Try-Celyn Court
New Bryngwyn Road, Newbridge, Gwent. NP11 4NF
Tel: 01495 246622
e-mail: Karen.thomas@wellcomecarehomes.com
Contract Monitoring Report
- Name/Address of Provider: Try-Celyn Court, New Bryngwyn Road, Newbridge, NP11 4NF
- Date Of Visit: Thursday 13th June and Thursday 27th June 2024
- Visiting Officer(s): Amelia Tyler - Contract monitoring officer, CCBC Caerphilly CBC
- Present: Karen Thomas - Home Manager, Wellcome care homes / Liama Jones - Deputy Manager, Wellcome care homes
Background
Try-Celyn Court opened 19th December 2016 and is owned by Wellcome Care Homes Ltd. It consists of two separate two storey buildings that are registered to provide care for a total of fifty one people with residential care needs and/or cognitive impairment. There was one new resident that was moving in on the 14th June and this would take the total number of residents to twenty three.
The previous formal monitoring visit to the home was completed on the 6th June 2023 and at this time there were fourteen actions identified (seven corrective and seven developmental). These were reviewed as part of this visit and the findings are outlined in the section below.
Dependant on the findings within this report, the home may be given corrective and/or developmental actions to complete. Corrective actions are tasks which must be completed (as governed by legislation etc.) and developmental actions are those deemed to be good practice.
Previous Recommendations
Staff files to contain full interview records, birth certificates, passports and signed contracts of employment and proof of Social Care Wales registration (from October 2022). RISCA schedule 1 regulation 35 (1) and schedule 2 Regulation 59 (8). Partially met. Only one of the staff files contained a birth certificate and a copy of the passport and there was no evidence of their registration with Social Care Wales. It is recommended that if it isn’t possible to obtain copies of their passport or birth certificate, a file note is held that is signed and dated by the employee and manager to evidence this has been discussed.
Personal plans are to record details of anyone involved in completing the document. RISCA version 2 (April 2019) Regulation 18. Met. It was pleasing to note that one resident and deputy manager had signed her personal plan on the 8th May 2024 and the other had been signed by the resident and deputy manager on the 24th May 2024.
All staff to receive mandatory training on a regular basis and for this to be to be reflected in the training matrix. RISCA version 2 (April 2019) Regulation 26. Partially met. There were gaps noted on the training matrix provided i.e. there were eight staff still to complete manual handling passport refresher training and ten to complete infection control. Additional detail is provided in the staffing and training section within the report.
Individual outcomes to be identified and recorded. RISCA version 2 (April 2019) Regulations 6, 14 and 80. Not met. There was insufficient evidence to demonstrate wellbeing outcomes. One file contained an individual outcome record that had been signed by the individual on the 1st June 2024, but this was very process driven and was a form with tick boxes rather than a meaningful discussion about what is important to them, what they would like to achieve and how they can be supported with this.
End of life wishes to be held on file or where the individual is not able to or doesn’t wish to discuss, this should be clearly dated and recorded. This is also to be discussed with the relatives where appropriate. RISCA version 2 (April 2019) Regulation 21. Partially met. One file contained a form that clearly recorded that the resident had not wished to discuss their end of life wishes and the second file contained a sheet for the individual’s representatives wishes, but this hadn’t been completed.
All files to contain completed consent forms for CCTV. RISCA version 2 (April 2019) Regulations 43 and 44. Met. There was evidence of consent forms on both files seen during the visit.
Residents that wish to access the local community to be supported to do so. RISCA version 2 (April 2019) 21, 43 and 44. Met. The contract monitoring officer was told that the activities coordinator holds a separate file of what activities are carried out and who was involved. It was stated that one lady is supported to go to a local shop with the activities coordinator and they purchase items for other residents if requested. It was explained that residents that wish to go out and are physically able to tend to go out with their relatives.
The supervision matrix to run consecutively rather than year-on-year to make it easier to confirm these were being held every quarter. Met. The manager had considered this but decided to keep it in its current format as they find this easier to use.
It is recommended that ex-members of staff are removed from the matrix and new starters are clearly highlighted to record when their first supervision/ end of induction session is due.
