Cwm Hyfryd

Contract Monitoring Report

  • Name/Address of Provider: Cwm Hyfryd, 48 Severn Road, The Bryn, Pontllanfraith Blackwood, NP12 2GA
  • Date of Visit: Monday 29th January 2024
  • Visiting Officer(s): Amelia Tyler: Contract Monitoring Officer, Caerphilly CBC
  • Present: Gemma Rawlings: Service Manager, Achieve Together


Cwm Hyfryd is a residential home for individuals with learning disabilities that is owned and staffed by Achieve Together, a registered provider within Caerphilly County Borough. The contract for the property for the new provider was fully signed in September 2022.

The most recent monitoring visit to the property was carried out on the 3rd November 2022 and at this time there five actions identified (two corrective and three developmental). These recommendations were reviewed, and the findings are outlined in the section below.

It was acknowledged that the home is registered to provide support for up to five people and there was one vacancy. One of the clients had been supported to move by Caerphilly CBC, two were supported by neighbouring authorities, and one from England. It was highlighted that the personal file viewed clearly recorded the details of the placing authority.

Dependant 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 legislation), and developmental actions are good practice recommendations.

Previous Recommendations

The initial assessment must be completed prior to the commencement of service, or if the person has moved in as an emergency, with 24 hours. RISCA version 2 (April 2019) Regulation 15. Not met. This was not present on the file checked for the person supported by Caerphilly CBC. It was noted that the lady had been living at the home prior to the support provision being taken over by Achieve Together, so it was explained that this information may not have been shared.

Personal plans to evidence the involvement of the individual and/or appropriate representative. Where signatures cannot be obtained, this should be clearly recorded on the document. RISCA version 2 (April 2019) Regulation 15. Not met. There was no evidence of co-production of the personal plan. It noted that the lady is unable to sign herself but didn’t demonstrate her level of understanding of the contents or even the existence of the document. There was nothing to highlight who had contributed, or given the option to contribute, to the plan.

Consent forms to agree to the taking and sharing of resident’s photos and signatures to be obtained from appropriate representatives, or refusals clearly documented. Met. There was a disclaimer on the file seen that had been signed and dated by a member of staff stating the resident doesn’t have capacity to consent.

Agreement to be implemented with relatives about being informed of any incidents. Met. It was clearly recorded that the individual only has one known relative, and the details were clearly held, but it was requested that in an emergency that the assessment care management team would be the first point of contact.

All areas of the personal plans to be completed fully. Met. The contract monitoring officer acknowledged that there were no sections that stated it is ‘non applicable’ and all areas had been completed including sexuality, religion and use of social media.

Findings from Visit

Desktop audit

There had been no concerns raised with the commissioning team since the previous monitoring visit. There were safeguarding reports received that were appropriately escalated and addressed in line with the safeguarding policy.

It was noted that the previous Care Inspectorate Wales visit had been carried out on the 25th January 2023 and at this time there were no no-compliance issues highlighted and one area for improvement around supervisions.

A copy of the training matrix was provided prior to the visit, and this recorded 72% compliance for classroom based training, 99% for eLearning and 88% for service specific training. Further detail is provided in the staffing and training section below.

There was no service user guide available, but the contract monitoring officer was provided with a copy of the service user agreement. In accordance with regulatory requirements, all tenants must be provided with the guide in a format that reflects their level of understanding.

The contract monitoring officer acknowledged the manager is registered with Social Care Wales.

The manager explained that resident records were stored securely in a lockable cabinet in the office at the home, but staff were able to access these as and when necessary.

Responsible individual

The previous two regulation 60 reports completed every quarter by the responsible individual were provided and these were dated the 17th August and 10th November 2023. These also contained any agreed outstanding actions. It was noted that the report stated the responsible individual spoke to two staff and two residents during their visit. It highlighted there were sufficient staff on duty; it is recommended that this be more specific to document the staffing ratios.

The statement of purpose was kept up to date and the version shared with the contract monitoring officer was dated 13th December 2023. It was stated that if the registered manager and responsible individual were both absent for 28 days or more, they would notify Care Inspectorate Wales and the commissioners. The responsibilities would be carried out in the interim by the service manager and deputy manager at Cwm Hyfryd with support from the managers in the local sister homes.

All mandatory policies and procedures, including admissions and commencement of service, safeguarding, client finances, restraint, staff development, staff discipline, infection control, medication, complaints, and whistleblowing were all accessible at the property. All policies had been reviewed and updated (if required) in 2023 except for HR development, staff discipline, and whistleblowing which were reviewed in May 2022 and are due every three years. The contract monitoring officer observed that the disciplinary policy was due for renewal in January 2024 at the time of the visit.

