Forest Care Village Elstree and Borehamwood

Forest Care Village Elstree and Borehamwood is a care home registered to provide personal and nursing care for up to 178 people aged 18 and over with a range of complex health and care needs. At the time of our inspection 143 people were using the service.

Accommodation for people is spread over three floors divided in separate units, each of which have separate adapted facilities. Three of the units specialise in providing care to people living with dementia whereas in the remaining four units are for people with nursing needs. There is also a short stay unit for people needing rehabilitation after a stay in hospital.

People’s experience of using this service and what we found

The registered manager effectively used the providers governance systems to identify areas in the service they provided where improvements were needed. These included improving documentation, recording in care plans and improving communication with health and social care professionals as well as relatives. They also identified the need for a clinical lead for the short stay unit. Regular meetings were in place for staff and people to ensure they were contributing their views about the running of the home and lessons were learnt when things went wrong. There was a service improvement plan in place and actions were checked for completion to ensure improvements were made where needed.

People and their relatives felt the care and support people received was safe and met their needs. Staff were proactive in identifying and reporting any concerns to their managers or external safeguarding authorities if there was a need for it. Risk assessments were developed to give staff guidance in how to reduce risks and keep people safe from harm. Staff wore correct personal protective equipment (PPE) and followed safe infection control processes to protect people from Covid-19. People’s medicines were managed safely. The registered manager had measures in place to help ensure there were enough staff to support people safely.

People’s needs were assessed prior of moving into the home and care plans were developed to ensure their needs were consistently met. Care plans were regularly updated, and people told us they were actively involved in this. People had enough to eat and drink. Staff asked for dietician and other health professionals’ input for those at risk of malnutrition. Staff received training and were supported through supervisions, team meetings and competency assessments to understand and carry out their roles effectively.

People were happy with the daily activities and entertainment offered to them by the engagement team. People told us the care and support they received was personalised and met their needs. Not every person living in the home wanted to discuss their end of life care wishes. For people who wanted and expressed their wishes these were included in their care plan and staff were knowledgeable about their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 09 October 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

People were clearly placed at the centre of their care. Their health and wellbeing were carefully assessed in regard to COVID-19. Decisions were made in people’s best interest where it was needed. At the time of the inspection there was a decision made to restrict visits. People had access to video calls or phone calls to communicate with their family.

Measures were in place for people who needed family support for maximising their health and wellbeing to have their family member visiting. These measures included relatives wearing appropriate personal protective equipment (PPE), same family member visiting and testing before being allowed in the home.

The registered manager increased the activities in the home at the beginning of the pandemic to ensure staff could spend one to one time with people. People were supported to spend time in communal areas if they wanted, socially distancing from other people and were given the option to wear face masks.

Regular testing was in place for staff and people. Where positive test results were found people and staff were self-isolating to minimise the risk of spreading the infection. Staff were allocated to work in their own units and only in emergency situations were asked to work in different areas of the home.

Staff told us they received Infection Prevention and Control (IPC) training, this included how to safely put and take off their PPE. The staff told us their unit manager and the registered manager were always available to support them if needed.

The service was clean and hygienic. Additional cleaning tasks and schedules had been implemented by the registered manager and enough housekeeping staff were allocated to ensure cleaning was on-going throughout the day.

The provider had developed and reviewed their policies, procedures and guidance for the service to ensure staff had up to date knowledge to care for people safely. The business continuity plan in place was updated by the provider to detail how to respond to emergencies during the pandemic including when high number of staff were unable to work.

Quality assurance audits were being completed during the pandemic and actions taken when needed to ensure best practice guidance was followed by staff.

Forest Care Village is a care home registered to provide personal and nursing care for up to 178 people aged 18 and over with a range of complex health and care needs. At the time of our inspection 129 people were using the service.

Forest Care Village spreads across three floors and accommodates people in separate units, each of which have separate adapted facilities. Three of the units specialise in providing care to people living with dementia whereas in the remaining four units people have nursing needs.

People’s experience of using this service and what we found

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People felt safe in the home and staff knew how to identify and report any concerns to their managers or external safeguarding authorities. Risk assessments were developed to give staff guidance in how to mitigate risks and keep people safe from harm. The environment in some places needed deep cleaning and re-decoration to ensure it not presented an infection control risk. Not every staff member responded promptly to an unplanned fire alarm on the day of the inspection. Some people felt there were not enough staff at times to take them out, however they had not had to wait long for their needs to be met in the home.

