Supporting People - Vale of Glamorgan · The Supporting People Contract Monitoring Officers...

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Evaluation Report Name of provider: Cartrefi Cymru Name of projects included: AR CC CR MW RD Address of projects: AR Barry

CC Dinas Powys CF64 CR Barry CF62

CF62

MW Barry CF62 RDr St Athan CF62 Date: 21/07/2015

Supporting People Team Email: [email protected]

INTRODUCTION The purpose of this report is to enable the Local Authority to evaluate the effectiveness of the support service based on the following criteria:

The service is delivering successful outcomes in line with the principals of the Supporting People programme

The service is delivering outcomes that are preventative and represent value for money

The service contributes to the overall aims of the Local Authority and the Welsh Government OVERVIEW INTRODUCTION / EVIDENCE DOCUMENTATION 1. STRATEGIC CONTEXT / CONTRIBUTING TO STRATEGIC OUTCOMES 2. COST EFFECTIVENESS / FINANCIAL 3. OUTCOMES AREA – Promoting Personal and Community Safety 4. OUTCOMES AREA – Promoting Independence and Control 5. OUTCOME AREA – Promoting Economic Progress and Financial Control 6. OUTCOME AREA – Promoting Health and Wellbeing 7. ENSURING PARTICIPATION AND CONSULTATION 8. SAFEGUARDING 9. EVALUATION QUALITY TO ENSURE THE SERVICE CAN DELIVER OUTCOMES 10. SERVICE USER / STAFF / STAKEHOLDER FEEDBACK

11. SUMMARY / CONCLUSIONS REPORT STRUCTURE

PROJECT

Archer Road

ADDRESS

AR Barry CF62

MANAGER

Lydia Evans

NUMBER OF UNITS

3

PROJECT TYPE

Permanent Supported Accommodation

DATE OF ON-SITE VALIDATION VISIT(S)

16/01/2015, 19/01/2015

DATE OF FIRST PROCEDURE EVALUATION

16/01/2015

NAME / DESIGNATION OF SP OFFICER

Hedd Wyn John Jane Anderson

DATE OF REPORT

08/06/2015

PROJECT

CC

ADDRESS

CC Dinas Powys CF64

MANAGER

Jodie Robinson

NUMBER OF UNITS

1

PROJECT TYPE



18/12/2014, 26/01/2015


18/12/2014



DATE OF REPORT

08/06/2015

PROJECT

Colcot

ADDRESS

CR Barry CF62

MANAGER

Jodie Robinson

NUMBER OF UNITS

2

PROJECT TYPE



10/12/2014


10/12/2014



DATE OF REPORT

08/06/2015

PROJECT

Morningside

ADDRESS

MW Barry CF62

MANAGER

Jodie Robinson

NUMBER OF UNITS

2

PROJECT TYPE Permanent Supported Accommodation


10/12/2014, 03/02/2015


10/12/2014



DATE OF REPORT

08/06/2015

PROJECT

RD

ADDRESS

RD St Athan CF62

MANAGER

Lydia Evans

NUMBER OF UNITS 2

PROJECT TYPE



11/12/2015, 12/01/2015, 19/01/2015


11/12/2015



DATE OF REPORT

17/06/2015

INTRODUCTION Cartrefi Cymru was founded in 1989. To give rural Wales and the Valleys a cutting-edge support provider so that people with Learning Disabilities, Autism, Physical Disabilities and Challenging Behaviour can enjoy their rights and freedom within the community and in their own home. Cartrefi Cymru Cyf is a charity registered in England and Wales. Registered Office: 5 Coopers Yard, Curran Road, Cardiff, CF10 5NB. Registered Charity: 702290. Registered Company: 2420623 The contract for these services began 08/10/2012. This is the first evaluation report by Supporting People for Cartrefi Cymru.

As part of the evaluation process, preparatory documentation was issued. To permit a more comprehensive evaluation additional supporting evidence was also requested. This report describes conclusions about the quality of the service based on previous monitoring information as well as the evaluation itself. Within this evaluation emphasis has been placed on the outcomes which have been achieved by examining the impact that the support has had on service users. Policy and procedure matters have been addressed where they affect the quality or safety of the service. Outcomes achieved for service users have been considered under the following headings:

Promoting Personal and Community Safety

Promoting Independence and Control

Promoting Economic Progress and Financial Control

Promoting Health and Well Being. Cartrefi Cymru statement: Our Values: “Cartrefi Cymru is a values-based person-centred support provider. That means we always put the people we support at the centre of their support plans and decisions. We have a Statement of Commitment to the people we support that says we will all do everything we can to ensure that they are respected, safeguarded and enabled. This is in everyone's Job Description. It is not just about ensuring that we are nice to people. It is about respecting people's rights and maximising their ability to make their own choices and decisions, and to hold us to account. Cartrefi Cymru is a values-based Welsh national company with strong local roots. That means we take seriously, and make a sustained contribution towards, the cultural, political, economic, social and environmental challenges facing Wales, nationally and locally. We understand that providing support in someone's preferred language is fundamental to quality of service. That's why we recruit local staff and have a high percentage of Welsh-speaking support workers. We also understand that the people we support are not best served by a life of isolation, and that we alone cannot create (or substitute ourselves) for healthy local communities. That's why we work closely with local authorities and the local voluntary sector and the people we support and their families - to build and sustain opportunities for individual participation and the development of networks of support and friendship. Cartrefi Cymru is a values-based not-for-profit organisation and a charity. That means we always put the people we support, now and in the future, at the centre of our business plans and decisions. We understand the importance of money, and the need to cover our costs and to have some reserves to help us stay afloat. But no one will become a millionaire from working for Cartrefi, and we don't have special perks for directors, and every spare pound we make is used to help us deliver the best support we can.

Cartrefi Cymru is a values-based people-oriented employer. That means we are continually striving to have the most motivated, creative and productive workforce possible. It is our support staff and their closely supporting managers who actually deliver our support services. Without their commitment and high-performing abilities we cannot provide high quality support. That's why we try to recruit and retain the right people, and why we invest as much as we can in providing the best possible training, management support, and conditions of employment. We want to feel proud of the brilliant work we do, and of the achievements of the people we support. We are building that pride on a platform of respect.” Cartrefi Cymru operates 5 permanent Supported Accommodation Schemes in the Vale of Glamorgan. AR: The service is for people over 18, with learning difficulties and associated physical needs who need accommodation with specialist support. Cartrefi Cymru provide a supported living service for service users with learning disabilities and physical needs, who want to live in supported tenancies in the community. Support is provided 24-hours a day to meet the service user’s needs. The service is provided in a purpose built bungalow. Each service user has their own room with en-suite facilities. There is also a communal lounge, kitchen, dining room, specialist sensory room and access to a garden. This service and can be accessed for as long as the client feels they need the support. CC: The service is for people over 18, with severe learning difficulties who need accommodation with specialist support. The service provides 24 hour supported living for clients with severe learning difficulties who want to live in supported tenancies in the community. Support is provided 24-hours a day to meet the service user’s needs. The service is provided in a house in a community setting. Each service user has a separate room. Other facilities are shared. This is permanent supported housing and can be accessed for as long as the client feels they need to. CR: The service is for people over 18, with learning difficulties who need accommodation with specialist support. The service provides 24 hour supported living for clients with learning difficulties who want to live in supported tenancies in the community. This service provided in a house in a community setting. Each service user has a separate room and shares other facilities with the other tenants in the property. This is permanent supported housing and can be accessed for as long as the client feels they need to. MW: The service is for people over 18, with specific or non-specific learning difficulties who need supported accommodation. The service provides supported living for clients with learning difficulties who want to live in supported tenancies in the community. Support is provided 24-hours a day to meet the service users’ needs. Accommodation is provided in a bungalow. Each service user has a separate room and shares other facilities with the other tenants in the property. This is permanent supported housing and can be accessed for as long as the client feels they need to.

