Ashville Residential Home

Bristol Terrace, Brithdir, New Tredegar, NP24 6JG
No. of Beds: 35 Care Home with Nursing
Category: 24 Dementia (Nursing) / 11 Older Person/Dementia
Dual Registered
Tel: 01443 834842

Contract Monitoring Report

  • Name/Address of Provider: Ashville Residential Home, School Street, Brithdir, New Tredegar NP24 6JH  
  • Date of Visit: 6 April, 2023, 10.00 – 2.45 p.m. 19 April, 2023, 11.30 – 3.45 p.m. 21 June, 2023, 11.30 – 2.55 p.m.
  • Visiting Officers: Andrea Crahart, Contract Monitoring Officer, Commissioning, CCBC, Jay Ventura-Santana, Senior Nurse Lead Governance & Safeguarding, ABuHB (6 April visit only)
  • Present: Marcella Taylor, Registered Manager, Angela Mason, Clinical Lead (present during visits on 6
    April & 21 June, 2023)


Ashville Care Home is registered to provide accommodation to 35 people who have dementia residential or dementia nursing needs.  At the time of the latest visit the Home was full to capacity with no vacancies available.

The manager is registered with Social Care Wales (the workforce regulatory body).

The Care Inspectorate Wales (CIW) undertook an inspection of the Home in April 2023, which read positively and there were no recommendations made for improvement.

Monitoring of the Home is often carried out jointly by Caerphilly County Borough Council (CCBC) Commissioners and the Aneurin Bevan University Health Board (ABuHB).   Visiting officers use a variety of monitoring systems to gather information and this includes observations of practice at the Home, examination of documentation and conversations with staff, residents, relatives, professionals etc. which is used to support with any improvements in care and inform of good practices etc.

Dependent 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); developmental actions are good practice recommendations.

Previous Recommendations

Corrective Actions

Current Statement of Purpose and Service Users’ Guide to be revised.  Timescale: Within 1 month. (RISCA Reg. 7).  Action met.

All Policies and Procedures to include a planned review date so that information is kept up to date.  Timescale:  Within 1 month. (RISCA Reg. 12).  Action met.

Contact details within the PEEP file to be updated.  Timescale: Within one month. (RISCA Reg. 19).  Action met.

Areas of the Home to be re-painted (woodwork) and to be included in the Maintenance programme.  Timescale: Within 6 months. (RISCA Reg. 44).  Partially met.

Two signatures to be recorded for all transactions relating to resident’s funds.  Timescale: Immediately and on going. (RISCA Reg. 44).  Action met.

Developmental Actions

‘Snug’ area in downstairs lounge to be de-cluttered, to enable people to play the piano if they wish.  Timescale:  Within 1 month. Action Met.

Suitable scenarios to be added to the staff interview record.  Timescale:  Within 2 months.  Action met.

RI to develop further the quarterly reports, to include other aspects of the service and split the information into headings, including any actions required.  Timescale:  Within 6 months. Action met. 

To continue to improve the bathing experience for people by making all bathrooms within the Home homely.  Timescale:  Within 12 months.  Partially met – there are plans to improve these areas. 

Managers/staff to have an awareness of the new All Wales Induction Framework (AWIF) which is being rolled out by Social Care Wales.  To also be aware of the registration process for carers which comes into effect in April 2022 for care home staff.  To disseminate to staff and encourage staff to access further advice/training sessions. Timescale:  Within 24 months.  Action met.

Responsible Individual

The Responsible Individual (RI) for the service visits Ashville care home on a regular basis, and as part of the role there is an expectation that quarterly reports are produced to report on the service and its quality, in addition to a 6 monthly Quality Review. 

The Home’s Statement of Purpose had been updated in March 2023 and provided a clear overview of the home’s aims and commitment to the residents it provides care and support to.

The Home’s policies and procedures were read and it was apparent that the majority had been reviewed this current year, with the exception of one having been reviewed in September 2022.  However, there were no planned review dates noted on the policies.

Registered Manager

The Home manager is registered at Ashville Care Home, and as a Director of a Home in the Newport City Council area.

The building has CCTV which is only situated in communal areas within the Home. The hub is sited in the manager’s office and arrangements are made for residents/their relatives to consent to this.  CCTV is not operational in individual’s bedrooms to ensure people’s privacy and dignity.

Homes are required to submit Regulation 60 documents to CIW and ensure ABuHB and Commissioning are aware of significant issues relating to people in the home and other incidents affecting the Home. The RI had reported on this in a recent visit to confirm that these are submitted when required.

Staffing and Training

Ashville Care Home access mandatory and non-mandatory training for their staff team via a range of training providers i.e. Langfords, CCBC/Blaenau Gwent Workforce Development Team and the Aneurin Bevan University Health Board (ABuHB).  Staff are also able to access on-line training via ‘Care Skills’ to enhance their learning. 

