Achieve Together
Contract Monitoring Report
- Name/Address of provider: Achieve Together, Suite 5, Tredomen, Gateway Building, Tredomen Park, Ystrad Mynach, CF82 7EH
- Date/Time of visit: 8th April 2024
- Visiting Officer(s): Caroline Roberts, Contract Monitoring Officer
- Present: Megan Hession, Regional Manager
Background
The purpose of the visit to the main office was to look at documentation and processes implemented within the properties.
Prior to the office visit, visits to some of the supported living premises were undertaken to view documentation, to look at the environment, to speak with the tenants and to also speak with members of staff.
Dependant on the findings within the report, Achieve Together will be given corrective and developmental actions to be completed. 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 and Developmental Actions
Corrective
For all staff to receive timely supervision sessions (RISCA Reg 36). Timescale: Immediately and ongoing. Met.
For Support Plans to evidence that an individual or representative has had the opportunity to assist with its development and to mirror the files held ‘in house’ (RISCA Reg. 15). Timescale: Immediately and on-going.
For staff records to retain a copy of the individuals birth certificate (RISCA Reg 59). Timescale: Immediately and ongoing. Met
Staff files to have two written references, including a reference from the last employer, if any. (RISCA Reg 35 – Part 1). Met.
Developmental
The Statement of Purpose have a review date for transparency of when the document is reviewed. Met.
Findings
Tenant Information and Tenancy Selection
Achieve Together provide support and assistance to individuals residing in several properties within the Caerphilly County Borough. The landlord and provider are not the same.
The process for potential tenants remains unchanged and commences with an Achieve Together Referral Officer, a Social Worker or an individual making a self-referral usually via the Regional Manager or via the Referral Team. Achieve Together will look at an individual’s needs and compatibility and then a transitional process is followed to ensure suitability. This may include being invited for lunch/dinner and an overnight stay. During this process staff will monitor the dynamics of individuals to see if the potential new tenant will be compatible with those already residing at the property.
All parties involved, will be given the opportunity to share their views of a potential new individual moving into the property.
Should the individual be compatible, appropriate transition is put into place.
Documentation
All documentation was observed to be stored in a lockable cabinet.
Out of the 2 files viewed, both files contained a Local Authority Care and Support Plan.
Neither file held a pre-admission assessment evidencing that the provider could meet the needs of the individuals taking up tenancy. Whilst these are held in the properties, the office files should mirror those at the property.
Achieve Together Support Plans mirrored information specified within the Local Authority’s Care Plan, with some additional information included. The Support Plans consisted of information relating to communication, personal care, maintaining relationships, leisure/recreation, activities, skills. Both Personal Plans outlines the likes and dislikes of the individuals. It was positive to note that the provider had taken on board the suggestion that such plans are written in the first person; therefore, providing a more person-centred approach.
Whilst there was no evidence that the individuals had signed their personal plans to indicate that they had taken part in their development, managers present during the office visit advised that the documentation had been signed and retained at the property. As the office data is to mirror that held within the individual properties, it is recommended that a signed copy is also retained on the office file. This was discussed with Mrs Hession, who would see that this was actioned.
Daily records were not observed during the office visit as these are retained at the individual properties.
Risk assessments were observed on both individual files, which outline what is required of staff to meet the needs of the individuals they are supporting. The monitoring officer observed risk assessments in relation to finances, social media, nutrition, allergies, accessing the community etc. Risk Assessments will vary to ensure that all risks are mitigated to ensure the safety of an individual.
The assessments included advice and information on what action should be taken should a risk be identified and what distractions should be used.
Monthly key worker reviews were observed to be undertaken in a timely manner.
Personal Emergency Evacuation Plans were also observed on each file.
Both files held a missing person’s profile.
An information index was located at the front of each file, indicating where specific information could be located. The files were found to be a neat order and well maintained.
Regional Manager’s (RM) Questions
During the monitoring visit the RM was asked a series of questions.
The RM advised that Achieve Together continue to use an electronic system, RADAR for recording various information. Medication audits are undertaken weekly and monthly. The audits are recorded on the system and any red flags (concerns) are highlighted for the RM to observe and take appropriate action should it be required. During the property visits, whilst viewing one MAR chart, miscalculation was observed, and this was brought to the house managers immediate attention and referred to within the monitoring report.
No tenant is being administered covert medication.
When administrating medication, only one staff member signs the MAR chart. However, should it be controlled medication, then 2 staff signatures are required, along with any required handwritten changes to the Mar chart. When commencing a new cycle of medication or ending a cycle, again 2 staff signatures are quired.
Staff undertake training regarding medication administration and any observed errors are recorded and reported to the house manager for their appropriate action.
The RM was able to describe what advocacy services are accessed and when should it be needed by an individual. Advocacy is usually sought via the Local Authority and all tenants are advised that they can access an advocate as and when they feel they require the support.
Achieve Together continue to manage repairs / maintenance and such work is discussed with the landlord and recorded via email on a maintenance portal. At the time of undertaking the monitoring visit, concerns have been raised in respect of timeliness of repair works being undertaken by one landlord. The provider and the Local Authority’s commissioning team are working together to seek resolution to the issues raised.
The RM was able to demonstrate her knowledge of safeguarding individuals and the lessons learned in respect of raising timely safeguarding referrals.
At the time of the visit, only one property has an individual who speaks Welsh. Staff have access to a Welsh conversational book, which aids them with conversing with the individual. Whilst the dialect may differ, the RM advised that the tenant appreciates the staff trying to converse in Welsh.
