CQC report explained · a residential care home
What the CQC found at Forge House Services Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were protected from abuse, infection risks and medicines errors, and staffing was sufficient. However, one falls risk assessment needed more detailed guidance and the process for recording maintenance concerns needed to be clearer.
- Effective?
- Requires improvement
- Care plans, food choices, health support, staff training and the environment had improved. Some records lacked names, dates and authors, and staff did not understand one person's sensory diet.
- Caring?
- Good
- Staff were kind, knew people well and supported dignity, privacy, choice and independence. People and relatives were involved in decisions about care.
- Responsive?
- Good
- Care and daily routines were personalised. People were supported to pursue interests, develop skills, use their preferred communication methods and spend time in the local community.
- Well-led?
- Requires improvement
- Management oversight, audits, incident reviews and the service improvement plan had improved. CQC said it needed assurance that these changes would lead to consistent good practice over time.
What inspectors found, May 2023
Forge House Services Limited was rated Requires Improvement; inspectors found much better, kind and personalised care, but safety, effectiveness and management still needed strengthening.
This was an unannounced comprehensive inspection on 29 March and 4 April 2023. Two inspectors visited the home, spoke with people and staff, reviewed four care records and examined management records. They also sought feedback from health and social care professionals.
The home had made significant improvements since its previous Inadequate rating. Care plans were more personalised, people had more choice and independence, and staff were kind and caring. People were supported with medicines, food, health care, activities and communication in ways suited to them.
Some problems remained. One falls risk assessment needed more detail, some care records were not properly identified or dated, and some staff did not understand a person's sensory diet. The home was no longer in breach of the regulations checked from the previous inspection, but CQC wanted to see the improvements maintained consistently.
More choice and independence
People were involved in decisions about food, activities and daily routines. Restrictive practices about healthy diets had stopped, and people were encouraged to develop skills and use their local community.
“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;” from the report
Kind and respectful staff
Staff knew people's preferences and supported them with kindness, dignity and compassion. People were comfortable approaching staff.
“We observed staff interactions with people which were caring and showed people were treated with kindness and compassion.” from the report
Personalised care planning
Care and support plans had been rewritten and gave staff clearer guidance about people's needs, goals and safe support.
“People's care and support plans had been rewritten and were more personalised and gave staff clearer guidance to support people safely.” from the report
Safer medicines support
Staff had specific medicines training. Medicines were given as prescribed, with suitable arrangements for storage, recording, checks and disposal.
“People received their medicines safely from staff who had received specific training to carry out the task.” from the report
Improved management oversight
The home had introduced more audits and a service improvement plan. Accidents and incidents were reviewed for patterns and learning.
“The provider had produced a service improvement plan (SIP) which set out the areas they were working to improve.” from the report
Falls risk assessment needed more detail
needs fixingA risk assessment for someone at risk of falling on the stairs did not give enough guidance for staff. The manager said it would be reviewed.
“We discussed with the registered manager the need to review a risk assessment they had put in place for a person who was at risk of falls when using the stairs.” from the report
Care records were not always complete
needs fixingSome records did not show the person's name, the date or who had written them. This could make it harder to track changing needs accurately.
“Not all care records displayed people's names, were not dated and did not show who had written them.” from the report
Training gap about sensory support
needs fixingStaff did not understand the sensory diet required in one person's behaviour support plan and had not received training about it.
“Staff spoken with did not know what this was and had not received training in this.” from the report
One consent assessment was missing
needs fixingA mental capacity assessment and best-interest decision had not been completed for one person's wheelchair seat belt. The manager said this would be done.
“Although we identified there was not one in place for one person who had a seat belt on their wheelchair” from the report
End-of-life plans were unfinished
minorOne person had an end-of-life plan, but plans for everyone else were still being completed.
“The registered manager confirmed they were working on completing end of life care plans for everybody at the home.” from the report
- 01What has been added to the falls risk assessment for using the stairs, and how do you check staff follow it?
- 02How have you ensured every care record has the person's name, date and the name of the person who wrote it?
