Cefn Glas

Contract Monitoring Report

  • Name/Address of Provider: Pobl
  • Name of Extra Care Service: Cefn Glas
  • Date of Visit: 23rd January 2024 - office visit, 24th January 2024 – visiting tenants
  • Visiting Officer(s): Caroline Roberts, Contract Monitoring Officer
  • Present: Linda Craven, Registered Manager / Lesa Mabbitt, Scheme Manager


Cefn Glas is a purposed built building, situated in Blackwood. Pobl is the provider that provides support and care to some of the tenants residing at the property.

The range of care and support tasks undertaken by Pobl under the contract includes personal care (e.g. assistance in bathing, washing, dressing, medication intake, toileting), nutritional care (e.g. assistance with eating and drinking, food and drink preparation, and food and drink intake monitoring), mobility care (e.g. assistance with getting in and out of bed, general movement), and domestic care (e.g. assistance with cleaning, shopping, other housework, arranging appointments). Staff are on site at all times, and people living at Cefn Glas are able to contact them at any time through the use of a call system, Tunstall.

Dependent on the findings within the report, the provider will be given corrective and developmental actions to complete. Corrective actions are those which must be completed (as governed by the Regulation and Inspection of Social Care (Wales) Act or the CCBC contract), and developmental actions are good practice recommendations.

The last monitoring visit was undertaken in November 2023, during which Corrective and Developmental Actions were noted:


Detailed information to be recorded in the personal plans around agreed goals/outcomes, how these are identified, supported, and reviewed. RISCA version 2 (April 2019) regulations 15, 18 and 21 and Service specification for Provision of an Extra Care Service Timescale: Immediate & Ongoing. Partially Met.

Staff to evidence in daily recordings that skin integrity is being checked as in line with the care plan. (Reg 21 RISCA) Timescale: Immediate & Ongoing. Met.

Developmental Actions

For consideration to be given to staff printing names on daily logs due to some signatures being illegible for auditing/inspection purposes. Not met – some signatures were still illegible for the visiting officer.

All Risk Assessments to be signed and dated by the Assessor. Met


Registered Individual (RI) and Registered Manager (RM)

Pobl’s Statement of Purpose was shared with the Monitoring Officer and stated that it was last reviewed in October 2023. It is recommended that the document is reviewed at least annually or when changes occur. The Statement of Purpose provides the reader with detailed information as to who manages the scheme, the range of needs that can be supported by Pobl, how a service is provided to individuals, staffing, facilities, governance, and monitoring arrangements.

The RI works closely with the RM, the Assistant Directors and the Director of Care.

In terms of contingency plans for management cover, Pobl would report both instances to Care Inspectorate Wales, if they were to be absent for more than 28 days. In the RI’s absence, the Assistant Director of the area would cover parts of the RI role with support from Pobl’s Safeguarding Lead. If an RM were to be absent, Pobl would use other RM’s in the area to support with the workload, and if this absence were to be for an extended period, Pobl would recruit for a temporary RM position.

Information received from the Assistant Director, Older Peoples Service, evidenced that Policy and Procedures were up to-date with a schedule in place for any renewals.

CCTV continues to be insitu at Cefn Glas; with appropriate signage informing individuals/visitors. However, it is not in place within individual tenant’s flats.

The service has no Welsh speaking staff or tenants. However, as an organisation, Pobl has Welsh speaking employees who would assist should Welsh be the chosen medium of communication. The provider is also able to provide bilingual documentation / signage in the medium of Welsh.

The RI undertakes Regulation 73 visits on a quarterly basis in order to check the quality and compliance of the service; therefore, the RI visits services within the Gwent Partnership area. The last four quarterly reports were shared with the visiting officer. The reports were observed to be detailed and during the visits, the RI continues to speak with individuals living at the services and, also family members. Reference is made to the quality surveys that were issued and the feedback received, medication errors, safeguarding concerns and their outcomes, falls, audits, inspections, the RI looks at staff supervisions, Personal Plans and personal goals/outcomes, staff retention etc.

Should there be any areas of concern, recommendations are made by the RI and these are to be acted upon within a timely manner.

The scheme manager advised that she felt supported by her RI and there are scheduled dates for the RI to visit the scheme.


Prior to the monitoring visits, the monitoring officer had not been informed of any concerns or complaints about the service being provided by Cefn Glas.

During the monitoring visit, three tenant files were viewed.

At the time of the visit, out of the three files viewed, only one held a pre-admission assessment, this is because the one individual had resided at Cefn Glas for a number of years and therefore, the documentation had been archived. With the second, the Team Leader advised it had not been printed.

Information is shared with the scheme, via the Local Authority and its Care and Support Plan. The plan describes what assistance and support the individual will require with i.e. mobility, personal care, medication. Their likes and dislikes are also noted. It will also include personal information about the individual including life history etc.

