Glan-Yr-Afon Nursing Home

Glan-yr-Afon Lane, Pengam, Blackwood, NP12 3WA.
No of beds: 49 Care Home with Nursing
Category: 19 Older Person Residential / 30 Older Person (Nursing) / Dual Registered
Tel: 01443 835196

Contract Monitoring Report

  • Name/Address of Provider: Glan-Yr-Afon Nursing Home, Glan-Yr-Afon Lane, Fleur-De-Lys, Blackwood, NP12 3WA
  • Date of Visit: 29 November 2022
  • Visiting Officers: Ceri Williams - Contract Monitoring Officer CCBC
  • Present: Alex Matthew, Manager, Glan-Yr-Afon 


Glan-Yr-Afon is a care home in Fleur-de-Lys that is registered to provide Residential care and Nursing care for a maximum of 39 people.  At the time of the visit there were no vacancies.

The last monitoring report was completed in July 2019 and at this time there were two corrective actions and no developmental action identified. Monitoring visits and close communication with home was maintained throughout the covid pandemic.

The home is owned by Comfort Care homes and the Responsible Individual is Swarnlata Bansal.  The service is registered with Care Inspectorate Wales and is required to meet conditions under the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA).

Previous Recommendations

Corrective Actions

All staff to receive one to one supervision no less than quarterly. (RISCA Regulation 36). Met: Staf receive regular supervision within timeframes set out in regulations.

Regular staff meetings take place, (a minimum of six meetings per year) and are recorded. (RISCA Regulation 38). Not Met: See body of report.

Findings from Visit

Staffing, Training and Supervision

The home is staffed by qualified nurses and carers. In addition to these staff are the Manager, Administrator, activity co-ordinators, maintenance person, kitchen, domestic and laundry staff.    

The home has previously used agency staff when needed but are currently fully staffed. When agency staff are used, they are from one agency and are two regular members of staff.

The staff team are flexible and pick up shifts when required in order to cover any shortages in the rota.

A staff file was viewed at the time of the visit. The file viewed contained current photograph of the member of staff and necessary proof of identity.

Detailed application forms were present on file along with an interview record with scoring mechanism and interview scenarios.

Signed contracts and job descriptions were also present on file.

There were no unexplained gaps in employment and two written references required were on file which had also been verified by the home.

There was evidence of an up-to-date DBS check using the annual update service.

Training is planned throughout the year and is provided for staff by an external training company. The home also utilises online training with each member of staff having log in details to complete online training.

Staff receive training in mandatory and non-mandatory subjects.

A training matrix was able to evidence that staff are up to date with necessary training enabling them to perform their roles.

It is a requirement that staff meet with for one-to-one supervision with their line manager, or equivalent officer, or a more senior member of staff, no less than quarterly. Samples of supervision provided to the Contract Monitoring Officer showed that staff are receiving supervision at the regular intervals required.

Examples of staff supervision were reviewed and evidenced that sessions include staff’s well-being and development and also practice based regarding the running of the home.

All staff had received an annual appraisal for the current year.


Two resident’s files were viewed as part of the monitoring visit.

Both files contained completed pre-admission assessments.

Personal plans viewed contained all needs highlighted in the local authority care & support plan. Plans were detailed regarding the care and support needs of residents; however, more detail could be included regarding likes/dislikes and routines.

Personal Plans are reviewed monthly which is good practice. There was no evidence of the individual or a representative being involved in reviews of care.

Suitable risk assessments were in place, where necessary, in order to meet the person’s needs.

A moving and handling care plan viewed on one residents file required updating following a recent O.T assessment in which the resident’s needs had changed. This was brought to the attention of the manager who actioned the changes immediately.

Daily recordings are detailed and included details of the persons care needs for that day. Recordings also contained information relating to the person’s well-being. Daily records are also reflected and considered in the monthly review of Personal Plans.

There was evidence in both files viewed of referrals being made to appropriate outside agencies such as Occupational Therapist, Physio etc when necessary.

A pen picture document was present on both files and contained detailed information for both residents regarding their life history and brief outline of health and care needs.

End of life care plans were present on both files. These were detailed and contained the resident’s wishes and preferences regarding their end of life care and support.

The home has a system in place with regards to DoLS applications including details of the applications made, expiry dates and when renewals are due.

Quality Assurance

No recent quality of care review has been completed; it was discussed with the manager that these should be completed every six months as required in regulations.

There were however documented quarterly visits from the Responsible Individual, this was a detailed report monitoring the performance of the service, engaging with staff and residents and overall inspection of the premises.

