Cynefin Care Ltd

Suite H- Britannia House, Caerphilly Business Park, Caerphilly, CF83 3GG
Tel: 0330 0436467 / 07837503481

Contract Monitoring Report

  • Name/Address of Provider: Cynefin Care, Suite H, Britannia House, Caerphilly Business Park, Caerphilly, CF83 3GG
  • Date of Visit: Thursday 11th January 2024
  • Visiting Officer(s): Amelia Tyler: Contract monitoring officer, CCBC
  • Present: Katie Jewell: Responsible individual / Caroline Jones:  Manager


Cynefin Care is a relatively new provider that registered with the Care Inspectorate Wales (CIW) on the 28th March 2022 and opened 19th April the same year.  It was acknowledged that a CIW inspection had been completed on the 23rd February 2023. 

The last monitoring visit was carried out on the 6th September 2022 and at this time there were two corrective and three developmental actions identified.  These actions were reviewed as part of the meeting and the findings are outlined in the section below.

The contract monitoring officer noted the agency had increased the number of hours being provided within the borough from 224 hours of care a week to approx. 479.  The number of clients had increased from 17 to 36 (as at the time of the visit)

Dependant on the findings within the report, the agency may be given corrective and/or 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

Daily notes to incorporate the emotional wellbeing of the individual and the little things that staff do above and beyond their role to support them.  RISCA version 2 (April 2019) regulation 21. Partially metIt was noted that this has improved a lot since the previous visit and some staff are more detailed in recording than others, but there needs to be more information around the emotional wellbeing and outcomes rather than having a task orientated focus.  It was evidenced this had been discussed in team meetings.

The responsible individual to send a copy of the first quarterly report around their internal monitoring system.  RISCA version 2 (April 2019) regulation 73. Met.  Quarterly reports were provided and had been completed on the 31st July and 31st October 2023 and the 3rd January 2024.  These incorporated discussions held with a selection of staff and clients.

Consideration to be given to adding a scoring mechanism to application forms. Met.  The responsible individual explained that this had been considered but had not been implemented as it wouldn’t be beneficial.  Scoring mechanisms are more meaningful at the interview stage where they can gauge the suitability of the person based on their knowledge and understanding.

Any letters or cards received to be dated to ensure they are included in the appropriate report. Met.  Compliments had been received on 17th March, 8th June and 27th November 2023 and these had been recorded in the appropriate quarterly report by the responsible individual.

The commercial manager and responsible individual to be added to the matrix. Not met.  This was not evidenced on the matrices shared with the contract monitoring officer.  Consideration to be given to having a separate spreadsheet for administrative staff to capture what training they have attended.

Findings from Visit

Desk top audit

There had been one safeguarding issue raised since the previous visit and it was acknowledged this had been appropriately recorded, reported, and addressed.  There had been no other concerns or complaints received either internally with the provider or externally.  Feedback was obtained from an occupational therapist who reported that when staff had noticed the hoist sling was too small, this was referred promptly and rectified.  The contract monitoring officer emphasised that staff had been proactive and rectified the matter as soon as it was noticed.

As mentioned previously, a CIW inspection had been carried out in February 2023 and this raised five areas for improvement and although the responsible individual had had issues with their laptop becoming corrupted, had taken active steps towards addressing these areas.

Responsible individual

As previously mentioned, the quarterly reports were being completed as required.  The statement of purpose was provided prior to the meeting, and it was noted this hadn’t been dated and made reference to the provider waiting to be fully registered.  It was requested that the amended document be forwarded to the contract monitoring officer.

The service user guide provided was dated April 2023 and was written in a format that was clear and easy to follow.  It is recommended that it is a requirement for this document must be reviewed at least annually, that the next planned review date or required frequency be added to the document.

At the time of the visit it was noted that the responsible individual was also the registered manager of the service.  It was explained that if they were absent for a period of more than 28 days, the commissioner and CIW would be notified in accordance with regulations 72 and 84.  The office manager (who has the appropriate level 5 qualification) would act as interim manager and the commercial director would cover the role of responsible individual.  If this was expected to be for a longer period, the commercial director would apply for the position with CIW.

