Ynysddu Nursing Home

The Old Police Station, Mount Pleasant, Ynysddu, Nr Crosskeys, NP11 7JQ
No of beds: 31 Care Home with Nursing
Category: 25 Older Person (Nursing) / 3 Older Person / 3 Physical Disability
Respite Care Available
Tel: 01495 200061
Email: ynysdducarehome@outlook.com

Contract Monitoring Report

  • Name/Address of Provider: Ynysddu Nursing Home, The Old Police Station, Mount Pleasant, NP11 7JQ
  • Date/Time of Visit(s): Thursday 29 June, 2023, 9.00 a.m. – 2.00 p.m. (with visiting Officers listed below) Wednesday 4 October, 2023, 9.30 a.m. – 12.35 p.m.
  • Visiting Officer(s): Andrea Crahart, Contract Monitoring Officer, Caerphilly CBC, Jay Ventura Santana, Lead Nurse CHC & Governance,  
  • Aneurin Bevan University Health Board (ABuHB) Karen Taylor, Lead Nurse CHC & Governance, ABuHB        
  • Present: Natasha James, Registered Manager


Ynysddu Nursing Home is registered to provide care to a total of 31 people, who either have residential or nursing needs.  The home comprises of 3 floors and is in an elevated position situated in the village of Ynysddu. 

At the time of the visits there were 29 people living at Ynysddu Nursing Home, with 2 nursing vacancies.    

The Care Inspectorate Wales (CIW) undertook an inspection in August 2023 which highlighted just a small number of areas for improvement, and the inspection report read positively about the care and support that is delivered at the Home.  

As part of the monitoring process feedback is gathered from professionals (social workers etc.) and relatives etc., and over the previous couple of years very few issues/concerns had been received.

Dependent on the findings within the report, corrective and developmental actions may be given to the provider to complete.  Corrective actions are those which must be completed (as governed by regulations) and developmental actions are those which are deemed good practice.  

Previous Recommendations

Corrective Actions

Job description to be updated with up to date terminology. Timescale: Within 1 month. RISCA Regulation 35. Action met.

Supervisions to evidence any 2 way conversations/discussions held with staff (and issues and concerns experienced, training needs, actions to take forward etc.) and for appraisals to be held.  Timescale:  On going.  RISCA Regulation 36. Partially met.

Supervision to be held between the manager and RI on a regular quarterly basis.  Timescale: Within 1 month.  RISCA Regulation 36.  Not currently documented.

Gaps in training to be prioritised and attended by all staff.  Timescale: On going. RISCA Regulation 36.  Partially met.

Responsible Individual

The Responsible Individual (RI) for the service visits Ynysddu Nursing Home on a regular basis to oversee the service and its quality.  The most recent quarterly reports were viewed for this year which indicated that key areas were being highlighted for improvement.  

The Home’s Statement of Purpose and Service User Guide were made available and had been updated in August 2022.

In the event that both the RI and Registered Manager were absent the Senior Nurse/Deputy Manager would act up in their absence.

Mandatory Policies and Procedures were requested and viewed (e.g. safeguarding, complaints, admissions/commencement of service etc), all of which had been reviewed in recent months, however some made reference to out of date terminology.

Registered Manager

The Manager is registered with Social Care Wales (the workforce regulator) and is visible and accessible for staff and visitors alike.  The Manager also has a ‘hands on’ approach and assists with providing care and support to the residents.  

The Home does not have CCTV (surveillance) anywhere inside or outside of the building, therefore consent documents are not required for completion by family members.

Staff Training

Staff training is accessed via organisations such as Evergreen, Langfords, the Blaenau Gwent/Caerphilly Workforce Development Team and the ABuHB.

Staff have access to a range of training e.g. safeguarding, infection control, fluids/nutrition, dignity and privacy, falls, health and safety etc.  The training matrix suggested that there were gaps in staff training, however there was evidence from certificates that the majority of staff had attended many training courses but that the matrix required updating to reflect this.  Some key training (safeguarding) is required for some staff who have not attended these courses.


