This focussed inspection took place on 6 and 7 December 2018 and was unannounced. Following a comprehensive inspection in May 2018 we rated the service as good overall with no breaches of legal requirements. This shorter inspection was carried out due to concerns that were raised with us.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At our previous inspection in May 2018 we made a recommendation regarding the systems for oversight of medicine administration. At this inspection we found some additional shortfalls in the management and administration of medicines, and have made a recommendation regarding the safe management of medicines.

We have made a recommendation that the service notifies CQC of all required notifications as required by the regulations.

We found some shortfalls in risks to people regarding some aspects of the premises. This was a breach of regulation. You can see what action we told the provider to take at the back of the full version of the report.

We identified shortfalls in the provider's governance, audit process and quality monitoring systems. Quality assurance systems were in place to monitor the quality of the service but had not identified all the issues found at inspection. This was a breach of the regulation. You can see what action we told the provider to take at the back of the full version of the report.

The registered manager and management team responded constructively to issues raised and stated the required improvements would be actioned as soon as possible.

Forest Hill House Nursing Home is registered to provide accommodation, nursing care and support for up to 36 older people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Forest Hill Nursing Home offers accommodation over three floors with lift access to each floor. People had access to bright, comfortable communal lounge and dining areas, a conservatory and accessible garden and outside space for people to enjoy in the warmer months. At the time of our inspection there were 22 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Immediately prior to this inspection we received information of concern regarding the risk people were not receiving appropriate safe care and support. We reviewed this information and carried out an inspection focussing on the questions, is the service safe? And is the service well led?

People told us they were well cared for and said they felt safe living at the home. Staff were aware of what constituted abuse and the actions they should take if they suspected abuse. Relevant checks were undertaken before new staff started working at the service which ensured they were safe to work with vulnerable adults.

There were sufficient numbers of appropriately qualified staff available to ensure people were cared and supported safely. Staff had the right skills and training to support people appropriately, and were supported to develop their training further if they wished. There was a programme of training that covered all core training requirements as well as additional training courses that staff may require for further development.

Staff spoke knowledgeably regarding infection control procedur

Forest Hill nursing home is a residential care home for up to 36 older people with dementia and mental health needs. The building offers accommodation over three floors with lift access to each floor. People have access to communal lounge and dining areas, a conservatory and accessible garden and outside space. There were 26 people living at the home at the time of inspection.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People were protected from the risks of abuse because staff understood the potential signs and how to report concerns. There were sufficient numbers of safely recruited staff available to meet people’s needs and staff knew people well and understood the risks they faced and how to manage these. Accidents and incidents were reported, recorded and learning shared with staff. People received their medication safely and these were mostly recorded accurately. Although medicines were audited, these were only completed monthly so there was a delay in picking up errors.

We have made a recommendation about the systems for oversight of medicine administration.

People were involved in pre-admission assessments which identified their physical, religious, emotional and mental health needs to ensure that these could be effectively met. There were assessments of capacity and decisions made in people’s best interests where required. People had a choice of meals and drinks and spoke positively about the food. Staff received regular support through supervision and had access to relevant training opportunities to provide them with the correct skills and knowledge for their role.

People were supported by staff who were kind and compassionate in their approach. We observed the use of gentle, tactile contact and staff communicating with people in ways which were meaningful for them. People were offered choices about how they spent their time and were supported with respect by staff who protected people’s dignity and promoted their independence. Visitors were welcomed whenever they wished to visit and were encouraged to feedback through regular meetings and annual surveys.

People’s care records showed that their support was reviewed at least monthly and was therefore responsive to changing needs. People were supported by staff to engage in a range of social opportunities and the registered manager explained about plans to make activities more person centred at the home. People and relatives were aware about how to raise concerns if needed and felt that these would be listened and responded to. End of life care was person centred and planned with people to ensure that wishes and preferences were understood and respected.

Feedback from people, relatives and staff was that Forest Hill was well managed. Everyone spoke positively about the registered manager who placed an emphasis on ensuring they worked with staff on shifts and was available and approachable. Feedback was gathered and used to drive changes at the home and audits were used to identify any gaps or trends to continually improve the service people received.

Further information is in the detailed findings below.