One property visited has a deaf tenant and whilst visiting the property, it was positive to note that staff continue to be able to communicate with the individual. Basic matakton guidance remains on the individuals file at the property in order to assist current staff and also any new employees.
When interviewing for new staff, tenants are permitted to be part of the interviewing process should they wish to do so. The RM advised that recently 2 tenants, from different areas, made a short, animated film, portraying the pros and cons of tenants not being part of the interview process. The RM advised it was a very effective way of encouraging tenants to participate in the process.
Achieve Together continue to have an on-call system to assist staff out of hours and this spans via several levels of seniors/management. Service Managers, Regional Managers, Head of Operations and Directors are always available out of hours if assistance is required.
Training
Staff can access e-learning and attend face-to-face training sessions including those held by Blaenau Gwent and Caerphilly Social Care Workforce Development Team.
Staff are required to undertake mandatory training courses i.e. Manual Handling Passport, Safeguarding, Medication Awareness, Infection Control. The visiting officer observed that staff also undertake additional training that coincides with their role and the support they offer.
Quality of the training is observed via practice and by obtaining verbal feedback during supervision sessions with staff.
Complaints and Compliments
Achieve Together have a ‘Speak Out’ App, which is uploaded to RADAR. Therefore, any complaints or compliments are easily accessible to the RM. The information initially goes through to the provider’s Quality Team, who then shares it with the RM.
The system holds the complaint details, what stage the complaint is at and whether or not the complaint is upheld or not.
The RM described the complaints process to the visiting officer and advised they would speak with the person raising the complaint in order to gain first-hand information and endeavour to resolve matters. All parties are kept up-dated during the process. Responses are provided in the format preferred by the complainant i.e. face to face or in writing.
Should staff be involved in a complaint, they are spoken to during team meetings or if it is more of a confidential nature, the staff member(s) will be spoken to individually during supervision sessions.
During the last 12 months 21 compliments were received.
Quality Assurance
The latest Regulation 80 report (July-December 2023) was viewed s were viewed by the visiting officer and were found to be detailed, with evidence of conversations being held with tenant, staff and family members. The report outlines what has been done well and what can be improved upon, covering various aspects of the service provided to the individuals. At the end of the report the RI, outlines a list of agreed actions, with the date the action is to be achieved and by who.
The last Regulation 73 (incorporating Regulation 74) was also observed and undertaken in February 2024. The report evidence that tenant and staff documentation was viewed, discussions with individual tenants were held, alongside conversations with staff members. The report covers leadership, the environment, complaints/compliments and again outlines agreed actions.
Appropriate policies and procedures were observed to be in place, with some being out of date n respect of being reviewed. The Responsible Individual advised the visiting officer that this piece of work is being undertaken by a member of staff within Achieve Together.
Staffing
Achieve Together use the Social Care Wales induction framework when new members of staff are employed and are in contact with the organisation in respect of incorporating the training evidence into the process.
With regard to the staffing levels being adequate, a care matrix is devised, and individual needs are looked at. The provider has worked in partnership with the Local Authority in respect of populating the care matrix and ensuring that accurate data is included. When the care matrix is completed, the rota is then devised around the needs of the tenants. Should an increase of staff be required, Achieve Together will refer matters to the Social Worker to request the increase.
Staff Documentation
The monitoring officers viewed two staff files. Two references were observed, with a job description, application form, interview record (using a scoring system), and a signed contract of employment. Both files contained a photograph of the individual staff members, along with a Disclosure and Barring Service (DBS) check, with no issues highlighted.
The visiting officer viewed one work booklet in respect of the individual staff member obtaining their Social Care Wales qualification, whilst the second staff member was in the process of going through the process.
Supervision
Staff receive 1:1 supervision, which provides an opportunity for individuals to raise any concerns they may have, training requirements, good practice, areas for improvement etc. If necessary, group sessions are held.
Whilst discussing viewing one supervision matrix, the dates of the supervision were note being recorded. This was discussed with the house manager as when being monitored, dates are required. The house manager has now implemented this into practice.
The RM audits supervision monthly and there is a system in place for managers to receive a monthly report, which highlights any gaps. This information is currently being transferred over to RADAR which will then highlight when supervision is due/overdue. This will also be used to record annual appraisals.
The RM advised the visiting officer that they have a good, open relationship with the service managers and maintains regular contact.
All service managers have a day allocated to work from the main office in order to ensure documentation is kept up to date.
General observations
The files located at the main office were found to be neatly presented and information was easily located.
Corrective and Developmental Actions
Corrective
For each house manager to retain a supervision matrix that highlights when supervision has been undertaken; therefore, evidencing it has taken place every three months. (RISCA Reg. 34).
For Service Plans to evidence that an individual or representative has had the opportunity to assist with its development and to mirror that held ‘in house’ (RISCA Reg. 15). Timescale: Immediately and on-going.
For staff records to retain a copy of the individual’s passport (RISCA Reg 59). Timescale: Immediately and ongoing.
Developmental
None identified.
Conclusion
It was positive to note all managers present during the office visit. This provides the managers to exchange advice and support. During the visit, managers were observed to be undertaking administrative duties to ensure all appropriate documentation is kept up to date.
It was positive to note that recommendations made during the last visit had been actioned.
Routine monitoring will continue, and the monitoring officers would like to thank the staff at Achieve Together for their time, the information shared, and the hospitality shown during the visit.
- Author: Caroline Roberts
- Designation: Contract Monitoring Officer
- Date: 15 May 2024