Ty Penrhos Care Home

2 Beddau Way, Caerphilly, CF83 2AX
No of beds: 83 Care Home with Nursing Dementia
Category: 10 Older Person (Residential Dementia) / 58 Dementia (Nursing) / 15 Adults with Physical Disability
Dual Registered
Tel: 029 20854340
Email: Karen.Davis@hafod.org.uk
Website: www.hafodcare.org.uk 

Contract Monitoring Report

  • Name/Address of Provider: Ty Penrhos
  • Date of Visit: 28 April 2023
  • Visiting Officers: Caroline Roberts, Contract Monitoring Officer, CCBC / Jay Ventura Santana, Lead Nurse Care Homes Governance and Safeguarding, ABUHB
  • Present: Karen Davis, Home Manager Karen Johns, Deputy Manager


Ty Penrhos is a large purpose-built care home in Caerphilly. The home is registered to provide dementia nursing and dementia residential care for 83 people, and there is also a separate provision for 15 younger adults with a physical disability.

The last full monitoring visit was conducted in 2022. A number of visits were undertaken during from September to November 2022, due to concerns regarding staffing and meal-time experience. During the visit, corrective and development actions were given.

A Monitoring Officer employs a variety of monitoring systems to gather and interpret data as part of monitoring visits, including observations of practice at the home, examination of documentation and conversations with staff, service users and relatives where possible.

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.


Responsible Individual

The Responsible Individual (RI) is Mr Marc Pullen-James. There is an expectation that quarterly reports are produced reporting on the service’s performance and quality.  This involves inspecting staff attire, the appropriate use of Personal Protection Equipment, Infection Control, interaction with residents, implementation of the Homes Policies and Procedures, Audits, discussion with residents and family to obtain their views on the service being provided etc.

Should the RI and registered Home Manager be unavailable, the contingency plan, would be that the Deputy Manager and the Clinical Lead, would oversee the service, with support provide by Director of Care.

Registered Manager

During the monitoring process, Mrs Davis was asked several questions relating to the service.  It was confirmed that no more than the one service is managed by the Registered Home Manager.

The property has CCTV around the building and in its car park, with signage on display.

Should significant events occur, either relating to the home itself or the individuals residing within the Home, the Registered Manager is required (within The Regulation and Inspection of Social Care (Wales) Act) to forward Regulation 60 documents to Care Inspectorate Wales, copying in the Local Authority’s Commissioning Team.  At the time of the visit, there were no outstanding notifications.

The Registered Manager was asked about the application of DOLs (Deprivation of Liberty Safeguards) and the visiting officer was advised that whilst all applications have been submitted, some individuals are yet to receive an assessment from the DOLs Team.

Mrs Davis advised that she felt supported by the RI and the staff team in order to provide a safe and caring environment for the residents at Ty Penrhos.


Two resident’s files were viewed during the initial visits. One file contained a pre-admission assessment; however, the second file was observed not to hold a pre-admission assessment and the Home Manager advised that this could possibly be archived.

Both files had personal centred plans; however, there was no evidence to suggest that the individuals or family members/representative had taken part in the development of one the plans.

Risk Assessments were observed.  The Monitoring Officer observed Risk Assessments in respect of Dementia, sensor mats, falls, pressure areas etc.

Some reviews were observed to be undertaken bi-monthly, whilst some were not.  It is recommended that consistency is used to ensure no gaps when reviewing individual documentation.

Daily recordings were observed to record how the individuals feel, their mood, what activities are undertaken, whether a person needs encouragement to interact with others to maintain socialisation. Separate records are maintained to record an individual’s urine output and skin integrity. However, the Managers have had a lot of discussions with staff, undertaken training and provided support to staff to ensure they are documenting and capturing pertinent information during the times they are looking after the residents. This should continue to take place on all units and will continue to be monitored.

Gwen am Byth documentation, which relates to improving oral care within care settings continue to be used at Ty Penrhos.  Personal Plans for continence care, elimination (Bristol Stool Chart), skin integrity (skin bundle), body mapping, Pressure Ulcer Assessments, Tissue viability, Deprivation of Living standards applications etc were observed.  Appropriate contact with professionals was also observed i.e. opticians, GP.

Deprivation of Liberty Safeguards were observed within both files viewed, along with a Do Not Attempt Cardio-Pulmonary Resuscitation advisory forms on one file.  It was explained to the visiting officer that the one individual’s family, were not ready to discuss this sensitive subject.