- 03What training have staff received about sensory diets, and how do you check they understand the support needed?
- 04Has the missing mental capacity assessment and best-interest decision for the wheelchair seat belt now been completed?
- 05How are you monitoring the service improvement plan and the remaining end-of-life care plans?
This was an unannounced comprehensive inspection covering all five CQC questions and checking whether the provider had followed its action plan after the previous Inadequate rating. This explanation was written from the published report of 27 May 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, January 2023
Forge House Services Limited rated Inadequate and remains in special measures; inspectors found improvements but continued failures in risk management and person-centred care.
This was an unannounced targeted inspection on 15 December 2022. Two inspectors spoke with six people and four staff, observed care, and reviewed five people's care records and other service records.
The inspection checked whether the home had acted on earlier warning notices about person-centred care and safe care and treatment. The home had made improvements, including better incident reviews, infection control, healthcare support, communication, choice and activities.
However, some risks were still not properly assessed or managed. Some care plans did not give staff clear guidance, and personalised assessments and care plans were not complete. The overall rating stayed Inadequate.
The five individual areas were inspected but not rated because this was a targeted inspection. The home remains in special measures, so CQC will continue monitoring it and normally re-inspect within six months.
Better incident learning
The home had introduced a system to review incidents, look for patterns and identify learning. Incidents were also being reported to outside agencies.
“Incidents were now being reported to other outside agencies.” from the report
Improved infection control
Inspectors found that earlier cleanliness problems had been addressed. Cleaning schedules, infection control audits and staff training were in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
More choice and involvement
People were more involved in decisions about their care and everyday life, including choices about shopping and meals.
“People were involved in their choices and decisions regarding their care, including shopping, choosing and preparing some of their meals.” from the report
Communication support
Staff used individual communication methods to help people express their views and take part in planning their day.
“At the beginning of each shift a daily plan for care and activities was created by people using individual ways of communicating.” from the report
Choking guidance followed
Inspectors observed staff following one person's choking risk assessment. This had not happened at the previous inspection.
“During the inspection we observed one person's choking risk assessment being followed.” from the report
Incomplete risk guidance
seriousCare plans did not always give staff clear and accurate instructions about behavioural, physical or mental health risks. Some important support plans were not available to staff during the inspection.
“Care plans did not provide clear and accurate information to guide staff on how to support people's behavioural, physical or mental health needs.” from the report
Environmental safety risks
seriousInspectors found further risks, including a fire door wedged open and hot water that was too hot in communal bathrooms and toilets. The kitchen had been unlocked without a safety risk assessment.
“These included a fire door being wedged open, and hot water in communal bathrooms and toilets being too hot.” from the report
Personalised plans still incomplete
seriousThe provider remained in breach because personalised assessments and care plans were not fully in place. Plans also did not fully describe people's goals, aspirations and achievements.
“The provider had failed to ensure personalised assessments and care plans were in place.” from the report
Inaccurate care record
needs fixingOne care plan had not yet been reviewed and still contained inaccurate information about reducing the person's fluid intake after 6pm.
“one person's care plan that was yet to be reviewed still contained inaccurate information.” from the report
- 01Have all missing behavioural, physical health and mental health support plans now been completed and made available to staff?
- 02How have you assessed and dealt with the fire door, hot water and unlocked kitchen risks identified by inspectors?
- 03How do you check that each person's care plan is accurate and reflects their current needs, goals, aspirations and achievements?
- 04What evidence can you show of progress since this inspection and the previous Inadequate rating?
- 05How are you responding to CQC's special measures and the action plan requested?
This was an unannounced targeted inspection of the warning notices concerning person-centred care and safe care and treatment, with infection control also checked; it did not assess all parts of the five key questions, so the individual areas were not re-rated. This explanation was written from the published report of 25 January 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 Forge House Services Limited
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Forge House Services Limited →
- January 2023Inadequatestayed InadequateSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not rated
Read what inspectors found at Forge House Services Limited →
- November 2022InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2022Inspected but not ratedEffective: Inspected but not ratedResponsive: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
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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