CQC report explained · a care home with nursing
What the CQC found at Forest Care Village Elstree and Borehamwood
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2022
Rated Good; inspectors found kind, personalised care, with some improvements still needed in short-stay records, staffing and communication.
The home provides personal and nursing care for up to 178 people with complex needs. At the inspection, 143 people were living there. The inspection was unannounced and included conversations with people, relatives, staff and health professionals, observations of care, and checks of care plans, medicines and quality records.
All five areas were rated Good. People and relatives said care was safe, kind and personalised. Inspectors found that staff managed risks and medicines safely, supported people with food and healthcare, respected people's choices and dignity, and provided a range of activities.
Inspectors also found areas the home needed to improve. Records and care plans for people staying briefly after hospital were not always accurate or personalised. Staff reported some shortages of nursing staff, and the home had identified weaknesses in communication, record keeping and clinical leadership for the short-stay unit.
Kind and respectful staff
People and relatives consistently described staff as caring, kind and respectful. Inspectors also saw friendly interactions between staff and people.
“Every person we spoke with told us staff were caring and respectful.” from the report
Safe care
Staff understood safeguarding procedures and people's risks. Medicines were given by trained staff whose competence had been checked.
“People's medicines were managed safely by trained staff whose competency to administer medicines were assessed.” from the report
Personalised support
Care plans included people's likes, dislikes, needs and abilities. People said they were involved in planning their care.
“People's care plans were developed well and had information about their likes and dislikes as well as guidance for staff about how to meet people's needs effectively.” from the report
Activities and relationships
People could choose from varied activities, and staff spent time with people who stayed in their bedrooms. Activities were optional and adapted to people's interests and abilities.
“Activities provided were varied to ensure everyone could choose what they liked to do depending on their interest and abilities to participate.” from the report
Quality monitoring
Managers used audits, meetings and an improvement plan to identify problems and check that actions were completed.
“Actions were clearly detailed and signed off for completion by the registered manager.” from the report
Short-stay care plans
needs fixingCare plans for people staying temporarily after hospital were not always current, accurate or personalised. The registered manager had identified this and had plans to improve it.
“Care plans for people who were only spending a short time in the home following a stay in hospital were not always up to date, accurate or personalised.” from the report
Communication and leadership improvements
needs fixingThe home had identified some ineffective communication with health professionals and relatives, along with a lack of clinical leadership for the short-stay unit. Record keeping also needed improvement.
“They identified the lack of clinical leadership and management on the short stay unit, lack of effective communication in some cases with health professionals and family members and the need to improve record keeping.” from the report
Mixed views about manager support
minorStaff generally received regular supervision, but their views differed about the support provided by unit managers. The registered manager had plans to address this.
“Staff told us they received regular supervisions, however they had mixed views about the support they received from their unit managers.” from the report
- 01What changes have been made to make short-stay care plans accurate, current and personalised?
- 02Does the short-stay unit now have dedicated clinical leadership and management?
- 03How do you make sure there are enough nursing staff on each unit, including when permanent staff are difficult to recruit?
- 04How are concerns about communication with relatives and health professionals monitored and improved?
- 05How do you check that improvements to record keeping have been completed and remain effective?
This was an unannounced inspection that rated all five key questions; Safe improved from Requires Improvement at the previous inspection, while the other ratings remained Good. This explanation was written from the published report of 25 February 2022 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, February 2021
Forest Care Village Elstree and Borehamwood was inspected but not rated; inspectors were assured about infection prevention and control.
This was an unannounced, targeted inspection on 26 January 2021. It checked infection prevention and control measures during the COVID-19 pandemic.
Inspectors found good practice. They were assured about visiting arrangements, testing, PPE, social distancing, cleaning, safe admissions and managing outbreaks. Staff were trained in infection prevention and control, and people could use video or phone calls to contact family.
The home had updated policies, a pandemic business continuity plan and quality checks. The service was inspected but not rated, so this report does not provide an overall quality rating.
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including testing, PPE and social distancing.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Family contact
When visits were restricted, people could contact relatives by video or telephone. Some relatives could still visit where this was needed for health and wellbeing.
“People had access to video calls or phone calls to communicate with their family.” from the report
Clean environment
The home had extra cleaning tasks and schedules, with housekeeping staff allocated throughout the day.
“The service was clean and hygienic. Additional cleaning tasks and schedules had been implemented by the registered manager” from the report
Staff support and training
Staff had infection prevention and control training and said managers were available to support them.
“Staff told us they received Infection Prevention and Control (IPC) training, this included how to safely put and take off their PPE.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current rules for family visits, including any testing and PPE requirements?
- 02How often are staff and residents tested, and what happens when a positive result is found?
- 03How do you prevent staff from moving between units, and when might they be asked to work in another area?
- 04What activities and one-to-one support are available for residents who cannot have normal visits?
This was an unannounced targeted inspection of infection prevention and control practices during the COVID-19 pandemic; the service was inspected but not rated. This explanation was written from the published report of 13 February 2021 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 Care Village Elstree and Borehamwood
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Forest Care Village Elstree and Borehamwood →
- February 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Forest Care Village Elstree and Borehamwood →
- October 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2012
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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