RD: The service is for people over 18, with specific or non-specific learning difficulties who need supported accommodation. The service provides supported living for clients with learning difficulties who want to live in supported tenancies in the community. Support is provided 24-hours a day to meet the service users’ needs. Accommodation is provided in a bungalow. Each service user has a separate room and shares other facilities with the other tenants in the property. This is permanent supported housing and can be accessed for as long as the client feels they need to. The Supporting People Contract Monitoring Officers representing the Vale of Glamorgan Council’s Supporting People Team were Hedd Wyn John and Jane Anderson. For any further information please contact the Supporting People Team on 01446 709326 Jenny Lewington, Strategy and Supporting People Manager.

EVIDENCE DOCUMENTATION

1. Strategic Context / Contributing to Strategic Outcomes

Project: AR SPGSUP111 Client Group & E number: Learning difficulties E2 Number of units: 3 The main referrers to the project are Social Services. The number of referrals received in the last year was 0 as there have been no vacancies in this period. Two service users have been on support for over two years. One service user has been on support over a year. This is the first review by Supporting People. Project: CC SPGSUP167 Client Group & E number: Learning difficulties E2

Number of Units: 1

The main referrers to the project are Social Services.

The number of referrals received in the last year was 0 as there have been no vacancies in this period.

The one service user has been on support for over 18 months.

This is the first review by Supporting People.

Project: CR SPGSUP173

Client Group & E number: Learning difficulties E2

Number of Units: 2



Both service users have been on support for over two years.


Project: MW SPGSUP100


Number of Units: 2


There is currently one vacancy for this project; the space is due to be filled shortly.

Both service users have been on support for over two years.


Project: RD SPGSUP175


Number of Units: 3



All three service users have been on support for over two years.


Do the services meet the needs of vulnerable people? The services have clear and up to date aims and objectives.

The needs mapping information in the Vale of Glamorgan reflects the demand for the services. The services are in line with the 2014 – 2017 local commissioning plan priorities. Over the last year there have been a high number of service users supported in these services.

Is the Scheme’s performance satisfactory, including good contract compliance, high utilisation/demand, adherence to eligibility criteria and acceptable evidence of support outcome? Performance indicator returns evidences low voids. Monitoring Returns, Annual Returns and Desk Top Audit forms are satisfactory. The provider has a good history of contract compliance. The provider evidences positive support through outcome monitoring. Service users are unable to provide verbal feedback due to the nature of their disabilities, however Contract Monitoring Officers have witnessed that service users have a good relationship with Cartrefi Cymru staff members. This objective has been met fully.

Do the schemes demonstrate good value for money? The schemes compare well when benchmarked against the SP funding levels of other similar schemes in the area. The scheme compares well when benchmarked against the SP funding levels of other similar schemes across the South Wales region. Audited accounts are available. It is clear what other funding is going into the schemes. This objective has been met fully. Does the service meet local and national priorities for meeting vulnerable people’s needs? The service contributes to/meets priorities in local strategies and plans: - Local Housing Strategy 2015-2010 - Supporting People Local Commissioning Plan 2015-2018 - Supporting People Regional Commissioning Plan 2014-2017 - Vale of Glamorgan Community Strategy 2011-2021 The Service contributes to meet priorities in national strategies and plans: - National Housing ‘Improving Lives + Communities – Homes in Wales’ - Ten year Homelessness Plan for Wales 2009-2019 - Strategy for Older People in Wales 2013-2023 - Welsh Government Mental Health Delivery Plan 2012-2016 - Welsh Government Learning Disability Strategy

These objectives have been met fully

Is the service eligible to receive SP funding and does it clearly demonstrate that it delivers Housing Related Support? The service demonstrates the delivery of housing related support through individual support plans. The service demonstrates that there is housing related support being delivered to enable skills development and independent living. The services also provides personal or domiciliary care which is funded by Social Services. The objectives have been met fully Is the scheme fit for purpose and does it take account for the wider strategic needs and emerging trends demonstrated for the client group? The findings of the most recent SP service review shows that the schemes are fit for purpose. The recent research concludes that the service delivery model is satisfactory for the client group, across all tenures and at all support need levels. The provider regularly attends the local SP liaison and planning meetings. The provider demonstrates an awareness of its strategic direction and ability to undertake positive change. The objectives have been met fully

Does the service demonstrate a commitment to continual improvement and best practice? The provider demonstrates best practice in some service delivery areas. The objectives have been met fully. All projects remain strategically relevant.

2. Cost effectiveness / financial

Summary of Findings

Cartrefi Cymru has provided a full financial breakdown of income and expenditure for each scheme in the Vale of Glamorgan. Staffing costs are comparable with other services of the type. Management costs are comparable with other services of the type. Annual funding is comparable with other services of the type. All staff salary information was made available as part of the review. All services are financially viable. Staff Structure AR staff members:

Staff member Role Contract

hours

1 SM 13

2 ASM / SSW 6

3 SW 30

4 SW 16

5 SW 19

6 SW 30

7 SW 30

8 SW 25

9 SW 35

10 SW 30

11 SW 30

12 SW 30

CC staff members:

Staff member Role Contract

hours

1 SM 9.25

2 ASM 6

2 SW 12

3 SW 37

4 SW 39

5 SW 37.5

6 SW 35

7 SW 30

8 SW 30

CR staff members:

Staff member Role Contract hours

1 SM 9.25

2 ASM 37

3 SW 37

4 SW 22

5 SW 30

6 SW 30

MW staff members:


1 SM 9.25

2 ASM 6

2 SW 13

3 SW 20

4 SW 20

5 SW 37.5

6 SW 5

7 SW 30

8 SW 30

9 SW 30

10 SW 20

11 SW 10

RD staff members:


1 SM 12

2 ASM 37.50

3 SW 37.50

4 SW 30

5 SW 30

6 SW 30

7 SW 20

8 SW 10

9 SW 30

Conclusion and Recommendations

Cartrefi Cymru provided a clear breakdown of their funding and the charges for each scheme and audited accounts are available. Cartrefi Cymru is cost effective and benchmarks well against similar schemes in the south Wales area. All services are financially viable.

3. Promoting Personal and Community Safety

Summary of Findings

Feeling Safe – Support in relation to improving or maintaining safety and security of accommodation have been met or needs of those experiencing violence discrimination or abuse. Cartrefi Cymru has a comprehensive Health and Safety Policy and a Health and Safety Roles and Responsibilities Policy in place. All staff members are required to undergo a DBS check before commencing employment; these checks are renewed every three years. All job offers are subject to the submission of two satisfactory references and the completion of a nine month probationary period. This was confirmed verbally during staff interviews and evidenced by the Contract Monitoring Officer during staff file checks. Cartrefi Cymru has a policy and procedure in place for risk assessment. Risk assessments are undertaken for all activities and tasks that are carried out with service users. Service Managers carry out risk assessments on all tasks and activities that are carried out with a service user. However during file checks across all schemes it was noted that numerous risk assessments had not been reviewed in over a year and Cartrefi Cymru’s Risk Assessment Policy requires all risk assessments to be reviewed on an annual basis or sooner if there is a change of circumstances. All staff members receive induction training and this training includes health and safety, safeguarding and safety at work training. All staff members are required to read all risk assessments that are in place, this is confirmed by a staff sign-off sheet which is in place in the risk assessment file. Core training was provided to all staff members that transferred over to Cartrefi Cymru from a different provider. Cartrefi Cymru has a lone working system in place; there is an emergency number and an on-call rota with a staff member available 24 hours a day. All staff members that were interviewed were aware of the Cartrefi Cymru Lone Working Policy. Cartrefi Cymru receives all of its referrals from Social Services who carry out assessments on service users and ensure that the individual is being referred over to a suitable service. Each service user is provided with a key worker and this staff member is responsible for the primary support for that service user. Key workers are assigned on the basis of experience and workload etc. Cartrefi Cymru has a Protection of Vulnerable Adults Policy and a Code of Conduct Policy. All staff members have received up-to-date Safeguarding (POVA) training; this was evidenced by the Contract Monitoring Officer during file checks.