All policies and procedures were seen during the visit, including admissions and commencement of service, infection control, whistleblowing, safeguarding and medication.  The contract monitoring officer acknowledged these had all been reviewed in December 2023.  Most of the policies stipulated these would be reviewed at least annually: the policy around the use of restraint highlighted this would only be reviewed in the instance of restraint being used.  The policies for staff development, staff discipline, and whistleblowing didn’t highlight a review date, but the responsible individual has the duty of ensuring these are kept up to date.

Registered manager

It was acknowledged that the responsible individual is appropriately registered with Social Care Wales and manages the one service which has a footprint in two authorities. 

There are no specified, planned dates for the responsible individual visits, but the contract monitoring officer was informed that every Thursday is a protected day for them to complete any tasks required for the role and this would allow them to complete the formal regulation 73 report.

There is only one property that the provider is aware of that has CCTV in place and staff are notified on the app prior to the visit to ensure they are aware of this.  It was also noted that the provider has one client that has assistive technology in their home which uses sensors to monitor her daily routines and a database is being collated as a pilot.

Discussion was held around the Welsh language and the active offer; the responsible individual explained there are currently no clients that speak Welsh as their first language the three members of staff that can speak fluent Welsh (one of which is office based).  It was noted that the preferred language is the first question that is asked in the initial assessment.

Client files

Two files were viewed during the visit, and it was highlighted that one contained an initial assessment that was carried out appropriately prior to the package of care commencing. The second file did not contain an initial assessment, however, did have the service delivery plan from the previous care provider.  The provider must ensure that an initial assessment is in place that is coproduced, up to date and outlines how they are going to meet the needs of the client and signed by the person or appropriate representative.

One of the service user agreements contained their preferred call times, but this wasn’t on the second file.  It is recommended that even where these slots aren’t available, this is documented so that if the time becomes available or additional staff are recruited this can then be offered.  Having this information also minimises the risk of any confusion through the involvement of third parties.

All the detail from the care plans completed by the local authority had been carried across into the personal plans, except for one highlighting that staff should be checking the bedroom for any soiled items.

Feedback obtained from one relative noted that if staff ask the person whether they want something to eat or have a shower, they are likely to decline.  It was requested that staff are more mindful of their approach i.e. instead of asking if they would like anything to eat staff should be asking what they would like and instead of asking if they would like a shower, ask when then would like their shower.  This detail is to be captured in the personal plan to ensure all staff are aware.

One of the plans gave detailed information around what is important to the person such as living at home with his wife, and socialising.  They suffer with pain but reluctant to take some types of analgesia and requires reassurance during transfers.  The second file documented that they love singing and enjoy sleeping, but there wasn’t such information around their past or what is important to them. 

Call monitoring

It was acknowledged that there is an electronic call monitoring system in place (Nurse Buddy) which allows members of staff to add notes to the whole staff team or tasks to be followed up during the next call e.g. ‘commented they didn’t feel well this morning and 2 x PRN paracetamol administered as per MAR chart’ or ‘please could the recycling bins be brought back in as hadn’t been collected at the time of the call’.

There were no missed calls over the previous 12 month period.

Outside of the normal office hours, it was reported that there was a rolling off duty rota between the five senior members of staff.  The senior on duty has responsibility for the mobile which will receive alerts if there are any missed or late calls and is also a point of contact for the carers to ring in an emergency.

The contract monitoring officer was told that the Nurse Buddy system uses Google Maps to calculate travel time to ensure this is more accurate to the times of day the calls are being carried out.  This was seen at the time of the visit and the responsible individual also highlighted that travel time and mileage is broken down separately on payslips to ensure transparency. 

Staff files

The supervision and appraisal matrix was shared and it was acknowledged that this was clearly recorded and included the date they commenced employment.  There were some gaps identified such as one employee commencing employment in July 2019 and there was a gap in supervisions until 15th November 2023.  There were six new starters that were not due for a supervision at the time of the visit.  At the time of the visit there were four appraisals that were overdue.

Both files contained one professional reference and one personal reference.  Where the applicant has previously worked with vulnerable adults, it is required that there is evidence that some verification has been sought to determine the reason for leaving.

There were detailed application forms on file and interview records that included scenarios and evidenced two interviewers had been present.  It was also praised that the provider uses a scoring mechanism to determine the applicant’s suitability and outcome, and these had been signed and dated.

