Woodland Lodge

Contract Monitoring Report

  • Name/Address of Provider: Cartrefi Cwtch, Woodland Lodge, Fleur de Lys, Blackwood
  • Date/Time of Visit: Thursday 30th November 2023
  • Visiting Officer(s): Caroline Roberts, Contract Monitoring Officer, CCBC
  • Present: Clare Williams, Home Manager


Woodland Lodge is a small residential home for individuals with learning disabilities, which was taken over by Cartrefi Cwtch in January 2022. Woodland Lodge is managed by Ms Williams, the Responsible Individual is Ms Nichola Evans.

Woodland Lodge is situated in the small village of Fleur de Llys and is a detached bungalow, that can accommodate 4 individuals. At the time of the visit, the home was at full occupancy.

The monitoring officer met with the Home Manager, care staff and met three people residing at the home. One individual was in in their room being supported on the visiting officer’s arrival and had later gone out into the community.

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



All documentation was found to be stored securely.

As part of the monitoring process, two resident’s files were examined.

One file evidenced that the individual had moved into Woodland Lodge as an emergency placement. There was no pre-admission assessment due to it being an emergency.The second file contained a transitional plan.

For one individual, positive behaviour plans were observed and the manager advised that this was an active live document, regularly being updated by the manager, the local health board and the social worker, with involvement from the individual’s representative also.

Risk Assessments were observed to advise staff of triggers, how to mitigate any risks. Files contained Positive Behaviour Support plans, along with WARRN assessments (which is a formulation-based technique for the assessment and management of serious risk), epilepsy support plans.

Reviews are undertaken monthly, with the Manager undertaking 3 monthly reviews, which includes the daily records.

Both files held CCBC Care and Support Plans. The manager advised that one individual is new to the home and can display challenging behaviour and therefore, the manager works very closely with the local health board and the allocated social worker to ensure that the personal plan is maintained; therefore, providing accurate information to aid staff in providing appropriate support.

The daily records completed by staff reflected the areas set out in the personal plans. The records observed, were signed by staff and recorded how individuals are supported to meet their needs. Recordings evidence the mood of the individuals, medication, health issues, skin integrity, any visitors i.e. professionals, family. Staff also record outings/activities that the individuals undertake i.e. Christmas shopping, supermarkets, local parks, local farms etc.

Outcomes/goals were observed i.e. ensuring that an individual develops their independence, domestic chores, accessing the community and the garden etc.

The files evidenced that staff at Woodland Lodge make appropriate referrals to outside agencies i.e. Occupational therapy, Learning Disability Nurse, Consultant Psychiatrist, Dentist to name but a few.

Not all files contained a written agreement with family/representatives to be contacted in case of an emergency. This was discussed with the home manager as being good practice.

Personal Emergency Evacuation Plans were observed.

Both files held an A4 brief history of the individuals.

At the time of the visit, no individual had a DNACPR in place.

Quality assurance

The RI has responsibility of overseeing the adequacy of resources of the service and as such must produce a report on a quarterly basis (RISCA Reg 74). Also, the RI has a duty to ensure there is a system in place for monitoring, reviewing and improving the quality of care and support the service provides and should be reviewed as and when but at least every 6 months (RISCA Reg 80).

Quality Assurance Reports for March, June and September 2023 were observed. The report covers various aspects of the service and describes what the provider does best and areas that require improving. The report evidences the RI speaking with staff and residents, along with viewing documentation, training, staff registration etc.

Staffing and training

The home is staffed by 4-5 staff during the day, 3 staff in the evening and 2 staff by night (one sleep in and one awake). The home has good staff retention, who are happy to work as a team and cover any absences; therefore, agency staff are not used by the provider.

Two staff members’ files were viewed, both contained 2 written references, job descriptions, application forms, signed contract of employment, copy of a passport but no copies of their birth certificates. Photographs of the individuals were retained on file, along with appropriate training certificates. Current, clear DBS (Disclosing and Barring Service) records. Both staff members are registered with Social Care Wales.

Staff receive 1:1 supervision and this is held on a 3 monthly basis.

During the last visit, the visiting officer viewed the handwritten Training Matrix, which highlighted what training is required and when. The provider continues to use a training matrix, which highlights the required training and any additional training that has been undertaken by the staff i.e. moving and handling, food hygiene, infection control, safeguarding etc.

Training is undertaken via a number of routes i.e. e-learning, by accessing the Local Authority’s workforce development team, NHS, by an external training provider. Any gaps in training are assessed via work performance.

Life at the home

On arriving at the property, individuals were either eating breakfast or preparing for personal care in readiness to go out.

Individuals were appropriately dressed for the cold weather and the house was found to be warm. One individual had decided to remain home and assist with some domestic chores, which they enjoy doing. The individual was relatively new to the home and had appeared to have had settled in well, making new friends and being observed as having a good relationship with the staff.

Activity Planners were observed to be in place; however, these are open to change, depending on the individuals’ preferences, mood and perhaps the weather.

Individuals are offered a choice of food, which is ordered online, and are offered alternatives should the individual not wish to have what is on the weekly menu. Staff also take into account, any individual that may have food allergies. All meals are home cooked.