People’s needs were assessed and care plans developed to give information for staff to meet those needs effectively. Staff received training and were supported through regular supervisions and meetings to understand their roles. People`s dietary needs were met and where they were identified at risk of malnutrition staff referred them for specialist support, like dietician or GP.

People told us staff were kind and caring and supported them in a respectful way. People were encouraged to participate in their care as much as possible and where they were not able, staff ensured that the care they received was in their best interest. Opportunities were created for people to participate in activities and social events organised by staff.

Governance systems in place promptly identified areas in need of improvement and these were actioned in a timely manner by the registered manager. Regular meetings were in place for staff and people to ensure they were contributing their views about the running of the home. Action plans were developed and checked for completion to ensure improvements were made where needed.

Rating at last inspection

The last rating for this service was requires improvement (published 8 September 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Following our inspection on 05 December 2017 we were informed by the local authority that Environmental Health officers had served a Hygiene Emergency Prohibition Notice on Forest Care Village due to an infestation of cockroaches. At this inspection we found that this notice had been lifted and the cockroach infestation had been eradicated.

Forest Care Village is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Forest Care Village is registered to provide personal and nursing care for up to 178 people aged 18 and over with a range of complex health and care needs. At the time of our inspection 120 people were using the service.

Forest Care Village spreads across three floors and accommodates people in separate units, each of which have separate adapted facilities. Three of the units specialise in providing care to people living with dementia whereas in the remaining four units people have nursing needs.

There was a manager in post who had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At this inspection we found that significant improvements were made and although some areas were still developing and improving, however, people received personalised care and support which was safe and protected them from the risk of harm.

Following the inspection on 05 December 2017 we shared our findings with the Local Authority and Clinical Commissioning Group (CCG). The different funding authorities and local commissioning group worked closely with the provider and the registered manager providing support to empower Forest Care Village staff and to monitor improvements as part of their quality improvement process. There were regular service improvement meetings where different health and social care professionals gave feedback following their visits and assessments carried out at the home to the provider and register manager. A manual handling specialist had observed staff’s practices and provided training. The CCG had allocated two nurses two days a week to observe and empower staff employed by the home to develop their skills further in recognising people`s changing health needs. At the time of this inspection the support from the different external professionals was recently withdrawn except for PEG specialist nurses who were training and assessing staff`s competencies in the management of percutaneous endoscopic gastrostomy (PEG)`s. PEG is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.

The provider reviewed their governance systems and developed this further to ensure that this was effective in identifying areas in need of improvement without the permanent support from the local authority. The provider has transitioned to electronic care planning which meant that staff could access people`s records from their hand-held devices and they updated the records when they delivered support to people.

People told us that they felt safe living in the home. Staff demonstrated they had the knowledge to identify potential abuse and also the process for reporting concerns. We saw notices and information displayed throughout the service informing people, staff and visitors how to report concerns and relevant contact numbers for external safeguarding authorities. Referrals to local safeguarding authorities and CQC were done in a timely manner.

There were adequate staff on duty to support people in a timely way. Call bells were responded to within a couple of minutes and people confirmed staff responded when they requested help. We reviewed rotas and saw that adequate staff were deployed to assist people safely.

People’s individual risks were assessed and where risks were identified, measures were put in place to help reduce and mitigate those risks. Staff demonstrated a good knowledge about people and could tell us how they mitigated risks to people`s well-being.

People who lived with specific health conditions had care plans in place to address this area of their needs and staff had guidance on how to maximise people`s health. People`s end of life care needs were assessed and plans were in place to evidence that people`s wishes, likes and dislikes were considered when staff created care plans. Staff could tell us what people liked and how they wished to be cared for.

Infection control measures were in place. Staff were observed to use personal protective equipment, including the use of gloves and aprons while supporting people with personal care. People’s medicines were managed safely in most cases. Medicines were stored safely and administered by trained staff.

Staff felt supported by the registered manager and unit managers and were encouraged to have their say about any concerns they had in how the service operated. Staff attended regular meetings and discussed issues that were important to them. They also had regular supervisions where their performance and development were reviewed. Staff told us they received training and support to carry out their roles effectively. Recruitment processes were robust and ensured that the staff employed were suitable to work in this type of care settings.

Electronic care plans were well developed, personalised and regularly reviewed. However not all the features this care planning system offered were developed to full capacity at the time of the inspection. Not every person we spoke with were aware of their care plans or the content of it, however they told us they had or were waiting for a review of their care needs.

