Forest Hill House Nursing Home

We found the following examples of good practice.

Safe practices were in place for welcoming visitors to the home. These included rapid COVID-19 testing, personal protective equipment (PPE), health and symptom checks and hand hygiene. Vaccination status was checked for all visiting professionals and records of staff vaccinations were maintained. The provider’s electronic system had made monitoring for compliance much easier by logging test results. Staff testing for COVID-19 was at the frequency in line with government guidance and a process was in place for monitoring it.

People told us they happy living at Forest Hill House Nursing Home. We spoke with people informally as we walked through the home who told us staff were caring. We observed some kind interactions between staff and people. The registered manager and staff at the home had worked hard to keep people safe. Policies and procedures within the home were robust and frequent monitoring meant that the home worked safely and within good practice and government guidelines.

Supplies of PPE were in good supply, stock checks maintained, and we observed staff wearing this correctly. Staff had training in infection prevention and control and were shown how to put on and take off PPE correctly. The home had a good standard of cleanliness. COVID-19 contingency procedures in place meant that the home could operate under pressures such as during an outbreak or staff shortages. Domestic staff worked hard to keep all areas of the home clean and tidy including high touch points and deep cleaning.

People were supported to maintain contact with their loved ones during the COVID-19 pandemic. This included assessing each individual person’s needs and working to ensure their visits took place in the most comfortable location. As visiting restrictions changed the home adapted its policies, practices and communicated to people and their relatives verbally by telephone. Risk assessments were completed for all aspects of care and support including additional risks related to COVID-19. Specific risk assessments had been completed for staff.

Forest Hill House Nursing Home is registered to accommodate and provide care, treatment and support for up to 36 older people. The service is split over three floors which were all accessible by stairs or a lift. There were 23 people using the service at time of inspection.

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

People told us they felt safe, supported and happy living at Forest Hill House Nursing Home. Since the last inspection improvements had been made to risk assessments and medicines management and these had improved safety. However, further development was needed to ensure they were robust. The registered manager and compliance officer worked to ensure these areas were robust during and directly following the inspection.

There was a homely, relaxed, yet vibrant atmosphere in the home. People were supported by staff who knew how to recognise and raise concerns. The systems in place meant that concerns were taken seriously and referred to the relevant agencies. The home was clean, tidy and improvements were ongoing. Staff were recruited safely, and staffing levels were kept under review. Lessons were learnt by the service and it was important to them to continually improve.

The staff demonstrated a good understanding of how to meet people’s individual needs. People’s outcomes were known, and staff worked with people to help achieve these. People were supported and encouraged to maintain their independence and live their lives as fully as possible.

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. Staff were respectful, and consent was consistently sought. People had access to healthcare professionals to support their general health needs.

People’s needs were assessed, and staff had access to care plans which were person centred and involved the person. People’s hobbies, wishes and desires were sought, and staff worked to achieve these for the person. People felt occupied and enjoyed the social aspects of the home. People and their relatives thought staff were kind, compassionate and caring.

People were supported to maintain contact with those important to them including family and friends. Staff understood the importance of these contacts for people’s health and well-being. Staff knew people well and gave individualised care and support. The home had received praise for its quality in end of life care.

People knew how to make a complaint; the home had a complaints policy, and this was followed to people’s satisfaction. The registered manager recognised it was their duty to be open, honest and apologise when things went wrong.

The management of the service was respected. Staff had a good understanding of their roles and responsibilities and were supported to reflect on their practice and pursue learning opportunities. The staff team worked and got on well together demonstrating team work. Staff were proud to work at Forest Hill House Nursing Home and told us they were a big family.

Quality and safety checks helped ensure people were safe and protected from harm. This meant the service could continually improve. Audits were robust and helped identify areas for improvement and this learning was shared with staff. The home worked well with external professionals and agencies and continued to build links within the community.

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

Rating at last inspection and update:

The last rating for this service was requires improvement (published 25 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

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.

This focussed inspection took place on 6 and 7 December 2018 and was unannounced. Following a comprehensive inspection in May 2018 we rated the service as good overall with no breaches of legal requirements. This shorter inspection was carried out due to concerns that were raised with us.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At our previous inspection in May 2018 we made a recommendation regarding the systems for oversight of medicine administration. At this inspection we found some additional shortfalls in the management and administration of medicines, and have made a recommendation regarding the safe management of medicines.

We have made a recommendation that the service notifies CQC of all required notifications as required by the regulations.

We found some shortfalls in risks to people regarding some aspects of the premises. This was a breach of regulation. You can see what action we told the provider to take at the back of the full version of the report.

We identified shortfalls in the provider's governance, audit process and quality monitoring systems. Quality assurance systems were in place to monitor the quality of the service but had not identified all the issues found at inspection. This was a breach of the regulation. You can see what action we told the provider to take at the back of the full version of the report.