The property enjoys a lovely garden and is surrounded by friendly neighbours.

One bedroom was observed during the visit, with the permission of the resident. The room was clean and tidy, and personalised with family photographs, ornaments, items recently purchased from the shops etc.

The home currently has no individual that communicates in the medium of Welsh. When asked how the Active Offer is being implemented, the Home Manager advised that they would learn basic Welsh language to communicate.

With regards to food hygiene, as previously reported, an inspection was undertaken in May 2022 and rated as three (generally satisfactory).


All individuals residing at the home have access to and use of a hoist, should this be required. Bath slings are insitu and all residents have been assessed for their use. Hoists are serviced every 6 months by Cymru Healthcare, wheelchairs are also serviced.

Risk Assessments and Moving & Handling Plans allow the use of the equipment to be used in the correct manner and supports the staff providing the support.

The wheelchairs used, all have foot plates and safety belts.

General internal checks are undertaken by the Home Manager and staff and local electricians undertake PAT testing. Appliances are insured and therefore, should any equipment become faulty, it is replaced.

Health and Safety

There were no accidents/incidents reported in the last month.

The last fire assessment was completed in July 2023 via Inferno. Advisory recommendations were made and undertaken.

Fire drills are undertaken and recorded appropriately.

Complaints and Compliments

Should individuals require external support to convey their wishes and feelings, the provider will request the appointment of an IMCA (Independent Mental Capacity Advocate).

With regards to the new resident, contact was made with the social worker in order to obtain feedback with regards to support provided. The social worker advised that “There's been a massive improvement in X’s well-being since moving into Woodland Lodge. X is overall happier, gone from not eating/drinking to having a very healthy appetite.

I find the home very forthcoming with any information/concerns. They are reliable, great when it comes to communication and take any of our concerns seriously and respond appropriately. Overall I'm really happy with the progress X has made and the support afforded to her from the house.

Manager and Staff Questions

During the monitoring visit, the visiting officer spoke with four members of staff in general, and asked standard questions which form part of the monitoring process.

Staff demonstrated that they had a good knowledge of the people they support, their likes and dislikes, how situations are managed should an individual display challenging behaviour etc.

Staff advised that the two newer residents are younger and on occasion can display challenging behaviour that they have, as staff members, had to adapt to. They advised that they enjoy the role and learning new skills to support the individuals who may display challenging behaviour in the home or out in the community.

It was positive to note that all four residents, are accessing the community much more, and are experiencing new environments etc.

Staff spoken to were very complimentary about the manager of the service and advised whatever the individuals want or need, they have.

With the residents that have communication difficulties, the staff demonstrated that they communicate by knowing the individual’s facial expressions, body language etc.

During the previous monitoring visit, the visiting officer was advised that the staff team would be treated once a month; however, it has since been requested by the staff team that this be changed to six monthly. It is evident that the management team continue to promote the health and wellbeing of the staff team.

When asked how they would challenge a colleague if they felt practice was poor, staff members advised they would share the concerns with the Manager.

The visiting officer also spent time with the Manager to discuss the running of the home. The Manager advised that the home does not have CCTV and had no concerns regarding the property i.e. equipment being used (hoists, washing machine), hot running water etc. All equipment was in good working order at the time of the visit.

The owners have and continue to work on the property, without causing any major disruption to the residents. The outside of the property has been painted and plans are in place to replace the flooring. The lounge area has been re-decorated and provides a more homely feel for the residents.

The Manager and the RI meet every Monday at Woodland Lodge and the RI will also visit the sister home on a regular basis.

All DoLs (Deprivation of Liberty Safeguards) renewal applications are up to date.

Policies and procedures were viewed by the monitoring officer including the provider Statement of Purpose.

Corrective / Developmental Actions

Corrective actions

None identified.

Developmental actions

For a photo / social media consent form to be put in place, evidencing permission has been sought for taking photographs and including them in any form of social media.

Whilst no one has a DNR in place, it is suggested that there is evidence that DNACPR discussions have been held with individuals or family/representative.

For individuals who have family/representatives supporting them, a written agreement is put in place regarding being contacted in case of an emergency.

The Home Manager to collate any compliments received and to share them with the Local Authority.

Any regulation 60 notifications submitted to the regulator to also be copied to CCBC Commissioning. (CCBC Contract).


The home environment is slowly being modernised/up-dated and the atmosphere at Woodland Lodge was found to be warm, relaxed, and welcoming.

A new resident has moved in since the last monitoring visit, and they appeared to have settled in well.

Staff were observed to interact well with the residents, and all appeared to be relaxed in each other’s company.

It was positive to note that during the first day of monitoring, at one point of the day, all 4 residents were out in the community, undertaking activities they enjoy.

As a provider, Cartrefi Cwtch are continuously looking for ways to improve the service and the environment for the individuals that reside at the property.

Monitoring will continue to take as planned, and the monitoring officer would like to thank all involved for the welcome given at the home.

  • Author: Caroline Roberts
  • Designation: Contract Monitoring Officer
  • Date: 15 January 2024