Not met. There were still members of staff on the matrix that were no longer employed by the home. To remove any confusion and ensure accuracy it is recommended these be removed.
The Radiator covers in the remaining rooms to be adjusted to ensure the thermostat is accessible. Met. An email from the home manager on the 14th March 2024 stated that the access ports to the thermostats had almost been completed, and it was noted this had been carried out in the two bedrooms seen during the visits.
The policies around control and restraint and staff discipline to be reviewed to ensure they are kept up to date. Partially met. The contract monitoring officer noted that the restraint policy had been reviewed in May 2024. There was no policy for staff discipline (although there was information around this in the staff handbook) and this is to be implemented in accordance with regulations.
Where possible, interviews to be carried out by two senior members of staff. Met. Both staff files seen evidenced that two interviewers had conducted the interview and the email received from the manager on the 14th March 2024 highlighted that if the manager or deputy manager were not available then a senior would stand in.
Nominate formal dementia champions, incorporate into relevant documentation and advertise to visitors in the foyer area. Partially met. The contract monitoring officer was told that the deputy manager would be the dementia champion, however, this has not been formalised. It is recommended that this be discussed in the next team meeting and a notice displayed in the foyer area.
Toilet seat in bathroom 1 to be fixed or replaced. Met. This had been rectified.
Findings from visit
Responsible individual
There is a contingency plan in place if the manager is absent for three months or more in line with regulation 67 where the deputy manager would carry out the role and notify the local authorities with people placed at the home and the Care Inspectorate Wales (CIW). It was explained that support would be provided from the responsible individual and the managers of the sister homes. A copy of the plan was shared with the contract monitoring officer following the visits.
A copy of the statement of purpose was shared and it was noted that this had been reviewed in March 2024 and contained up to date information. The training matrix shared contained a worksheet evidencing the care staff registered with Social Care Wales. The contract monitoring officer noted that eleven members of care staff were not appropriately registered; it is a requirement that all staff delivering care and support are registered within six months of their start date.
Copies of the policies and procedures were provided that included safeguarding, infection control and medication. As previously highlighted, there was no policy in place around staff discipline and this is to be addressed. All policies had been reviewed in 2024 by the HR legal team Peninsula. It is recommended that the policies include the next review date or period to evidence these are kept up to date.
The most recent quarterly reports by the responsible individual were dated 18th January and 3rd April 2024; These were short handwritten notes outlining observations and a discussion with the home manager rather than a comprehensive report evidencing feedback from staff and residents to monitor the performance of the service and identify areas for development.
It was highlighted that the complaints policy needs to be developed to include timescales, written outcomes and the contact details of external parties that concerns can be made to anonymously if necessary, such as safeguarding, the care inspectorate Wales, and the local authority. This can be cross referenced with the safeguarding and whistleblowing policies. It should also highlight that this is available in an easy-read format.
The home manager to consider updating the supervision policy to highlight any preparative work expected of the employee prior to the meeting to demonstrate a meaningful two-way conversation.
Registered manager
There is CCTV at the property that monitors the corridors and the outside of the buildings: this is included in the service user guide. There is also a notice in the foyer area to inform visitors and it was noted that agreement forms were in place on the files viewed.
No concerns were raised in relation to the fabric of the building or equipment i.e. the lift and sluice were working well and there were no issues with the temperature of the running water in the rooms. There had been an issue with flooding in the wet room on the ground floor, but this was being rectified by the maintenance man during the first visit.
At the time of the visit there were no outstanding regulation 60 notifications, and these were being forwarded to the commissioning team when completed.
All deprivation of liberty safeguarding applications were up to date and the contract monitoring officer was made aware that the deputy manager has a system in place that is reviewed every quarter for any safeguards that are due to expire.
As previously mentioned, the deputy manager was the unofficial dementia ambassador, and there was an intention for them to attend the next course in August delivered by the Alzheimer's Society. It was acknowledged that that this is primarily around talking to the individual, completing the ‘this is me’ booklet and linking in with relatives to carry out the dementia bridge tool.
The manager and deputy manager said they spend time out in the home directly with staff and residents every day; the manager said they were helping with the cleaning the day before the initial visit and was supporting a resident to the bathroom when the contract monitoring officer arrived.
