Forest Care Village Elstree and Borehamwood

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not always supported to be involved in managing risks to their health and wellbeing. Some people’s care documentation did not contain clear and consistent information to guide staff about how to care for them safely. Daily notes showed care plans were not always followed to ensure people received safe care. Medicines were not managed safely, and there was not always guidance to ensure medicines could be administered in line with the prescriber’s intentions. Some areas of the service were not clean or maintained to a standard to ensure infection risk was managed well. There were not always enough staff to meet people’s needs to uphold their dignity or meet their social and emotional needs. Staff did not understand restrictive practice well. Mental capacity assessments lacked sufficient detail to assure us the correct process had been followed and had not always been completed for people who were restricted. Applications had not been applied for in a timely way to ensure people were not unlawfully deprived of their liberty. Staff had received training in safeguarding people from abuse and knew how to report any concerns.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from people about feeling listened to. A person told us they raised concerns, but managers did not respond. They said, "It's all talk. Nothing gets done.” We were told about concerns relating to the security of the building at night and whilst the manager told us this had been addressed, this had not been effectively communicated to reassure people. However, we were also told, “The organisation is wonderful, I can’t fault anything. They listen if I have a problem, they are all so kind. They told me the room is mine and I can have whoever I like in it and do what I like."

Staff completed incident forms. A staff member told us there were no team meetings and they did not tend to hear back about concerns they reported. Another staff member was unable to give an example of a recent incident but told us information was shared at handover. They said, “I don’t feel like it is enough. If you are on shift, you are told, but if you were not here the next day for handover you may not hear about it.”

The service did not always manage incidents well. We reviewed an incident log which included initial action taken in response to incidents, but it lacked details to show evidence of investigations and shared learning. We did not see evidence of analysis to identify themes. The team meetings minutes we received were from several months ago and did not include discussion of learning from incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed feedback from people about feeling safe. Some people told us they did not feel safe at night. One person said, “Yes, I do feel safe - they are very kind. I could speak to someone in charge if I wasn't, one of the managers or staff I know.”

Staff confirmed they had completed training in safeguarding people from harm and were able to give examples of concerns they would report.

Safeguarding concerns were not always managed well. The safeguarding log lacked information on outcomes and what action was taken to keep people safe. We found some incident reports included potential safeguarding concerns which had not been included on the safeguarding log. Therefore, we were not assured all safeguarding concerns were referred to the local authority as required. However, recent safeguarding allegations had been reported appropriately and reported to both the local authority and CQC as required. People’s mental capacity to make specific decisions was not robustly assessed in line with the principles of the Mental Capacity Act. Some assessments reviewed were completed after the first site visit and lacked accuracy and detail to show correct process had been followed. There was no evidence to show what support the person received to understand the decision being made. The service had not always made timely applications to deprive people of their liberty. We reviewed the Deprivation of Liberty Safeguards tracker and found some were made following our visit. A professional said they had seen some recent improvement in how the service responded to safeguarding concerns, but further improvement was needed. They said, “I don’t want to have to badger them for a response” and “I feel the problem is you can’t get hold of people. Safeguarding is important, and we need managers to act swiftly when a request for information is made.”

People we spoke with did not feel involved with planning their care and reviews. A person said, “I am not aware of a care plan or discussing my care.” Another person said, “No I haven’t seen it.” We were also told, “I am sure if I asked, I could see it” and “I haven’t had a need to.” One person felt they had not been adequately consulted about restrictions on their liberty. Staff were able to describe people’s modified diets. However, we found these were not always managed well. We observed a person on a soft diet putting food in their handbag; they had declined the soft option and been presented with an alternative. We told senior staff who were aware of this, but they had not taken any action to mitigate this potential risk.

Staff did not all understand restrictive practice. For example, one person had items removed from their room. We discussed this with staff who explained the reasons for this. However, there was no documentation to evidence this was in the person’s best interests.

People’s risk assessments had very limited evidence of involving people. They did not always include enough guidance for staff to mitigate risks and in some cases had been completed unnecessarily where there was no identified risk. People’s records did not always demonstrate they were receiving care as required. We reviewed daily logs for a person who had lost a significant amount of weight and found they did not always receive fortified milkshakes as prescribed. The service’s restrictive practice policy was unclear. It did not clearly include the need for strategies and positive management plans or describe behaviour as an expression of unmet need. We reviewed a person’s care plan and behavioural charts which described taking them to their room as a strategy for when they were expressing distress. This is a restrictive practice which had not been assessed as in the person’s best interest and the least restrictive option.

