Luk Ros Residential Home

Contract Monitoring Report

  • Name of Provider: My Choice Healthcare    
  • Name of Service: Luk Ros Residential Home (Learning Disabilities)
  • Date/Time of Visit: Thurs 12th October & Weds 18th October
  • Visiting Officer(s): Ceri Williams, Contract Monitoring Officer 
  • Present: Nicola Mullins (Operations Manager)            

Luk Ros is a Residential Home for individuals with Learning Disabilities which is owned and run by My Choice Healthcare, who are a registered provider within Caerphilly borough.The provider also owns two other residential homes in the borough.

Luk Ros is a four bedded bungalow, in a quiet residential area of Pengam. At the time of the visit there were three residents: two funded by CCBC, one funded by a neighbouring local authority and one vacancy.

At the visit, the monitoring officer was able to meet residents, some members of staff and the Operations Manager. Paperwork was also examined during the visit, and all areas of the home were seen.

Dependent 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), and developmental actions are good practice recommendations.

Previous Recommendations

Personal Plans to be fully updated to reflect up to date, accurate information regarding resident’s current care and support needs and how the care is to be provided. (Regulation 15, The Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA)). Met: Personal Plans were accurate and had been fully revised.

Risk Assessments to be fully updated to reflect residents current care and support needs and the steps to be taken to mitigate identified risks. (Reg 15, RISCA). Met: Risk Assessments had been updated and fully revised.

Non-mandatory training relating to specific care needs of residents to be added to the training matrix. Met: Non-mandatory training has been added to the training matrix.

Routine checks on Mobility Aids & equipment to be documented. Not Met: No documented evidence was available that routine checks are carried out on mobility aids and equipment .

Documentation used to review Personal Plans and Risk Assessments to be updated to evidence that reviews are being carried out in meaningful and timely manner. Met: Personal Plan review documentation has been reviewed and is clear.

Service Planning

Personal Plans were viewed for two of the residents who live at the home.Files were well organised, and information could be found easily. The format of care planning documentation has been updated and improved. Files contained good information regarding individuals living at the home including pen pictures, and health/life history.

Personal plans were detailed and reflective of care and support needs of residents. Plans were clear regarding the support required by residents and what could be achieved independently.Plans were also detailed regarding residents likes/dislikes and routines and gave staff clear instruction how to offer support in a person centred manner.

There were some areas of support identified on local authority care and support plans which were not included on the resulting Personal Plans for individuals.This was discussed with the Operations Manager at the visit and will be rectified.

Risk Assessment documentation had also been updated.Risk Assessments were in place for any risks identified, regarding individuals care and support, were clear regarding risk and included actions for staff in order to reduce risk.

All personal plans and risk assessments included read and sign sheets for staff to evidence they have read and understood plans to support residents.

Reviews of personal plans are undertaken within necessary timeframes. Review documentation also included comments on whether the personal plan was still relevant or whether it had been amended as a result of the review.

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.  These communication documents were accompanied by staff signing sheets to ensure all staff are aware of any outcomes from healthcare appointments.

Daily recordings were detailed and included information on personal care and support tasks. There was no evidence in daily recordings regarding activities enjoyed by residents.  This information is kept in a separate folder which includes detailed information and photographs of residents enjoying various activities.  Whilst the separate activities folder evidences that residents are engaging in chosen activities, it is recommended that reference to activities is also included in daily recordings.

Deprivation of Liberty Safeguarding (DoLS) paperwork for residents was viewed on files and was found to be up to date and correct.

Staffing & Training & Supervision

The home benefits from a stable, well-established staff team who have supported the residents for many years and are knowledgeable regarding the residents needs and personalities.

During the day Luk Ros have two members of staff on duty and one member of staff during the night. The home does not use agency staff, the staff team are flexible and will cover any gaps in rota’s.

Staff employed at the home undertake training via e-learning and in-person training courses. A training matrix was provided and evidenced that all staff are up to date with Mandatory training and non-mandatory training courses.

Some staff were overdue training in a specific procedure, this was discussed with the operations manager who advised that training is being sought with colleagues in the health board.

Two staff files were reviewed whilst at the visit. All necessary recruitment documentary evidence was available on file including proof of identity, references from previous employers, evidence of DBS checks, application forms and contracts of employment.