Discission was held around conducting visits out of normal working hours and it was stated that the manager and deputy manager do this on an ad-hoc basis. It was noted the deputy manager will occasionally work night shifts. Although there were no notes initially, this had already been implemented and evidenced by the second meeting.
A copy of the policy around social media was provided, and it was noted that it commented ‘Wellcome Care Homes will be professionally accountable for the use of social media’; the contract monitoring officer explained this needed to specify that it is only accountable for its own Facebook page to ensure there is no misunderstanding. Nothing is published without the consent of those in any pictures and staff are not to divulge where they work.
The senior staff team were noted to have completed appropriate safeguarding training.
Staffing and training
A copy of the training matrix was provided, and it was acknowledged that this contained all mandatory training such as manual handling, food hygiene, safeguarding, first aid, administration of medication etc. There was also non-mandatory training such as legionella, diet and nutrition, confidentiality, diabetes, epilepsy, diversity and sexuality, pain management and iStumble (falls). The manager said that they have signed a new contract with a training provider, Care Skills Academy that will manage the matrix for all the online training and ensure it is up to date.
There were five kitchen staff that did not appear to have completed food safety levels two and three, and two that hadn’t attended food safety awareness training. The manager explained three staff had completed their food hygiene courses, but they were waiting for their certificates and once received, the manager said she would update the matrix. Ten staff were not shown to have attended infection control, one to attend safeguarding, and eight to complete their all Wales passport refresher training around manual handling.
The spreadsheet that contained DBS information and registration with Social Care Wales (SCW) contained gaps and it was discussed that this needs to be updated fully. It was acknowledged that one of the bank staff had completed her application to SCW and was just waiting for this to be processed; it is recommended that a note be put on the worksheet.
There were five supervisions that were overdue at the time of the first visit including a bank member of staff.
Over the past year it was explained ten members of staff had left, and there had been nine new starters and they were waiting on confirmation from another applicant. This represents approx. 56% of the care team. The manager highlighted the difficulties in recruiting and retaining staff due to competition both within and outside the sector. It is challenging to spend a lot of time and money recruiting an employee and training them up, for them to then find employment elsewhere.
It was explained that during the day there are four members of staff on duty and three during the night, at least one of which is a senior, and there are also the manager and deputy manager that are supernumerary. Additionally there is also an activities coordinator that is contracted to work fifty five hours including the occasional weekend, catering staff, domestic staff and the maintenance man.
There are two overseas care staff that are sponsored by the home and the sponsorship licence was reported to be with the home office and being processed. The manager stated they had satisfactory linguistic ability, and this was evidenced in their references and interview record.
Agency staff are utilised when needed, although this is rare. The manager uses an agency called SL Agency and they provide a staff profile prior to starting work which contains a photo, copy of their passport, training records, qualifications, DBS and education.
Training providers that have been used are accredited and includes Social Care TV, Care skills academy, and MIND consultancy and this was evidenced by the certificates displayed in the home and staff files. The quality of training is assessed by the manager also completing these courses, team meetings, evaluation forms, and speaking to staff about whether there is anything else they feel needs to be included. The level of understanding is ensured through feedback sheets, general discussions, end of course tests, informal conversations, supervisions and observations.
The contract monitoring officer was told there were no staff regularly working more than forty eight hours a week.
The Welsh language is encouraged within the home, and it was noted that the manager sends her emails in English and Welsh. There is a resident that used to work as a Welsh teacher and will use conversational Welsh daily and has taught staff some key phrases and words. The Activities coordinator can also speak Welsh.
It was stated there was no formal manual handling champion, but this would be the home manager initially, although it was highlighted that a member of staff has a particular interest in this area and would be ideal for the career development. The contract monitoring officer recommended this be added to the training matrix and displayed in the foyer once completed.
Two files were seen for staff that had commenced employment in December 2023 and February 2024; both contained appropriate references, detailed application forms, full employment histories, interview records (with two interviewers), signed employment contracts (statements of employment), photos, DBS checks, and signed and completed induction checklists.
Only one of the files contained a job description, and the manager must ensure this is in place for all staff. It was also noted that training certificates were not present on the files seen, but it was acknowledged these are held separately.
