Cwmgelli Lodge Nursing Home

Lon Pennant, Blackwood, NP12 1BR 
No of beds: 24 Care Home with Nursing Over 18 yrs.
Category: 24 (Nursing)
Tel: 01495 232500

Contract Monitoring Report

  • Name/Address of Provider: Cwmgelli Lodge, Lon Pennant, Blackwood, Caerphilly, NP12 1BR
  • Date of Visit: Wednesday 8 November and Thursday 16 November 2023
  • Visiting Officers: Amelia Tyler: Contract monitoring officer
  • Present: Catherine Ryall: Home manager, Fieldbay Stacey Morgan: Deputy manager, Fieldbay


Cwmgelli lodge is a large, purpose-built care home that is situated close to the town of Blackwood with easy access to all the local amenities. The home was brought into the Fieldbay company in October 2020. It is built over two floors and is registered to provide care for 26 people with nursing and mental health needs to carry out activities of daily living.

At the time of the visit there was one vacancy which was already held in reserve for a new admission. There were two residents that were supported by Caerphilly CBC and the local health board and a total of ten individuals supported by the local health board.

Since the last report there has been a change of manager, and the home has been through the provider performance process where they have worked through an action plan with the local authority and local health board.

The purpose of the visit is to speak with residents, relatives and staff members and complete the monitoring template. The previous monitoring visit was carried out on 19 October 2022, and at this time there were five corrective actions and five developmental actions identified. These were reviewed and the findings are outlined in the section below.

Depending on the findings within this report, the Manager may be given corrective and/or developmental actions to complete. Corrective actions are tasks which must be completed (as governed by legislation etc.) and developmental actions are those deemed to be good practice.

Previous Recommendations

Two written references to be held for each member of staff, including a reference from the previous employer, if any. RISCA version 2 (April 2019) Schedule 1, regulation 35, Part 1 (4)

Met. These are held electronically and there was at least one professional and one personal reference on each of the two files shared.

All staff files to have a photograph present. RISCA version 2 (April 2019) Schedule 1, regulation 35, Part 1 (1)

Met. There were photos on the files seen.

Every member of staff to complete annual appraisal. RISCA version 2 (April 2019) regulation 36

Not met. The information that was shared with the contract monitoring officer demonstrated that 27 appraisals were overdue from a staff team of 64 (42%)

Initial assessment/personal plans to be in place for each client prior to the commencement of service. RISCA version 2 (April 2019) regulation 15

Met. Initial assessments were not in place for the two people that were supported by Caerphilly CBC as they had lived at the home prior to Fieldbay taking over. Initial assessments were seen for two new residents that had been completed prior to moving into the home.

Detailed information to be recorded in the personal plans around agreed outcomes, how these are identified, supported, and reviewed. RISCA version 2 (April 2019) regulations 15, 18 and 21.

Met. Agreed outcomes are incorporated into the personal plans. For one of the residents, it highlighted the importance of accessing the community, that he should be pain free and should be monitored for any indication that he may be in pain using the Abbey Pain Scale. It mentioned a tribute band and a day trip to Longleat that had been carried out within the past few months. For the other person, it highlighted the importance of maximizing their involvement in activities of daily living, having pamper sessions and any events taking place within the home. It was recorded that activities had been planned for Children in Need the following day and one of the activities was going to be decorating a Pudsey biscuit.

It is recommended that the statement of purpose records the date of the next planned review to evidence this is completed annually, in line with RISCA regulation 7.

Not met. There was nothing on the statement of purpose to highlight when the next review is due.

Consideration to be given to adding the review date and next planned review to all policies.

Met. It was evidenced that this is being done.

The manager to consider adding the full date of the last training course to the matrix and/or when this is next required.

Met. The training matrix contained the full accurate date of the last training sessions attended.

Where possible, interviews to be held by two members of staff.

Not met. The files highlighted that both had been interviewed by one member of Fieldbay staff. To minimise the risk of any conflict of interest or challenge, it is recommended that interviews are conducted by two experienced members of staff.

Photographs to be considered to assist in decision making for individuals with communication difficulties.

Met. This was being done and were seen on the units.

Findings from Visit

Responsible individual

Copies of the quarterly 73 reports were forwarded following the visits and these were last completed on the 6 July and 3 October 2023. It was acknowledged that these included feedback from residents, staff, and visitors to Cwmgelli.

The bi-annual regulation 80 report was provided that covered January to June 2023. This highlighted that there had been twelve compliments and three complaints, all of which had been dealt with by Fieldbay.

