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: 4th June 2024
Visiting Officers: Caroline Roberts, Contract Monitoring Officer, CCBC / Karen Taylor, Lead Nurse Care Homes Governance and Safeguarding, ABUHB
Present: Karen Davis, Home Manager / Karen Johns, Deputy Manager

Background

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 therefore is also a separate provision for 15 younger adults with a physical disability.

The last full monitoring visit was conducted in 2023. During the latter half of 2023 and the beginning of 2024, focussed monitoring was undertaken to support the home. It is positive to note that the provider worked in partnership with the Local Authority and the Local Health Board.

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.

Previous Corrective and Developmental Actions

Corrective

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. Outcome: Partially Met. Whilst supervising is improving, gaps were still observed.

For staff to complete mandatory training in a timely manner i.e. Safeguarding. (RISCA Reg. 36) Outcome: Met, with non-mandatory training also undertaken.

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. Outcome: Documentation viewed stated monthly reviewing; however, a senior advised that staff are informed to undertake bi-monthly reviews. Whilst the regulations state reviews are to be undertaken at least every 3months, it would be good practice for reviews to be undertaken monthly or alternatively, to avoid confusion for any new member of staff, for the review documentation to be re-worded and a definitive time frame recorded for staff.

Developmental

For staff files to retain evidence of staff registration with Social Care Wales. MET – A separate matrix is retained on staff registration.

Findings

Responsible Individual (RI)

The RI is Mr Marc Pullen-James, and the Director of Care is Ms Sherri Sargent. There is an expectation that quarterly reports are produced reporting on the service’s performance and quality.

Copies of the last 4 quarterly regulation 73 visits carried out by the responsible individual were provided and reported under regulation 74. The reports cover a vast area of the service such a Care and Support, Standards of Care, Leadership and Management, Environment, Well-being, Resident and Relative feedback, Staff feedback etc. Each area reported on also includes the RIs findings and any actions required.

The last 2 regulation 80 reports were also viewed as part of the monitoring process.

The statement of purpose was provided, and this had been reviewed in May 2024 and will be next reviewed in 2025, unless there are any changes to the service.

The Service User Guide was also shared with the monitoring officer, and it had been last reviewed in February 2024. This will be next reviewed in February 2025 or sooner, if required.

Policies and Procedures were shared with the monitoring officer, and all had recently been reviewed.

Registered Manager

The monitoring officer was informed that the home operates CCTV. Notifications of the system can be located on entrance to the home.

At the time of the visit there were no ongoing concerns in relation to the building.

Regulation 60 notifications are forwarded to the Care Inspectorate Wales and copies are sent to the monitoring officer. At the time of the visit, there were no outstanding notifications. Only one service is managed by the registered home manager. The home manager is well supported by the RI and the Quality Care Director. Should neither be present at the home, they are available via a TEAMs call or via telephone.

During the visit, evidence of referrals being made to external professionals were observed.

When asked how much time is spent on the floor by the home manager, the manager was open and transparent in responding that she does not spend as much time on the floor as she would like, and it usually equates to approximately 5 hours a week. The home manager advised that the deputy manager spends more time visiting the communities. However, it is suggested that every effort is made to increase the home managers time on the communities, so that she is having more personal insight into the lives of the individuals residing in the various communities within the home.

The home manager has undertaken out of hour visits and usually commences her shift between 05:00 hrs/05:30hrs to support night staff and to provide an opportunity for the night staff to personally convey any appropriate information.

Staffing and training

At the time of the monitoring visit, the home manager was asked if there were any staff members that were not registered with Social Care Wales. The home manager advised that not all staff are registered as some are working toward the qualification and / or are awaiting their registration number. It was positive to note that there is a matrix detailing all care staff, date of employment, registration date and renewal date.

Staffing on the day of visiting was: 3 nurses during the day, with 20 carers, 3 unit leads and 2 nursing assistants. During the night: 3 nurses, 1 nursing assistant, and 12 care staff, with 1 twilight staff member.