Cartrefi Cymru regularly liaises with other agencies such as Social Services, Health Professionals, Housing Associations, family members and advocates etc. Contact with Social Services or Health Professionals are carried out directly with them by the Service Users’ Care Manager and contact is documented in the service users’ personal file, this is done in place of link worker meetings. This was evidenced by during file checks and staff interviews. Cartrefi Cymru has an Equality and Diversity Policy in place which all staff have read and signed. Cartrefi Cymru issues guidance for staff members entitled, ‘Management of challenging behaviour for staff’, ‘Working with people with challenging behaviour in cars policy’ and ‘Managing the Boundary between Professional and Social Contact. Cartrefi Cymru have Behaviour Management Plans in place to instruct staff members the most appropriate way to respond to service user’s behaviour. Annual gas safety checks are carried out at all five properties; up-to-date gas safety certificates for all five properties were provided to the Contract Monitoring Officer. Fire extinguishers are checked on a regular basis and are also serviced annually; this was evidenced by the Contract Monitoring Officer. Cartrefi Cymru Fire Policy requires that fire drills are carried out on a six monthly basis at each property. It was evident during the review that the required amount of fire drills had not being carried out at all the properties. The Contract Monitoring Officer highlighted this to Cartrefi Cymru and their policy has now been revised to require that a drill be carried out every April and every October. The April drills for the year 2015 and have been carried out at all properties and paperwork was provided to evidence this. Several Cartrefi Cymru service users own mobility vehicles and use them as a means of transportation. As none of the service users are able to drive designated staff members are required to drive the service users’ cars. All staff members who drive are required to submit valid driver’s licenses to Cartrefi Cymru. Copies were provided to the Contract Monitoring Officer. Cartrefi Cymru has car insurance in place for all mobility vehicles that provides cover for registered staff members to drive each vehicle. All service users’ vehicles had up-to-date tax and MOT certificates in place; this was confirmed through the DVLA online system. Cartrefi Cymru carry out a monthly car check on each service users’ vehicle and complete a corresponding form which details the checks carried out. It was noted during file checks at Morningside Walk that no car check had been carried out in the previous month and there were several gaps throughout the year. Cartrefi Cymru has Employers Liability insurance for £10 million with Travelers Insurance Co and Public Liability insurance for £10 million also with Travelers Insurance. The documentation was made available to the Contract Monitoring Officer.

Feeling safe – Outcomes:

October 2013 – September 2014 Outcomes for Cartrefi Cymru service users. The following results are produced as a percentage of progression for service users whose goals that are relevant to the outcome.

Feeling safe -

Service users acknowledge they have goals in this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time- bound goals 33% Service users have made substantial progression of time-bound goals 0% Service users have achieved goals 67%

Contributing to safety and well-being of themselves and others - Service users acknowledge they have goals in this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time- bound goals 33% Service users have made substantial progression of time-bound goals 0% Service users have achieved goals 67%

The outcomes indicate that all service users have been supported to either achieve relevant goals in this area or to make some progression towards achieving their goals.


Cartrefi Cymru has comprehensive policies on risk assessment and Health and Safety in place to ensure the safety of their staff and service users. Cartrefi Cymru carries out regular checks on fire extinguishers, alarms and emergency lighting at all five houses. However Cartrefi Cymru records indicate that the number of fire drills carried out in several houses did not match the amount set in Cartrefi Cymru’s Fire Safety Policy. As a result Cartrefi Cymru has implemented a new policy whereby all houses are required to carry out fire drills every April and October. Cartrefi Cymru ensures that staff members receive a wide variety of training to ensure their safety and the safety of service users. All staff members have received Core training which includes safeguarding, health and safety and first aid training etc. Cartrefi Cymru has a lone working system in place and all staff members interviewed were aware of the Lone Working Policy. Cartrefi Cymru liaises regularly with Social Services, health professionals, family, friends and other relevant parties. All relevant information is documented in the service users’ personal files.

Cartrefi Cymru has a Risk Assessment Policy in place that requires risk assessments to be reviewed at least on an annual basis or sooner if there is a change of circumstances. Service Managers confirmed that they complete risk assessments for tasks and activities that are carried out with service users and that their team has input on the content such as a change in circumstance. All support workers confirmed that they had input on the content of risk assessments carried out by the service manager. During file checks at all houses it was noted that numerous risk assessments were over a year old and had not been reviewed or updated since their initial completion. Cartrefi Cymru carries out monthly car checks on all service users’ mobility vehicles which staff members use to transport service users, however there were several gaps in the records at Morningside Walk. All relevant staff members are licensed to drive service users’ vehicles and Cartrefi Cymru has insurance in place on all vehicles. It was confirmed that all mobility vehicles had valid MOT certificates and up-to-date vehicle tax in place. Recommendations: Cartrefi Cymru to ensure that fire drills are carried out on a six monthly basis as per the Fire Safety Policy. Cartrefi Cymru to ensure that monthly car checks are carried out and the corresponding paperwork is completed. Cartrefi Cymru to ensure that all risk assessments are reviewed at least annually as per the Risk Assessment Policy.

4. Promoting Independence and Control

Summary of Findings

All referrals made to Cartrefi Cymru are provided by Social Services following an assessment with the service user to ensure that they meet the criteria of the learning disability projects. All service users supported by Cartrefi Cymru have their own personal files which contain an person centred care plan and a support plan. One property that was inspected had 2 personal files missing, staff members advised that they had been taken out to be updated but not returned. The service users’ files hold crucial information relating to the care and support to be provided to the service user and should be available to staff members to be used as a guide/reference at all times. Furthermore it was noted that in two personal files that were inspected the support plans had not been reviewed since 2013 and as such were overdue a review. Cartrefi Cymru keep detailed daily communication notes in a designated communication book, staff record details of daily incidents/events through each day so staff are aware of daily activities that have occurred. The information entered into the communications book is signed and dated by the staff member making the entry. These were made available to during the review process. A house diary is maintained at all houses, they contain a plan of all upcoming health appointments, day trips/lunches, regular weekly events (Vale Plus, Amelia Trust Farm etc.).This allows staff to know what activities/appointments are planned day to day. It was evidenced through service user working files that all service users have their own tenancy agreements and instructions for support staff on helping the service user adhere to the terms and conditions of their tenancy. This section was signed and dated by all staff members to indicate that they understood this. All service users have an individual Communication Policy in place as all of Cartrefi Cymru service users in the Vale are either non-verbal or have limited verbal skills. The Communication Policy explains how the service user is able to communicate with staff members, family etc. and the policy is signed and dated by all staff members to evidence they have read and understand it. It was evidenced through service user working files that the Communications Policies had not been reviewed since 2013. It is recommended that all service users’ communication policies are reviewed and updated on annual basis or when there is a change of circumstances. Through the Supporting People monitoring visits it was found that Cartrefi Cymru were only able to provide one set of team meeting minutes. It was evident from staff interviews that team meetings were not held on a regular basis and quarterly meetings are a requirement of Cartrefi Cymru’s policy. House Meetings are held regularly for service users at all schemes with the exception of CC.

