CQC report explained · a residential care home
What the CQC found at Forest Brow Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines, safeguarding, moving and handling, fire safety and infection control had improved. However, some medicines audits and as-required medicines records were incomplete, and a trained medicines staff member was not always physically on the night shift.
- Effective?
- Good
- Staff received suitable training and support, people's consent and best-interest decisions were handled in line with the law, and people received support with food, drink and healthcare. Some care plans still contained contradictory information about eating and drinking.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Inspectors saw patient and empathetic interactions, and people were involved in decisions about their daily care.
- Responsive?
- Good
- Care was personalised and adjusted when people's needs changed. Activities, visiting arrangements, complaints handling and end-of-life planning had improved.
- Well-led?
- Requires improvement
- The new management team had improved staffing, communication and oversight. However, checks had not found all problems with medicines, nutritional information and care records, so management systems were not yet fully reliable.
What inspectors found, August 2023
Previously rated Inadequate and in special measures; now Rated Requires Improvement, with safer care and kind staff but records and checks still need work.
This was an unannounced follow-up inspection after serious concerns at the previous inspection. Inspectors visited on 23 June, 29 June and 6 July 2023. They spoke with people, relatives, staff and professionals, observed care, and checked care plans, medicines records, audits and other documents.
The home had made significant improvements. Inspectors found people were not at risk of harm during this inspection. Medicines were stored and given safely, safeguarding systems had improved, staffing was more consistent, and infection control and fire safety arrangements were better.
There were still weaknesses. Some medicines audits did not identify all problems. Records about medicines, food and drink, and repositioning were not always complete or accurate. Information about some people's dietary needs was also unclear or contradictory.
The overall rating is Requires Improvement. Effective, caring and responsive care were rated Good. Safe and well-led were rated Requires Improvement. The home had previously been Inadequate and in special measures, but it is no longer in special measures.
Improved safety systems
The home had improved safeguarding, incident review, fire safety and infection control. Inspectors found people were protected from abuse and avoidable harm.
“People were protected from the risk of suffering abuse or coming to avoidable harm.” from the report
Safer medicines handling
Medicines storage was clean and organised, including controlled drugs, and staff were observed giving medicines safely.
“Medicines storage areas were clean and well organised.” from the report
Kind and respectful care
People and relatives described staff as kind, gentle and attentive. Inspectors observed staff treating people with patience, warmth and respect.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support and activities
Staff knew people's routines and preferences. The home had also increased activities, trips and opportunities for people and families to spend time together.
“People's preferences around their daily routines were identified in their care plans.” from the report
Medicines checks
needs fixingAudits did not identify every issue, including medicines storage temperatures going outside the recommended range. Some as-required medicines records did not explain why a medicine was given or whether it worked.
“Further improvements were needed to ensure audits were used to pick up all issues and areas for action.” from the report
Night medicines cover
needs fixingPeople received medicines as prescribed, but a medicines-trained member of staff was not always physically on the night shift. The provider was training night staff at the time of the inspection.
“Staffing arrangements were not robust and a medicines trained member of staff was not always physically on shift.” from the report
Food and drink information
needs fixingNutritional records were not always accurate, and guidance about some people's diets was unclear or contradictory. Staff knowledge reduced the risk, but the written information needed improvement.
“Information for staff around people's nutritional needs was not always consistent or clear.” from the report
Incomplete care records
needs fixingSome records did not show the care that staff said had been provided. This included gaps in repositioning records, which senior staff had not identified or addressed.
“Care records were not always accurately completed or reflect the care people received.” from the report
- 01Has every staff member working overnight now completed the required training to administer medicines, and who is physically available to give medicines at night?
- 02How do you check that as-required medicines records explain why the medicine was given and whether it had the desired effect?
- 03How are you making sure kitchen staff have clear, up-to-date information about each person's dietary needs and food texture?
- 04What checks are now in place to make sure repositioning, food and drink, and other care records accurately show the care provided?