The registered manager and management team responded constructively to issues raised and stated the required improvements would be actioned as soon as possible.

Forest Hill House Nursing Home is registered to provide accommodation, nursing care and support for up to 36 older people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Forest Hill Nursing Home offers accommodation over three floors with lift access to each floor. People had access to bright, comfortable communal lounge and dining areas, a conservatory and accessible garden and outside space for people to enjoy in the warmer months. At the time of our inspection there were 22 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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 2008 and associated Regulations about how the service is run.

Immediately prior to this inspection we received information of concern regarding the risk people were not receiving appropriate safe care and support. We reviewed this information and carried out an inspection focussing on the questions, is the service safe? And is the service well led?

People told us they were well cared for and said they felt safe living at the home. Staff were aware of what constituted abuse and the actions they should take if they suspected abuse. Relevant checks were undertaken before new staff started working at the service which ensured they were safe to work with vulnerable adults.

There were sufficient numbers of appropriately qualified staff available to ensure people were cared and supported safely. Staff had the right skills and training to support people appropriately, and were supported to develop their training further if they wished. There was a programme of training that covered all core training requirements as well as additional training courses that staff may require for further development.

Staff spoke knowledgeably regarding infection control procedures and ensured people were protected from the risk of cross contamination.

Staff created a calm, friendly, professional atmosphere which resulted in an open and honest culture in the home. Staff told us they felt well supported and said the management team and colleagues were always available for additional guidance and support. New staff felt welcomed and supported when they started working at Forest Hill House Nursing Home.

The provider sought regular feedback from people, relatives and staff. People felt listened to and action was taken if required. Relatives told us they were made to feel welcome at any time and felt fully involved and consulted in the care of their relative.

The service had established links with the local community through regular visits by local ministers, schools and toddler groups regularly visiting the home and providing entertainment and activities for people to take part in if they wished.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People were protected from the risks of abuse because staff understood the potential signs and how to report concerns. There were sufficient numbers of safely recruited staff available to meet people’s needs and staff knew people well and understood the risks they faced and how to manage these. Accidents and incidents were reported, recorded and learning shared with staff. People received their medication safely and these were mostly recorded accurately. Although medicines were audited, these were only completed monthly so there was a delay in picking up errors.

We have made a recommendation about the systems for oversight of medicine administration.

People were involved in pre-admission assessments which identified their physical, religious, emotional and mental health needs to ensure that these could be effectively met. There were assessments of capacity and decisions made in people’s best interests where required. People had a choice of meals and drinks and spoke positively about the food. Staff received regular support through supervision and had access to relevant training opportunities to provide them with the correct skills and knowledge for their role.

People were supported by staff who were kind and compassionate in their approach. We observed the use of gentle, tactile contact and staff communicating with people in ways which were meaningful for them. People were offered choices about how they spent their time and were supported with respect by staff who protected people’s dignity and promoted their independence. Visitors were welcomed whenever they wished to visit and were encouraged to feedback through regular meetings and annual surveys.

People’s care records showed that their support was reviewed at least monthly and was therefore responsive to changing needs. People were supported by staff to engage in a range of social opportunities and the registered manager explained about plans to make activities more person centred at the home. People and relatives were aware about how to raise concerns if needed and felt that these would be listened and responded to. End of life care was person centred and planned with people to ensure that wishes and preferences were understood and respected.

Feedback from people, relatives and staff was that Forest Hill was well managed. Everyone spoke positively about the registered manager who placed an emphasis on ensuring they worked with staff on shifts and was available and approachable. Feedback was gathered and used to drive changes at the home and audits were used to identify any gaps or trends to continually improve the service people received.

Further information is in the detailed findings below.

The home had a lift so people could travel from the ground floor to their rooms on the first and second floor. There was a large outdoor area including an open garden space for people to enjoy.

The home was last inspected on the 27 September 2013 and found not to be meeting the standards in the safety and suitability of premises. We found that the home did not have appropriate measures in place to ensure the security of the premises, or to consider the risks presented by the garden pond and greenhouse. The home had also inappropriately placed broken equipment in the grounds.

At this inspection improvements had been made to the safety and suitability of the premises. Broken fixtures had been repaired, the pond had been covered with a safety guard and hazardous items had been removed or safely secured.

The manager who was a registered manager had been at the service since 2015. A registered manager is a person who has registered with the Care Quality Commission 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 2008 and associated Regulations about how the service is run.

The service was safe because there were sufficient staff to meet people’s needs. Staff were available to support people with their nursing care needs and to assist people when they were involved in their personal, social and leisure activities. Employment checks were carried out when staff were recruited. This meant that prospective staff with the appropriate qualifications, experience, skills and abilities were suitably screened before they were employed.

Medicines were stored in a locked trolley and staff carried out medicine administration safely. Medicine charts were completed and signed in line with the policy. Where errors were identified these were safely and swiftly managed. Controlled drugs, used to treat pain and other complex symptoms, were stored in a separate locked wall cupboard in line with current legislation.

