Abbey Lodge Residential Home 

Contract Monitoring Report

  • Name of Provider: Abbey Ambitions
  • Name of Service: Abbey Lodge Residential Home (Learning Disabilities)
  • Date of Visit: 16 March 2023
  • Visiting Officers: Ceri Williams - Contract Monitoring Officer CCBC
  • Present: Wendy Gloster (Manager/Proprietor)


Abbey Lodge is a Residential Home for individuals with Learning Disabilities, which is owned and run by Abbey Ambitions, who are a registered provider within Caerphilly borough.  The provider also runs another residential home in the borough, called Beechlea.

Abbey Lodge is a four bedded home, in a quiet residential area of Ynysddu. At the time of the visit there were two residents who are funded by CCBC, along with one resident who were funded by another local authority. The home currently has one vacancy.  On the day of the visit, the monitoring officer was able to meet all of the residents, some staff, the Manager, as well as having a tour of the home.

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

Previous Recommendations

This was the first monitoring visit to the home since 2019 due to Coronavirus restrictions. Therefore, previous recommendations have not been taken into account.

Any new corrective and development actions will be given to the provider as an outcome of this report.


Service Planning

Personal Plans were viewed for two of the residents who live at the home.  Files contained a lot of information, some historic, and could be better organised for clarity.

Personal Plans were detailed and person centred and reflected the care and support needs identified by the care and support plan from the local authority.

The plans included likes/dislikes, routines and triggers for the individuals being supported.

Personal Plans had been compiled several years ago and would benefit from updating and re-writing as some information was historic and no longer relevant to the individuals care and support needs.

It was noted that Personal Plans had not been signed by residents or their representative to evidence that they had been involved in the formulation of the plans and agreed with the content.  Whilst it is acknowledged this can be difficult depending on the capacity of an individual to understand, it should be documented as to why the documentation has not been signed.

There was evidence available on files that referrals are made to appropriate outside agencies, when needed, and good records of communication with health professionals and outcomes of any health assessments or appointments that residents had attended.

Evidence was found on Personal Plans of agreed outcomes for people and how they were going to be supported to achieve the,

Reviews of personal plans are being undertaken within the timescales required.  However, reviews could be more meaningful, it was evident that there was historic information contained in personal plans which had not been identified and amended through the review process.

Reviews did not contain evidence that the individual receiving care and support had been involved in the reviewing process.

Daily recordings reflected the areas set out in the individuals personal plan. Daily recording information also captured outcomes and achievements, any activities and general presentation.

The provider follows the correct procedure for Deprivation of Liberty Safeguarding (DoLS), and although the paperwork on file was overdue an assessment there was evidence available that the provider had completed the request for re-assessment in a timely manner and had been in contact with the DoLS team to chase up.

Risk Assessments

Risk Assessments were evidenced on files for a number of risks associated with the needs of individuals.  Risk assessments were detailed and included clear guidance for staff regarding actions to be taken to mitigate or react to the risks should they arise.  RA’s had been signed by staff as evidence they had been read and understood.

Risk Assessments had been compiled and were written some years ago and require updating.   

There was no evidence available that individual risk assessments are being reviewed within the necessary timescales set out in legislation.

Staffing Training & Supervision

The home benefits from a stable, well-established staff team who have supported the residents for many years and are very knowledgeable regarding the resident’s care and support needs.

The home is staffed by one member of staff from 9 a.m. to 12p.m., two members of staff from 12pm until 9pm and one member of staff from 9pm until 9am.

The home rarely uses agency staff. Staff are flexible and will cover any gaps in rota’s and can also utilise staff form the sister home within the borough.

Staff training is conducted by face to face or online training.  Courses are also utilised from the Caerphilly & Blaenau Gwent Workforce Development team.

A training matrix was provided.  It was evident that staff had all completed courses in mandatory and non-mandatory training areas however, some staff were overdue refresher courses.

Two staff files were viewed during the visit. Both files contained proof of I.D. and included photographs, full employment history and two references.

Evidence was provided of DBS checks for staff, and all were current.

A supervision matrix was provided which evidenced that staff receive supervision with a senior member of staff every three months.

Supervision records viewed were meaningful and included views from staff members on their well-being, training, areas for development, any support needs, and goals and objectives.

Although staff had received the required level of Supervision, they had not received an annual appraisal in the last 12 months.


There are no set mealtimes and individuals are given choice as to when and what they would like to eat.

A healthy diet is encouraged as much as possible, resident’s preferences are taken into consideration. The residents are encouraged to help with food preparation and cooking and can also help themselves to snacks whenever they require them.