Documentation
On one of the files viewed, it was acknowledged the lady was at high risk of falls, and this wasn’t appropriately reflected in the risk assessment; the document to be updated to ensure it outlines what the risks are, how these are to the be managed and are consistent with the personal plan around safety and mobility.
The contract monitoring officer noted that it was recorded on her one page profile that she viewed herself as a devout Catholic, but this wasn’t replicated in the plans surrounding spiritual needs and how she is supported to observe her religious beliefs. It was also observed there was insufficient information in the eating and drinking plan; whilst it is acknowledged that detail around any likes, dislikes, portion size etc, is held on a separate file in the kitchen, either a copy of that information should be held on their main file, or cross referenced in the personal plan.
It was highlighted there is one resident that has type one diabetes but refuses to follow a diabetic diet and there are two people that have type two insulin dependent diabetes and they both have an electronic monitor. There are three people who are on a pureed diet and have had the appropriate speech and language referrals. It was explained there are no known allergies to food, however, there is one individual that is allergic to wasp stings and has an EpiPen in place.
Pre-admission assessments were in place and had been completed before moving to the home, however, one had not been completed in full by the deputy manager. Both files contained appropriate risk assessments and there was evidence of l monthly reviews of the personal plans and risk assessments where required (except for the mobility assessment previously highlighted).
Although both ladies had moved to the home recently, there was evidence on the one file of appropriate referrals being made to medical professionals through a bone density scan appointment and the outcome of medication reviews.
Only one of the files contained a ‘This is me booklet’ which was personalised and provided an invaluable insight into her life, what matters to her, and what she enjoys. Although there was a one page profile on the second file, there was no life history to offer the detail around wellbeing and assisting to develop meaningful outcomes.
There was some brilliant detail on one of the personal plans that stated the individual likes to use a cotton flannel to wash her top half and a disposable cloth for her lower half. The other plan commented that they preferred to be supported three times a week with their personal care by a female member of staff.
The contract monitoring officer noted there was no personal plan on one file around medication on the file of one resident; whether there is any medication to be administered when required for any pain, or anything for dementia, and it is recommended this be put in place.
Quality Assurance
It was explained that the activities coordinator had helped residents to make their own anniversary cards and cards for their partners and for valentine’s day. Two of the ladies whose husbands that don’t live with them had sperate tables set up for them with afternoon tea to celebrate. There were four thank you letters seen in relation to Valentine’s Day, St Patrick’s Day, the Easter party and from the family of a resident who had passed away. It was mentioned that these are discussed in team meetings and held in a file in the foyer area.
Evidence of team meetings were provided, and it was noted these are mainly held monthly, with the previous two being completed on the 27th May and 6th June 2024. It was pleasing to note that the people who attended were recorded, and the areas discussed included sleeping shifts, care plan allocations, the medication room, documentation and accident reports.
There were no minutes from meetings held with residents as it was explained that meetings would be difficult to chair due to the lack of capacity and the fact that some individuals would find a formal forum off-putting. Feedback is sought informally from residents and family members around activities and things they would like to do in future, but this was not evidenced. The contract monitoring officer was told the activities coordinator has her own records and surveys are carried out; it was advised these are completed as much as possible with residents and relatives and comments analysed and included in the regulation 80 report carried out every six months.
Handovers are carried out at the beginning of each shift and the senior member of staff that has finished their shift will hand over to the oncoming team. These handover meetings are carried out in the area at the back of the lounge so that observations can continue. To maintain confidentiality, residents are referred to by their room number and the notes are signed off by both senior members of staff.
It was explained that no residents required any advocacy services at the time of the visit, however, if they felt this was needed, they said they would come through to Caerphilly Information, Advice and Assistance Team. The contract monitoring officer also stated they would share the contact details for the Gwent Access to Advocacy service.
Staff feedback
Feedback was obtained from a new member of staff that had worked at the home for six weeks. It was discussed that most of the residents are happy, but if they needed any emotional support, they would spend time with them, listen, and provide reassurance. Some residents are not able to explain why they are upset, and in this situation, staff would listen, or try distraction techniques (depending on the individual). The staff member said they had worked as a nursing assistant previously and Try-Celyn had a much more relaxed environment.