Minutes were recorded for the meetings and made available to the contract officer. Topics discussed in these meetings included room decoration, holiday ideas and activity plans etc. Cartrefi Cymru advised that house meetings do not take place at CC as they would not be suitable for the sole service user that lives there. As stated in section 3 several service users have their own mobility vehicles enabling them to access the community, and carry out shopping trips, pub lunches, touch trust etc. These vehicles are driven by designated staff members. Cartrefi Cymru promotes service users to access the community, and encourage them to participate in their interests and hobbies when appropriate, they also encourage their service users to participate in the following: shopping, banking, sensory room, touch trust, family visits, lunches out, days out, holidays, peddle power sessions, shows etc. Cartrefi Cymru promotes service users’ involvement in education when appropriate, one service user has started a QCF course and several regularly attend the Vale Plus day service. This service provides learning and leisure opportunities for people with learning difficulties in the Vale of Glamorgan. Several service users also volunteer at the Amelia Trust Farm. It was evidenced through staff interviews that staff will prompt and support service users when needed to complete household tasks to encourage them to be as independent as possible. Cartrefi Cymru will ensure that service users are provided with an advocate if needed, this is to help enable service users to have an independent person to provide a voice on behalf of the service user providing them with the ability to pass on their views and wishes, this allows the service user to exercise as much control as they are able on their own lives. October 2014 - September 2014 Outcomes for Cartrefi Cymru. The following results are produced as a percentage of progression for service users whose goals that are relevant to the outcome. Managing Accommodation: Service users acknowledge they have goals In this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time-bound goals 27% Service users have made substantial progression of time-bound goals 0% Service users have achieved goals 73%

Managing Relationships: Service users acknowledge they have goals in this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time-bound goals 27% Service users have made substantial progression of time-bound goals 0% Service users are in the initial stages of goal progression 73%

Feeling Part of the Community: Service users acknowledge they have goals in this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time-bound goals 64% Service users have made substantial progression of time-bound goals 18% Service users have achieved goals 18%

The outcomes indicate that all service users have been supported to either achieve goals in this area or to make some progression towards achieving their goals. The goals with the highest success were the ones related to managing relationships.


All referrals are made to Cartrefi Cymru through Social Services. All service users have their own personal file which contains their care and support plans, two personal files had been removed from one of the Cartrefi Cymru properties to be updated and had not been returned to the property at the time of the Supporting People visit. File checks indicated that two support plans had not been reviewed within 12 months as required by Cartrefi Cymru’s policy. All houses use a communication book to pass on information to each other regarding day to day events, activities, appointments and chores that have taken place throughout the day. All houses contain a daily diary in which they enter appointments, activities and events that are planned in the future. All service users have their own instructions in their personal file on how to maintain their tenancy and also containing their tenancy

agreement. All service users have their own personal communication policy which is specific to their needs and enables them to communicate as effectively as they can with staff, family etc. It was noted during file checks that several communication policies had not been reviewed since 2013. Cartrefi Cymru requires team meetings to take place at least quarterly; it was highlighted during staff interviews that team meetings were taking place less frequently than the quarterly basis required. Cartrefi Cymru supports their service users to access the community and to be involved in social activities if desired, several service users have their own mobility cars that are driven by Cartrefi Cymru staff members. This enables them to access social events, medical appointments, shopping, etc. Cartrefi Cymru staff members prompt servicers and support them to complete household tasks to enable them to be as independent as they can be where possible.

Recommendations Cartrefi Cymru to ensure that all service user support plans are reviewed on an annual basis or whenever there is a change in circumstances. Cartrefi Cymru to ensure that service user personal files are not removed from service users’ houses so that support workers have access to the files at all times. Cartrefi Cymru to ensure that all service users’ communication policies are reviewed and updated on an annual basis or sooner if there is a change in circumstances. Cartrefi Cymru to ensure that team meetings are carried out on a quarterly basis. Minutes of the meetings are to be recorded and made available to all staff members. Cartrefi Cymru to ensure that service users are given the opportunity to hold celebrations and festive/social events with the other houses in the Vale if desired.

5. Promoting Economic Progress and Financial Control

Summary of Findings

All of the service users that are supported by Cartrefi Cymru in the Vale have significant learning and physical disabilities. As a result service users require virtually all financial transactions and arrangements to be done on their behalf and there is no prospect of current service users managing their financial affairs independently. One service user is able to make rent payments at the local post office and withdraw money from the local bank with support; all other aspects of their finances are overseen by Cartrefi Cymru. Another service user’s finances are managed by a separate appointee but Cartrefi Cymru complete transaction forms and monitors the income and outgoings for that service user. In accordance with their Service User Finance Policy Cartrefi Cymru ensures that service users do not accrue enough savings to affect their benefit entitlements. Several service users are supported to visit the Vale Plus educational service on a weekly basis, however given the nature of the disabilities involved service users are not supported to seek employment, though several service users volunteer at the Amelia Trust Farm. Cartrefi Cymru provides several options for service with regards to communal expenditure; these include setting up a household kitty which food and bills are paid from, a system where service users buy their own food and household kitty to pay the bills or a system where service users buy their own food and pay their share of bills etc. Cartrefi Cymru’s policy is to consult service users with regards to their preferred option however when service users are non-verbal then decisions are made in consultation with family members, appointees etc. All service users have a personal finance file in place, these files contain: Personal Finance Policy Finance forms Personal Expenditure Sheet Financial reconciliation forms Recent bank statements Financial correspondence Financial statements Each file contains a Personal Finance Policy which is written by the Service Manager in conjunction with the Assistant Service Manager. Finance policies are required to be reviewed on annual basis or sooner if there is a change of circumstances. When the Contract

Monitoring Officers carried out finance checks it was noted that several policies had not been reviewed within the 12 month period required by Cartrefi Cymru. The Finance Policy contains a detailed list of a service user’s sources of income and outgoings. The policy serves as guidance for staff members and details the process staff must follow when withdrawing money for a service user and the process for the payment of service users’ bills. Each service user has a locked money tin which is stored in a secure place in the house. This tin contains service user’s petty cash and each service users finance policy sets a limit on the maximum amount to be stored in the tin at £100. Any amount over the limit must be banked. Staff members are required to note down on a personal expenditure sheet whenever money is taken from the tin, the amount and what it was spent on and whenever money was put into the tin. Comprehensive receipts for all purchases are kept and stapled to the corresponding sheet at the end of each week. During finance checks it was noted that the £100 limit on the amount in the money tin was routinely being exceeded in several houses. A review of completed personal expenditure sheets indicated that those service users made a significant amount of cash payments on a regular basis. As such the £100 limit would not be suitable for service users that regularly required access to more than that amount in cash. Section 4.18 of Cartrefi Cymru’s Service User Finance Police that states the shift leader going off and the shift leader beginning their shift must sign the personal expenditure sheet, however it was noted by the Contract Monitoring Officers that personal expenditure sheets were not always signed by two staff members.

