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 6 June, 2024, 9.00 – 2.30 p.m / Wednesday 26 June, 2024, 1.00 p.m. – 3.40 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
Background
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 30 people living at Ynysddu Nursing Home, with 1 nursing vacancy.
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.
The Home has received a Food Hygiene inspection in 2023 and awarded a score of 4 which is deemed as ‘good’. There were some recommendations which have been completed as part of this process.
As part of the monitoring process feedback is gathered from professionals (social workers etc.) and relatives etc., and over the previous year 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
Supervision to be held between the manager and RI on a regular quarterly basis. Timescale: Within 1 month. RISCA Regulation 36. Not currently documented.
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. Partly met/Ongoing.
Supervision/Appraisal matrix to include dates when sessions have been held. Timescale: Within 3 months. RISCA Regulation 35. Action met.
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 evacuation ‘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. Not met.
Developmental
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. Action 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 and part of last year.
The 6 monthly Quality of Care Review was made available (from November 2023 to March 2024) which was informative and comprehensively written.
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 however some amendments were required to ensure they reflect current legislation and 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 Aneurin Bevan University Health Board (ABuHB).
Staff have access to a range of mandatory training e.g. safeguarding, infection control, first aid, fire training etc. At the present time there are gaps in the training received, however the manager has some dates set for future training this year and plans to organise other training so that all staff will be up to date by the end of the year.
Staffing
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. There are Welsh communication books for all staff to use also.
A staff file was viewed which indicated that a robust recruitment process had been undertaken. 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 the staff member was present.
Supervision and Appraisal
The supervision/appraisal matrix indicated that staff had received supervisions at regular intervals i.e. 3 monthly and appraisals had been recorded also. 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 provider is required to produce 6 monthly quality assurance reviews 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 and referred to above.
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 were introduced in 2023 and have proved a valuable way of obtaining direct feedback from family members. The books 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. It was evident that any issues highlighted are rectified as soon as possible.
At the present time staff team meetings and residents/relatives meetings are not held. The Manager confirmed that staff will communicate any issues they are having directly to her.
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, all of which had been reviewed on a regular basis to ensure that they were still reflective of the person’s care needs. Arrangements had been made for Personal Plans to be in a typed format rather than written, making it easier for the reader.
Daily records were comprehensively written and had been signed and dated by the staff member completing them.
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 and other contractors are requested when required e.g. a painter/decorator, electrician etc.
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. This is due to be renewed in July 2024.
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.
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 manager in the absence of a suitable maintenance person and at various times of the day, some being in the evening when the manager will visit unannounced.
The manager reported that there had been no accidents/incidents experienced by residents i.e. no falls sustained. However, there had been 2 accidents where a staff member and a relative had tripped, but these were not serious events.
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 she enjoyed the meals and how staff were good to her.
Relative questionnaire
A relative was spoken to during a visit to the Home who confirmed that she was very happy with the care being given to her husband. She stated that the staff could not do enough for her husband.
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-ordinator employed to provide activities to residents. Activities are organised e.g. pampering, sing-a-long sessions, chair exercises etc. and pictures could be seen of people enjoying cookery and colouring. 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. A party had been held during the week of the second monitoring visit to celebrate a gent who has lived for 20 years at Ynysddu which also include a few staff who had worked for this length of time also. The Home was decorated and there were photographs taken of the celebrations also. ‘Thank you’ cards could be seen displayed on the notice board also expressing relatives thanks for all that the staff had done for their loved ones.
Over recent years the Home has had some substantial work carried out e.g. a new roof, cladding, new windows, gas boiler and radiators (the heating can now be controlled by the new thermostats).
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, is a safe and pleasant area with a lovely view and there are pots of flowers in the outside area.
Green agenda
The manager was asked if the Home had introduced any initiatives to improve their carbon emissions as an organization. The Home ensure they re-cycle, with clothes being given to other residents (where appropriate), low wattage light bulbs are used, all radiators are thermostatically controlled, the windows are double glazed and there are new doors.
During hot weather the Home manage the heat by opening windows and fans in bedrooms and lounges are sufficient.
Corrective/Developmental Actions
Supervision/Appraisals to be conducted between the Manager and RI on a regular and ongoing basis and to be evidenced. Timescale: within 3 months and ongoing. (This is an action that was brought forward from the previous monitoring report). RISCA Regulation 66.
Statement of Purpose and Service User Guide to be reviewed to ensure they are up to date. Timescale: Within 2 months. RISCA Regulation 6.
Mandatory policies to be updated to reflect current legislation and terminology. Timescale: Within 2 months. RISCA Regulation 12.
Staff meetings to take place bi-monthly. Timescale: Within 6 months. RISCA Regulation 38.
Staff training to be brought up to date, continued on an ongoing basis and added to the matrix (e.g. food hygiene, dementia care, stroke awareness etc.). Timescale: Within 6 months. RISCA Regulation 34.
Conclusion
Ynysddu Nursing Home continues provides a caring environment for residents and visitors.
The Home’s documentation was robust with people’s personal plans and risk assessments having been reviewed on a regular basis and a recommendation from the previous monitoring visit having been followed through. Staff files indicated there continued to be a robust recruitment process in place. There are improvements required in relation to staff training, however the Manager is ensuring that all training will be brought up to date by the end of the year.
Ynysddu Nursing Home continue to advertise and seek a maintenance person to oversee repairs and re-decoration at the Home, however they have not been able to recruit a suitable person to date.
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: July 2024