Ty Derwen Residential Home
Kendon Road, Crumlin, Newbridge, NP11 4PN.
Tel: 01495 243028
Email: tyderwen@btconnect.com
Contract Monitoring Report
Name/Address of Provider: Ty Derwen Residential Home, Kendon Road, Crumlin, Newbridge, NP11 4PN.
Date of Visit: Wednesday 26 April, 2023, 11.30 – 2.30 p.m / Wednesday 21 June, 2023, 10.00 – 1.00 p.m.
Visiting Officers: Andrea Crahart, Contract Monitoring Officer, Commissioning Team, Caerphilly CBC
Present: Dawn O’Sullivan, Registered Manager
Background
Ty Derwen is a residential Home registered to provide care for 28 people (8 with personal care needs and 20 with a cognitive impairment). There were 4 vacancies at the time of the visit in June. The Home is a large, detached, 3 storey building situated in Crumlin, within the area of Caerphilly borough.
The Care Inspectorate Wales (CIW) undertook an inspection in November 2022 and identified one area for improvement which would be re-visited at their next inspection.
The home’s Service User Guide is available for issuing when new residents move into Ty Derwen, however it was previously updated in June 2022, and requires re-visiting to ensure it is up to date.
The home’s Statement of Purpose was reviewed in February 2022 and requires reviewing on an annual basis.
Regular feedback is received within the Caerphilly County Borough Council Commissioning Team from visiting professionals who visit the home and very few issues have been received in the previous year. A visiting social worker reported that during her visit in October last year she found documentation to be easy read, up to date and had been reviewed regularly. She also confirmed that the manager knows the people living there very well and that there was a lovely atmosphere in the lounge during her visit.
In terms of ‘The Active Offer’ - More than Just words (revised Welsh language legislation), Ty Derwen actively ask their staff during induction if they would like to undertake a Welsh language course, however this has not been taken up to date. The registered manager agreed to explore ‘The Active Offer’ and how to introduce into the home.
Dependant on the findings within the report the provider will be given corrective and developmental actions to complete. Corrective actions are those, which must be completed (as governed by legislation etc), and developmental actions are those which are deemed to be good practice.
Previous Recommendations
Corrective Actions
Fire Risk Assessment to be reviewed and up dated on an annual basis. Timescale: Immediately and on going. RISCA Regulation 57. Action met.
Service User Guide to be re-reviewed to ensure some of the terminology is altered in line with RISCA. Timescale: Within 3 months. RISCA Regulation 19. Action met.
To further improve the grounds of the Care Home by weeding, re-potting plants, cleaning windowsills etc. Timescale: Within 3 months and an ongoing plan to maintain these. RISCA Regulation 44. Action not met.
To explore further meaningful and stimulating activities for residents to enjoy. Timescale: Ongoing. (Some Dementia Care Matters information forwarded to the Home to assist). RISCA Regulation 21. Action met.
Responsible Individual
The Responsible Individual (RI) role is to ensure the performance and quality of the service and there is a requirement for quarterly reports to be written to illustrate that this is being regularly monitored and overseen. A recent quarterly report (dated February, 2023) was made available which indicated that feedback was being received from residents/their families, staff etc. in addition to other areas of quality within the home. Some comments had been captured from residents and their relatives, which were noted to be positive and observations of the mealtime experience were captured, with some actions identified in terms of training needs and the Care Docs electronic system.
The Home’s Statement of Purpose was made available to view and had been reviewed in February 2022, with a further date for reviewing in February 2023.
The Home’s Policies and Procedures were viewed (e.g. Safeguarding, Complaints, Medication etc.). These were available in paper format for staff to read and had been reviewed this year. There was also reference in some of the policies to terminology relating to the English regulatory body as opposed to Wales’s regulatory body, which was brought to the manager’s attention for amendment.
The contingency plan, in the event that the Responsible Individual and Registered Manager were unavailable would be that the service would be managed by the Deputy Manager.
Registered Manager
The manager does not manage any more services other than Ty Derwen Care Home. The manager is registered with Social Care Wales and holds a relevant NVQ qualification in Health and Social Care.
The manager confirmed that the property has CCTV, however this is only to survey the outskirts of the building (entrance doors, car park), therefore individual’s consent would not be required as the CCTV is not situated within the building.
Where significant events occur, either relating to Ty Derwen itself or individuals living within the Home, the manager is required within the Registration and Inspection of Social Care Wales (2016) Act (RISCA) to forward Regulation 60 documents to CIW and the Commissioning Team. The contract monitoring officer is aware that Regulation 60’s are reported upon.
The manager confirmed that the RI is in contact with the manager on a regular basis.
The radiators in individual rooms can be adjusted to the required temperature, however all of the radiators are located behind wooden covers, making it difficult for resident’s themselves to adjust.
Staffing
Ty Derwen continues to a good staff retention record with staff having worked at the home for a number of years. However, in recent times the home has experienced some staff shortages and difficulties in recruitment which has necessitated the employment of bank staff. Staff shift patterns ensure that people do not work more than 48 hours a week and shift patterns are 7 hours in length.
Two staff files were examined and information was organised in both files. The information included e.g. written references which had been verified by the manager, a detailed application form with no gaps in employment evident, a signed Contract of Employment, Job Description, Interview record, Disclosure and Barring Service (DBS) information. At the current time the DBS information does not include the outcome of the check e.g. whether it was clear or if there were any convictions to consider. Training certificates were present within the files also.
A supervision matrix indicated that carers had received supervisions this year, with further sessions arranged in 3 months’ time. Some old supervision records were contained on the two files viewed, however the majority of the records are stored on the home’s ‘Care Docs’ system, where it was evidenced that sessions had been held on a regular basis.