File and documentation audit

The contract monitoring officer viewed the file for the individual supported by Caerphilly CBC, and it was noted (as in the previous visit) there were no initial assessments in place. It is acknowledged that this resident had lived at Cwm Hyfryd for many years and had been supported by a different provider. This document cannot be completed retrospectively. To comply with legislation, the manager must ensure this document is completed with any future residents.

The personal support plan highlighted that she is unable to sign and will regularly ask for a coffee and to go to the toilet and there has been a recent increased risk of falls. The plan is person centred and produced in an easy read format to assist in the level of understanding. There was no evidence of co-production, and the manager must ensure there is evidence of input from professionals, advocates, and key workers. It was acknowledged that there is minimal input from external professionals at the time of the visit, however, the manager confirmed that this would be captured in the three monthly review where appropriate.

It was noted that suitable risk assessments were in place to meet the person’s needs including choking, fire safety, medication, cellulitis, epilepsy, changing behaviour, finances, and a personal evacuation plan. These had been reviewed and amended (where necessary) every three months, with the last review being completed on the 17th January 2024.

Daily recordings were detailed and there was also a three monthly wheel of engagement that outlines the activities, events and appointments held. It was noted that there was evidence of staffing issues and limited drivers impacting on the ability for staff to support community engagement. This was also observed during the visit as one resident had to attend a GP appointment which resulted in the other two residents having to remain at the home (the remaining person was in hospital at the time).

Although it was known that the person supported by Caerphilly CBC had been referred to Speech and language four months prior to the visit, the communication and contact log hadn’t recorded anything since June 2022. Staff must ensure that any input from professionals is appropriately recorded on this log.

The personal plan lacked evidence of long and short term goals and wellbeing outcomes. It was acknowledged that they enjoy visiting farms, theme parks and coffee mornings at one of the sister homes in the local area, but there were no agreed ambitions to emphasise what they wished to achieve; this can either be skills they wish to develop and increase their independence and wellbeing, events they wish to attend or places they want to visit.

Discussion was held around what activities are available to people who choose or need to spend time in their rooms and the service manager explained they usually play on their handheld games console, watch TV, do some painting, or listen to music.

There wasn’t much detail on file around the life history of the resident, but it was noted that there were preferences i.e. they enjoy sweet foods, going out for a coffee morning, baking, having their nails painted and crafts. It was recorded that they do not like being bored or feeling left out and there was a deprivation of liberty safeguard (DoLS) that was dated February 2023.

Staffing and training

Staffing levels at the home are two by day and one waking night staff in addition to the service manager who is contracted to work 37½ hours a week. It was also explained that every Monday, Wednesday, and Friday there is an additional member of staff that works a six hour shift to assist with any activities or community access.

It was noted that staff absences would be covered by the service manager if within the normal working day. There are also two bank staff that can work flexibly, but if this isn’t possible the overtime would be offered to staff in the other homes in the area. Agency staff would only be used as a last resort.

When assessing the quality of the training being provided, it was explained that the service manager also attends the courses and feedback on the training is requested as part of team meetings and supervision sessions. The eLearning provider ‘Access’ also requires staff to pass an exam at the end to determine the level of understanding. It was stated that there is an amber alert on the system to inform the service manager of when training courses are due for refresher. The contract monitoring officer also noted the service manager works directly with the staff at the home (those that work during the day) and this allows her the opportunity to observe the training being put into practice.

At the time of the visit there were two staff members that regularly worked over 48hours a week and it was explained that they have both signed a declaration opting out of the working time directive.

It was stated that the active offer in relation to the Welsh language is not implemented, however, all residents are asked their preferred language is as part of the initial assessment. Where the individual is not able to communicate verbally, the home will go on the information provided and gauge their level of understanding and what language they are used to. It was noted that there were no Welsh speaking staff or clients at the time of the visit.

There were eleven staff members working at Cwm Hyfryd at the time the visit was carried out and all had completed safeguarding, infection control, first aid, medication, and communication training. The contract monitoring officer acknowledged that medication competency had also been completed for all staff and this is carried out at least annually.

Some gaps were identified in the training matrix; five staff to complete manual handling, one to undertake food hygiene and four to complete dementia awareness. There were five staff booked onto the positive behaviour support training on the week of the visit and the service manager explained that this would then take this course up to 100%. Overall, it was noted that the home was 62% compliant and this was due to staff needing to complete catheter care.