People were asked for their consent to the day to day care and support they received from staff. We observed staff assisting people and communicating with them and asking for their involvement in the task. People told us and we observed that staff protected their dignity and privacy.

The principles of the Mental Capacity Act 2005 (MCA) were followed by staff and where Deprivation of Liberty Safeguards (DoLS) authorisations were in place with conditions listed on the restrictions to people`s freedom plans were in place to meet these and keep people safe.

People were positive about the care and support they received and told us staff were kind and caring. People were supported to engage in a range of arts, crafts, and hobbies that were of interest to them. There were singalong musical events, sporting events and outside entertainers visited the home. People were also supported to attend community events. People who were less able to engage in social activities had an identified need for staff to spend meaningful moments with them outside the care delivery, however we saw that some of these moments were not completed. This area of the service was still improving to ensure that people in their bedrooms were not at risk of isolation.

People told us they liked the food provided to them and they had enough choices. People`s dietary needs were met and we found that staff referred people to specialist support in case they were at risk of malnutrition.

After the previous inspection there was extensive support provided by the Local Authority, CCG and other partner agencies involving deployment of their own qualified staff to help the provider identify where they needed improvements and agreed actions were put in place to improve the quality and safety of the care provided to people. This support was recently withdrawn and the registered manager and the provider were yet to prove that the service could sustain the improvements achieved.

Systems had been developed to identify shortfalls and address these areas as needed. Communication through the management team had been improved. There were monthly clinical and quality meetings to discuss all areas of the service, internal audits completed and any incidents that had occurred. This enabled the management team to review previous and ongoing action plans to help ensure they were effective. Lessons were learned following incidents.

The registered manager effectively monitored the quality of the care provided to people and they were regularly walking the floors helping, coaching and mentoring staff. Regular surveys carried out evidenced that people were feeling positive about the changes in the home.There were regular relatives and residents meetings organised and a `you said, we did` poster to evidence when people requests were fulfilled, however there were some people who told us that they were disappointed that not all the issues they brought up in meetings were actioned.

Forest Care Village is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Forest Care Village is registered to provide personal and nursing care for up to 178 people aged 18 and over with a range of complex health and care needs. At the time of our inspection 161 people were using the service.

Forest Care Village spreads across three floors and accommodates people in separate units, each of which have separate adapted facilities. Three of the units specialise in providing care to people living with dementia whereas in the remaining four units people have nursing needs.

There was a manager in post who had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People who were able to talk to us told us that they felt safe living in the home. However seven people and two relatives felt there were not enough staff to meet their needs in a timely way and also that the agency staff working in the home were not knowledgeable about their needs which had impacted on their dignity and general well-being. Some staff also told us they were rushed and felt under pressure to complete tasks not having time to spend with people. We observed staff working in a task led way. For example, asking people to finish their meals in a hurry or moving people without giving people time to actively participate in the process.

Risks to people`s well-being and health were not always identified, assessed or mitigated in a way to reduce them. Where people were assessed as requiring a fortified diet to help reduce the risk of malnutrition they were not provided this by the kitchen staff who were not aware of people’s needs. Where people had pressure relieving equipment in place to help prevent the development of pressure ulcers the checks carried out by staff did not effectively identify faults or wrong settings on air mattresses. There was a risk that this shortfall had contributed to people developing pressure ulcers.

People who lived with specific health conditions had no care plans in place to address this area of their needs and staff had no guidance on how to maximise people`s health. People`s end of life care needs were not assessed, there were no plans in place to evidence that people`s wishes, likes and dislikes were considered when staff created care plans. Staff could not tell us what people liked and how they wished to be cared for.

People who came to harm because of the measures in place to mitigate risks were ineffective had not been referred to local safeguarding authorities. This meant that further actions had not always been implemented to keep people safe. Staff were knowledgeable about signs and symptoms of abuse and their responsibilities to report. However we noted instances when staff had reported concerns to their managers but these had not been reported to external safeguarding authorities as required under local safeguarding protocols.

People were not always protected from the risk of infections. There were insufficient control measures implemented to help protect people and staff from infectious diseases. Medicine management systems were in place to aid staff to administer medicines safely as intended by the prescriber; however we found in one instance where a person had not received their pain relief as prescribed.

People who had complex health care needs had not been properly assessed and care plans had not been developed around their health needs to offer guidance to staff on how to maximise people`s health and keep them safe.

