Rachel Kathryn Residential Home

Contract Monitoring Report

  • Name of Provider: Rachel Kathryn Residential Home
  • Date of Visit: Monday 24 July, 2023, 10.00 a.m. - 1.15 p.m.
  • Visiting Officers: Andrea Crahart, Contract Monitoring Officer, Caerphilly CBC
  • Present: Claire Hobbs, Registered Manager / Dawn Hobbs, Responsible Individual


Rachel Kathryn is a small, 2-storey property which is home to people with a learning disability, physical disability or mental health issues. It is set in a quiet residential area of Argoed on the outskirts of Blackwood. At the time of the visit there were 3 residents living at the property (funded through Caerphilly Borough Council) receiving residential care.

No concerns or issues had been received within the Caerphilly Services Commissioning Team over the previous year that needed to be addressed with the provider.

The home received an inspection from the Care Inspectorate Wales (CIW) in 2020 where a few areas were recommended for improvement, and a contract monitoring visit was undertaken by the Commissioning Team in May 2022 where one recommendation was made at the time.

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

Corrective Actions

Policies and Procedures to be reviewed to ensure they reflect current legislation and are accurate and up to date.  Policies to include the date they have been reviewed.  Timescale: Within 1 month and ongoing.  RISCA Regulation 12.  Partially met.

Development Actions

There were no development actions.

Responsible Individual

The Responsible Individual (RI) for the service visits Rachel Kathryn on a regular basis and as part of this role there is an expectation that the RI will produce quarterly reports to check regularly on the service and its quality.  Recent reports were requested and it was evident that a number of areas had been checked during the visits, with feedback having been sought from people using the service.

The Home’s Statement of Purpose had been reviewed in April 2023 and reflected the service being provided.

The home’s Service User Guide had been updated in April 2022 and had been compiled as an easy read version.

The contingency plan that would be put in place should the Responsible Individual and manager be absent would be for the senior carer to cover in their absence.

The home’s mandatory policies and procedures were viewed following the visit (e.g. Safeguarding, Staff support and development, Complaints etc.).  Some of the policies had been reviewed in recent months, whereas others did not include a review date.  The RI confirmed that she was currently updating these to ensure they were reflective of the service  and review dates would be added.

Registered Manager

The manager is registered with Social Care Wales (the workforce regulator for Wales), and manages another small residential home within Caerphilly borough, which is also registered with CIW and monitored by the Caerphilly Commissioning Team.

The property has CCTV, which is situated in the outside area of the property/driveway. Consent from individuals is therefore not a requirement as there is no infringement on people’s privacy.

The manager ensures that notifications (Regulation 60’s) are forwarded to CIW if/when significant events occur.

Findings from Visit

Personal Plans (Service Delivery Plans)

Resident’s files are stored in a suitable lockable cabinet in the Home.

The Personal Plan (Service Delivery Plan) within a file was written in a person centred way which detailed the way the person wanted to be cared for which had been signed by a family member.  The plan included routines which are required for various times of the day (i.e. morning, lunch, tea, evening and nighttime) and the person had been asked what goals he wished to achieve. The Personal Plan was explicit for example in how to best support the person with the administration of medication and personal care.  There was a DNACPR (do not attempt cardiopulmonary resuscitation) on the front of the file also.

Daily records had been written in a detailed way which captured e.g. how the person presented, how much he had eaten, what personal care had been delivered etc. and had been signed up to by the staff on duty.

The file included a Health log of important contact details for health professionals, there were appointment letters and ‘professional phone call’ sheets which evidenced when contact had been made with individuals regarding the person’s care (district nurses, pharmacy etc), as well as a close family member.

There were records maintained to capture where there had been concerns/incidences and guidance information for staff relating to nutritional food consistency (SALT) and a safer handling plan.

Risk Assessments

A Risk Assessment was present which covered a number of areas of risk e.g. pressure areas, mental health, choking etc. which required some more detail to enable staff to ensure the risks are mitigated as far as possible.

There was reference to bed rails being in place for the gent which required signing up to in order for consent to be given for the use of these.  

Complaints and Compliments

Rachel Kathryn continues to have a robust complaints policy in place to be followed if a complaint were to be made.  In the event that any complaints are received the registered manager would be responsible for processing these and auditing them.  The manager confirmed that no complaints had been received in the previous 12 months.

The manager made the contract monitoring officer aware of a compliment that had been received from family members in recent weeks.  This was extremely complimentary of the staff team in terms of how caring, compassionate and professional they had been in caring for their relative.  They also commented how ‘they were made to feel part of the family’ when they visited Rachel Kathryn.  


On the day of the visit there were sufficient staff to support the individuals living there. During periods of sickness absence the manager is able to utilise staff from a sister home within the borough which reduces the need for agency or relief cover arrangements.