Personal Emergency Evacuation Plans (PEEPS) were not observed on either resident’s files.  However, this was discussed with the unit leads during the last monitoring visit.  The visiting officer was advised that PEEPs were retained on a ‘grab’ file in the unit’s office.

The home has an up-to-date Statement of Purpose (dated April 2022) and Service User Guide (dated March 2023), which explains to residents the service the home offers and what they can expect from the provider. It outlines the staffing structure within Hafod, and also provides the reader with a brief background of the RI and the Director of Care.

Within the last monitoring report, it was reported that Hafod had made changes to its dependency tool, and this resulted in staff morale being low and therefore, impacted the individuals on the units. The 2023 Statement of Purpose has been amended to reflect the staffing numbers required to provide the level of support and assistance expected.

Staffing and Training

The home consists of 5 communities: Mountain View, Daffodil Rise, Caerphilly, Ogmore and APD.  The APD unit has younger physical disabled residents.

At the time of the initial visit, a new Activity Co-ordinator had commenced employment. The home continues to endeavour to recruit additional Activity Co-ordinators due to the size of the home; however, care staff also share the responsibility of providing activities and stimulation to the residents.

Agency staff are utilised as and when is necessary.  A regular agency is used, and appropriate checks are undertaken i.e. PINs, registered with Social Care Wales, DBS checks etc.  If new to the home, an induction is provided.

The home has a number of residents who communicate through the medium of other languages i.e. Russian, Polish, Chinese etc.  The staff communicate with the individuals by accessing Apps, pictures and by the home purchasing various books.  The Home Manager advised that every effort is made to communicate effectively with the residents from a different ethnic background.  The Home Manager explained that the home purchased a Bible for one individual and arranged for an Orthodox Priest to visit the home.

The Home Manager advised that some staff work more than 48hours per week and that the Working Directive has been signed by each individual staff member.

Two staff files were viewed during the visit.  The job description was not retained on file and the Monitoring Officer was advised that it had been given to both applicants.  Both files contained CVs from the individual staff members.  Two references for each individual were observed.  The home adopts a scoring system when interviewing.   Both files held a contract of employment; however, they were not signed.  Hafod’s HR department retains such information.  Both individual files held details of current DBS checks/Government of the Peoples Republic of Bangladesh.  Both files held copies of birth certificates and photographs of the individual staff member.     

Training certificates are retained on-line, and the Monitoring Officer observed training certificates relating to one staff member only.  The second staff member had only recently commenced employment at the home and therefore, this file will be viewed during future monitoring.

As with all providers, it recommended that they retain details of care staff registration with Social Care Wales.  It is recommended that either the certificate should be held on file or the registration number, date, and expiry date.

There is a strong management structure in place, with a Manager, Clinical Lead, and a Unit Lead for each of the nursing and residential units.

During the visit, the monitoring officer spoke to a member of staff and asked a series of questions relating to their employment at the home and about the support they provide and what they receive as employees.  The feedback provided was positive with the staff member advising that should a resident be upset, they knew how to support them.  They were able to provide the correct information should they observe poor practice.

The staff member advised that the home promotes independence, supporting individuals to make choices i.e. what clothes to wear, showering themselves etc.

The monitoring officer was informed that staff on Ogmore unit (residential only residents) are led by the residents in respect of what they want to do.  The staff member felt that they were flexible in their role and had time to sit and chat with the residents.

When asked if the Home Manager spends time walking around the home, engaging with staff and residents, the response received was “depends what [work] they have on”.

The Monitoring Officer viewed the training matrix, it was observed that staff have  attended mandatory training; however, the training matrix stated that Safeguarding Vulnerable People is to be completed once.  It is suggested that this area of training is undertaken every 3 years and therefore, it is recommended that staff attend training as soon as possible. Other mandatory training was observed i.e. Moving and Handling (Theory) 57.42% and Moving & Handling (Practical) 61.11 %, Food Hygiene 81.56%, Infection Control 85.26%, First Aid 46.15%, Medication Awareness 78.02%.  It is acknowledged that only qualified nurses and Nursing Care Assistants are permitted to administer medication.  Non mandatory training is also undertaken i.e. DSE, GDPR (data Protection), Dignity at Work, Cyber Security, Social Media, Think Before you Click, Epilepsy, along with others.

The provider uses e-learning and classroom learning.