People with less complex care needs told us they knew about their care plans. However, they told us they had not reviewed these for a long time. Care plans we reviewed for people who were less able to communicate with us were not up to date and not reflective of people`s current needs. Care plans we reviewed were written in a style that did not promote people`s dignity.

People were not asked for their consent to the day to day care and support they received from staff. We observed staff assisting people without communicating with them or asking for their involvement. People who were less able to communicate verbally had not always had their dignity and privacy protected by staff. Staff did not follow the principles of the Mental Capacity Act 2005 (MCA). Staff were not aware if people had Deprivation of Liberty Safeguards (DoLS) authorisations in place which put restrictions on people`s freedom in order to keep them safe.

People with less complex care needs and who were more independent were positive about the care and support they received and the way staff supported them to remain independent and participate in social activities. They told us staff protected their dignity and privacy and they were very happy living in the home.

Staff told us they received training and support to carry out their roles effectively. We saw that there was an effective training monitoring system used by the registered manager to identify staff who needed refresher training. Recruitment processes were robust and ensured that the staff employed were suitable to work in this type of care settings.

People told us they liked the food provided to them and they had enough choices. People who had to maintain a healthy diet and lose weight were appropriately supported by staff; however the needs of the people at risk of malnutrition or requiring special diets were not always met effectively.

The atmosphere at Forest Care Village was welcoming throughout the day. People who were able were congregating in the main foyer where they had drinks and cakes served and had live entertainment, however people who spent time in their bedrooms were at risk of social isolation.

Some people told us they did not know who the registered manager was; however they knew the unit manager responsible for the unit they lived in. They gave us mixed views about if they felt confident to raise concerns and complain to the managers. Some people told us they did not feel they had a voice; other people told us they felt listened to.

The registered manager had no formal systems in place to provide them with an overview of the service. They had no system to identify themes or trends and were dependent on feedback from the clinical manager for their information and on different audits carried out on the units. However we found that these audits were not consistent and at times only provided limited information about the issues found. There was little evidence found in meeting minutes that lessons were learned or that actions were implemented to improve the quality of the care people received.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Forest Care Village provides accommodation; personal and nursing care for up to 178 people aged 18 and over with a range of complex care needs. At the time of our inspection 161 people were using the service.

There was a manager in post who had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People who used the services at Forest Care Village, their relatives and professionals involved with people’s care and support gave us positive and complimentary feedback about the service and said that they had no concerns about the care and support that people received.

People told us they felt safe living at Forest Care Village. People had health care and support plans in place to help staff know how they liked their needs to be met. Risks to people’s safety and welfare had been identified and support had been planned to enable people to live as safely as possible whilst enjoying a variety of opportunities for engagement and stimulation. There were appropriate numbers of staff available to meet people’s care and support needs.

Staff members understood their roles and responsibilities and were supported by the registered manager and unit managers to maintain and develop their skills and knowledge. People enjoyed a varied healthy diet and their health needs were catered for.

The atmosphere at Forest Care Village was welcoming and there was a comfortable rapport between the staff and people who used the service. People’s relatives were encouraged to be involved in developing people’s support plans and to visit the home at any time. Staff treated people with compassion, promoted their dignity and treated them with respect.

There was an open culture at the home, people’s relatives and staff told us that they were completely comfortable to speak with the registered manager if they had a concern. The provider had arrangements in place to regularly monitor health and safety and the quality of the care and support provided for people who used the service.

We looked at how people were cared for and we found that care plans were up to date and gave staff good instructions on how to care for people. Medicines were stored, administered and recorded as prescribed. The management of the home had systems in place that ensured all aspects of the service and care offered to people were regularly audited and action plans drawn and implemented to address any anomalies found.

People we spoke with told us they were satisfied with the way the service managed their medicines.

People were positive about the choice of meals available.

We identified concerns regarding the cleanliness of some areas of the service.

People we spoke with said they were happy with the way the service managed their medicines but we identified concerns regarding the recording of medicines.

We identified that people were being supported by a permanent team of staff with the training, skills and experience to meet their needs.

Not everyone we spoke with or contacted us between our inspections felt that their concerns had been listened to. We found that people's concerns had not always been recorded within the provider's complaint monitoring systems.

We identified that the provider's quality monitoring systems had not been robust enough to identify the issues we raised at this inspection in relation to cleanliness, medication and staff supervision.