for there to be a minimum of two interviewers in the event the outcome be challenged. It is noted that it is difficult to free two members of staff to do this but would be done where possible.

A copy of the supervision and appraisal matrix was forwarded, and this evidenced that staff had completed either an appraisal or supervision session since the beginning of 2023. The matrix clearly recorded new starters and those that were on sick leave. The responsible individual explained that supervisions are completed as a formal 1:1 session at least every 3 months and appraisals annually.

Over the previous 12 months, it was highlighted that 18 staff had left the organisation and 23 had been recruited. It was also stated that there were 4 support staff on maternity at the time of the visit.

There is an on-call system in place for staff to contact a senior member of staff that is monitoring on a rolling-rota system. There are 10 managers that have the mobile phone 1 day a week and 1 in every 3 weeks. The contract monitoring officer was told that the on-call manager will speak to each of the homes to check everything is ok and what training is being held the following day.

Corrective / Developmental Actions

Corrective actions (to be completed within 6 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

The registered manager to ensure a policy is in place in relation to staff discipline. RISCA version 2 (April 2019) RISCA regulation 14

Mandatory training to be up to date for all employees and the matrix updated accordingly (RISCA regulations 35 and 36)

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

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

The incomplete reference should be addressed to ensure fitness of staff. Regulation 35

Policies to be put in place for commencement of service and staff discipline. Regulation 12

Developmental Actions

Training matrix to use consistent format to record full dates training was provided.

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

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.

Contracts of employment to be signed by manager and employee.

Conclusion

There were no concerns raised in relation to the support provided and everyone spoken to demonstrated a thorough knowledge of the individuals they support. The tenants feel confident in being able to speak to the responsible individual about any concerns, and this was observed during the visit. The tenants can be transparent and are encouraged to voice anything that might be bothering them.

It was evident that a lot of effort has gone into making the documentation outcomes focussed and making the entire service as truly person centred as possible. The monthly reports completed demonstrate that the individuals are worked with to carefully plan what is important to them and what needs to be done to achieve their goals.

Staff appear to feel confident, flexible, and valued and are committed to their roles and the people they support. From the conversations held, the documentation viewed and the statement of purpose, there is a core value of maximising the quality of life for the tenants.

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: 19 April 2023

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