A copy of the statement of purpose was shared with the contract monitoring officer and had been updated in September 2023 to include the name of the new manager and deputy manager. There was no future review date on the document or anything to highlight the need to carry out the next review in twelve months.

If the registered manager and responsible individual were both absent unexpectedly for a period, the home would be supported by the deputy manager and senior management team. It was also noted that as Fieldbay are a large provider, they could also utilise staff from other homes if necessary. It is recommended that this be incorporated into the statement of purpose.

All policies and procedures were available electronically, such as referrals and admission, safeguarding, client finances, infection control, medication management etc. It was noted all had been reviewed in 2022 and they were due to be reviewed either every two or three years.

Registered manager

There is CCTV at the property at the front of the building that overlooks the entrance and car park for security purposes. At the time of the visit there were no issues regarding the property apart from a ceiling track hoist that was in the process of being fixed. The deputy manager explained that this wasn’t having any impact on the resident as they were being supported with a transportable hoist.

Residents can change the temperature of the radiators in their rooms but may not have capacity or be physically able to do this and is therefore monitored by staff. It was noted that the windows on the upper floor can be opened (with window restrictors to maintain their safety) and there are also patio doors that can be opened on the bottom floor.

The contract monitoring was told there were no outstanding regulation 60 notifications at the time of the visit, but the commissioning team would be copied in if this were required for the two residents supported by the local authority.

Planned regulation visits are arranged with the home but it was also stated the responsible individual normally visits every week. It was explained that the responsible individual and the senior team are still very involved and offering support within the home.

Referrals to professional teams and assessments are carried out regularly and the last meeting had been held on the 31 of October. The contract monitoring officer was told that a floor bed had been discussed for one resident, one gentleman was having physiotherapy from the Fieldbay team, and an external referral had been made for a wheelchair for another resident. Two residents were also having support from the internal speech and language team. There was also involvement from the Huntington’s Nurse team, specialist dieticians, the community mental health team and commissioning teams.

The home was up to date with all DoLS applications (Deprivation of Liberty Safeguards) and these had been submitted for new residents and they were waiting on the dates for the assessments to be carried out.

Desk top audit

A copy of the training matrix was shared with the contract monitoring officer on the 6th November, and this stated that the overall compliance with training was 85.9%. Medicine competency was 37% which was queried with the deputy manager as this had formed part of the provider performance action plan and it was felt that this may not have been reflected on the matrix.

The manual handling passport was on the matrix as ‘manual handling of objects’, first aid was called ‘basic life support’. Other mandatory training was recorded on the matrix including safeguarding, food hygiene, sensory impairment, and infection control etc. and most had been refreshed within the recommended three years.

It was positive that two of the health care practitioners had been successful in being selected to undertake their nursing qualification with the open university. The deputy manager said this is a three year course alongside their full-time roles, but they would be allowed some supernumerary hours to assist them in completing the course. This demonstrated the commitment of the company to developing their own existing carers that wish to progress along the nursing route.

There were additional courses shown on the home specific matrix provided which were geared around the specialist needs of the individuals: 16 staff had done PEG feeding, 4 had done catheter care, 2 nurses had done venepuncture to allow them to take bloods, 9 had done active support training, 20 had completed diabetes , 28 had done dysphasia training, 32 had done pressure area care and 25 had attended training around professional boundaries and 5 had attended training around Huntington’s.

Staffing and training

The staffing at the home during the day is two qualified nurses, or 1 nurse and a health care practitioner and a minimum of 7 care staff. During the night shift there is 1 nurse and 1 health care practitioner on shift with 6 carers. It was acknowledged that this is in addition to the manager, deputy manager, activities coordinators, catering staff, domestic staff, therapies etc that may be present.

At the time of the visit there were three full time activities coordinators that were contracted to work 37½ hours a week, which then allows greater cover over weekends and doesn’t have such an impact if one goes on annual leave or had to take sick leave. The contract monitoring officer was told that one is due to go on maternity leave, so they are advertising for a fourth coordinator.

Although the home is not reliant on agency staff, it was explained that there are times when they utilise this service, and when this is used, the agency provides the required information around their DBS checks and qualifications.

Training is delivered on-line through a platform called Care Skills and there is also internal training and face-to-face training. It was explained that the on-line courses have a quiz at the end of the module with a specified pass mark to ensure the learners have achieved a good understanding. Competency assessments and practical training is also used for topics such as manual handling.