The Home have training matrices that clearly show when training courses are planned for. The matrices indicated that there had been a good attendance on mandatory training courses (i.e. manual handling, food hygiene, safeguarding etc.) with few staff needing to undertake these to bring them up to date.

The Home has introduced an alternative e-learning package (Key Skills Academy) for staff to work to. The contract monitoring officer was informed that training had recently been delivered for catheter care and venipuncture and that the District Nurses were in a position to be able to carry out competency tests for the catheter care training, which was agreed to be beneficial.

Staff continue to sign up to the QCF qualifications in social care as part of their role.  At the current time the nursing team are led by a clinical lead, who is supervised by the RI, and there are four registered general nurses and two registered mental health nurses.  There are four senior staff, carers, domestic, kitchen, laundry and maintenance staff.

During the day there are also a minimum of six carers, two qualified nurses, and overnight three care staff and one qualified nurse.  This is always under review to ensure the number of staff is sufficient to meet the residents’ needs.

‘The Active Offer’ – More than Just words (revised Welsh Language Act) requires providers of social care to provide communication in Welsh without the person asking for this.  The manager is aware of the Act and how it can be applied, however at the current time the home is unable to accommodate anyone whose preference is to speak Welsh.

Staff Files and Supervision

Two staff files were viewed which were neatly organised, included an index and the information was easy to locate.

Both files included information that would have been collected as part of the recruitment process i.e. a detailed application form, written references, interview records, contracts of employment, DBS (Disclosure and Barring Service) check, a photograph of the carer and training certificates.  One of the contracts of employment had omitted to have been signed, which was brought to the manager’s attention during the visit and the references had not been verified as part of the process.

Interviews had been undertaken with the candidates which had been signed and dated by the interviewers concerned.  The questions posed included pertinent questions and a scenario to test the person’s knowledge of what they would do if they thought there was poor practice.

It was evident from the training certificates on file that staff are supported to attend many different training courses to enhance their knowledge of caring for people, which are provided face to face, on-line learning and by direct observations of practice.

The Homes’ current supervision matrix was viewed.  It was apparent that supervision sessions had been held on a regular basis (i.e. three monthly) with all staff employed at the home and appraisals had been planned for also. 

File and documentation Audit

Two files were viewed as part of the monitoring process which were organised in an orderly way and included pertinent information relating to DNACPR, admission details, a profile of the person (including a photograph), ‘This is me’ document etc. and consent had been gained in terms of taking photographs of the person and the use of CCTV in communal areas, Caerphilly County Borough Council (CCBC) Care and Support plans etc.

The Personal Plans (Care and Support Plans) were in place for all aspects of care e.g. health and wellbeing, personal care, mobility, skin integrity, continence care etc. and were detailed and written in a person centred way. Risk Assessments were also present in relation to e.g. bed rail safety, choking hazards etc.

The Personal Plans had been reviewed at least monthly basis to reflect when people’s needs had changed, or where incidences had occurred (e.g. falls) and were very descriptive.

There were records to indicate that the appropriate professionals were involved in this person’s care as GP visits had been documented and a multi-disciplinary record had been completed from other professionals also.

The Daily Records were viewed for one of the individuals and were reflective of the care and support that they required (as outlined in their Personal Plans).

Quality Assurance systems

The RI continues to have an oversight at Ashville by undertaking regular visits to the home and reports were readily available to evidence these visits.

The RI reports were viewed for the previous three quarters and confirmed that the RI is very much involved in the life of the home in communicating with staff, residents and relatives and obtaining feedback from them.  The reports also include outcome incidents/accidents, audits etc.

The Home’s latest Quality Assurance 6 monthly report was made available (up to March 2023) which covered many areas e.g. an internal audit of training, staff and resident’s files, quality assurance systems, staff and relative feedback etc.  Although no dates or initials of people who had been spoken to had been captured as evidence of who had been spoken to

The manager continues to have an ‘open door’ policy in terms of enabling one to one communication between relatives, visiting professionals etc. to enable any concerns to be discussed and this was confirmed by a visiting relative who was spoken to also.

Staff handovers are undertaken by the nurses or senior carers on a daily basis and these are undertaken to relay information regarding the health and wellbeing of the residents, and can include e.g. general health, their skin integrity needs, how they have slept, professional visitors advice etc.  

Staff team meetings are regularly held with care staff, domestic staff, the nurse team to discuss pertinent topics.  Recently a meeting with carers included goals, achievements and recognition of good practices, improvements within the home, the role of the clinical lead, expectations of job roles etc.  It was evident that these meetings are held on a regular basis. 

In April 2023 the home achieved a Food Hygiene rating of 3 which indicates a satisfactory level of achievement.

Medication reviews are undertaken at least annually by the General Practitioner, however this person does call more frequently if required. 