There are 2 Activities Co-ordinator employed to provide activities to residents.  Many activities are organised e.g. pampering, sing-a-long sessions, chair exercises etc.  People are also supported to enjoy social activities in the individual’s own rooms for those who do not wish to use the lounge, or who are unable to.   There were pictures displayed on the wall of people enjoying themselves and some beach party digital pictures were available from a party held during the summer.  ‘Thank you’ cards could be seen displayed on the notice board also.

Staffing levels remain as 2 qualified nurses on duty during the day, 5/6 carers during the morning and afternoon.  At night time there is 1 nurse on duty and 2 carers, however given the demands associated with the layout of the building a third carer on duty would ease the pressures.  The Home access a nursing agency when this is required, who ensure the same staff work at the setting to ensure consistency.

‘The Active Offer’ – More than Just Words (the revised Welsh Language Act policy) requires providers of social care to provide communication in Welsh to people whose first language is Welsh, without the person asking for it.  The Home try to accommodate those who wish to converse in Welsh, which the Home’s Statement of Purpose reflects.  However, if a resident is fully Welsh speaking the Home would not be able to cater for their needs. Presently, there is a resident who is Welsh speaking and there are staff who can speak conversational Welsh.  There are Welsh communication books for all staff to use also.

Two staff files were viewed which indicated that a robust recruitment process had been undertaken in each case.  The information contained included e.g. references, application forms, staff photographs, DBS (Disclosure and Barring Service) information, a Contract of Employment, interview records etc.  The Home have acquired a Sponsorship license which enables them to recruit people from oversees, and pertinent documentation relating to visa information and a Residence permit for one of the staff members was present.

Supervision and Appraisal

There is a supervision/appraisal matrix, however currently this is absent of any dates to indicate when sessions have taken place.  Sessions are held between the member of staff and the Manager.  From the staff files viewed it was evident that supervision sessions had taken place, however the Manager does not have a documented supervision on an ongoing basis, although conversations about her role etc. do take place.

Quality Assurance

The Nursing Home is required to produce quality assurance reports on a 6 monthly basis evidencing the involvement of residents, relatives, staff and other stakeholders.  This should also include an analysis of this feedback, the lessons learnt from complaints/safeguarding, trends/outcomes of audits, RI visits and inspections.  The most recent report was provided which was acknowledged to be a comprehensive overview of the service.

Staff handovers are undertaken at the start of every shift which includes all staff on shift at the time.  There is also a report book where important updates are noted by staff so that people coming on shift, who may have been absent for a few days can read and be brought up to date with recent events.  The Home also uses a WhatsApp group to communicate information to the staff team.

Communication books have been introduced for all residents so that visitors (family/friends) can write any comments that will feed into the quality assurance process to ensure valuable feedback is captured and actions can result.  These are collected on a regular basis however visitors are aware that there remains an ‘open door policy’ so that individuals can raise any concerns in a timely way also.

At the present time staff team meetings and residents/relatives meetings are not held.  The Manager confirmed that there are plans to re-start staff team meetings.

File and documentation audit

Two files were viewed which contained an index and all information was easy to locate.

Personal Plans (care plans) were in place for many areas of need e.g. mobility, nutrition, personal care, continence, communication etc., and suitable risk assessments were present also.  The personal care support plan omitted to include some detail about the person’s preferences for bathing, and medication personal plans did not appear to be present. However, the Manager confirmed that medication management is captured in another suitable Care and Support plan.

Personal Plans and Risk Assessments had been reviewed on a monthly basis to take into consideration any changes to the person’s care needs.

Daily records were comprehensively written and had been signed and dated by the staff member completing them.

The ‘This is me’ document is being introduced so that residents who cannot easily share information about themselves can be captured.  This includes details such as the people who are important in their lives, important life events, their preferences etc. and can be a valuable  support tool for staff looking after people.

The contract monitoring officer was informed that there are plans to put resident information into an electronic format instead of written format in the near future.  