Although the member of staff said they didn’t support the residents out in the community, they explained the activities coordinator arranges different activities and events daily and the community are invited into the home and there is a summer beach party planned for the end of July.
A conversation was held around a specific resident, and it was acknowledged that the staff member understood their diagnosis and what their needs are, but also what he can do independently, what is important to him, and his what his personality is.
The contract monitoring officer was informed that staff can be flexible in their role, encouraged to offer suggestions to improve the quality of life and wellbeing of the residents and try to maximise the independence of the people living at the home.
If they witnessed any poor practice or abuse, they said they would report straight away to the manager or deputy manager, and if this wasn’t actioned appropriately, they explained they would escalate to the responsible individual and/or the Care Inspectorate Wales.
It was pleasing to note that the manager and deputy are present to offer advice and support and it was commented the deputy ‘is amazing with the residents’ and ‘I find it a lovely place, brilliant for support!’. There was an understanding of the social media policy and they stated they weren’t to publish anything online about their work or residents, no photos with their uniform on or photos within the home.
Resident feedback
In addition to three ladies that were spoken to during lunch, another resident was met with to gain their views of the service; it was reported they like documentaries about farms and wildlife. They said they used to enjoy gardening and acknowledged the activities coordinator had tried very hard to get her involved, but she was quite content with her own company and visits from family.
The food was said to be nice, and the resident said they had enjoyed the roast lamb they had the previous Sunday. The contract monitoring officer was told that she had a poor sense of taste and smell, and her swallowing was deteriorating because she has Parkinson’s, but this is being managed.
Staff were said to be very friendly and helpful, and some are more professional, and there are others that she felt able to have more of a chat and a laugh with.
The resident said there wasn’t anything they could think of to be improved but mentioned the bedroom door is too heavy for her to open by herself, but staff check on her regularly and she also has a call bell if she needs anything. It was explained the door can squeak a bit and will wake her if staff are looking in during the evening (this was reported to the manager and the maintenance man was looking into this during the visit). The contract monitoring officer was told the lady has seven children and four stepchildren, so is never short of visitors, or for people to support her if there were any concerns that needed to be addressed.
It was also observed that there was personalisation in her room, including family photos and her own armchair.
Relative feedback
Feedback was obtained from two relatives, and one stated her Mum had moved to Try-Celyn eight and a half months ago and has a diagnosis of diabetes and dementia. They explained the deputy manager had gone out to do the initial assessment and gave them reassurance. The staff were described as fantastic and said everyone is treated like family. It was pleasing to hear that they felt staff knew all her Mum’s needs and they are open and honest, and she is now able to visit and spend ‘quality time’ with her. She emphasised that she had known little about dementia previously, but staff were supportive and explained this to her. There was nothing she would change and said the activities are varied and the kitchen staff are also involved and will come and talk to the residents and ask them what they thought of the meals and will show them the options rather than just asking.
The second relative said they were always made to feel welcome at the home and described the atmosphere as ‘very good’ and commented she often hears people laughing. They said they believed their relative thought of Try-Celyn as their home and said they had been invited to events at the home such as the Easter fete and the upcoming beach party.
It was commented they weren’t encouraged to get involved with general activities of daily life, such as making their own drink or setting the dinner table, but just spend time with their relative. Communication with the home was good and they were confident they would be informed of any changes. If there were any concerns, they said they would feel confident in raising this with staff; it was explained that one of the relatives had needed to raise a concern previously and this was addressed straight away.
The relative felt the home had been successful in providing a good quality of life for their Mum as she wasn’t able to manage on her own and she has more interaction than she had previously.
General observations
The deputy manager reported that a social worker had carried out a review recently and commented the personal plan was one of the best he’d seen. There were some lovely thank you cards displayed in the foyer area which praised the care provided at the home. The contract monitoring officer emphasised that these should be dated to make it more meaningful and so they can be reflected in the appropriate quality assurance report.
Certificates were also displayed in the foyer area from MIND consultancy for the home in relation to safeguarding, the mental capacity act, depression in older people and dementia awareness.