People did not always have the correct equipment to ensure they received safe care. On our second visit, we identified 3 people who had high profile beds with crash mats. This put them at risk of injury.

Staff did not always have access to enough equipment to support people safely. We were told there were not enough handheld devices to record care notes at night. A member of staff said, “There are lots of times when important things do not get recorded”. Staff also told us there were not enough shower chairs. We fed this back to the provider who completed an audit of equipment to identify action to address this.

Whilst we found the environment to be in a poor state of repair in places, on the second day of the inspection we saw some improvement had been made throughout the home. For example, they had bought new tables and chairs.

The provider completed health and safety audits monthly. They had a business continuity plan which included information for if a serious incident occurred at the home.

Most people we spoke with told us there were enough staff with the right skills and knowledge to support them well. However, 2 people said they did not feel staff cared for them safely in relation to moving and handling, describing staff as rough. Another person said there were not enough nursing staff available.

People were not always supported by enough staff to meet their needs. Whilst staff told us people’s physical care needs were met safely, this had an impact on other needs. A member of staff said, “There are always 2 people for hoisting but that means 1 person in the communal area doing everything else.” Another staff member said, “We sometimes cannot respond when required and have to wait for someone to help from another unit.” They further explained this could be more distressing for people living with dementia. Senior staff told us a staffing dependency tool was used to identify staffing requirements which was flexible daily if managers made a case for additional staff. However, the version we reviewed was not completed and it was not clear how managers monitored this. Therefore, we were not assured there were always sufficient staff to support people’s emotional needs and wellbeing.

People were supported by staff in a task-oriented way; there was a lack of social interaction between staff and people. For example, we observed a member of staff bring a person a drink they had requested without speaking or looking at them. At mealtimes staff were occupied in the dining area and therefore less able to respond to needs of people in their rooms when they pressed their call bells.

People were supported by staff who received relevant training. Managers completed staff competency assessments for moving and handling and administering of medicines. Whilst the medicines competencies were completed fully, we found the moving and handling assessments we reviewed lacked sufficient detail to show how judgements about competency were made.

People said staff did not always use Personal Protective Equipment (PPE). For example, they did not always change their gloves between tasks. We received mixed feedback from people about the cleanliness of the home. Comments shared with us included, “It is disgusting in the common parts. Filthy.” And “Toilets stink of urine.” However, during our visit we were also told, “They clean the room every day and once a month they pull out the cupboards and move the bed to give a full clean.”

We received mixed feedback from staff regarding the condition of the service. A member of staff told us, “The place is very filthy, we even had issues with bedbugs. The place needs renovation in both the residents’ rooms and the immediate surroundings. The kitchens are in poor condition, leaks, and no dishwasher to wash even though there can be infection control outbreaks around and therefore there is a need to sterilise everything.” Senior staff told us there was an extensive redecoration program planned and a member of staff said, “The environment is neat.”

The home was not well maintained, and some rooms were unclean. We found some bathrooms had significant limescale marks and sinks were unclean. The integrated kitchen in the communal lounge on one floor was in a poor state of repair. Work tops were split, and the sink cupboard had water damage. We told senior staff, who said the kitchen was not in use. However, we saw staff using the kitchen during lunch. Most staff used PPE appropriately. However, we observed a staff member pick up a mouse trap and then serve lunch without washing their hands or changing their gloves. At our second site visit, we found the provider had taken action to address some of the infection control concerns we identified.

Staff completed regular audits with a timeline for any actions identified to be completed. However, they had not identified the issues we found during our site visits.

We received mixed feedback from people about how their medicines were managed. A person told us, “My medication is brought to me on time twice a day, I am never worried.” However, prior to our visit a relative told us they had concerns about the timeliness of evening medicines.

Staff told us they received training and had their competency assessed to administer medicines safely.

People’s medicines were not always administered safely. Some medicines with additional administration or safety requirements had not been identified properly in people’s records. We found expired medicines in cupboards and in one case staff were unable to confirm whether it had been administered. The provider did not always follow their medicines policy. For example, guidance on how to administer PRN (as and when required) medicines was not always completed and reviewed. Staff completed regular audits. However, these did not always identify issues we found. For example, when handwritten amendments were made to Medicine Administration Record (MAR), entries had not always been checked by two staff.