The quality of training is assessed through supervisions and appraisals as well as the management team monitoring and guiding the team. The deputy manager said they look for any development needs of staff and this is also taken into consideration when carrying out initial assessments for new residents; one example given was the need to source laryngectomy training for a new gentleman moving to Cwmgelli.

It was noted that the active offer is relation to the Welsh language was covered as part of the initial assessment but was then incorporated into the communication section of their personal plan which outlines what language they wish to converse in. At the time of the visit there were no residents that said they wished to speak Welsh.

Staff files were not held physically at Cwmgelli as the information is managed electronically by the corporate human resources department. Detail was requested and shared for two members of staff: both contained a minimum of two written references, one of which was from a previous employer. Both files had job descriptions, birth certificates, photographs, copies of their passports and DBS check. There were no detailed application forms shared, but it was noted that feedback had been recorded for the trial shift. Interview records were provided and as previously mentioned, these were only completed by one interviewer.

The contract monitoring officer acknowledged that there were no unexplained gaps in employment history. Where there were gaps a clear reason was stated. One of the files had a signed copy of the contract that had been signed and dated by the new employee and the home, but the second contract only had one signature and it wasn’t clear who had signed it. Following the visit, this was rectified, and a signed dated contract was shared.

Supervision and appraisal

All members of staff attend supervision at least every three months. At the time of the visit there were eight that appeared to be overdue (one of which was on maternity leave). As mentioned earlier in the report, there were annual appraisals that were overdue.

Supervision sessions are held as a confidential, formal 1:1 session. The member of staff is informed of when the meeting is planned and comes from a wellbeing perspective of the staff member. The employee has opportunity to give their views on how they are performing, good examples, and development opportunities or any concerns. The supervisor provides feedback and then they will look at objectives and outline an action plan for the next 3 months.

File and documentation audit

Personal plans were person centred and there were some outcomes identified. One of the individuals supported by Caerphilly CBC has had a lot of support from her social worker and has two daughters. It was noted that they were unable to be formally or directly involved in compiling the plans the care staff were involved who have known her for many years and have a good understanding of her routines and preferences. There was evidence seen of an email the manager sent to one of the daughters, but no evidence that they had been involved in compiling or reviewing the personal plan.

The second resident had a diagnosis of Huntington’s and there is involvement from dieticians, speech and language, social worker, and a specialist nurse. Although the risk assessments and personal plans appear to incorporate the findings from representatives and key carers, this isn’t clearly recorded. It was also observed during the first meeting that a senior member of staff was going through the personal plan and risk assessment with a relatively new resident to ensure they agreed with the contents.

Risk assessments were in place, and these had been viewed throughout the provider performance process. Appropriate risk assessments were present around areas such as deteriorating mobility, diet, accessing the community, diabetes, choking etc. and these had all been reviewed at least every three months. The contract monitoring officer noted that one resident was being weighed weekly due to their condition and had lost weight, but staff were aware of the need to encourage them to eat and to fortify their food as much as possible.

Daily records are held electronically to assist staff in documenting interactions in real time. The records highlight wellbeing, the Abbey pain scale, activities, skin integrity, mood, nutritional intake, and accidents or incidents and mobility.

People who choose or need to stay in their rooms are checked on regularly and those that can join in with any group activities are given the option. The activities coordinators will go in and talk to them, or if they are doing some baking, they may go and ask them if they wanted to help with the mixing and take the bowl to their room. Some residents may like having their nails painted, having a newspaper or book read to them, watch TV etc.

Quality Assurance

The most recent quality assurance report was seen, and it documented ‘we have enjoyed the sun and outdoor fun with trips to Bryn Bach Park, Pen-Y-Fan pond, shopping centres, Cwmbran, just to name a few. The activities team continue to organise for the future and there are plans to go to a Bob Marley tribute concert and Elvis tribute event, various charity events and look forward to Halloween and bonfire night’. The bi-annual report also contained information around accidents, compliments, and complaints. Any compliments are dated by the administrator and shared with the commissioning team. In the current quarter there had been a compliment via a thank you card from a member of staff that was leaving.

It was stated that team meetings are generally quite open, but a blank template is circulated beforehand to give staff opportunity to note and agenda items they would like to discuss. Minutes were seen for the most recent meeting on the 27 July covered feedback from the last visit undertaken by the local health board, Christmas preferences, training, sickness queries, roles, and responsibilities. Minutes were also provided for a meeting held on the 9 August, which was to introduce the new manager, the intention to do more activities, confirmation of the closure of the provider performance process and feedback from the staff team. Minutes are not signed but are circulated and a copy is left in the staff room for everyone to read.