People were safe because staff were aware of how to protect people from harm and explained how they would report, record and manage a safeguarding incident. People and their relatives made comments about the safety of the home. One comment included, “You couldn’t feel safer here” and “I’ve never felt unsafe here, there is lots of staff and the place is very secure”.

Accidents and incidents had been reported, investigated and recorded. These were monitored by the registered manager. When risks were identified, for example the risk of falls or the risk of injury from accidents, these were reviewed and measures were taken to reduce the likelihood of further incidents. People had individualised personal evacuation plans for staff to follow in the event of an emergency.

Staff at the home followed the guidelines of the Mental Capacity Act (MCA) 20015 and people were supported and cared for when they had Deprivation of Liberty Safeguards (DoLS) in place to protect them from harm.

People received support from healthcare professionals to meet their on-going health and well-being needs. People explained they were given optical tests and foot care from services they visited or when these services visited the home. Several people required hearing devices which were kept clean and well maintained.

People were encouraged to make decisions about their care and were supported in making choices and achieving their goals. Records included people’s signatures where this was possible and where people were able to contribute.

Meal times were a relaxed and social experience for people. If people were hungry in between meals, they were offered snacks. There was sufficient food available and a variety meant people had choice of hot and cold food. One person said, “It’s more like a hotel than a home”. People were provided with the level of support they needed and this was documented in their care records.

People were cared for by well trained staff. The team received regular training to support them in their roles. Each staff member had a training plan and received support from their supervisor. People and their families described staff as ‘professional’ and ‘experienced’. Staff comments included, “I have a mentor and everyone is very helpful and supportive” and “feeling in a safe learning environment”.

Staff treated people with kindness, respect and understanding. People were kept comfortable and asked about their well-being. People at risk of experiencing pain were asked if they were comfortable. One nurse asked if someone needed medicine for their pain. Another staff member spoke with someone about their posture and level of comfort. People described the staff as “patient and caring”, “supportive” and “attentive”. One person commented, “I’m very pleased with the staff here, they give me time and never hurry me”. When one person appeared lost, staff spoke gently to them and assisted them to a more familiar part of the home.

People experienced a responsive service that met their changing needs. Staff described the care that individuals needed and this corresponded with details in their assessments, reviews and care plans. People were involved in decisions about their care. This was reflected in personised care records and comments we heard during the inspection. One relative explained that when they had visited the service, staff asked questions and showed an interest in understanding how to meet their family member’s requirements. They told us, “Staff asked my relative questions and involved me in the discussion as well”.

A range of group and individual activities were provided at the home. The activity leader showed examples of previous activities carried out at the service. These included creative group activities and games, music and song. Special events were celebrated and suggestions for activities were sought from those using the service.

Complaints, concerns and suggestions were used in a positive way to review and develop the service. These were well managed and seen as a means of understanding how to improve people’s experiences. The registered manager had a complaints policy and staff were aware of the procedure should a complaint be raised. Complaints, One relative said, “I’ve no complaints or concerns, I never have to worry at this home”.

The service was well-led through an experienced and supportive management structure. There was consistent leadership and the home had a registered manager and a deputy to oversee day to day activity. The home was considered by staff, people and relatives somewhere people could feel relaxed, safe and secure. The registered manager and staff had a shared understanding of the values of the service, with the focus being on people and their experiences.

The registered manager and team learned from events and incidents. For example, some medicines had been difficult to administer accurately on night shifts and the registered manager took swift action to identify and work to resolve this. An action plan was completed and the activity was monitored following the agreed changes.

People and their relatives were regularly consulted to provide feedback and suggestions as part of the on-going improvements within the home. Staff, relatives and people described the management team and the registered manager as ‘visible and approachable’, ‘professional’, ‘interested in people’ and ‘easy to communicate’ with.

People's needs were assessed and planned, and the home delivered care that protected their welfare. A person told us, "I have been here since 2008. My dressings are looked at regularly. They ask my permission before they do anything." The home also had arrangements for dealing with foreseeable emergencies.

The home had policies and procedures to protect people from abuse and that their human rights were protected. A person told us, "The atmosphere is really nice here."

The design and layout of the home was suitable for people's needs. However, the home did not have appropriate measures in place to ensure the security of the premises, or to consider the risks presented by the garden pond and greenhouse. The home had also inappropriately placed broken equipment in the home's grounds.

People had their needs met by sufficient numbers of staff. The home also had systems for monitoring the quality of service people received.

During our visit we spoke with two people who used the service and four members of staff including the registered manager. We spent time observing how staff interacted and supported people. We saw staff treating people in a sensitive, respectful and professional manner.

All the people we saw looked happy living at Forest Hill Nursing Home. People told us that it was a good place, and that the staff were helpful. One person said the staff were lovely and very kind, another said they were wonderful.