Blue Bird Care

20 Commercial Street, Pontypool, NP4 6JS
Tel: 01495 366885
CCBC Contract Monitoring Report

Contract Monitoring Report

  • Name/Address of Provider: Bluebird Care; Birch Suite, Mamhilad House; Mamhilad Park Estate; Pontypool; NP4 0HZ
  • Date of Visit: Monday 25th September 2023
  • Visiting Officer(s): Amelia Tyler, Contract monitoring officer, Caerphilly CBC
  • Present: Rhiannon Rees, Manager, Bluebird Care / James Kuchera, Responsible individual, Bluebird Care


Bluebird Care is a relatively new provider and were added to the domiciliary care framework at the end of 2019.

At the time of the meeting, it was confirmed that Bluebird Care had 9 clients in Caerphilly borough delivering 80 hours of care a week (an increase from 4 clients and 37.25 hours the previous year).

The last monitoring visit was carried out on the 14th July 2022, and at this time there were four actions highlighted.These were reviewed and the findings are outlined below.The agency had moved office since the last visit and there was a new manager.

Dependant on the findings within the report, Bluebird Care may be given corrective and developmental actions to complete.  Corrective actions are those, which must be completed (as governed by legislation etc) and developmental actions are those deemed to be good practice.

Previous Recommendations

Service providers have rigorous selection and vetting systems in place to enable them to decide on the appointment or rejection of all staff; interview scoring systems to be completed.  RISCA version 2 (April 2019) Regulation 35. Partially met.  Two files were viewed during the meeting, and both contained application forms and interview records, but they had not been scored.

Detailed risk assessments to be completed in relation to refusal to wear incontinence products and smoking in the property.  RISCA version 2 (April 2019) Regulations 14 and 21. Not met.  These documents were requested via email on the 27th Septeber, but had not be received at the time the report was completed.

The manager to contact SCW to get advice of registering carers via the employer’s assessment route. Met.  Advice had been obtained but there were still members of staff that were not registered but they are working towards this.  Are they working towards being registered now?

Consideration to be given to the shadowing process for staff new to the role. Met.  The contract monitoring officer saw comprehensive shadowing forms that were signed off by a senior member of staff to confirm the competence of the new starter and the employee.

Findings from Visit

Responsible individual

It was explained that the manager was new to the role and was not registered with Social Care Wales at the time of the meeting but was waiting on her interview with Care Inspectorate Wales before being able to complete this. 

There was a copy of the statement of purpose, and this had been reviewed on the 18th September 2023 to include the new manager and the change of address.

It was noted that the service user guide was up to date but didn’t have the date of review on the document.  The contract monitoring officer recommended this be added to ensure compliance.

Although there is an agreement that the manager and responsible individual do not book annual leave at the same time, if they had to take unplanned leave, the contingency is that the Care Inspectorate and local authorities would be notified, and the level three coordinator would carry out any necessary tasks in the interim.  There is also succession planning, and it was stated that the same coordinator is hoping to complete her level 5 qualification.  This arrangement is to be formalised to demonstrate conformity with regulations.

All the mandatory policies and procedures, including safeguarding, whistleblowing, medication, infection control, and complaints were in place, and these had all been reviewed within the previous twelve months and have the date of the next planned review on the document.

Registered manager

The manager manages the one service, and it was explained that the responsible individual sets reminders every quarter to carry out the regulation 73 visits and complete the report.

It was noted that the manager is supported by the responsible individual and is present in the office three or four days a week whilst the manager completes her induction phase.

None of the properties that are attended in the borough have CCTV but it was stated that this would be tagged on the system to inform staff if this was in place.

The contract monitoring officer was told that the active offer is adhered to and that approx. 22% of staff can speak Welsh including the manager and coordinator.  At the time of the visit there were no clients wishing to converse in Welsh and this is discussed during the initial phone assessment, however, this wasn’t formalised.  To evidence compliance with legislation, this must be clearly evidenced on the initial assessment.