Relative’s meetings are not held due to non-attendance; however, the contract monitoring officer was informed that the manager and deputy manager have lots of ongoing conversations with family members and any issues are addressed appropriately. Feedback is gained informally at gatherings such as Halloween parties, birthday parties and BBQ’s etc. It is recommended that verbally feedback be recorded in the compliments book so they can be incorporated into the regulation 73 quarterly reports.

Handover reports are available on the electronic Nourish system and there is the ability to add comments at handover where needed. Nurses make notes at the end of every shift and provide a summary of the shift which all care staff can then access.

At the time of the visit there wasn’t a dementia champion; dementia champions are staff members with a special interest in dementia and improving the care and experience of dementia patients in the area where they work. It is recommended that the manager asks the staff team if anyone would like to take on this role and nominate relevant staff.

Staff questionnaire

The contract monitoring officer spoke to two members of staff who demonstrated a thorough understanding of the residents, their needs, preferences, and routines. They said they support the emotional needs of residents by taking the time to listen and understand them, offering reassurance where needed, and for some residents they may try and distract them and talk about other topics.

If they saw a resident upset, they explained they would use strategies learnt from their positive behavioural support training and be patient to try and understand what might be causing them to be upset. One member of staff said that with some residents, they would take them to a quiet area and ask them what might be causing them to be upset.

Neither member of staff said they went out in the community very often but explained that the activities coordinators or staff from the therapies team take them out. The contract monitoring officer was also informed that many residents go out with their families. One of the gentlemen was due to visit his wife on the day of the first visit. It was also mentioned that most residents really like going out in the community and that it shows on their faces when they return how much they enjoy it.

Detailed information was given about two residents and in addition to explaining their support needs and how a new starter would need to assist them, they also provided an insight into their past, what they enjoy doing and what is important to them.

There are residents in Cwmgelli with communication difficulties and it was acknowledged that staff have completed training on this. Staff will sometimes use photos or PEC cards to assist in communicating with residents and details around their communication is included in their personal plans. Some residents can show carers what they want but body language and facial expressions are also important in understanding what they want to say. The staff members also explained there are individuals who require people to speak slowly and clearly where they can see your mouth, and some that will respond to visual cues, such as holding up a mug for a hot drink or a glass for a cold drink.

The contract monitoring officer asked if they were able to be flexible within their roles and they both said yes to a certain extent. One carer said there has to be some level of structure to safely meet the needs of the residents and the other member of staff said that although there are different teams such as the activities, therapies, domestic, catering, nursing teams etc, they are very much a team and although they have different roles, they all work closely together. It was pleasing to note that one carer said that they now feel comfortable to be able to sit and chat to residents.

If there was a spare five minutes and there was little stimulation one carer said that they would play a board game, ask them if they would like to watch a film or if they would like to go for a walk.

Both staff said they felt able and encouraged to offer suggestions about improving the quality of life for their residents. They explained that during staff meetings and supervisions they discuss any areas that can be developed. The contract monitoring officer was told there are more activities going on and there is a greater staff presence which is having a positive impact on the people living there. An example was given where there was a concern where two residents weren’t getting on well and one of them was given the opportunity to move to a different floor, and as a result they are both much happier. The contract monitoring officer observed that staff feel empowered and valued within the home. They explained what action they would take if they witnessed any poor practice or abuse and would escalate appropriately in line with the safeguarding and/or whistleblowing policy.

To help people do things for themselves staff explained that they don’t step in to help people do tasks that they can do independently and to be patient when supporting them to maintain their freedom. They encourage residents to make their own decisions and complete manual handling assessments to provide them with any equipment they may need to help them carry out activities of daily living.

It was pleasing to note that both staff said the manager and deputy manager spend time walking around the home and engage with staff and residents and are available to offer advice and support. It was reported that this has improved since the main office has moved onto the rose unit and are move accessible. Positive feedback was given about the new manager and the contract monitoring officer was told that it was going well.

Resident questionnaire

Feedback was obtained from two residents: one told the contract monitoring officer they are supported to go out shopping, they had recently been on a day trip to Porthcawl and had been to see some tribute bands. Recently the home had held a Halloween party, and it was reported that this had gone well. It was important to them that they were able to vape outside independently when they wanted to. The second resident didn’t provide much detail about how they spend their day, but he was observed baking coconut cakes with a member of staff during a visit.