Following the visit the service manager informed the contract monitoring officer that the electronic report was not providing a date for when epilepsy training was provided. This was raised with the learning developing department and requested that this be added to the service specific training. Expiry dates were provided for this training and there was only one that appeared to be out of date (although it was stated this was thought to be an error and needed to be updated).

Two staff files were seen, and it was noted that one only contained one reference and the other contained a professional and character reference but there was no indication of who had completed it or the relationship. It is recommended that all references are clearly signed, dated, have the name of the person giving the reference and the capacity in which they know the applicant.

One file did not have a passport and the other didn’t have a recent photo.

Both files had interview records that had been scored, evidence of DBS check, birth certificates and signed contracts of employment. It was not possible to determine whether there were any gaps in employment as only the year was provided on one file. It is a regulatory requirement to ensure that all staff files contain a full employment history with a written explanation for any gaps.

The files seen did not contain job descriptions or evidence of induction and only one contained an application form. As this information cannot be obtained retrospectively, and some members of staff have been working for the provider for many years, it is recommended that the manager puts a file note in place that is signed and dated giving a brief explanation of why the information is missing.

Supervision and appraisal

The supervision matrix was provided ahead of the visit, and this evidenced that supervisions were being carried out at least every three months. The matrix did not document the actual dates but stated the type of supervision held.

Annual appraisals had been carried out where these were due. Supervisions are held as a formal confidential 1:1 meeting. Staff are expected to think about their role and the service as a whole and to contribute to the meeting to ensure that meaningful feedback is provided from both sides.

Approach to care / general observations

The home was clean and tidy and free from any odour. There was some redecorating taking place at the property at the time of the visit.

Staff interaction observed during the visit was caring and friendly and the residents appeared relaxed and comfortable in their home. Staff were encouraging and reassuring when one resident was being supported to an appointment an when discussing medication with another lady.

There is a four weekly menu that is repeated for a three month period. The service manager said these are planned with the residents and where necessary, they use photos to allow people with communication difficulties to give their preferences.

Staff encourage residents to eat healthily and try to support them to eat a variety of food. It was highlighted that they make home cooked meals and try to minimise any processed foods. Residents can choose when they want to want to eat; mealtimes are generally routine but can be flexible depending on the residents, activities, appointments etc. Residents can re-heat their meal, or this can be refrigerated. Breakfast differs depending on what time they get up and they also have access to snacks if wanted.

It was mentioned that two of the residents are able to get involved with meal preparation (and are encouraged to do so) but there is one gentleman that prefers to watch staff arranging his meal. It was also noted that residents assist with food shop, and this is alternated each week, with Mondays and Fridays being the main shopping days.

If the needs of any of the residents changed, it was stated this would be discussed initially in a team meeting, be noted in the communication book to make staff aware, an email would be circulated to the necessary parties and a multi-disciplinary meeting would be arranged and any necessary referrals made.

Only one of the residents at the time of the visit was able to communicate verbally and tell staff what she would like to do. The two individuals that are non-verbal and use reference picture to inform staff as well as basic BSL and Makaton. The service manager also explained that there is information in their personal files around what activities they enjoy.

All staff have collective responsibility for organising activities and this can include housework and activities of daily living as well as community access. Meetings are held monthly to discuss activities and the residents are encouraged to participate as much as possible. There is an activities timetable in place which included bowling, meals out, equine therapy, garden centre visits, picnics and a local touch trust which provide sensory stimulation sessions.

Residents had been appropriately assessed for relevant equipment and there was nothing they were waiting for or could think of that was required.

Health and safety

It was explained that there is no accident book at the property as this is all done electronically. There were no accidents or incidents in the month prior to the visit and the last recorded incident was a seizure on the 27th November 2023 and there were no injuries caused. There were no trends identified over the last six months.

The most recent fire drill was carried out on the 6th November 2023, and it documented who was involved and that the evacuation took two minutes. There was clear recording which highlighted that one of the residents had taken two attempts to stand, but there were no concerns and no actions that needed to be actioned. It was recorded on the most recent internal audit that all members of staff working at the home had been involved in a fire evacuation.

There was no evidence at the home of the external fire inspection and the service manager said she would contact the compliance team to obtain a copy. The contract monitoring officer was informed the external company was inferno that complete the fire risk assessment. The most recent internal review was dated the 23rd November 2023.