The same section also states that bank reconciliations must be done on a monthly basis for every bank/post office account that a service user is being supported to manage. During the finance checks it was noted that the monthly checks were not routinely being regularly carried out across all services. It was noted during a check of service users’ finances at Colcot Road, that one service user’s bank account came close to being depleted of funds in December 2014. It was confirmed through staff interviews that Cartrefi Cymru became aware of the issue when a staff member was supporting the service user to pay a cheque and was told by the bank that the account contained insufficient funds to clear the payment. After speaking to the staff members and reviewing monthly bank statements it was evident that the service user’s bank balance had been slowly decreasing over the previous year. A change of circumstance had occurred in 2013 when the service user took out a lease on a new mobility car. The lease was funded directly from the mobility component of the Disability Living Allowance received by the service user. This was previously being paid directly into the service user’s bank account. Despite this change of circumstance, Cartrefi Cymru had not updated the Personal Finance Policy and therefore expenditure on activities such as Touch Trust and Sensory therapy continued at the same level as before. With monthly bank reconciliations not taking place it was not identified that the service user’s monthly outgoings exceeded their monthly income and that the balance slowly decreased until the

account was almost empty. Following this event the management ordered a review and carried out a full audit of the service user’s finance records and checked every payment and all receipts on purchases made over the previous year. During this review it was found that all transactions and purchases over the previous year were legitimate. As a result Cartrefi Cymru have now adjusted the number of activities the service user takes part in to ensure that monthly outgoings do not exceed the monthly income. Cartrefi Cymru store recent bank statements in service user’s finance files though in one file several statements were missing, staff interviews revealed that the statements had been removed to carry out a finance check but had not been returned. Archived personal expenditure records reconciliation forms and accompanying receipts were found be stored in different places at each property however the Service User Finance Policy states that once checked and approved, the Area Manager will archive the personal income and expenditure accounts, bank reconciliation form and receipts in their office. During service user finance checks at each property it was identified that an inventory of personal possessions was only in place for one service user, however an inventory of all valuable personal property belonging to a service user is required for all service users under section 4.19.1 of the Service User Finance Policy. Cartrefi Cymru stated that going forward inventories on all service users’ valuable property would be carried out. Outcomes Promoting Economic Progress and Financial Control October 2014 – September 2014 outcomes for Cartrefi Cymru service users. The following results are produced as a percentage of progression for service users whose goals that are relevant to the outcome. Managing money: Service users acknowledge they have goals in this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time- bound goals 33% Service users have made substantial progression of time-bound goals 67% Service users have achieved goals 0%

Engaging in education/learning:

Service users acknowledge they have goals in this area 13% Service users are in the initial stages of goal progression 0% Service users have some progression of time- bound goals 13% Service users have made substantial progression of time-bound goals 13% Service users have achieved goals 63%

Engaging in employment/voluntary work: Service users acknowledge they have goals in this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time- bound goals 0% Service users have made substantial progression of time-bound goals 0% Service users have achieved goals 100%

The outcomes indicate that most service users have been supported to either achieve goals in this area or to make some progression towards achieving their goals. Given the service users disabilities, it would be unlikely that goals in managing money would be fully achieved and this is reflected in the outcomes.


Due to the nature of the physical and learning disabilities of the service users on support Cartrefi Cymru carry out virtually all financial related activities on the behalf of the services with the exception of one service user who with support is able to make carry out some financial transactions. Without the work carried out by Cartrefi Cymru the service users would not be able to maintain their own tenancies. Cartrefi Cymru has a comprehensive Service User Finance Policy in place however it is clear from finance checks that the policy is not being fully adhered to in a number of areas and this resulted in a detrimental impact on one service user’s finances. Cartrefi Cymru carried out an internal audit which identified failings following the situation at Colcot Road and measures have been put in place to prevent a repeat occurrence. The checks carried out by the Contract Monitoring Officers on the service users’ finance files indicated that there is room for improvement in the monitoring of service users’ finances and record keeping.

Recommendations: Cartrefi Cymru to review the limit on the amount of money that is kept in service users’ money tins. In order to adhere to Cartrefi Cymru’s Service User Finance Policy, the following must be carried out: Cartrefi Cymru to ensure that all service users’ personal finance policies are reviewed on an annual basis or when there is a change of circumstances as per Service User Finance Policy Cartrefi Cymru to ensure all Personal Expenditure Forms are signed by two staff members as per Service User Finance Policy. Cartrefi Cymru to ensure that bank reconciliations are carried out on a monthly basis on the bank accounts of all service users as per Service User Finance Policy. Cartrefi Cymru to ensure that all bank statements are kept in service user finance files unless they have been archived. Cartrefi Cymru to ensure archived personal expenditure records; archived reconciliation forms and accompanying receipts are stored in the Area Manager’s office as per Service User Finance Policy. Cartrefi Cymru to ensure that an up-to-date inventory of service users’ valuable property is maintained as per Service User Finance Policy.

6. Promoting Health and Wellbeing

Summary of Findings

Cartrefi Cymru understands the importance of promoting the health and wellbeing of its service users with the focus upon physical health, mental health and general wellbeing. It was evidenced via Cartrefi Cymru support staff interviews that they are responsible for carrying out the shopping for service users (taking service users shopping with them when appropriate) and ensuring that they buy nutritious food to provide them with a healthy diet. This is particularly important as most service users have specific dietary requirements set out by their doctors. The dietary requirements are written in each service users’ file and staff members ensure that meals adhere to them. It was evidenced that Cartrefi Cymru support staff look after their service users health and wellbeing by making sure that they attend regular health checks e.g. Doctors’ appointments, specialist appointments, Dentist, Opticians, Occupational Health, multi-disciplinary agencies, orthotics, podiatry, medication, eating & drinking clinic etc. All service user working files contain care plans which record all the needs of the service user and have policies/procedures set out for all activities/tasks such as Morning Routine Policy, Personal Hygiene Routine etc. All policies are specific to each service user. Cartrefi Cymru seeks to improve the wellbeing of the service users and expand their horizons by carrying out stimulating excursions and take service users outside of their usual environment e.g. attending Sensory Room sessions when appropriate. The rooms in the houses are designed for people with limited communication skills to develop their senses. Cartrefi Cymru service users are encouraged to attend peddle power riding sessions and swimming which enables them to carry out physical exercise when appropriate. Oct 2013 – Oct 2014 Outcomes for Cartrefi Cymru. The following results are produced as a percentage of progression for service users whose goals that are relevant to the outcome. Physical Health – Outcomes Show:

Service users acknowledge they have goals In this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time-bound goals 0% Service users have made substantial progression of time-bound goals 45% Service users have achieved goals 55%

Mentally Healthy – Outcomes Show: Service users acknowledge they have goals In this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time-bound goals 0% Service users have made substantial progression of time-bound goals 9% Service users have achieved goals 91%

Leading a Healthy & Active Lifestyle Outcomes Show: Service users acknowledge they have goals In this area 0% Service users are in the initial stages of goal progression 0% Service users have some progression of time-bound goals 45% Service users have made substantial progression of time-bound goals 18% Service users have achieved goals 36%

The outcomes indicate that all service users have been supported to either achieve goals in this area or to make progression towards achieving their goals. Service users displayed good success at meeting their goals in being mentally healthy.


All service users have their own specific Health Policy in place and Cartrefi Cymru provides comprehensive support to encourage service users to improve their personal health and wellbeing. Cartrefi Cymru support service users to buy nutritious food and provide them with meals that fit their individual dietary requirements. Service users are encouraged to attend peddle power sessions and other activities to enable them to partake in physical exercise. Cartrefi Cymru regularly liaise with outside agencies to maintain the health and wellbeing of service users e.g. health professionals, social workers etc. Cartrefi Cymru seeks to improve the wellbeing of the service users and expand their horizons by carrying out stimulating excursions and take service users outside of their usual environment.