One resident said the food was ok and they didn’t have any complaints. It was noted that they didn’t have any favourite meals but there was a good variety and there wasn’t anything they wanted that wasn’t on the menu. The other resident said that the food wasn’t always the best and there was inconsistency depending on which staff were on. They highlighted the meals can be quite repetitive and the quality wasn’t always the best. The gentleman said he would like to have more pies and pasties on the menu.

One gentleman told the contract monitoring officer that he thought he would be happy at the home, and that he got on well with some of the other residents and the staff all seemed nice, but it was early days as he had only recently moved to the property. The other resident said he was happy at Cwmgelli.

The one gentleman reported that he doesn’t get to go out often and that he would like to. When asked, he responded that he didn’t know where he would like to go but commented that he liked Rugby. It was acknowledged that the home had previously arranged for a free tour for residents at the Rugby ground in Newport, but this was prior to this individual moving in and might be an option in future. The other gentleman said that he can go out in the community and do what he wants. It was stated that the only thing limiting him is the amount of expendable finances. It was observed that this gentleman was supported to go out in his wheelchair with three other residents during one of the visits.

Both residents said staff were kind and made them feel cared for. One gentleman explained that his mobility is deteriorating and is currently using a walking stick, he stated that he is worried about falling and feels safe at the home. He said the staff support him with anything he needs. The second gentleman said that staff are always kind, and if he had any problems, he would feel confident in raising it with the manager or contract monitoring officer.

It was noted that both individuals felt they could talk to the staff about anything, and one said they had watched the news with a carer the day before and chatted about what was going on in the world. When asked if they had needed any advocacy support, one of the residents did mention that he would like an advocate and social worker to meet with him.

Relative questionnaire

Feedback was sought from two relatives/representatives of residents living at the home; both commented they were always made to feel welcome and said the atmosphere is always friendly. One said that there always seemed to be something going on, either a movie afternoon, arts and crafts, baking etc. They reported that they felt comfortable in engaging with any activities that might be going on. Both said they hadn’t been invited to a relative’s meeting but had been involved in review meetings. It was acknowledged that they felt confident in raising and concerns or complaints and wouldn’t wait for a meeting to discuss any issues. Neither had felt the need to raise any concerns but said they felt assured that any issues would be addressed if needed.

It was noted that both representatives felt informed and said that the communication was good with the home. The contract monitoring officer asked if there was anything they would change about the home and neither respondent could think of anything that would improve the quality of care provided. One commented that ‘they are meeting her needs, and she seems happy and settled there’.

Positive comments were made about the carers and the support they give and said that the one resident does things now that they wouldn’t have been able to do otherwise. One also commented that staff were enhancing their relative’s quality of life and gave an example of a specialist bowl that had been purchased to enable them to feed themselves and maximise their independence.

Corrective / Development Actions (to be completed within 3 months from the date of this report)


Every member of staff to complete annual appraisal. RISCA version 2 (April 2019) regulation 36

The statement of purpose is to be reviewed at least annually and it is recommended that the next review date is stipulated on the document or for it to highlight that it is required within twelve months from the date of the current version to evidence this is completed annually, in line with RISCA regulation 7. RISCA version 2 (April 2019) regulation 7


Where possible, interviews to be held by two members of staff.

It is recommended that the statement of purpose includes the contingency if the registered manager and responsible individual are both unexpectedly absent.

The training matrix must be updated to accurately reflect the true medication competency compliance.

When reviews are carried out it is good practice to evidence the document has been co-produced and signed by the individual (if able) and those who have been involved.

Verbal feedback (positive or negative) to be documented and included in the regulation 73 reports.

Consideration to be given to nominating a dementia champion(s).


It was acknowledged that seven of the ten previous recommendations had been completed. The home has been through a period of transition with the commencement of a new manager and having been through the provider performance process and the change in staff culture and the morale of staff has improved noticeably. There were more activities taking place, more staff interaction and better communication with families and between staff. Feedback was also gained from a social worker who reported there were a lot of positives at the home and acknowledged improvements throughout and since the provider performance process. The only area for improvement was around communication as they were still waiting on information around DNAR wishes (Do Not Attempt Resuscitation).

The contract monitoring officer would like to take this opportunity to thank everyone involved in the monitoring process for their time, assistance, and hospitality.

Unless it is deemed necessary for it to be completed beforehand, the next monitoring visit will be completed in approx. twelve months’ time.

  • Author: Amelia Tyler
  • Designation: Contract monitoring officer
  • Date: 7 December 2023