There didn't appear to be any gaps in employment, but only the year was specified, so it wasn’t possible to confirm.  There were signed contracts of employment, recent photos, training certificates, valid DBS checks and spot checks.  The contract monitoring officer noted there was no evidence of induction and shadowing process and it is required that this be implemented for all new starters.

Support worker feedback

Feedback was obtained via telephone conversations with two members of staff: both said that travel time had been built into their rotas and this generally gave sufficient time between calls, although one did mention this could be hit and miss at times if another staff member had had to take unexplained leave or if there were unplanned roadworks.

It was highlighted that the rotas provided enough time to carry out all necessary tasks, and if there was any deterioration, or they were regularly going over their allocated call time, they would address this with the office.

The contract monitoring officer was told that the rotas were planned well and allocated every fortnight.  It was stated that if they had to take any time off at short notice e.g. to attend a funeral or emergency childcare issues, that the agency does their best to accommodate this, however, this can also mean that rotas can change quite quickly.

When asked if they felt supported by their supervisor, both members of staff said they felt supported and that all office staff and senior staff are approachable.  It was acknowledged that both staff reported they had received a proper induction and shadowing process.  It was noted that both had worked in the sector previously.

General observations

It was positive to see that the administrative team has grown since the previous visit, and this has reduced the pressure on the responsible individual and the commercial director.  All files were well organised, and all information was easy to locate.

The responsible individual advised that in the previous year there had been fourteen leavers (Approx. 50% of the staff team) for a wide variety of reasons..  It was pleasing to note that eighteen new starters had been recruited within the same period.

Minutes were seen from the last team meetings, and these were held on the 18th October 11th December and 14th December 2023.  The meetings covered agenda items such as teamwork, punctuality, carers notes, PPE, the Christmas rota, gifts policy, the blue light card, and the returning to work policy.  It was nice to see that staff had received a thank you hamper from the provider for their hard work, and this was reflected in the minutes.

Corrective / Developmental Actions

Corrective actions

Daily notes to incorporate the emotional wellbeing of the individual and the little things that staff do above and beyond their role to support them.  RISCA version 2 (April 2019) regulation 21

Initial Assessments to be completed prior to the commencement of service for all clients.  RISCA version 2 (April 2019) regulation 15

The supervision and appraisal matrix to evidence that all staff have a supervision every three months and an annual appraisal.  RISCA version 2 (April 2019) regulation 19

The updated statement of purpose to be shared with the contract monitoring officer.  RISCA version 2 (April 2019) regulation 7

Where someone has previously worked with vulnerable adults, evidence should be available, so far as reasonably practicable, to verify why the position ended.  RISCA version 2 (April 2019) schedule 1, regulation 35, part 1 (5)

Evidence of meaningful induction to be present on staff files.  RISCA version 2 (April 2019) regulation 36

Developmental actions

Consideration to be given to highlighting the preferred call times on the initial assessments alongside what times have been agreed.

The commercial director and responsible individual to be added to the matrix.

It is recommended the service user guide provides the date of next planned review or the required frequency of review.


Although the team have grown noticeably since the last visit and there were some new members of staff, they were working closely together, and the feedback received highlighted that they were communicating effectively and sharing good practice, and this is supported by the new administrative staff.  The new structure is that there is an office manager who oversees recruitment and the daily running of the office, there are two coordinators, an administrator and a field care supervisor who was on a fifteen hour contract at the time of the visit but was being increased to twenty.  It was explained that there are also twenty four members of staff delivering direct care.

The electronic call monitoring system appears to be working well and staff informed the contract monitoring officer that all necessary information was accessible via the app on their phone.

It was explained that over the coming months the responsible individual will be taking a less active role in direct care to enable them to focus on their role and further developing the agency.  There were no concerns raised in relation to the provider and it was felt that the provider has a client-led approach where their staff endeavour to enhance the quality of the lives of the people they support.

The contract monitoring officer would like to thank the responsible individual and the staff involved in the monitoring process for their hospitality, their time, and help with collating all the necessary information.

Unless it is deemed necessary to be carried out sooner, the next visit will be carried out in approx. twelve months’ time.

  • Author: Amelia Tyler
  • Designation: Contract monitoring officer
  • Date: 26 January 2024