Forest Place Nursing Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Requires improvement

• Responsive

  Requires improvement

• Well-led

  Inadequate

Our view of the service

We carried out a responsive assessment of Forest Place between 27 February and 24 March 2025. This assessment included a site visit on 27 February 2025. The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls, unsafe equipment, risk management and governance.

This inspection examined those risks.

Two inspectors and an expert by experience visited the service. Forest Place is a nursing home that can accommodate up to 120 people, some of whom live with dementia. At the time of our assessment visits there were 90 people living at the service. We carried out this assessment due to concerns identified around safe care, safeguarding and overall governance.

We have found breaches at this inspection in relation to safe care and treatment, safeguarding adults, medicines management, consent, meeting people’s personal care and dignity needs and overall, the management of the service.There were widespread and significant concerns in relation to risk management, including failure to identify, assess and mitigate risks of falls, and risks associated with people’s health needs. Incidents were not effectively monitored and analysed to reduce those risks and to support staff learning. Safeguarding incidents had consistently been identified or reported. The management systems for checking quality were not effective in identifying shortfalls, including in the administration of medicines, poor record keeping and failures to deliver personal care. Staff did not receive the specialist support they needed, and deployment of staff did not meet peoples needs. People were not consistently receiving the support they needed, even when this was on a one to one basis and care was not personalised. There was a lack of organised activities, and people were at risk of isolation. People were unlawfully deprived of their liberty and staff had not assessed what the least restrictive method was to keep some people safe from harm.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this on our website after any representations and / or appeals have been concluded.

This service is in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

People's feedback about their experience was variable. People told us they felt their care was safely managed, but our findings showed there were ongoing risks to people which had not been identified, reported, managed or monitored to ensure people were safe and protected from harm., We found instances where people had experienced harm which was preventable.

People and relatives told us they felt safe with the care received. However, our findings demonstrate that care was not consistently provided in a way that safely met people’s care needs.

Peoples experience of staffing levels was variable. Some people said there were enough staff, others were less positive. People were not an active partner in planning their care, although some people and their relatives told us they were involved in the planning of their care, this was not always documented which demonstrated it was in line with statutory requirements. Decisions around individual people’s capacity and how to care for people in their best interests were made by staff with no communication with the person or their representative.

People did not experience care that took account of their strengths, abilities, aspirations, culture, unique backgrounds and protected characteristics. People did not always receive person-centred care. They were not supported to access information in accessible information formats that they could understand to aid communication. Feedback from people, relatives and others showed the provider and management team did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. People were not supported to stay in touch with their community or maintain and develop interests and hobbies.

Overall their experience was less positive due to the widespread failings in the overall management of the service to identify and sustain improvements to the wider care delivery.

People and relatives felt that staff were kind and caring towards the people they supported. Staff seen were observed to be kind, caring and supportive to people.