CQC report explained · a residential care home
What the CQC found at Forest Edge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found missing post-fall observations, incomplete follow-up of incidents and no risk assessment for one person at risk of choking. Records for prescribed creams also had gaps, although staffing, infection control and oral medicines had improved.
- Effective?
- Good
- People's needs and choices were assessed, staff training and supervision had improved, and people were supported with food, healthcare and day-to-day decisions. The home had also improved its environment and care planning.
- Caring?
- Good
- No separate Caring rating was given in this report. Inspectors observed kind, compassionate and person-centred interactions, and said staff knew people well.
- Responsive?
- Good
- Care plans were person-centred and included communication needs. The home provided activities, trips and opportunities to maintain relationships, and had a complaints process.
- Well-led?
- Requires improvement
- The provider had not reported three significant incidents to CQC. Audits had not identified some problems with medicines, falls and incidents, although people, relatives and staff were positive about the management.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found kind and effective care, but important safety and management checks were not reliable and the home is no longer in special measures.
This was an unannounced follow-up inspection on 16 and 18 May 2023. One inspector and an Expert by Experience spoke with people, staff, relatives and health professionals. They reviewed care, medicine, staffing and management records.
The home had improved since its previous inadequate rating. People were treated kindly, received suitable food and activities, and were supported to access healthcare. The home was clean and had enough staff during the inspection.
However, inspectors found that risks from falls and choking were not always assessed or followed up. Post-fall observations were missing, some incidents were not fully investigated, and records for prescribed creams had gaps. The provider had also failed to report three significant incidents to CQC.
The overall rating changed from Inadequate to Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective and Responsive were rated Good. The home left special measures, but CQC asked for an action plan and will continue to monitor progress.
Kind, person-centred care
Inspectors saw respectful and compassionate interactions. Staff knew people well and supported their choices.
“We observed people received person-centred care and support. During the inspection we saw many lovely interactions with people and staff, and it was clear staff knew people well and wanted the best for them.” from the report
Staffing improved
There were enough staff during the inspection. Staff were not rushed and responded promptly to requests for help.
“People and relatives felt staffing levels were sufficient. We observed staff were not rushed and responded promptly and compassionately to people's requests for support.” from the report
Activities and relationships
The home had a fuller programme of activities, including music, games, outings and seasonal experiences. People were observed taking part and enjoying them.
“Activities observed during inspection showed people were engaged and enjoying activities.” from the report
Improved environment
The home had been refurbished, with improvements to flooring, furniture, bathrooms, signs and lighting. Changes were also made to better support people living with dementia.
“Following the last inspection, the provider had refurbished the home. This included new flooring, furniture and bathrooms.” from the report
Falls and other risks
seriousPost-fall observations were not recorded, including after possible head injuries. Some incidents were not investigated or acted on, and one person at risk of choking did not have a supporting risk assessment.
“While viewing records we saw 3 incidents that required further investigation and 4 incidents had not been followed up or actioned.” from the report
Prescribed creams
needs fixingSome records had gaps showing when prescribed creams were applied. Inspectors could not be assured that people always received them as prescribed.
“Gaps were identified on some records for prescribed creams which meant we could not be assured people always received their prescribed creams.” from the report
Incidents not reported to CQC
seriousThree incidents that should have been reported to CQC had not been notified. This was a breach of the registration regulations.
“We viewed 3 reportable incidents that had not been reported to CQC.” from the report
Management checks missed problems
needs fixingThe provider had audits, but they had not found the concerns about medicines, accidents and incidents identified during the inspection.
“They had not identified the concerns we found during this inspection, including but not limited to concerns about medicines management, and the management of accidents and incidents.” from the report
- 01What changes have been made to ensure post-fall observations are completed, including after unwitnessed falls or possible head injuries?
- 02How are choking risks identified, recorded and shared with staff in each person's care plan?
- 03How do you now check and record that prescribed creams have been applied every time?
- 04What system makes sure all significant incidents are reported to CQC within the required timescale?
- 05How do your audits now check falls, incidents and medicines, and what happens when a problem is found?
This was an unannounced follow-up inspection focused on action from the previous inspection and infection prevention and control under Safe; for key questions not inspected, previous ratings were carried forward. This explanation was written from the published report of 1 July 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
Overall rating remains Inadequate and special measures continue; inspectors found improvements in management and infection control, but the home was not fully reassessed.
This was an unannounced targeted inspection on 27 January 2023. One inspector spoke with the managers and checked records, audits, policies and risk assessments. The inspection followed a warning notice about how the home was being managed.
Inspectors found that the warning notice had been met. Management systems had been strengthened, new audits were in place, and improvements had been made to the environment, training and cleanliness. However, some cleaning work was still unfinished and high-touch points were not included in cleaning schedules.
This inspection looked only at specific parts of Safe and Well-led. It did not review either area fully, so those ratings were not changed. The overall rating remains Inadequate, and the home remains in special measures. Inspectors said the provider was still in breach of other regulations identified at the previous inspection.
Governance improved
The home had introduced new audits and stronger checks on the quality and safety of care. Inspectors found that the warning notice about good governance had been met.
“Enough improvements had been made, the provider was no longer in breach of Regulation 17 (Good governance).” from the report
Stronger management team
The management team had been expanded, with a deputy manager and two new heads of care appointed.
“Following the last inspection, the registered manager had strengthened the management team.” from the report
Environmental improvements
Changes had been made to support people living with dementia, including better signage and lighting. Worn tables and a stained stairway carpet had also been replaced.
“At this inspection all the tables had been replaced and a new carpet was in place.” from the report
Training action
Training had been completed in areas including dementia, the Mental Capacity Act and first aid. Further specialist training had been booked.
“Training had now been completed in areas such as dementia, MCA and first aid.” from the report
Other breaches remained
seriousThe report says the provider was still in breach of regulations from the previous inspection. These included staffing and training, medicines, premises, person-centred care, risk management and decisions for people who lacked capacity or had fluctuating capacity.
“The provider remains in breach of regulations found at the last inspection.” from the report
Cleaning was not fully complete
needs fixingFurther refurbishment was needed in communal bathrooms. Cleaning schedules also did not cover high-touch points when inspectors visited.
“Whilst there were cleaning schedules in place, these did not include the cleaning of high touch points.” from the report
Visits were still restricted
minorVisitors could visit, but they could only see people in their rooms. The home had planned a meeting with relatives about opening communal areas to visitors.
“However, the provider was still cautious about the risks of transmitting COVID-19 and visitors could still only visit people in their rooms.” from the report
- 01What has been done, and by when, to address the remaining breaches about staffing and training, medicines, premises, person-centred care, risk management and mental capacity decisions?
- 02Have cleaning schedules now been updated to include high-touch points, and has the remaining bathroom refurbishment been completed?
- 03How often are the new audits completed now, and how are you checking that they identify and fix problems?
- 04When will relatives be able to visit people in communal areas as well as in their rooms?
- 05What evidence can you show of the training completed in dementia, the Mental Capacity Act and first aid?
This was a targeted inspection of specific parts of Safe and Well-led, including infection control and the Regulation 17 warning notice; it did not fully assess any key question and did not change the existing ratings. This explanation was written from the published report of 3 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 Edge
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- December 2022Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateWell-led: Inadequate
- November 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2020Goodstayed GoodSafe: GoodEffective: GoodResponsive: Requires improvementWell-led: Good
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Registered with the Care Quality Commission on 28 February 2014.
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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