Appraisals had been held for all staff in 2022 with some having been held in 2023, and the matrix indicated that these were all planned for a years time.
During the visits staffing levels appeared to be sufficient to support people. Staffing levels throughout the day and night are calculated in relation resident’s needs to ensure safe staffing levels, and these need to be continually under review in accordance with people’s changing needs and new admissions.
Training
The training matrix illustrated that staff are able to access a range of training e.g. first aid, food hygiene, manual handling, dementia care etc. However, at the present time there are a number of staff who are required to have refreshers to bring them up to date.
Other courses on offer include e.g. pressure care, DoLS (Deprivation of Liberty Safeguards), oral care, falls, fire safety etc. Some of the courses had been attended however there were a number of gaps for some courses. Providers of care have often not been in a position to access all training due to the Covid-19 pandemic and subsequently are needing to catch up and wait for courses to be available.
Training is delivered by an organisation named, ‘Future Training and Consulting Ltd’, in addition to sourcing from the CCBC/Blaenau Gwent Workforce Development Team, and Aneurin Bevan Health Board (ABuHB) for courses such as sepsis and oral health care. Other staff training is undertaken via E-learning.
All care staff currently employed have achieved an NVQ/QCF qualification in Health and Social Care, level 2, 3, 4 or 5 and have either registered with Social Care Wales (SCW) or are going through the process.
File and Documentation Audit
The records of a resident were viewed during a visit and included e.g. CCBC documentation (Initial Assessment, Care and Support Plan, Long term care review, Complex Risk Assessment) to enable the care home to form the person’s Personal Plans and care for the person.
The care home had developed Personal Plans (Care Plans) and a document providing basic details about the person e.g. a photograph, basic details/appearance/description etc. and personal history, interests, relationships, religion etc.
There were suitable Personal Plans in place in relation to care needs e.g. personal care, skin integrity, communication etc. The skin integrity personal plan was very detailed and provided guidance in relation to the creams that are to be applied, with body maps being present also to aid the carer in where to apply.
Personal plan reviews had been undertaken and had been undertaken in a timely manner following the person’s return from hospital which required an update to one of the plans.
The Daily records that are completed for the person correlated with the information in the Personal Plans and had been written in a comprehensive manner, with dates, times and had been signed by the carers concerned also.
Quality Assurance
Ty Derwen have achieved a score of 5 (very good) from a recent Food Hygiene
The Environment/Home Maintenance
There were no malodours noted during the monitoring visits.
There has been new wooden flooring fitted to the lounge and dining room areas and new curtains. The area near the entrance to the home is due to be re-furbished also. A new bath has been installed and new flooring added to the bathroom area.
The outside patio area is now fit for purpose and will be a welcome space for residents, friends and relatives to use.
Fire Safety/Health & Safety
The Home’s Fire Risk Assessment had been updated in December 2022 and a new fire alarm system installed at the same time. There were no other actions identified.
There are Personal Emergency Evacuation Plans (PEEP’s) in place to support staff with evacuating residents in a safe way, with another resident list outlining their support needs located near the front door.
Health and Safety checks are undertaken in relation to e.g. wheelchair checks, water tanks and fire safety (alarm systems, fire extinguishers, emergency lighting) etc.
Managing residents’ monies
Ty Derwen manages the monies of a small number of residents on an ongoing basis, and procedures are in place to support this. Each person has a personal record to indicate any income and expenditure, with receipts being present and 2 signatures always being in place to support all transactions.
Mealtime experience
The mealtime experience was observed during a visit and were undertaken in an unhurried manner, with staff available to support people. Some people chose to eat their meals in the main lounge, whilst most people have theirs in the dining room which is decorated nicely with clean table clothes, serviettes, condiments and vases of flowers.
Activities
A gent was enjoying playing dominoes with one of the care staff during one of the visits, and the monitoring officer is aware that the ladies will often enjoy having their nails painted and enjoy other activities.
Some residents confirmed how the staff were very good and that nothing was anything trouble. Another resident commented that the food was very nice.
Corrective Actions
Statement of Purpose and Service User Guide to be reviewed to ensure they are up to date. Timescale: Within 3 months. RISCA Regulation 6.
Terminology within some Policies and Procedures to reflect the regulatory body in Wales rather than England. Control and Restraint policy to be written. Timescale: Within 3 months. RISCA Regulation 12.
DBS information to capture detail as to whether the check was clear or not and if there are convictions for a suitable risk assessment to be in place. Timescale: Within 1 month and ongoing. RISCA Regulation 35.
Training for staff to be brought up to date. Timescale: Within 6 months. RISCA Regulation 36.
Developmental Actions
To explore ‘The Active Offer’ – More than Just Words with a view to introducing into the home so that the home is providing a service in Welsh without the person having to ask for this.
Some re-planting of flowers in garden pots, clearing of dust and cobwebs is still suggested to the window sills.
Conclusion
Ty Derwen Care Home have a staff team who are well trained and qualified in their roles. However, some challenges have been faced in terms of recruitment, which is currently an issue affecting the Social Care Sector. Bank staff have needed to be appointed to ensure the staffing levels are safe and is hoped will only be a short term solution.
Areas of the Care Home have benefitted from re-decoration, some new furnishings and new flooring to the lounge areas. The appointment of a full time maintenance person has been beneficial to the home.
Documentation continues to be robust, reflective of people’s needs and reviewed regularly.
There is good evidence of regular supervisions being undertaken with staff and appraisals also.
The Contract Monitoring would like to take this opportunity to thank the staff, residents and manager of Ty Derwen for their time and hospitality during the visits.
Author: Andrea Crahart
Designation: Contract Monitoring Officer
Date: June 2023