At the time of the monitoring visit the home had one full time activities co-ordinator and was awaiting another individual to commence their employment as another activity co-ordinator.

The current activity co-ordinator was observed interacting well with the residents and spends time on each community. When not on the other communities, activities are left for the care staff to undertake.

Residents enjoy the opportunity to undertake activities in their own environment, outside in the garden area and/or out in the community, having access to a minibus. The visiting officer viewed the activity board, which highlighted the activities for the week i.e. bingo, baking, fitness, local school visiting, church service, singer, out for lunch, floor games etc.

Training is evaluated through observations of the manager and senior staff, along with staff verbal feedback.

At the time of the visit, no staff member was working more than 48 hours.

The home has 2 staff who are Welsh speakers, but at the time of the monitoring visit, there was no resident who chooses to communicate in the medium of Welsh.

Overseas individuals are employed by Hafod, and the process of employment is overseen by Hafod’s Human Resources Team.

As part of the monitoring process, 2 staff files were viewed, both holding 2 references.

Both held detailed application forms; however, HR retain copies of all signed job descriptions, along with the individual contract of employment.

A record of the interviews was observed, and it was noted that a scoring system used to determine that the individual meets the required standard required for employment at the home.

Both files held a copy of the individual's passport and there was evidence of a current DBS.

One file held the appropriate NC PIN (nurse registration), and the second file evidenced the individual staff member being registered with Social Care Wales.

Supervision and appraisal

Supervision was discussed with the home manager, who confirmed that there are still gaps; however, it was observed whilst viewing the supervision matrix that there has been an improvement. However, there was no evidence to support that the home manager is receiving formal supervision and the home manager advised that the last documented supervision was dated 21.09.23. This area will continue to be monitored.

The training matrix was observed by the visiting officer and whilst the mandatory training contained high % figures, it was noted that some staff still need to complete some areas of training or refresher courses. It was noted that additional, non-mandatory training is undertaken by the home i.e. dignity at work, environmental awareness, asbestos awareness, COSHH, GDPR, Positive Behaviour Support to name but a few.

The home has 2 staff members who are manual handling champions and have been trained via an oust sourced company.

Documentation

Two resident files were seen during the visit, from differing communities. Both files contained a pre-admission assessment.

One file evidenced that the individual had been involved in compiling their Personal Plan, whilst the second did not. Both files held appropriate information pertaining to mental health, mobility, personal care, weight, nutrition, continence care. The documentation noted the individuals likes/dislikes, oral care, skin integrity, infection control plus additional information relating to the individual.

Appropriate Risk Assessments were observed in respect of falls, community access, pressure areas, refusal of medication etc.

Documentation for reviews state monthly; however, the home continues to undertake bi-monthly reviews (which is still in line with RISCA). However, the documentation could cause confusion for any new staff member, and it is recommended that the documentation be changed to reflect the timely reviews.

Reviews observed for one individual evidenced the involvement of a relative at the request of the resident. At the time of the visit, there were no current reviews for the second individual as they were very new to the home.

Review of the personal plans were found to be detailed. When undertaking reviews, staff are to include the individual and/or representative. If this is not possible, they are recommended to document/evidence that this is not feasible.

When viewing a mobility plan, the documentation stated that the last fall was recorded on 23.03.24; however, the review documented the last fall was 03.06.24. It is imperative that all documents are align with each other and reflects accurate, timely data. This was discussed with the senior on shift.

There was evidence to support that the home makes referrals to appropriate outside agencies such as opticians, Community Psychiatric Nurse, Drs, District Nurses, Social Workers etc.

There was personalised information around the person’s life story in the ‘This is Me’ leaflet, and contained detail such as the individuals background, habits, routines, communication, mobility, employment, family etc.

Both files held ‘Do Not Attempt Resuscitation’ (DNACPR) forms in place.