Two staff files were checked which were clearly indexed/had sections, and included a recruitment checklist.It was evident that a robust recruitment process had been followed as both files included two written references, a job description, a detailed application form, Contract of Employment, photograph, interview records, training certificates and DBS (Disclosure and Barring Service) information.For one of the files it was not certain that gaps in employment had been explored, however the manager agreed to check these with the individual concerned to ensure they were accounted for.


The home’s training matrix was viewed which indicated that staff had attended appropriate training such as, Manual Handling, Food Hygiene, Safeguarding, Infection Control, Health & Safety, First Aid, Medication Awareness, DoLs (Deprivation of Liberty Safeguards), Mental Capacity Act, Autism/Learning Disabiity awareness, Sensory Loss and Fire Safety.  The dates when staff had attended spanned the years 2020 to 2023 and therefore were within the three yearly timeframe that the majority of training is required to be updated by.

Training is accessed via the CCBC/Blaenau Gwent Learning & Development Workforce (which is largely e-learning / webinar training) and face to face training via group sessions through a local Domiciliary Care agency (for new employees). Train the Trainer group sessions are held in relation to Manual handling, Safeguarding and First Aid by the home’s registered manager. 

All staff have either achieved an NVQ/QCF qualification in Health and Social Care (level 2 or 3) or are working towards one.  The majority of staff have already registered as a carer with Social Care Wales, and the newer staff will be required to do so when they have completed suitable qualifications.

Supervision And Appraisal

The home’s supervision/appraisal matrix indicated that staff were up to date with their one to one supervision sessions, which are held on a quarterly basis, and dates had been planned for in advance for the current year.

The supervision records that were viewed showed that many areas had been discussed with the staff members e.g. reliability, awareness of policies/procedures, feedback from the staff team and residents etc.

Annual Appraisals had either been held, or it was evidenced had been planned in advance for staff members.

Quality Assurance

Feedback was sought from a family member who relayed how brilliant the staff had been in supporting her relative, and the difference their care had made.  The family member also confirmed how staff had acted quickly in contacting health professionals when required and kept her up to date with changes to her relatives care.       

Managing Resident’s money

There are differing arrangements in place for the individuals living at Rachel Kathryn, which have been organised according to their specific needs and individual circumstances.  Records could be seen for a gent whereby the home manage his monies in terms of accurately recording the amounts that are received and amounts being spent.  There was a clear record sheet where the date of the transaction was written, the amounts taken out, receipts had been attached and numbered to correspond with the transaction, there was a running balance and two signatures had always been maintained.

Fire Safety

The home’s Fire Risk Assessment was viewed, which was dated in October 2020. The contract monitoring officer was informed that there were plans to request that this is revised and that a different company will be requested to do this.

Personal Emergency Evacuation Plans (PEEP’s) had been written for each current resident, and were reflective of their needs (mobility, sensory loss etc.) and had been reviewed on a regular basis to ensure they were up to date so that staff could support people out of the property in the event of a fire.

Fire alarm tests/extinguishers etc. had been undertaken at regular intervals.

Fire drills had been undertaken in December 2022 and May 2023 with no issues having been evidenced.  The contract monitoring officer advised to capture the initials of the individuals who had taken part in the fire drills so that it is clear who has been part of them, and who still needs to be part of one.

Home Environment

The home was clean and tidy with no malodours noted at the time.

The outside space at the rear of the property is very inviting, with a large open garden,  pegoda and seating area.

There is an outside shed that people can use to smoke if they choose to.   

Rachel Kathryn has a large conservatory that can be used as a quiet lounge if any residents wish to talk with a visitor(s) without having to go to their own bedrooms etc. and can be used by staff for meetings/supervision etc. 

Suitable locks are fitted to bathrooms and bedrooms (i.e. bolts have been removed and locks fitted which will allow these doors to be opened from the outside, in the event of an emergency).

Contract Monitoring Officer Observations and Comments

Only one resident was in the communal area during the visit, and there were no issues with their general appearance.

There were no issues with regard to safety, cleanliness and comfort in the home.

Corrective / Developmental Actions

Fire drills – to capture the initials of those who take part in these drills.  Timescale: 6 monthly.

Bed rail document to be signed up to in order to gain consent for the use of these. Timescale:  Within 2 months.


Staff recruitment processes were robust, with information within the files being stored in an orderly way and the recruitment process had been followed.

A resident’s file included a lot of detail about the person, and had been reviewed on an ongoing basis.  Daily records that had been written by staff reflected the Personal Plan (Care Plan) that outlined the care and support he required, and it was evident that health professionals and been contacted in a timely way when their advice/action was required with relatives being kept informed of changes also.

Rachel Kathryn continues to provide a homely environment for people to live in and staff are supported in their roles.

The Contract Monitoring Officer would like to take this opportunity to thank the staff and residents at Rachel Kathryn for their time and hospitality.

  • Author: Andrea Crahart
  • Designation: Contract Monitoring Officer
  • Date: July 2023