Home maintenance

Currently there is a vacancy for a home maintenance role which the Home is actively trying to recruit to.  Presently, all maintenance checks are being undertaken by the Home Manager.

Fire Safety/Health & Safety

The most recent fire risk assessment had been completed in July 2023 and included a number of recommendations for the Home to address. The manager confirmed that all recommendations have been completed. A ‘grab file’ is in situ for use in the event of an actual fire/fire drill which includes evacuation procedures and reference to people’s mobility, and how to support them in the event of a fire.  Some Personal Emergency Evacuation Plans (PEEP’s) were not present which was brought to the attention of the Manager at the time of the visit.

Fire drills had taken place on a regular basis this year.  These had been well attended by staff, with a brief overview of where the fire drill had taken place and how well it had been undertaken.  These had been carried out by the Registered Manager in the absence of a suitable maintenance person.

A Food Hygiene rating of 4 (good) was awarded in August 2023 which included a number of recommendations to address.

Resident questionnaire

No specific questions were asked from the Monitoring Tool, however general conversations were held with people living at the Home who were complimentary about the care being received. A resident expressed how the staff were ‘as good as gold’ and that she felt she was very well cared for.

Relative questionnaire

A relative was contacted for their feedback who relayed that the care his brother receives at Ynysddu was very good.

Observations (Activities, Environmental, Facilities)

Care staff were present in the lounge during the visits and were seen to be engaging with  residents in an unhurried manner.

There are 2 activities co-ordinators employed at the Home who provide stimulation for the residents and the flexible visiting arrangements enable family and friends to visit at any time.  The contract monitoring officer was made aware of themed events which have consisted of curry nights, bingo and a beach party.  There are photographs displayed on the walls of some activities people have taken part in.

The Home has benefitted from a new roof and cladding this year, new windows, a new gas boiler and radiators are being fitted (due to the thermostats not working).  

Call bells were heard to be sounding and were answered promptly during the time of the monitoring visits.

Ynysddu Nursing Home is a non-smoking Home so would not accept any resident if they were smokers.

The Home was noted to be clean, tidy and free of any malodors.  The outside patio area has tables and chairs for people to use and is a safe and pleasant area with a lovely view.

From viewing some people’s rooms, it was evident that they had been personalized with their own bedding, pictures, photographs etc. in order to make as homely and comfortable as possible.

Corrective/Developmental Actions

Training matrix to be brought up to date to ensure it captures all training that has been undertaken.  For key mandatory training to be accessed for all staff.  Timescale:  Within 3 months and ongoing.  RISCA Regulation 34

Supervision/Appraisal matrix to include dates when sessions have been held.  Timescale:  Within 3 months.  RISCA Regulation 35

Policies/Procedures to include up to date terminology.  Timescale: Within 2 months. RISCA Regulation 38. Completed following the visits.

PEEP’s to be written for those that have not been added to the fire exacuation ‘grab file’ yet. Timescale:  Immediately.  RISCA Regulation 57   Completed following the visits.

Staff team meetings to be re-introduced and consideration given to residents/relatives meetings.  Timescale:  Within 6 months.  RISCA Regulation 38


To consider introducing medication personal plans for all individuals, or alternatively ensure that medication management is covered robustly within another support plan that all staff are aware where to find.  Timescale:  Within 1 month


Ynysddu Nursing Home continues provides a welcoming and caring environment for residents and visitors.  

The Home’s documentation was robust, with people’s personal plans having been reviewed on a regular basis, and staff files indicated there was a robust recruitment process in place.  Although the contract monitoring officer was aware that staff training had taken place this was not always evidenced on the training matrix, however assurances were given that this would be updated to reflect the training that has taken place.

There has been investment at Ynysddu Nursing Home in terms of some major refurbishment which is positive.  

Systems and processes are in place to ensure residents and staff’s wellbeing are catered for.

The Contract Monitoring officer would like to take this opportunity to thank the staff at Ynysddu for their time and hospitality.

  • Author: Andrea Crahart
  • Designation: Contract Monitoring Officer
  • Date: October, 2023