Both files held applications for Deprivation of Liberty Safeguards.

Whilst viewing one resident’s food and fluid intake, gaps were identified. It is important that all documentation notes consistent information. The amount of fluid provided requires documentation, along with the amount taken.

Quality assurance

The monitoring officer viewed minutes of staff meetings. Minutes for January, February, April 2024 were viewed, and the meetings covered varied topics i.e. supervisions, documentation, inspections, training, skin bundles, fluid output, equipment etc.

Minutes from family meetings were observed for 2 units, during which, conversations are held on a variety of topics i.e. mealtimes, activities, purchasing personal items, labelled clothing etc.

Handovers are undertaken by the Seniors/Nurses on shift. There is a handover file; however, this is not signed. It is recommended that staff responsible for handover, signs when they have handed over and the recipient senior/nurse, also signs as evidence of receiving the information.

At the time of the visit there were no residents that required involvement from the advocacy service.

The home employs 2 maintenance employees and regular maintenance checks are undertaken, with data being regularly entered into a logbook i.e. water temperature checks, flushing, bed checks, window restrictions, fire alarm system, and fire extinguishers etc. All checks are signed off by either the home manager or the deputy manager on a monthly basis.

The last fire assessment was undertaken 08.06.23 and the maintaining employee advised that the home was expecting their annual assessment to be undertaken any day. Recommendations were made in 2023 and it was noted that they had been evidenced as completed and the deputy manager confirmed that all the points highlighted had been addressed.

When discussing fire evacuation, although these are undertaken there was no written record to evidence what staff had or hadn’t attended a fire drill. This was discussed with the deputy home manager and a maintenance employee, both agreed to devise a record in which staff can be identified if they have / have not attended a fire drill within the last 12 months.

Resident finances were discussed with the financial officer, who confirmed that there are 2 signatures for any money that goes in or out. Receipts were observed by the visiting officer. Separate records are retained for individuals, cash, cards etc.

With regard to the provider reducing its carbon footprint, the deputy manager advised that the home is doing far more recycling and separating items as requested by the Local Authority, the home has LED lights and fruit and veg is sourced via a local farm. Hafod have agreed to work in partnership with customers, communities and colleagues to educate individuals about lifestyles, attitudes and consumption habits to reduce carbon usage. A Strategy Programme and Financial Plan will be developed by 2036 and the business aims to become a carbon neutral organisation by 2025.

Staff feedback

Feedback was sought from a new staff member. It was positive to note that the staff member interviewed, asked who the visiting officer was, and if they were permitted to share the information prior to engaging in conversation with the visiting officer.

The staff member was able to explain how they would support the emotional wellbeing of the named resident (chosen by the visiting officer). Due to being new, the staff member had not had the opportunity to assist residents out in the community; however, advised that residents access the community regularly, and are accompanied by the activities co-ordinator and other staff members.

The staff member was able to describe the resident and clearly evidenced that they knew the individual, their likes/dislikes, their personality, and the risks they may encounter.

When asked how the staff member would communicate with someone who has communication difficulties, they advised that they observe the body language, facial expressions and if appropriate, use pictures to aid communication.

The staff member stated that they had time to sit and chat with the residents and that they felt encouraged to make suggestions about improving the quality of life for the residents.

If witnessing poor practice, the staff member advised that they would go straight to the unit lead/senior and report what they had observed and record it.

When asked what the home does to maximise independence, the staff member advised that they offer encouragement to for individuals to do things for themselves, if able to and without causing them discomfort. When asked if they share any personal information with the residents, the visiting officer was advised they do not. They share some personal information but not a lot.

When asked if the manager engages with staff and residents, offers support and guidance, the staff member responded by saying yes; however, they were referring to the clinical lead.

Resident feedback

During the monitoring visit, the monitoring officer spoke in general to a few of the residents. All looked well and the monitoring officer overheard 2 individuals, on different occasions, saying to care staff that they loved them.