A supervision matrix evidenced that staff receive regular supervision.  Supervision is recorded and documents viewed evidenced in-depth and meaningful sessions are conducted with staff.  Staff also receive annual appraisals.


Residents have menus which are varied and nutritional and based on their preferences. Although menus are planned for each week residents are also offered choices.  Staff encourage a healthy diet as much as possible and there are prompts and instructions to assist staff with this.

Residents sometimes help with food preparation and regularly participate in baking and preparation of healthy snacks such as smoothies. 


There were no care plans present on file regarding activities for residents. As there are specific activities mentioned in the local authority care and support plans for residents, it is recommended that activities are care planned for. This can provide clear guidance for staff to be aware of residents personal preferences and outcomes. 

Evidence of activities enjoyed by residents was available and included accessing the local community, holidays, arts and crafts and games.  Staff were also observed engaging in activities with residents whilst the monitoring officer was at the home.

Mobility Aids & Equipment

There are several aids and equipment in use at the home. Evidence was available that aids are up to date with servicing.

It was verbally confirmed that weekly checks are undertaken by staff to ensure the condition and safety of the aids but these internal checks are not documented.  It is recommended that these checks are documented.

Managing Residents Money

There are robust systems in place for managing residents money and appropriate records and receipts are kept.  There was also evidence of financial records being audited by the manager.

While the ledger book was completed fully and to a high standard it is recommended that staff making the entry should add a signature for a more complete record and audit trail.


Medication is stored securely within the home. Care plans are in place for individuals who require support with medication.  Whilst viewing the care plans it was noted that only some of the prescribed medication was listed, it is recommended that if medication is to be listed on personal plans, all medication prescribed for an individual is included on the care plan.

Medication Administration Records (MAR) were viewed, these were completed fully for all individuals. All staff were up to date with medication administration training.  Monthly medication audits are also completed by the manager.

Health & Safety

The home is well presented throughout with no hazards being observed.A number of routine maintenance checks are carried out weekly and monthly and are recorded.In addition the Manager compiles a monthly Health & Safety report for internal monitoring.Any incidents/accidents or near misses are recorded and reported to senior management who will review and advise on any actions to be completed.Incidents are also collated and reported within quality assurance documents.

Evidence was available for routine weekly and monthly checks with regards to fire safety within the home which included checks on the fire alarm, emergency lighting and fire extinguishers.An internal fire risk assessment was also available and all staff had read and signed the document.Fire drills occur regularly and are recorded including names of participants and timed evacuation.

Personal Emergency Evacuation Plans were in place for all individuals who live at the home and are reviewed every three months.

Quality Assurance

Copies of the two previous Quality of Care Reviews were provided to the monitoring officer. These were comprehensive documents, achieving the purpose of monitoring, reviewing and improving the care and support provided by the service.The reviews included feedback from both staff and residents. The reports included recommendations and actions following the review.

Regular visits are scheduled by the Responsible Individual (R.I.) and the quarterly reports were avaible for the monitoring officer to view.Again, these were comprehensive documents and included all the requirements as set out in legislation by the regulator.

There had been no complaints received by the service since the last monitoring visit.Compliments had been received and recorded by visiting professionals.


The bungalow is well maintained throughout with no hazards or malodours observed. It was evident that there has been re-decoration to the living room and kitchen and also improvements to the garden area since the last monitoring visit.

Residents rooms are comfortable and personalised to each individual including photographs and sensory items.

Corrective/Developmental Actions

Corrective Actions

Personal Plans to include areas of support included in the Local Authority Care and Support Plan. (Regulation 15, Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA)).

Developmental Actions

If medications are listed on Personal Plans, all medications that are prescribed to be included. Staff signatures to be included on ledger book recording residents monies. Routine checks on Mobility Aids & equipment to be documented.


This was a positive monitoring visit to the home and it was clearly evident that improvements have been made in a number of areas since the last visit.  Documentation was well organised and clear for both staff and professionals. There was a warm, homely atmosphere at the home with staff observed engaging with residents throughout the visits. Residents continue to be supported by staff who are committed to helping individuals achieve their outcomes. Senior management are supportive and have good oversight of the service.

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

  • Author: Ceri Williams
  • Designation: Contract Monitoring Officer
  • Date: 27 October 2023