Complaints and compliments

It was stated that when a complaint is received either in writing or verbally, this is recorded of the Radar database used by the organisation. Once on the system an action plan is generated with timeframes for completion. Any investigation that may be required is carried out and the complainant will be notified of the outcome in writing.

Staff are made aware of complaints through team meetings and a formal 1:1 meeting with the staff member involved if the complaint is against an individual. If appropriate, the lessons learnt are then shared with the other home managers.

Practices have been changed because of a complaint around an unsafe discharge from hospital and it was explained that there is now a full discharge checklist for when a resident is returning home. It has also been reiterated to staff that if there is any indication that someone’s health is deteriorating, that they be pro-active and phone 111 for advice. This has been recorded in teams’ meetings and the communication book.

Resident and stakeholder feedback

One of the residents was spoken to during the visit to obtain feedback; they said that the staff at the home are good, and they get on well with them. When asked if they liked the other residents, they commented that they liked them and was good friends with one of the gentlemen.

They told the contract monitoring officer that they couldn’t go out in the community independently but is able to tell staff if there is anything she wants to do. They explained that they were having a visit from the district nurse on the day of the visit, and they had planned to visit two shops the day after. When asked if there was anything they wanted to do that they weren’t doing now, they said there wasn’t anything they could think of.

It was highlighted that they enjoy arts and crafts and using their iPad. They also commented that they like listening to hardcore music and have headphones for this. When asked if staff had helped them to achieve any goals, there wasn’t anything specific that had been discussed and they weren’t aware of their personal plan. It is a regulatory requirement that residents have a copy of the coproduced plan and if a copy hasn’t been provided a written reason is held for not doing so.

The resident was happy living at Cwm Hyfryd and said that if there was anything wrong, she would speak to the service manager. The only thing that was mentioned that they would like to do was to paint their room yellow.

The home environment

There is no smoking room at the property, and it was noted that all residents’ rooms seen were well maintained. There was evidence of personalisation and one room contained sensory lamps, a fitness ball, a drum, keyboard, a massage chair, photos, and a glitter ball.

The home was tidy, and all areas appeared clean. It was noted that there is a large living area and conservatory in addition to the activities room, so there is plenty of space for residents to spend time on their own without having to go back to their room.

It was noted that there were new bathroom and bedroom doors fitted in the property which have locks. The bathroom doors have turnkey locks that can be opened with a coin from the outside in an emergency. Residents have the option of having their own keys and it was highlighted that this needs to be incorporated into the personal plans and the decision of the individuals if they wish to carry these or not.

Over the previous twelve months the improvements made to the home included a new TV being installed on the wall of the living room, a new bathroom had been fitted, a new central heating system and a new conservatory. It was mentioned that there are plan in place to redecorate the small room at the end of the corridor that was being used for storage and activities.

Staff questions

One member of staff was spoke to during the visit and they stated that they were aware of where the personal plans and risk assessments were held and that they signed the documents to verify they had been made aware of any updates. If there are any changes it is requested in the communication book that staff are to read and sign the document.

The contract monitoring officer was informed that the service manager spends time walking around the home and engages with staff and residents.

It was noted that staff take residents out in the community and two went out for lunch the previous weekend and that one of the sister home had visited to celebrate two birthdays recently. It was highlighted that one staff member had needed to support one resident in hospital for ten hours a day which had impacted on the ability of staff to take people out, but they try to provide a minimum of eight hours a week doing different activities.

The member of staff was knowledgeable and was able to explain the most important things about the residents and what matters to them. It was noted that most of the residents have communication difficulties, and they use their own version of Makaton to make staff aware of what they want.

They said they felt able to be flexible in their role and had opportunity to sit and chat with the residents. If there was a spare five minutes and they didn’t feel there was much stimulation they would get out the big bowling set, the football net, or balloons.

Staff are encouraged to offer suggestions about ways to improve the quality of life for their residents and their views would be listened to. If there was something wrong or they observed poor practice they explained they would report to the service manager or regional manager. They were aware of the whistleblowing policy and felt confident is escalating any issues.

It was stated that they were able to identify any training needs, but there wasn’t anything they felt they needed at the time. No concerns were raised with the way the home was operating during the visit.

Registered manager questions

It was explained that the manager oversees two services. There are planned dates for the responsible individual to complete their regulation 70 quarterly visits, but these are booked in closer to the date rather than a year in advance.

The manager felt supported by the responsible individual, and they could approach them if there were any issues.