All three files were observed to have had the information from the Local Authority Care Plan transferred over to Pobl’s Personal Plan. The information was detailed and written in the first person, with two individuals signing their plan, which evidences that they had taken part in its development. One individual is unable to sign, and it was positive to note that this was documented throughout the file.

Both files also evidenced that the individual’s were given the opportunity to provide their preferred call times, and these matched the logbooks when observed.

Both files held a one-page profile on the individual, which outlined areas such as ‘what people appreciate about me’, ‘what am I good at’, what is important to me’ and ‘how to support me’ etc. This provides the reader with appropriate knowledge to commence a conversation with the individual and put them ease.

Personal Plans were observed to be detailed and written in the first person. The personal plans were broken down into each call, outlining how to enter the flat, how the tenant wishes to be greeted, how to provide support for that particular call, their individual preferences. It was recorded that one tenant likes to rush through the calls; however, staff are to remind the tenant that there is time and there is no need to rush.

At the time of the visit, both files evidenced that timely reviews had taken place, however, it is recommended that more evidence is required to demonstrate that the individuals have been involved in the review process.

Appropriate Risk Assessments were observed for two files observed i.e. interim Moving & Handling plans, Medication, Epilepsy.

The monitoring officer read 2 weeks of daily records for three tenants. Staff were noted to record what support is provided or declined and all records were observed to be dated and signed, with no gaps identified.

During the last visit, support workers were observed to be signing the daily logs, and some signatures were not always legible. For auditing purposes, it was requested that the scheme manager request staff to print their names. This remains ongoing as during this monitoring visit, some signatures remained illegible.

Whilst comparing the planned times agreed by the individual to those recorded in the daily records, it was observed that the planned v’s actual were overall consistent for the tenants receiving support. Some calls were observed being slightly earlier than scheduled for one individual; however, there were no concerns raised in respect of this by their representative.

The Daily Records are collected weekly by the management team at Cefn Glas and audited for any inaccuracies or errors. Details are checked i.e. medication times, Tunstall calls, length of calls etc. Once the audit has been completed, the team member will sign the weekly logs to evidence an audit has taken place and this was observed during the visit.

A Handover book is insitu and any issues are recorded in the book i.e. any tenant requiring additional medication, falls, new tenants etc. There is also a book that records all Tunstall calls and a white board that highlights those tenants who are in hospital and any changes that staff need to be made aware of.


Some individuals are assisted with medication, and this is undertaken in line with Pobl’s Medication Policy. Individuals sign an agreement should they wish to be assisted with their medication. Whilst viewing two separate MAR chars, a gap was noted on one. This was discussed with the scheme manager and team leader.

Call Monitoring

The scheme has a handover folder in place and during handover of shift, any issues recorded within the documentation is discussed with those coming on shift i.e. any concerns from the previous shift, requirement for more medication, any falls, new tenants.

The visiting officer was advised that within the last 12 months, there had been no missed calls.

There is an on-call system place. Staff hold work mobiles and individuals can summon assistance by using the Tunstall system. Staff will advise the office should they be late to a call and in turn individual tenants are advised. The Team Leader advised that all office staff continue to be on hand to offer assistance when required.

The Team Leader audits planned calls against actual to ensure times are consistent for the tenants receiving support. Should it be apparent that there be a trend that staff are spending more time with an individual or less time, then individual cases are discussed with the allocated social worker to either increase the time or make a reduction. Such matters will be discussed with the tenant in order that they remain informed.

A member of staff is on site at all times, including a sleep-in shift at night.

It is important that carer consistency is maintained and whilst viewing the daily recordings and the rota’s times for staff members, it was noted that consistency overall is maintained and within the Local Authority’s contractual threshold.

Staff Files

Two staff files were viewed during the monitoring process, both files held 2 written references. Only one file held a job description, detailed application forms (neither of which had gaps in employment), and both held interview records. Whilst there were no written exercises or scenarios, it was noted that Pobl use a scoring system when interviewing.

Individual Contracts of Employment are held at Head Office within the Human Resources department; therefore, these were not observed by the monitoring officer. The files held photographs of the individual staff members. Both files also held Disclosure and Barring Service certificates, with no issues raised.

Evidence of staff have a meaningful shadowing process and being signed off by the mentor, was observed by the visiting officer. Staff members were quality checked in respect of their time keeping, uniform, interaction with tenants, Moving & Handling, Infection Control and completion of the individual daily logs.

Spot checks continue to be undertaken on a regular basis unless there are areas of concern.Should concerns be raised/highlighted, the spot checks are increased.During the spot checks, uniforms, completion of documentation, IDs, disposal of continence products, Moving and Handling equipment, interaction etc. are observed, with feedback recorded.