This unannounced inspection took place on 14 and 26 January 2016 by one inspector. The home is a residential nursing home and provides nursing, support and personal care for up to 36 older people including some who had dementia. At the time of our inspection there were 32 people using the service.

The home had a lift so people could travel from the ground floor to their rooms on the first and second floor. There was a large outdoor area including an open garden space for people to enjoy.

The home was last inspected on the 27 September 2013 and found not to be meeting the standards in the safety and suitability of premises. We found that the home did not have appropriate measures in place to ensure the security of the premises, or to consider the risks presented by the garden pond and greenhouse. The home had also inappropriately placed broken equipment in the grounds.

At this inspection improvements had been made to the safety and suitability of the premises. Broken fixtures had been repaired, the pond had been covered with a safety guard and hazardous items had been removed or safely secured.

The manager who was a registered manager had been at the service since 2015. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was safe because there were sufficient staff to meet people’s needs. Staff were available to support people with their nursing care needs and to assist people when they were involved in their personal, social and leisure activities. Employment checks were carried out when staff were recruited. This meant that prospective staff with the appropriate qualifications, experience, skills and abilities were suitably screened before they were employed.

Medicines were stored in a locked trolley and staff carried out medicine administration safely. Medicine charts were completed and signed in line with the policy. Where errors were identified these were safely and swiftly managed. Controlled drugs, used to treat pain and other complex symptoms, were stored in a separate locked wall cupboard in line with current legislation.

People were safe because staff were aware of how to protect people from harm and explained how they would report, record and manage a safeguarding incident. People and their relatives made comments about the safety of the home. One comment included, “You couldn’t feel safer here” and “I’ve never felt unsafe here, there is lots of staff and the place is very secure”.

Accidents and incidents had been reported, investigated and recorded. These were monitored by the registered manager. When risks were identified, for example the risk of falls or the risk of injury from accidents, these were reviewed and measures were taken to reduce the likelihood of further incidents. People had individualised personal evacuation plans for staff to follow in the event of an emergency.

Staff at the home followed the guidelines of the Mental Capacity Act (MCA) 20015 and people were supported and cared for when they had Deprivation of Liberty Safeguards (DoLS) in place to protect them from harm.

People received support from healthcare professionals to meet their on-going health and well-being needs. People explained they were given optical tests and foot care from services they visited or when these services visited the home. Several people required hearing devices which were kept clean and well maintained.

People were encouraged to make decisions about their care and were supported in making choices and achieving their goals. Records included people’s signatures where this was possible and where people were able to contribute.

Meal times were a relaxed and social experience for people. If people were hungry in betw

We found that people understood the care, treatment and support choices available to them. We found that people were involved in making decisions about their care and had their privacy and dignity respected. A person told us, "I can choose when I want to go to bed and get up." Another person told us, "They are very good at explaining things."

People's needs were assessed and planned, and the home delivered care that protected their welfare. A person told us, "I have been here since 2008. My dressings are looked at regularly. They ask my permission before they do anything." The home also had arrangements for dealing with foreseeable emergencies.

The home had policies and procedures to protect people from abuse and that their human rights were protected. A person told us, "The atmosphere is really nice here."

The design and layout of the home was suitable for people's needs. However, the home did not have appropriate measures in place to ensure the security of the premises, or to consider the risks presented by the garden pond and greenhouse. The home had also inappropriately placed broken equipment in the home's grounds.

People had their needs met by sufficient numbers of staff. The home also had systems for monitoring the quality of service people received.

We were informed that there were twenty nine people living at Forest Hill House Nursing Home. We looked around the building which was clean and free of unpleasant odours. The majority of rooms were single occupancy with their own en-suite with a shower. The rooms were personalised with photographs, TV’s and pictures and some people had their own furnishings. There was a lift so people could access the first and second floor.

During our visit we spoke with two people who used the service and four members of staff including the registered manager. We spent time observing how staff interacted and supported people. We saw staff treating people in a sensitive, respectful and professional manner.

All the people we saw looked happy living at Forest Hill Nursing Home. People told us that it was a good place, and that the staff were helpful. One person said the staff were lovely and very kind, another said they were wonderful.