One resident advised the monitoring officer that the care staff were kind.

It was positive to note staff offering alternative meals when individuals were declining what was on the menu.

Individual rooms were decorated and evidenced personalisation, with rooms decorated with family photographs, ornaments, throws, personally chosen bedding/curtains etc.

Plenty of smiles between the carers and the residents were observed during the visit.

Relative feedback

One relative was spoken to during the visit and advised that they always feel welcomed when visiting. When describing the atmosphere, the visitor stated that the community is calm, sometimes ‘manic’ due to some behaviours displayed by individuals living in the community. However, the relative advised that this is not always the case and that they “enjoy coming into visit”.

The relative felt that their parent felt that Ty Penrhos was now their home and feels this is because of the way the individual is treated by the staff. The relative stated that they were happy to leave at the end of visiting as they know the staff love her parent.

When asked if the relative is encouraged to get involved in any activities, the relative advised that they would but due to other commitments, it is not always able to attend.

When asked if they felt comfortable in raising any issues, the relative replied ‘yes’ and advised that they have in the past with regards to staff moving to other communities. This matter was discussed with the deputy home manager in respect of the changes possibly affecting the individual residents. The deputy home manager advised that they only move 1-2 staff members; therefore, this is not considered to be a big change and that the change may not necessarily involve the day staff, it can be night staff also. This allows staff to obtain experience on different communities and therefore, do not become complacent.

The relative was asked how successful you feel the home has been in providing a good quality of life for their relative. The response was positive and the relative advised “very good, they all work very hard”. “They provide encouragement, they give her ice-cream and provide her with [soft] drinks in a wine glass to support fluid intake”.

General Observations

Key fobs to enter the main areas of the foyer are stored securely by the receptionist.

The reception area now incorporates a drink vending machine to allow relatives/visitors to purchase drinks. The area was observed to be clean and inviting for visitors.

Meals were observed to be delivered to each community in a bain-marie. Each unit has a kitchen area, where staff serve the meals to the individual residents. Menus were observed on the dressed dining tables. On the day of monitoring the menu displayed the meals for the day which was: lunch: a choice of sausage casserole or cauliflower cheese and mash with chocolate pudding and white sauce for dessert. If residents did not like chocolate pudding there was a choice of yogurts in the fridge and ice-cream could be sought from the kitchen. Rice pudding was also being served at 3pm. Containers consisting of 2 various squash was also available, along with hot drinks if requested by a resident. Mealtimes have much improved and were observed to be a social occasion with staff interacting with residents that wished to eat in the dining area and were being assisted to eat where necessary.

Each community is decorated with drawings/paintings and each entrance is inviting. The lounge areas are decorated with photographs of some of the residents and ornaments to give it a homely feel.

Corrective / Developmental Actions

Corrective actions

There was no evidence to support that the home manager is receiving formal supervision and the home manager advised that the last documented supervision was dated 21.09.23. This area will continue to be monitored. RISCA Reg 36.

When preparing or reviewing a personal plan, the service provider must involve the individual, the placing authority (if applicable) and any representative. RISCA Reg 15.

Whilst viewing one resident’s food and fluid intake, gaps were identified. RISCA Reg. 21.

Developmental actions

Fire records to be implemented in order to evidence which staff require fire evacuation/drill experience.

It is recommended that staff responsible for handover, sign when they have handed over information, and that the recipient senior/nurse, also signs as evidence of receiving the information.

It is suggested that every effort is made to increase the home managers time on the communities, so that Ms Davis is having more personal insight into the lives of the individuals residing in the various communities within the home.

Conclusion

The contract monitoring officer would like to thank the manager, deputy manager and others who were involved in the monitoring process for their time and hospitality throughout. Unless it is deemed necessary, the next monitoring visit will be carried out in approximately twelve months’ time.

Author: Caroline Roberts
Designation: Contract Monitoring Officer
Date: 19th July 2024

Share on Facebook