7. Ensuring Participation

Summary of Findings

Cartrefi Cymru provides service users with a wide range of opportunities for participation in social and recreational activities. Given that most service users are non-verbal and have significant learning disabilities, service users are limited in their ability to influence the service that they receive. Support workers are keen on ensuring that service users are able to access new experiences and make a full effort to ensure that activities they take part in are enjoyed by the service user. Cartrefi Cymru hold House Meetings at all houses where it is deemed suitable for service users, these meetings are intended to give service users a voice in the support they receive, minutes of the meetings were made available to the Contract Monitoring Officer. Topics discussed in these meetings included room decoration, holiday ideas and activity plans etc. A diary is kept in all the houses to prepare/plan weekly events and activities. This enables staff to communicate to each other and ensure service users don’t miss appointments/activities as most service users are nonverbal and unable to communicate this information to staff. This was evidenced by diaries kept at service user’s houses. It was evidenced through service users’ individual working files that all service users have communication instructions as most are non-verbal, the communication instructions enable staff members and relevant parties to communicate effectively with service users by using alternate means. Cartrefi Cymru actively support and encourage service users to maintain contact and good relations with their families. Service users will visit their families or vice versa, they can also join families on activities when appropriate (i.e. swimming). Service users are given the opportunity to attend an array of different social events such as: Bowling, lunch trips, day trips e.g. Barry Island, Porthkerry park, Cosmeston Lakes, ‘Judgement Day’ rugby event, theatre visits etc. Service users are given the opportunity to go on holidays when appropriate and staff members support them to do this. Cartrefi Cymru service users are encouraged to attend peddle power riding sessions and swimming which enables them to take part in physical exercise when appropriate. Several service users have their own mobility vehicles which are driven by Cartrefi Cymru staff members which enables them to access the community, and carry out shopping trips, pub lunches, touch trust etc. Following staff interviews and service user file checks it became apparent that the social interaction between the service users in the five Cartrefi Cymru houses in the Vale of Glamorgan is limited. It is recommended that service users are given the opportunity to hold

celebrations and festive/social events with the other houses in the Vale if desired.


Cartrefi Cymru support service users to take part in numerous activities and social events. Where appropriate service users are supported to take part in educational courses and service users are supported to engage in activities that are intended to provide health benefits such as swimming, peddle power etc. Service users are also given the opportunity to experience new environments by being supported to go on holidays where suitable. All houses maintain a house diary which contains the dates and times of activities and appointments that are planned for service users. Service users have communication policies in place within their personal files which enables staff and family to communicate more effectively with service users. Cartrefi Cymru encourages services to interact with their family and several service users have mobility vehicles that are driven by Cartrefi Cymru staff members. Cartrefi Cymru carry out house meetings for service users at all houses were it is deemed suitable and minutes were provided to the Contract Monitoring Officers. Staff interviews and service user working files revealed limited social interaction between the service users of the five houses in the Vale of Glamorgan; it is recommended that service users are given the opportunity to hold celebrations, festive/social events with the other supported houses in the Vale if desired.

Recommendations Cartrefi Cymru to ensure that service users are given the opportunity to hold celebrations and festive/social events with the other houses in the Vale if desired (also in section 4).

8. Safeguarding

Summary of Findings

Cartrefi Cymru has policies and procedures in place to help safeguarding which were made available to the Contract Monitoring Officers these include:

Accident Recording and Reporting Procedure

Challenging/Violent/Aggressive Behaviour Policy

Complaints and Concerns Policy

Confidentiality Policy

Customers Privacy, Dignity and Respect Policy

Data Protection Policy

Equality and Diversity Policy and Guidance

Health and Safety Policy Statement

Health and Safety and Responsibilities

Inclement Weather Policy

Lone Working Policy

Management of Challenging Behaviour

Managing the Boundary Between Professional and Social Contact

Mental Capacity Act Policy Statement and Additional Guidance

Procedure on the Notification of Serious Injury and Other Incidents

Risk Assessment Policy

Safeguarding Adults from Abuse – Pova Policy

Smoke Free Policy

Whistle Blowing Policy

Working with People with Challenging Behaviour in Cars Policy

All Cartrefi Cymru employees have access to all policies and procedures through the Cartrefi Cymru intranet. All Cartrefi Cymru support staff are trained in:

Challenging Behaviour Training

Child Protection

Conflict and Breakaway Techniques

Drug Harm Prevention

Fire Awareness

First Aid

Health and Safety/Manual Handling

Infection Control

Lone Working

POVA

Professional Boundaries

Risk Assessment

Substance Misuse

Understanding Mental Health and Mental Health First Aid

Although it was evidenced that all staff members have received fire safety training. One staff member was unsure of the file policy at the property they work in, this was fed back to Area Management who advised that it would be looked into. It is recommended that Team Meetings and Supervision sessions take place regularly so that staff members have the opportunity to discuss any relevant issues such as training with their manager. Staff members who are unsure of a policy or procedure can then be provided with the appropriate refresher training. During file checks it was noted that several properties were overdue fire drills; this was discussed with Cartrefi Cymru management who have implemented a system in place for fire drills to take place on a set basis. All Cartrefi Cymru employees have an up to date DBS check before the commencement of employment. DBS checks are renewed every three years. DBS forms are recorded by Head Office in individual staff files: these were made available during the review to the Contract Monitoring Officer. Staff records confirmed that Safeguarding training was valid and up-to-date. All staff members confirmed knowledge of the lone working procedure and the on-call system. Area Management advised that on-call staff members are not required to answer the phone immediately and have up to one hour to return any calls. During one staff interview a support worker was under the impression that the on-call phone had to be answered immediately and was not aware that the on-call staff member has one hour to respond to phone calls. It is recommended that Cartrefi Cymru ensures that all staff members understand the on-call procedure. Cartrefi Cymru requires all applicants to provide two satisfactory references before the commencement of employment and all must

complete a probationary period of 9 months which is evidenced via their staff files. Cartrefi Cymru holds copies of all staff members driving licenses, Cartrefi Cymru ensure that all designated drivers are full covered by insurance. Copies of staff members’ driving licenses and vehicle insurance were provided to the Contract Monitoring Officers. The Contract Monitoring Officers found that weekly car checks were not taking place in one of the houses supported by Cartrefi Cymru. It is recommended that all houses follow the car check list and sign and date when the checks have been made. Cartrefi Cymru are insured by Bollington Care the insurance applies to any property which is owned, leased by or used in connection with the insured’s business activities or any activity out within the United Kingdom in connection with the Insured business. Employers Liability: £10,000,000, Public Liability: £10,000,000, Product Liability: £10,000,000, Abuse Liability: £5,000,000 and professional Indemnity: £2,000,000. The Insurance Policy Number: UC PMH 3661328


Cartrefi Cymru has comprehensive policies and procedures in place to enable the safeguarding of service users and staff members. Cartrefi Cymru has a Recruitment Policy in place that ensures that all employees have a DBS in place, and have provided two satisfactory references before commencing employment. In addition to this all staff members must pass a 9 month probationary period. DBS checks are renewed every three years. It was evidenced that Cartrefi Cymru provide safeguarding training, and comprehensive safety training to staff members as part of their induction into a service. However one staff member highlighted that they were unsure of the Fire Safety Policy at the scheme they work in, Cartrefi Cymru stated that this issue would be addressed. It is recommended that Team Meetings and Supervision sessions take place regularly so that staff members have the opportunity to discuss relevant issues such as training needs with their manager. Staff members that are unsure of a policy or procedure can then be provided with guidance or with refresher training if necessary. Cartrefi Cymru Fire Safety Policy requires that all houses undertake two fire drills every year, it was revealed during staff interviews and corresponding file checks that the required number of fire drills was not being carried out. This was highlighted to the Area Manager and now a fire drill is taking place at each property every April and October.