File and documentation audit

Two client files were viewed during the visit and there were no clear initial assessments’ available.  One contained a care plan that had been completed by Caerphilly CBC and the other had a care plan which had been developed, but there was nothing prior to the service commencing about outlining how the person wants to be supported, what their preferences are, and how the provider can meet their needs etc.

One of the plans had been clearly signed and dated by the individual needing support and the supervisor at Bluebird.  This had been signed to confirm they had been involved in writing the plan and agreed with the contents.  On the second file, it was acknowledged that the personal plan reviews had been signed by the client, and provider but not the main document. 

There were no recordings of the individual’s preferred call times; even if this isn’t possible to achieve, this should be recorded so that if additional staff are employed, or the time slot becomes available, the coordinator is aware of the clients wishes.  This should also be discussed during any review meetings in case they have changed their preference.

Personal plans were individualised and contained some person-centred detail e.g. one client had worked as a crafts teacher, wears glasses and has three children. The other personal plan highlighted that their family was important to them and can communicate verbally but can be forgetful.  There was insufficient detail around preferences, what they can do independently (to maintain these skills) and outcomes.  To have a focus on the wellbeing of the person and support them to achieve these goals, the carers need to know what is important to them and how they want to achieve their ambitions.

Staff related documentation

At the time of the meeting, it was pleasing to note that Bluebird had employed five new starters who were due to commence training the following week.

Evidence was available for staff having attended training around manual handling, food hygiene, safeguarding, infection control, basic life support, and medication awareness.  There was nothing around challenging behaviour, dementia, sensory impairment, or stroke awareness.  Due to us having an aging population and there is an increase of people being diagnosed with dementia or cognitive impairment, it is recommended that dementia training is provided as a priority to support staff carry out their roles.

The contract monitoring officer viewed 2 staff files as part of the monitoring process: one of these contained two professional references, there were no references available on the second file.

There was a job description and a detailed application form on both files, but the scoring mechanism had only been completed for one of the members of staff; to demonstrate that the applicant has met the criteria for interview, there should be a clear scoring tool to evidence their suitability.

It was acknowledged that interview records were held on file and scenarios were given as part of the meeting and these are taken from a crib sheet.  Both records highlighted there had only been 1 interviewer; it is recommended that 2 senior members of staff carry out interviews to safeguard against the situation where the outcome is challenged.  The responsible individual explained that where possible, they do try to allow for 2 interviewers, but this isn’t always possible, and they don’t want to slow the recruitment process down or risk losing candidates to another agency whilst waiting to clear the diaries of appropriate interviewers.

Carer feedback

Only one of the carers that works in the Caerphilly borough returned the call from the contract monitoring officer and they stated that there is sufficient travel time between calls, but this is mainly due to primarily working the later shifts.  It was acknowledged that the new 20mph speed limit has impacted on the amount of time spent between calls.

Discussion was held around the induction process and the carer explained this was sufficient and they felt confident in carrying out calls independently, however, they had worked for another agency for ten years previously, so it was mainly around getting to know the company and the systems and processes.

It was felt that there was good information available on their company’s phones to allow them to carry out the calls in the way the individual wishes.  The contract monitoring officer was told that if there are ever any queries, they can speak to one of the other carers or the senior on duty.  The carer felt the manager and responsible individual are approachable and accessible if there are any problems.  Overall, it was highlighted that communication is good in the organisation.

The training provided is appropriate and the carer said they had recently had stoma and catheter care training.  There was no further training they felt they needed at the time of the conversation.

The only areas that were raised that could improve the service was recruitment and the need to employ more carers as it can be quite pressured at times.  There are some new carers that are new to the sector and aren’t fully aware of what is required, and it takes time for them to be fully trained and able to carry out calls on their own.