A person-centred approach was evident when it came to activities.  Individuals are given choice and control over how they wish to spend their time daily.

All staff are responsible for activities and discussions were observed between staff and individuals regarding activities during the day.

Activities are aligned with peoples preferences and abilities and outcomes are included in personal plans.

There is an activity planner in place however this is dependent on the wishes of the individual for that day.  Evidence was seen of residents enjoying trips to the theatre, bowling, cinema, and meals out in the community.  One resident told the monitoring officer that they were looking forward to a holiday that they had planned later in the year.


Medication was stored securely in a locked cabinet.  Audits are carried out monthly and evidenced checking of stock, dosage amounts expiry dates and completion of MAR charts.

Mar charts were reviewed and found to be completed correctly with no missed doses.

Health & Fire Safety

Regular maintenance checks are carried out and recorded including fire alarm, emergency lighting etc.

The last independent fire assessment was carried out in September 2020 and the two recommendations from the report had been completed.

Fire drills are carried out regularly and are timed and recorded.

Personal Emergency Evacuation Plans are in place for each resident and provide staff with clear instructions if there is a need to evacuate the property and also differentiate between evacuation during the day and evacuation during the night.

No accidents have been recorded at the home within the last 12months.

The home has retained it’s 5 star rating following the latest inspection by the Food Standards Agency evidencing that food hygiene standards are correctly followed and are excellent.

The Environment

The home is warm and welcoming and decorated and maintained to a high standard throughout.

The property was clean and tidy throughout with no hazards and no malodours.

Residents rooms are individually decorated with lots of personalised displays and items important to individuals.

There home has benefited from refurbishment this year with a new kitchen being fitted and the vacant room fully decorated with new bed and furnishings purchased.

There is a large communal lounge and separate dining room, and pleasant patio area to the rear of the property. Bathrooms are clean and accessible for individuals.

Quality Assurance

The manager provided copies of Quality Audit’s for the home which are carried out every six months as required by regulations.

The quality audits contained all the necessary feedback from stakeholders, staff and residents, analysis of patterns and trends, outcomes of the Registered Individual (R.I.) quarterly monitoring visits.

The report is analysed and an action plan is compiled from the findings of the report with clear guidance on what action is to be taken, by whom and a date by which the action is to be achieved.

Regular visits are scheduled by the R.I. and the quarterly reports were available for the monitoring officer to view.  The reports were dated and are carried out within the timeframes set out in regulations.

The report covered areas of the service such as feedback from the residents, the environment, staffing, leadership, reviews of any concerns, compliments & complaints and included any actions identified from the visit.


The two CCBC residents who live at the home are settled and have lived there many years.  There was an excellent rapport between them and staff who are clearly knowledgeable regarding their care and support needs.

The Commissioning team have received no concerns or complaints regarding the home.

Staff were observed communicating and engaging well with residents throughout the visit.

The home has the necessary policies and procedures in place to support staff and residents and these are reviewed annually.

A handover was witnessed while visiting the home and was communicated clearly face to face as well as recorded in a handover book.

Staff are supported in their roles by a Manager and R.I. who are accessible and spend a lot of time at the home.<

Resident are given choice and control over their everyday lives and are supported to achieve agreed outcomes and goals.

Corrective / Developmental Actions

Corrective Actions

Personal Plans and Risk Assessments are kept under review and are amended and developed to reflect changes in the individuals care and support needs and personal outcomes. (Regulation 16, The Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA).

Personal Plans to be signed by the individual or a representative, where appropriate to evidence they have been involved in co-producing the plan or, a reason to be documented as to why this would not be possible. (Reg 15 RISCA).

Following the completion of any review the provider must consider whether the Personal Plan and/or Risk Assessment should be revised and revise the plan as necessary. (Reg 16 RISCA).

Reviews are undertaken involving the individual and, where appropriate, with the agreement of the individual, their representative. (Reg 16 RISCA).

Staff to be up to date with all mandatory training courses and refreshers. (CCBC Contract 13.3).

All staff to receive Annual Appraisals which provide feedback on their performance and identifies areas for training and development in order to support them in their role. (Reg 36 RISCA).

Developmental Actions

To archive historic information on files to ensure information is current and reflective of the individuals care and support needs.


There was a welcoming and friendly atmosphere at the home.  Staff were knowledgeable of the care and support needs of the people they supported and good interaction and communication was observed. Individuals were relaxed in a comfortable home environment.

The monitoring officer would like to thank residents and staff for their time hospitality throughout the visit.

  • Author: Ceri Williams
  • Designation: Contract Monitoring Officer
  • Date: 31 March 2023