Cartrefi Cymru ensures that all drivers possess a valid Driving Licence and that valid car insurance is in place to cover all drivers. Cartrefi Cymru carry out monthly car checks on service users’ vehicles and records of this are maintained, however it was noted that in MW at the time of the Supporting People visit the monthly car check was overdue and that there were several gaps over the previous year in the record held on file. Cartrefi Cymru has comprehensive insurance in place to cover Employers Liability, Public Liability, Product Liability, Abuse Liability and Professional Indemnity.

Recommendations Cartrefi Cymru to ensure that team meetings are carried out on a quarterly basis. Minutes of the meetings are to be recorded and made available to all staff members (also in section 4 & 9). Cartrefi Cymru to ensure that staff supervision sessions take place every 6-8 weeks in order for staff members to have the opportunity to discuss relevant issues such as training needs with their manager (also in section 9). Cartrefi Cymru to ensure that all staff members understand the on-call procedure. Cartrefi Cymru to ensure that all risk assessments are reviewed at least annually as per the Risk Assessment Policy (also in section 3).

9. Evaluating quality to ensure the service can deliver outcomes

Summary of Findings

Cartrefi Cymru maintains a file for each member of staff at their office in Cooper’s Yard, Cardiff. All files were indexed and contained job descriptions, offer of employment letters, references and copies of driving licences. Training files, supervision notes and sickness records are stored at the Bridgend office. All support staff received a job offer letter stating that the job position was subject to two satisfactory references and CRB (DBS) disclosures before the commencement of employment, this was evidenced via staff files. All staff files checked indicated that staff members had completed an induction course which included a full induction to the service, health & safety training, shadowing and supervision from a service manager. This was also confirmed verbally by the staff members that were interviewed. Staff members that tupeed across to Cartrefi Cymru were all provided with core training following the transfer. All staff members confirmed that they had passed a nine month probationary period and this was documented in the corresponding staff file. All Cartrefi Cymru supported houses contained diaries and a communication books where staff members are able to communicate daily occurrences and organise future plans and appointments. In the supported houses visited by the Contract Monitoring Officers it was noted that the organisation of service user files was somewhat inconsistent. Some files contained an index which the contents corresponded to however many other files did not contain an index and the contents were not in order. It is recommended that Cartrefi Cymru ensures that all service users’ personal files feature an index and that the contents of the file match the index. All Cartrefi Cymru support staff have access to a staff handbook and policies and procedures through the Cartrefi Cymru intranet. Physical copies of Cartrefi Cymru’s policies and procedures were also kept at all houses in the Vale. During staff interviews a few support workers highlighted that they had not received training on the IT systems that they use and stated that they were unsure how to do certain things on the system. Furthermore two staff members stated that the data on the LINC system sometimes gets lost and that all team members in a house can’t always access the same data which is held in the computer file. This issue was highlighted to Area Management who advised that they are in the process of installing an updated and improved LINC system. It is recommended that all staff members receive training on the current IT systems in use by Cartrefi Cymru and any new systems that are introduced.

Staff are kept informed of organisational changes through email, or through the line manager – this was evidenced through staff interviews It was evidenced through staff interviews that staff supervisions take place sporadically; one member of staff had not received supervision for over 12 months. It is recommended that staff supervisions are carried out monthly, and that training opportunities and risks are discussed, all supervision notes should be stored in staff files, and signed and dated by both staff member and supervisor/manager. It was evidenced through staff interviews that team meetings take place on a sporadic basis; the Contract Monitoring Officer was only able to obtain a copy of the minutes for one team meeting. It is recommended that all Cartrefi Cymru houses carry out regular team meetings and that the minutes are recorded, all team meeting invitee’s should be given a copy of the minutes of the meeting. With the exception of CC, house meetings are carried out at all houses and minutes were made available to the Contract Monitoring Officer. It was clear from staff interviews that annual appraisals were not taking place on a regular basis. It is recommended that appraisals are taking place annually and that they discuss training opportunities and risks this must be recorded and kept on the staff file. During staff interviews two staff members from CR stated that they believed communication from management could be improved, they felt unsure of who was in the leadership position in the house and believed there were issues surrounding the delegation of some tasks. This was highlighted to Area Management who advised that recent changes had been made in the Colcot Road scheme which a small number of staff members had opposed. Area Management also advised that the same staff members had expressed resistance towards several previous service managers. It is recommended that staff members are provided with the opportunity to discuss any relevant issues or ideas with management via regular staff supervisions, appraisals and team meetings. Area Management advised that a team meeting for the staff at Colcot Road was scheduled to discuss any issues. It was evidenced that Cartrefi Cymru carries out regular internal audits which identifies areas for improvement in those audits and included in an action plan. It is recommended that the monitoring of supervision sessions, team meetings and appraisals plays prominent role in any future internal audits. All Cartrefi Cymru houses contain a complaints and concerns file which is kept on the property in accordance with the Complaints and Concerns Policy, only one complaint had been received in the previous 12 months which was not related to the delivery of housing related support.

Cartrefi Cymru records outcomes data for their service users and submits it to the Supporting People Team on a six monthly basis.


Cartrefi Cymru provides comprehensive training for support staff covering all aspects of the role. All staff members received a service induction at the beginning of their role and passed a mandatory probationary period. Staff members that transfer from one house to the next receive a house induction immediately following the transfer. Cartrefi Cymru policy requires staff supervisions, appraisals and team meetings to take place on a regular basis however staff interviews and file checks indicated that these were occurring sporadically. However staff confirmed that when supervisions and team meetings did take place they were able to discuss training, personal development, health & safety etc. Staff members have access to all of Cartrefi Cymru’s policies and procedures which are available as hard copies and digitally. Cartrefi Cymru ensures that staff members are kept informed of organisational changes through email, the communication diary and verbally by service managers. Staff interviews identified that IT training is required by several staff members on the systems they use and that there were issues surrounding data being lost on the system in MW. Cartrefi Cymru have advised that an updated computer system is in the process of being rolled out. During staff interviews two staff members from the CR scheme expressed some concerns about the communication and leadership they were receiving from management. This feedback was highlighted to Cartrefi Cymru and Area Management advised that a small number of staff members in CR had opposed recently introduced changes in the service and that the same staff members had been resistant to the leadership of several of the current scheme manager’s predecessors. A team meeting at the scheme was scheduled to take place at CR to discuss any issues. Cartrefi Cymru service user’s files were organised in an inconsistent manner, some were indexed and organised accordingly while the contents of others were not indexed and were not set out in any discernable order. This made finding relevant information more difficult than was otherwise necessary.

Recommendations: Cartrefi Cymru to ensure that all service user personal files are checked and information is stored in the correct sections in date order and corresponds to the file index.

Cartrefi Cymru to ensure that all staff members are trained in the use of the current IT system and the new system when it’s introduced. Cartrefi Cymru must ensure that staff supervision sessions take place every 6-8 weeks in order for staff members to have the opportunity to discuss relevant issues such as training needs with their manager. (also in section 8) Cartrefi Cymru to ensure that team meetings are carried out on a quarterly basis. Minutes of the meetings are to be recorded and made available to all staff members (also in section 4 and 8). Cartrefi Cymru must ensure that annual appraisals are taking place every year. Appraisals should include discussion about training opportunities; this should be recorded and kept on the staff file. Cartrefi Cymru to ensure that the monitoring of supervisions, appraisals and team meetings plays a more central role in the internal audits.