Staff supervision was observed to be up-to-date and undertaken every 3 months or sooner if any concerns.1:1 supervision sessions are held with staff, during which, various topics are discussed i.e. problems with calls, annual leave, sickness, trigger points, learning and development, competency assessments, any personal issues etc.

The training matrix was observed and was found to be up-to-date for all mandatory training i.e. Moving and Handling, Infection Control, Food Hygiene, Safeguarding, First Aid, with staff undertaking additional training to meet the needs of the individuals they support i.e. professional boundaries, Mental Capacity, working at height, cyber security to name but a few.

In the last twelve months, two staff members have left the organisation for new careers.

RISCA, Regulation 38 states that Regular staff meetings take place (a minimum of six meetings per year), are recorded and appropriate actions are taken as a result. Team meetings were observed to be undertaken on a regular basis, with a variety of items on the agenda i.e. Daily records (logbooks), DNR’s, tenants, reviews with other professionals, hospital admissions, call times etc.

Staff Members Feedback

As part of the monitoring process one member of staff was spoken to and a series of questions were asked.

The staff member advised that they felt they have sufficient time to provide the care they are required to provide and felt that the rotaring system works well.

The staff member advised that they felt supported by their supervisor and advised that they have worked at the scheme for the last 5 years.The staff member felt they had an appropriate induction, shadowing and training, with appropriate documentation in the individual flats.They advised if they had any doubt in what support was required, they would ask the office staff for advice and guidance.

When given the option to provide any other comments, the staff member advised that “it is a great company to work for”.

Tenant Feedback

Four tenants were interviewed as part of the monitoring process and a series of questions were asked of each tenant.

One tenant eagerly showed the visiting officer their artwork, which is also displayed throughout the scheme building.The individual advised that if carers are late to support him, it is usually because someone else needs help.The tenant advised that he had settled well and had been living there for 6 years and wished he had moved there sooner.

None of the four individuals spoken with had raised a complaint.

All four individuals advised that cares give them an opportunity to make their own choices. The carers always show confidence when supporting the tenants, and the visiting officer was informed that they always have time to chat with the individuals when supporting them.

ID is worn by support staff and all four individuals advised that the care staff treat them with dignity and respect. For the majority of the time, the individuals stated they have the same care staff.

Comments made about the scheme and the support staff were “Fab, can’t praise them enough”, “staff are brilliant, they can’t do enough for me”, “love it here, would recommend to anyone”, “I love it.I have my own space and we’ve had some really good concerts here, Elvis, 1920s themed night, fish and chip evening, bingo, coffee mornings, quiz night”, “thrilled he’s there, he seems settled and happy there”.

It was evident that after speaking with the individuals at the scheme, they are happy residing at Cefn Glas.


The environment of Cefn Glas was found to be inviting and welcoming. The communal areas were noted to be clean and tidy with no malodours or hazards observed during the time of the visits. However, at the time of visit, the scheme had experienced a leak from the roof, which has caused some damage just off the reception area. This is currently being addressed by the scheme’s manager and Pobl’s maintenance team.

The atrium continues to look inviting, and the residents and family members continue to utilise the area in warmer weather.

The flats visited were spacious, clean and homely. Individuals had their personal items on display i.e. family photos, individually chosen d├ęcor and some individuals displayed small ornaments on their windowsills outside in the corridor.

The commissioned catering team continue to work with the manager to try and meet all the requirements of the individuals that utilise the restaurant. Any problems are relayed to the scheme manager and both parties work in partnership to resolve matters.

Corrective and Developmental Actions


Pre-admission assessments are to be signed by the assessor and dated. (RISCA Reg 14).

For staff reviewing documentation to evidence the participation of the individual/representatives and to evidence what documents have formed part of the review i.e. daily logs, social worker, family member(s). (RISCA Reg 15).

Ensure all MAR charts are completed fully. (RISCA Reg 58).

For staff to have a job description on their individual file (RISCA Reg 38).

Developmental Actions

For pre-admission assessments to be printed and retained on individual’s file.

For staff to consider the terminology they use when completing the daily records.

The service is reminded to copy in the Local Authority Commissioning Team with any Regulation 60’s submitted and also any Duty To Report forms submitted.


The flats at Cefn Glas continue to be very welcoming and maintained to a high standard, with the tenants visited being proud of their flats. The Housing Manager continues to play an active role, with the Scheme Manager, to ensure there are activities held and that communal areas are inviting for both tenants and family/friends.

The Contract Monitoring Officer would like to thank the tenants and the staff at Cefn Glas for their hospitality during the visit.

  • Author: Caroline Roberts
  • Designation: Contract Monitoring Officer
  • Date: 28th February 2024