At the time the visit was carried out there was no CCTV at the property and there were no concerns such as the heating system, leaks, water pressure etc. All residents can change the temperature in their rooms as they can open their windows and access the thermostat. Some residents may not have capacity to be able to do this, so this is monitored by staff and room temperature checks are carried out.

There were no outstanding regulation 60 notifications, but the manager said these would be shared with the commissioning team if completed. The last referral that was required was for speech and language in November 2023 and this was evidenced on file.

It was highlighted that the home was up to date with the applications for Deprivation of Liberty Safeguards and were aware that these must be submitted in a timely manner when they are due to expire.

The manager stated that it is difficult to involve the friends and relatives of the residents in activities due to their physical and/or learning difficulties, however, if there is a birthday party or special event, they phone them to invite them and they regularly get together with other sister homes locally where they have established friendships. It was mentioned that one individual meets with their siblings every month.

Community participation is encouraged through the implementation of the activity planners and daily shift planners. Activities are discussed at team meetings and daily with the residents to ask what they would like to do; this could be going to a local coffee morning, doing the weekly food shop, or going for a walk with residents from one of the other sister properties.

Residents have limited input in the recruitment of new staff due to communication difficulties. The manager highlighted that there is an option for residents to be on the interview panel, but they often decline any involvement. It was acknowledged that one lady has asked questions informally. The manager said that new starters get to meet the residents at the second stage of the interview process.

Corrective / Developmental Actions

Corrective actions

The initial assessment must be completed prior to the commencement of service, or if the person has moved in as an emergency, with 24 hours. RISCA version 2 (April 2019) Regulation 15.

When a personal plan is being revised it is co-produced with the individual receiving care and support, the placing authority (if applicable) or any representative/professional. RISCA version 2 (April 2019) Regulation 15.

Personal plans to evidence the involvement of the individual and/or appropriate representative. Where signatures cannot be obtained, this should be clearly recorded on the document. RISCA version 2 (April 2019) Regulation 15.

Individual plans to be given to everyone receiving the service in a language and format appropriate to their level of understanding. If there is a reason for not doing so this is documented. RISCA version 2 (April 2019) Regulation 15.

A written service user guide is made available to individuals, the placing authority, and any representatives, which provides information about the service. RISCA version 2 (April 2019) Regulation 19.

Where there are multiple professionals involved in an individual’s care and support the service provider establishes roles and responsibilities for referral and advice. This is recorded and is clear for the individual and staff involved in their care and support. RISCA version 2 (April 2019) Regulation 33.

Evidence to be held of the service being suitable to meet the individual’s care and support needs and to support the individual to achieve their personal outcomes. RISCA version 2 (April 2019) Regulations 14 and 66.

All staff to have two references on file, one of which should be from previous employer (if any) and these should be signed and dated with the name of the referee and the capacity they know the individual. RISCA version 2 (April 2019) Regulation 21.

There must be evidence of meaningful induction on file. RISCA version 2 (April 2019) Regulation 36.

All staff to have full employment history on file together with written explanation for any gaps. RISCA version 2 (April 2019) Schedule 1, Regulation 35, part 1 (8).

The manager to incorporate the decision making of residents around carrying their own set of keys. RISCA version 2 (April 2019) Regulations 43 and 44.

Developmental actions

To ensure accuracy and transparency, the manager must record the actual dates supervision sessions were carried out.

It is recommended that rather than stating there are ‘sufficient’ staff on duty in the quarterly reports that specific staff: resident ratio are recorded.

The service manager to ensure epilepsy training is added to the matrix and all staff have completed within the specified timeframe.

Arrange for the resident to choose new paint for her bedroom.


There were no issues raised in relation to the appearance of the residents and they appeared comfortable.

As previously noted, there were no concerns regarding the safety, cleanliness, and comfort within the home. There was redecorating being carried out at the property, but this did not appear to have any negative impact on the people living there and they were supported to carry out their normal

Staff seemed knowledgeable about the needs and preferences of the people they are supporting. No concerns were raised around the care and the staff team appeared to be working well together. Although there are fifteen actions identified, the contract monitoring officer is in no doubt the manager will address these with support from the staff team and the registered manager overseeing the service

Unless required, the next monitoring visit will be carried out in approx. 12 months’ time. The contract monitoring officer would also like to take this opportunity to thank everyone involved in the process for their time gathering the documentation and during the visit, their help and hospitality.

  • Author: Amelia Tyler
  • Designation: Contract monitoring officer
  • Date: 23rd February 2024