There was no evidence of formal staff meetings taking place and recorded as required within regulations. The manager advised that staff are kept informed and updated of any changes by means of handovers at change of shifts and also by digital communications.  The manger is visible throughout the home and approachable by staff should they require to speak to him.

A number of audits carried out at the home both internally by staff and also by external agencies such as Complex Care Pharmacist, Fire Service, Environmental Health.

Internal audits completed by the manager include Accidents, Incidents, Complaints, Medication, Food Safety, care Plans, Client equipment and the Home Environment, Maintenance Checks, Prevention of Sharps, Hand Hygiene and PPE and Satisfaction Surveys.

The home has a robust daily handover which takes place every change of shift and is attended by all staff.

All residents are discussed, and this is documented on individual daily handover sheets. A summary of daily handover is also printed off with each resident listed and any significant information recorded and provided to each member of staff

The handover also contains discussions regarding the general running of the home including staffing, any maintenance issues, messages from relatives etc.

The home employs a full-time maintenance operative and has an annual maintenance plan and schedule. Various checks are carried out weekly, monthly quarterly and six monthly.  These checks are recorded and kept on the maintenance file.

A number of improvements to the environment of the home have taken place since the last monitoring visit including decoration, new flooring throughout, investment in new laundry equipment and two new large screen T.V.’s for the lounge.

The annual Fire Safety assessment for the home has been arranged. The last assessment was provided for the Contract Monitoring Officer and evidenced that there was one recommendation which had been actioned.

Evidence was available of documented fire drills which had taken place at the home and personal emergency evacuation plans for residents viewed were clear regarding the support required in the event of an emergency.

Resident and Relative Feedback

During the monitoring visit feedback was sought from residents and relatives of residents who were visiting the home at the time of the visit.

A relative spoken to during the visit praised the staff, the manager and particularly the catering staff at the home, describing the food as excellent.

A further relative was contacted by phone for feedback. They described the home as marvellous with their relative since they had moved in, and we have nothing but praise for the staff. They advised that they are always made to feel welcome at the home and that communication with them was good.

The resident spoken to during the visit, told the monitoring officer that they were very happy living at the home.

They advised that they prefer to spend time in their room but are always encouraged to go to the lounge and attend any events or activities that are taking place within the home.

The resident advised that they enjoyed spending time on their room reading and that staff would regularly come in and enquire if they were ok.

The resident stated that the staff were kind to her, felt that they responded quickly to them when needed and that they never felt rushed when carrying out care tasks.

Facilities, Observations & Activities

The home is pleasantly decorated and feels homely. There were no malodours noticed when walking around the home.

A number of improvements to the environment of the home have taken place since the last monitoring visit including decoration, new flooring throughout, investment in new laundry equipment and two new large screen T.V.’s for the lounge.

Observations during the visit evidenced people are treated with dignity and respect and care is person-centred. Staff were engaging and sharing with residents and catering to personal preferences.

Food is freshly prepared and locally sourced, catering to personal preferences and offering alternatives if required.

Two full time activities co-ordinators are employed at the home and there are a number of activities available on a regular basis. There are themed events for all residents and also one to one time for residents who are in their rooms. 

Activities are arranged based on feedback from residents and are tailored to individual interest. Residents also enjoy trips out in the local community.

Corrective / Development Actions

Corrective Actions

Personal Plan reviews are undertaken involving the individual, or when appropriate, their representative. (RISCA Regulation 16)

Timescale: At least every three months

Regular staff meetings take place, (a minimum of six meetings per year) and are recorded. (RISCA Regulation 38).

Timescale: Minimum of six meetings per year

Quality of Care review to be completed every six months. (RISCA Regulation 80).

Timescale: Immediate and then every six months.

Developmental Actions

The manager to forward all Regulation 60 notifications to CCBC Commissioning team.


This was a positive monitoring visit to the home, with examples of person-centred care being observed throughout and all feedback received, regarding the home and the staff, was extremely positive.

It was clear that there was a caring relationship between the staff and residents, and a very relaxed and pleasant atmosphere during the day. There was a good staff presence, and it was clear from observations that the staff ensure that there are plenty of activities for residents to be involved in each day. 

In line with Caerphilly’s Contract Monitoring Strategy, a further monitoring visit will be carried out in approx. 12 months unless required to be completed beforehand.

The visiting officer would like to take this opportunity to thank the residents, staff and relatives for their time and hospitality during the visit.

  • Author: Ceri Williams
  • Designation: Contract Monitoring Officer
  • Date: 04/01/2022