10 (i) Summary of Stakeholder Feedback

Cartrefi Cymru have a good working relationship with the Supporting People Team, Cartrefi Cymru provide annual returns and outcomes submissions to the team on a regular basis and in a timely manner. Cartrefi Cymru produce a quarterly report and provide this to the Supporting People Team and also hold regular provider meetings with the Supporting People Team. During the review process the Contract Monitoring Officers noted that Cartrefi Cymru was on the whole very co-operative however there was repeated difficulty obtaining information from one service manager that hindered the review process. This was highlighted to Area Management at the time and the information was subsequently provided.

10 (ii) Summary of Service User Feedback

As the service users in each of the five houses are non-verbal, Contract Monitoring Officers were unable to carry out any service user interviews. However Contract Monitoring Officers were able to meet service users in all houses, view several activities that were being carried out with service users and were given access to the quarterly reports and personal files which detailed service user’s routines, activities, care needs etc. It was clear that Cartrefi Cymru places service users’ needs and goals at the centre of support.

10 (iii) Summary of Staff Feedback

As part of the review process the Contract Monitoring Officers interviewed 20% of the Cartrefi Cymru staff members that work in the

Vale. Staff members displayed enthusiasm towards their roles and good knowledge of the support they provide. All staff members confirmed that they received 9 months’ probation and had undergone a DBS check before beginning their role. Staff members confirmed that training opportunities were discussed during supervisions but that supervisions and appraisals occurred infrequently. It was also evident via staff interviews that team meetings across all houses were only carried out on a sporadic basis. Several staff members advised the Contract Monitoring Officers that they had not received IT training on the LINC computer system. Two staff members in one house raised concerns about communication issues between the service manager and staff; they felt that were issues surrounding the delegation of tasks and that regular team meetings would improve communication between them. This was highlighted to Area Management and a team meeting was scheduled to take place at the house.

11. SUMMARY / CONCLUSIONS Cartrefi Cymru provides a valuable support service that delivers support which is adequate for the needs and goals of its service users; several improvements have been recommended to ensure the consistency in the support delivered to all service users. As the service users on support have significant disabilities the Contract Monitoring Officers were unable to carry out interviews with them but it was apparent from staff interviews and house visits that staff members have a good rapport with the service users and detailed knowledge of their service users’ individual needs. Due to the nature of the service user’s disabilities, service users are unable to live independently without the extensive involvement of a care agency and the likelihood for service users to achieve any significant improvement in their independent living skills is low.

Cartrefi Cymru has policies and procedures in place which lower the risks to staff and service users but policies have not always been updated as frequently as required by their Risk Assessment policy and it was noted that fire drills were not being carried out at properties in accordance with the Fire Safety Policy. Detailed files are maintained on all aspects of the service users’ support however the files are organised in an inconsistent manner and room for improving the record keeping has been identified.

Cartrefi Cymru hold comprehensive records of the recruitment process on individual staff files and staff members are provided with extensive training, though staff interviews highlighted the need for training in certain areas most notably IT. Cartrefi Cymru carry out staff supervisions, appraisals and team meetings but checks indicated that these were being carried out infrequently and did not meet the required frequency set up in Cartrefi Cymru policy. Recommendations have been made for improvement in this area with the aim to ensure that support workers have regular opportunities to discuss relevant topics with management and fellow team members.

Cartrefi Cymru provides extensive support to their service users in financial matters. Due to the nature of the service user’s disabilities the financial affairs and transactions are largely carried out by Cartrefi Cymru on behalf of service users. File checks indicated that Cartrefi Cymru’s Service User Finance Policy was not being adhered to in several areas, this lead directly to a failing in the support provided to one service user. Several recommendations have been made for improvement in this area to ensure that a repeat of the incident does not occur again.

Cartrefi Cymru provides comprehensive support to encourage the health and well-being of service users and detailed files are maintained on service users’ health needs. Staff members regularly liaise with professionals when needed and support service users to attend health related appointments. Cartrefi Cymru encourages service user participation through support plans and numerous service user events. Service users enjoy the events and this is well documented in Cartrefi Cymru files. Cartrefi Cymru regularly hold events and activities the benefit of service users, however an opportunity to promote the interaction between the service users in the Vale houses was identified during the review.

Recommendations:

Action Required Target Date SP Sign-off

Cartrefi Cymru to ensure that fire drills are carried out on a six monthly basis as per the Fire Safety Policy.

Immediately

Cartrefi Cymru to ensure that monthly car checks are carried out and the corresponding paperwork is completed.

One month

Cartrefi Cymru to ensure that all risk assessments are reviewed at least annually as per the Risk Assessment Policy.

Immediately

Cartrefi Cymru to ensure that all service user support plans are reviewed on an annual basis or whenever there is a change in circumstances.

Immediately

Cartrefi Cymru to ensure that service user personal files are not removed from service users’ houses so that support workers have access to the files at all times.

Immediately

Cartrefi Cymru to ensure that all service users’ communication policies are reviewed and updated on an annual basis or sooner if there is a change in circumstances.

Immediately

Cartrefi Cymru to ensure that team meetings are carried out on a quarterly basis. Minutes of the meetings are to be recorded and made available to all staff members.

One month

Cartrefi Cymru to ensure that service users are given the opportunity to hold

Three months

celebrations and festive/social events with the other houses in the Vale if desired.

Cartrefi Cymru to review the limit on the amount of money that is kept in service users’ money tins.

One month

Cartrefi Cymru to ensure that all service users’ personal finance policies are reviewed on an annual basis or when there is a change of circumstances as per Service User Finance Policy.

One month

Cartrefi Cymru to ensure all Personal Expenditure Forms are signed by two staff members as per Service User Finance Policy.

Immediately

Cartrefi Cymru to ensure that bank reconciliations are carried out on a monthly basis on the bank accounts of all service users as per Service User Finance Policy.

One month

Cartrefi Cymru to ensure that all bank statements are kept in service user finance files unless they have been archived.

One month

Cartrefi Cymru to ensure archived personal expenditure records; archived reconciliation forms and accompanying receipts are stored in the Area Manager’s office as per Service User Finance Policy.

One month-

Cartrefi Cymru to ensure that an up-to-date inventory of service users’ valuable property is maintained as per Service User Finance Policy.

One month

Cartrefi Cymru to ensure that staff supervision sessions take place every 6-8 weeks in order for staff members to have the opportunity to discuss relevant issues such as training needs with their manager.

One month

Cartrefi Cymru to ensure that all staff members understand the on-call procedure.

One month

Cartrefi Cymru to ensure that all service user personal files are checked and information is stored in the correct sections in date order and corresponds to the file index.

One month

Cartrefi Cymru to ensure that all staff members are trained in the use of the current IT system and the new system when it’s introduced.

Three months

Cartrefi Cymru to ensure that annual appraisals are taking place every year. Appraisals should include discussion about training opportunities; this should be recorded and kept on the staff file.

Three months

Cartrefi Cymru to ensure that the monitoring of supervisions, appraisals and team meetings plays a more central role in future internal audits.

Three months

Future Monitoring

The next full service review will take place in approximately 3 years’ time. Monitoring meetings will continue quarterly. Acknowledgements The Vale of Glamorgan Council Supporting People Team would like to acknowledge Cartrefi Cymru’s co-operation during the reviewing process, which was greatly appreciated.

Date post:	24-Jun-2020
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Supporting People - Vale of Glamorgan · The Supporting People Contract Monitoring Officers...

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