Home Maintenance

Maintenance checks of the building are undertaken by the maintenance staff.  This role involves many duties e.g. painting and decorating, checking that wheelchairs are in good repair, fire safety checks undertaken etc. It was evident that areas for repair had been identified and it was confirmed they had been addressed.

Fire Safety/Health & Safety

The most recent Fire Assessment was completed in February 2021 and all areas for improvement had been marked as completed by the Home Manager.

Fire drills had been attended by staff on a monthly basis which included different staff team members (e.g. carers, domestic, nurses, administration) on a number of occasions.  All evacuations were undertaken in a timely manner and there were no issues recorded.  The contract monitoring officer was informed that fire drills are held on a regular monthly basis to ensure that all staff have the opportunity to be part of these, as new staff are appointed.

In terms of fire evacuation, the Home has made the arrangement with a local church that in the event of the residents needing to evacuate to ‘a place of safety’ that they are able to do so and contact details are readily available.

Personal Emergency Evacuation Plans (PEEP’s) were viewed for people living at the home.  It was apparent that these had been reviewed regularly.  Some contact details within the file were out of date for some individuals which were updated immediately.

Managing resident’s funds

The administrator in the home manages people’s monies and it was evident that there was a clear and robust system for recording when monies were received and taken out. Any transactions were signed by 2 signatures and receipts had been obtained.

Staff Feedback

A number of conversations were held with staff during the course of the visits, where it was evident that staff were engaged in the life of the home and spoke highly of the team they work with and the support they receive.

Relatives Feedback

A relative relayed that their loved one is very well looked after at Ashville and that they are very happy with the care provided by everyone at the home.  They confirmed that they are always made to feel welcome when they visit, being offered a drink and something to eat, and that staff are so helpful.  Their loved one is made to feel at Home as staff meet her needs on a daily basis, spend time talking with her and paint her nails, which is something she really enjoys.

General Observations


Staff could be seen spending time with the residents in communal areas, talking with people and having meals with them to encourage them to eat more. There are bowls of fresh fruit in the lounge areas and hallways available for people to help themselves when they wish and a sweet trolley and ice cream stand for people to enjoy.

Bathrooms were free of clutter and the contract monitoring officer was informed that some bathrooms in the home would be receiving a complete refurbishment in due course.

The Home has four lounges which are very homely, and two of which have breakfast bar facilities so that carers can make drinks and snacks for the residents and visitors as and when they would like them.  The large downstairs lounge is a multi-purpose space that comprises of the main kitchen, chairs, tables sofas, a piano, and the outside garden is accessible via this lounge.  The Home currently uses this for large events and are considering other uses e.g. a Dementia café.     

Mealtime experience

The mealtime experience was observed in the upstairs lounge during one of the visits. People were assisted to eat, where this was required which was undertaken in an unhurried way.  Tables were set with condiments, sauces and table clothes. The contract monitoring officer was made aware that the table clothes are changed every day to ensure they are clean and pressed.

On the day people had a choice of fish, lasagne or ham (all with chips and vegetables which smelt and looked appetising).    

There were plenty of staff available to support people with their meals with fresh drinks being offered.  The sweet trolley included choices of desserts e.g. homemade cakes bread and butter pudding, angel delight with cream and small smarties, jellies and yoghurts.


Activities are organised by carers throughout the day and are either organised as a group, and/or on an individual basis according to what people choose to do.

During one of the visits a staff member brought their dog to the home and was seen to be providing a lot of enjoyment to the residents and the contract monitoring officer was made aware that the dog was a frequent visitor.


There were many lovely interactions noted between staff and residents, with patience being shown, time spent singing along to a favourite song with a resident.  A gent, who had previously loved lemon curd on his toast and could no longer have this due to his swallowing problems was now having this added to his pureed food.

Residents looked well cared for during the visits.

Corrective Actions

Staff references to always be verified as part of the recruitment process and contracts of< employment signed up to by both parties.  Timescale:  Immediately and ongoing. RISCA Regulation 35

Planned review dates to be added to all mandatory policies/procedures.  Timescale: Within 3 months. RISCA Regulation 12                                  


Interactions between staff and residents were lovely, with staff showing kindness and patience to residents and undertaken in an unhurried way.  The contract monitoring officer saw lots of happy times when a dog was brought in to visit people in their lounges which made them smile and was aware that this occurs quite frequently.

The staff team attend a range of training courses, some of which are classroom based and others via e-Learning and the majority of training is up to date.

Documentation relating to staff is stored in an orderly manner and the recruitment processes are robust.  In terms of residents’ documentation, this also continues to be filed in an orderly way with Personal Plans (Care Plans) being detailed and written in a person centred way. The reviewing of the Personal Plans had been undertaken on a regular basis and the information written was meaningful.

The contract monitoring officer would like to thank the managers and staff for their time and hospitality during the monitoring process.

  • Author: Andrea Crahart
  • Designation: Contract Monitoring Officer
  • Date: July 2023