- 05Has the manager's application to register with CQC been completed, and who is responsible for the home until then?
This was an unannounced follow-up inspection covering all five CQC key questions, including infection prevention and control; it checked progress after the previous Inadequate rating and regulatory breaches. This explanation was written from the published report of 12 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2023
Rated Inadequate and in special measures; inspectors found unsafe medicines management, risks in moving people and fire safety, and weak safeguarding processes.
This was an unannounced targeted inspection. Two inspectors and a medicines inspector visited on 24 January 2023, and inspection activity ended on 3 February 2023. They spoke with people, staff and a visiting professional, and checked care records, medicines, safeguarding records and the building.
Inspectors found continued serious problems. Medicines were not managed safely, some moving and handling practices could cause injury, and fire evacuation arrangements and staff training were not sufficient. Infection control had improved in some ways but was still not reliable.
There were no proper incident reporting processes. This increased the risk that injuries or possible abuse would not be identified and investigated promptly. People said they were happy and felt well cared for, but the home remained in breach of regulations.
The overall rating remained Inadequate and the home remained in special measures. The questions were not fully re-rated because this inspection only followed up specific warning notices.
People felt cared for
The people inspectors spoke with said they were happy and felt well cared for by staff.
“People told us they were happy and felt well cared for by staff.” from the report
Some fire safety improvements
The home had installed new fire doors and a fire panel. However, evacuation risks and staff training still needed attention.
“The provider had made significant improvements to the fire safety within the home, such as new fire doors and a fire panel.” from the report
Some infection measures were assured
Inspectors were assured that visitors were protected from catching and spreading infections, and that outbreaks could be prevented or managed.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Some required notifications were made
The provider had made relevant notifications to CQC since the previous inspection.
“We noted that the provider had made appropriate notifications to CQC where these were relevant since the last inspection.” from the report
Unsafe moving and handling
seriousStaff used equipment that raised safety concerns, and one technique observed by inspectors could cause a serious injury. Many staff had not completed or renewed their moving and handling training.
“The provider had failed to manage risks to people's health and safety. This placed people at risk of harm.” from the report
Medicines were not safely managed
seriousInspectors found problems with as-needed medicines, time-sensitive medicines, patches, staff competence and controlled drug records. Audits had not identified the problems found during the inspection.
“People's medicines were not being properly and safely managed. This placed people at risk of harm.” from the report
Fire evacuation risks
seriousFire doors on upper-floor evacuation routes did not automatically unlock and could delay evacuation. Some staff had not received fire training or taken part in fire drills.
“They continued to pose a risk to people's safety in that they did not automatically unlock and could impede timely and safe evacuation of people in the event of a fire.” from the report
Weak incident and safeguarding processes
seriousThere was no clear incident reporting process. Inspectors were not assured that injuries or safeguarding concerns would always be investigated quickly and properly.
“The provider failed to have clear incident reporting procedures in place. This placed people at risk of harm.” from the report
Infection control was inconsistent
seriousInspectors found shared equipment, dirty or damaged items, missing cleaning records and limited infection control training. Some areas still needed cleaning.
“The provider had failed to ensure that systems to prevent and control infection were implemented effectively.” from the report
- 01Have all staff who move people completed current practical moving and handling training, and what equipment is now being used?
- 02How do you check that medicines, including as-needed and time-sensitive medicines, are given correctly every time?
- 03Are controlled drug registers now complete and available, and how are medicines audits checked for effectiveness?
- 04Have the upper-floor fire doors been fitted with automatic releases, and have all staff completed fire training and drills?
- 05How are injuries, incidents and possible safeguarding concerns reported, investigated and reviewed?
This was a targeted inspection of specific concerns linked to warning notices for Regulation 12 and Regulation 13, not a full assessment of all five key questions, so the previous overall Inadequate rating carried over. This explanation was written from the published report of 7 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Forest Brow Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023Inspected but not ratedSafe: Inspected but not rated
- January 2023Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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