As previously reported, the Home Manager views the training matrix once a month to have an overview of what training is out of date, requires renewing etc.  Each Unit Lead also has access to the matrix and can monitor their staff teams developments/training needs. Staff are also expected to hold responsibility for any training they feel they may need to best support the individuals residing at the home.

The quality of training is assessed by staff being observed on how they undertake and carry out new techniques/skills that have been learned.  New techniques and practice are also discussed during the supervision sessions.  However, as reported, whilst viewing the training matrix for 2022-2023, it was evident that regular quarterly supervision is not taking place as required.

The home is very proud of its staffing team and the self-development individuals achieve.  Some of the staff continue to train to become qualified nurses.

Facilities / Observations         

General observations of staff were found to be positive; staff were observed to have good interactions with the individuals they support, showing warmth and encouragement.

The Manager holds a 10:10 short meeting each morning with representatives from each part of the home, such as unit leads, activities co-ordinator, chef, maintenance staff etc. The Monitoring Officer observed said meeting and it was positive to see that the staff provide relevant updates about residents, staffing and any issues that require attention/action.  Conversations were held in respect of resident of the day, activities (gardening, now that the weather is improving and, also the Kings Coronation), vacancies on each unit etc.

The home was observed to be clean, with no hazards observed at the time of the visit.

Managing a resident’s money

Money is received by reception staff, following the same procedure of signing in and out.  However, the Home Manager advised that the majority of payments are now made via BACs (Bankers' Automated Clearing System).

Home Maintenance

Ty Hafod have an estate team and an estate operative that oversees regular maintenance checks.  Sub-contractors are also used for plumbing, lights etc.

At the time of the visits, there were no issues reported with regards to concerns for the property.  The Manager advised that the home has a good working relationship with the estate agent.  The Manager advised that one washing machine was out of order at the time of the visit after being fixed a few days before.  This has been reported and other washing machines are available of staff to use.

Residents are able to change the temperature of their room.

A new heating system has been installed at the home, improving the heating throughout the home.


During the visit, it was positive to see that staff were engaging with the residents and that there was plenty of smiles and laughter.  A relaxed atmosphere was observed between the residents and the staff.

During the course of the visit, residents were observed making items in readiness for the Kings Coronation on 6th May 2023.  Flags, Buntin, Big Ben were being made, with the residents assisting staff sticking flags together and painting paper crowns.

Residents enjoy visiting the local shops and pubs for meals/drinks.  During the warmer weather, gardening is undertaken, meals served outside, or ice cream afternoons are enjoyed.

Activities, take place on the individual units and in the ‘street’ area.  Recently the home has enjoyed watching chicks hatch and developing.  Opera singers have visited and entertained the residents and the home is preparing for the Coronation and, also the FA cup, which will be viewed on the big screen in the street area, with drinks and a buffet.

For those cared for in bed, the Home Manager advised that the activity co-ordinator is expected to read or provide other stimuli i.e. hand massage, listen to music etc.

Quality Assurance

Mr Pullen shared his Regulation 73 quarterly reports with the monitoring officer, which covers a number of areas i.e. CIW feedback, reviews of policy and procedures, complaints and compliments.

Staffing levels, discussions with the Home Manager, staff and residents/relatives.

During the visit the RI will look at the environment.

The report concludes with providing the Home Manager with actions that have a required completion date.  This will then be revisited during the next visit, which is scheduled for 16th May 2023.

Corrective / Developmental Actions


Staff meet for one-to-one supervision with their line manager or equivalent officer, or a more senior member of staff, no less than quarterly. (RISCA Reg. 36) Timescale: Immediately and ongoing.

For staff to complete mandatory training in a timely manner i.e. Safeguarding. (RISCA Reg. 36) Timescale: Immediately and ongoing

Some reviews were observed to be undertaken bi-monthly, whilst some were not.  It is recommended that consistency is used to ensure no gaps when reviewing individual documentation.  (RISCA Reg. 16) Going forward and will be monitored during the next monitoring visit.


For staff files to retain evidence of staff registration with Social Care Wales.


The home appeared more settled since the last visit and staff morale was observed to be positive.  The residents looked well, and smiles and laughter were observed throughout the visit.

Routine monitoring will continue, and the visiting officers would like to thank the staff for their hospitality during the visits.

  • Author: Caroline Roberts
  • Designation: Contract Monitoring Officer
  • Date: 23/05/2023