Photos were seen of the D-Day celebrations and residents playing pin the cigar on Winston Churchill, they won a competition with a local fish and chip shop where they won a takeaway for lunch for everyone. There were other activities shown such as a movie afternoon with ice creams, making their own pizzas for national pizza day, growing plants in the garden, inflatable skittles, musical instruments, moving to music etc. There were also photos of St Patrick’s Day celebrations where they wrote what made them feel lucky.
It was explained that they were hoping to arrange dog therapy days with a greyhound rescue charity.
There were pictures of residents outside their room with a couple of things they enjoy or that are important to them which is personalised; these assist residents find their room and helps visitors or new staff to have a little insight into each person. There was evidence of personalisation in the two bedrooms seen including furniture, family photos, soft toys etc and staff had displayed in one frame all the tickets from the football matches the gentleman had been to and another with all the concerts he’d seen.
The contract monitoring officer enjoyed lunch with three ladies during one of the visits and reminisced about their lives, foods they enjoy and places they have travelled. They appeared very content at the home and couldn’t think of any improvements that could be made and were very complimentary about the care they receive, entertainment, and the staff team. It was highlighted that all of them said they would feel confident in raising a complaint with staff if there was something upsetting them.
Corrective / Developmental Actions
Corrective (to be completed within three months from the date of this report)
Staff files to contain full interview records birth certificates, passports and signed contracts of employment and proof of Social Care Wales registration. RISCA schedule 1 regulation 35 (1) and schedule 2 Regulation 59 (8).
All staff to receive mandatory training on a regular basis and for this to be to be reflected in the training matrix. RISCA version 2 (April 2019) Regulation 26.
Individual outcomes to be identified and recorded. RISCA version 2 (April 2019) Regulations 6, 14 and 80.
Policy to be implemented around staff discipline. RISCA version 2 (April 2019) Regulations 12 and 39.
All staff delivering care to be registered with Social Care Wales within six months of their start date and this is to be reflected on the spreadsheet. RISCA version 2 (April 2019) Regulation 35.
All staff are provided with a written job description which states clearly their responsibilities, the duties currently expected of them and their line of accountability. RISCA version 2 (April 2019) Regulation 38.
The complaints policy to be amended to include the stages and timescales for the process and written outcome. RISCA version 2 (April 2019) Regulation 64.
Quarterly reports to be developed to include evidence of the date of the visit, details of discussions with staff and individuals, records reviewed, and the outcome of the visit such as actions taken to make any improvements required. RISCA version 2 (April 2019) Regulation 73 and RISCA statutory guidance Version 3 (March 2024).
End of life wishes to be completed and discussed with the relatives where appropriate. RISCA version 2 (April 2019) Regulation 21.
Personal plan to be implemented on the one file around medication. RISCA version 2 (April 2019) Regulation 15.
Developmental
Any members of staff that no longer work for the company to be removed from the working supervision/appraisal matrix and the training matrix.
Consideration to be given to adding the next review date to the policies or a statement saying it will be reviewed every year/ other year etc.
It is recommended the supervision policy be updated to include the preparation expected of staff to support meaningful engagement.
The social media policy to specify that it is only responsible for its own Facebook page.
All compliments to be clearly dated.
Nominate formal dementia and manual handling champions, incorporate into relevant documentation and display this for visitors in the foyer area.
The mobility and safety plan for the one resident to updated as she is at high risk of falling, and the personal plan around religion and spirituality to be developed to bring it in-line with the profile.
Conclusion
The atmosphere in the home was calm and relaxed and it was lovely to observe some meaningful interaction between staff, residents, and visitors. There were no concerns in relation to the care provided at the home and it was nice to see staff taking part in an activity. The quality of the food was good and all residents that were spoken to said they enjoyed the meals provided.
From the previous fourteen recommendations made, seven had been met, five partially met and only one that wasn’t met. Feedback was given virtually following the last meeting and both the manager and deputy manager are committed to meeting the actions outlined in this report.
The contract monitoring officer would like to take this opportunity to thank everyone involved in the monitoring process for their time, assistance in providing all the necessary documentation, and hospitality.
Unless it is deemed necessary to be carried out beforehand, the next monitoring visit will be completed in approx. twelve months’ time.
- Author: Amelia Tyler
- Designation: Contract monitoring officer
- Date: 22nd July 2024