Client feedback

The contract monitoring officer spoke to two clients receiving support from Bluebird and neither raised any concerns or complaints.  One of the individuals said that carers will help her to the bathroom and help her to get washed and changed using the stairlift.  It was reported that the carers are ‘lovely’ and they are never made to feel rushed during the calls.  They stated they had never needed to make a complaint and was aware that there was a new manager.  It was pleasing to note that they felt they were involved in their care and told the contract monitoring officer, laughing ‘oh yes, I’m in charge!’.  The only area raised for improvement is that they wished there wasn’t such a high turnover of staff but understood why this can happen.

The second person spoken to was also happy with the care provision and told the contact monitoring officer that the carers always stay for the full length of the call and never appeared hurried.  They had only ever needed to make one complaint, which was a missed call on a weekend due to an error on the electronic system and this had been a one-off.  They explained that there is good shadowing and when there are new staff, they are given a detailed handover.  It was highlighted that they felt involved in their care package and can tell staff what they want or if there is anything wrong.  There was nothing they could think of to improve the service.

Relative feedback

Two relatives were spoken to for feedback: They were both happy with the service and the level of care they provide.  They both stated that the morning calls can sometimes run late, and one said that this was usually due to an earlier call running over as the individual often asks them to do more.  This can have an impact on their relative as they are diabetic, and it is important she eats at certain times.  One relative highlighted that the carers will try to let their Mum know if they are going to be late.  The contract monitoring officer fed this back to the manager and responsible individual to consider if additional time needs to be allocated to the earlier call.

Both relatives stated they had been invited to attend review meetings, although one did comment that this hadn’t happened for a while, and the other relative explained that this can sometime be planned quite quickly and she isn’t always able to get the time off work, so additional notice would be helpful.

Neither relative said they had need to raise any complaints, but they would feel confident in doing so if required.  When asked if anything else could be improved, they said no and one explained that their mother had some lovely carers going in.

Corrective / Developmental Actions

Corrective actions

The date of review to be added to the service user guide to ensure the most up to date version is being used.  RISCA version 2 (April 2019) regulation 19.

The initial assessment to formally record what language the individual wishes to converse in and receive any written information.  RISCA version 2 (April 2019) regulation 24.

Bluebird care to implement clear initial assessments for any new client outlining their needs and preferences and the decision making about whether they can meet the person’s needs and how.  RISCA version 2 (April 2019) regulation 14.

Detailed risk assessments to be completed in relation to refusal to wear incontinence products and smoking in the property.  RISCA version 2 (April 2019) Regulations 15 and 18

A written contingency plan to be completed if the responsible individual and registered manager are unexpectedly both absent for a period.  RISCA version 2 (April 2019) Regulation 72

Personal plans to highlight individual outcomes and how they are supported to achieve these.  RISCA version 2 (April 2019) Regulations 15, 16 and 17

Dementia / cognitive impairment training to be provided to all staff.  RISCA version 2 (April 2019) Regulation 21

Developmental actions

Service user guide to include the date of next planned review.

The scoring mechanism to be completed for each interview to evidence their suitability.


The office appeared to be well run and it was pleasing to see the manager had full support from the responsible individual.  The finding of the contract monitoring officer was that communication was good throughout the organisation.

It was acknowledged that the electronic system was very thorough, and most of the information requested was easily obtained.  The feedback collated from clients, relatives and staff member were all consistently positive, with only small areas identified for improvement.

Although the number of clients in Caerphilly was still quite low at the time of the visit, it would be pleasing to see this number grow within the borough as the number of carers increase.

This report has highlighted seven corrective and two developmental actions that need to be addressed and the contract monitoring officer requests that these be carried out within three months from the date of this report.

The contract monitoring officer would like to take this opportunity to thank everyone involved in the monitoring process for time, help and hospitality.  Unless it is deemed necessary, the next monitoring visit will be carried out in approx. 12 months’ time.

  • Author: Amelia Tyler
  • Designation: Contract Monitoring Officer
  • Date: 13th October 2023