Forest Place Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service was not safe and people were placed at risk of harm. We found breaches of regulation around safe care and treatment, staff training and support and safeguarding. The service failed to identify, plan for and effectively manage risks to people. The service also failed to ensure people’s medicines were managed safely and administered in line with the instructions of the prescriber. The provider failed to operate systems to identify and investigate possible abuse. The provider had not identified these issues independently and taken action to protect people. The service was in breach of legal regulations in relation to people’s safe care and treatment, medicines management, staffing levels and training, and their failure to safeguard people.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Our findings demonstrated that a culture of learning from events was not embedded within the service. Incidents had occurred which were not investigated and lacked the necessary learning to be shared among the staff team which meant that people continued to be at risk of ongoing unsafe care as those systems to continually identify and embed good practices were not in place.

Staff were able to tell us how they reported to management but were not able to describe how they were included as part of the reflective process to continually learn, identify and embed good practices. One staff member told us “I have reported incidents and injuries, and while I may not always receive detailed feedback on the outcome, I appreciate that management takes the time to follow up when needed. I am hopeful that more detailed updates will be shared in the future.” A second staff member said, “I have reported an incident to the management. I followed the correct protocol and documented the incident. The management investigated the issue, took appropriate action, and ensured the resident’s safety. I later learned that measures were implemented to prevent recurrence.”

In discussion the home manager recognised the routine around pad changing by the staff needed to change but had told us it had been “More about the time of day and to suit the staff.” They had not considered the personal care concerns and routine pad changes as a contributing factor.

There were not established systems in place to improve the quality of care and mitigate recurrence through learning and reflection. The investigations regarding incidents were not robust and did not seek to find ways to prevent recurrence, consider themes or trends, or consider wider factors that may contribute to those incidents. For example, 6 people were identified with moisture lesions in the home. The management team did not consider the trend or review the timeliness of the personal care delivery that may have been a cause. Since December 2024 incident logs showed an increase in unwitnessed injuries including for those people being supported with 1:1 care. There had been no analysis or shared discussions among staff to identify the root cause of this increase. Strategies to understand and mitigate this increase were only put in place following CQC and partner agency requests to carry out competency checks of staff, provide additional training and update body maps which record the sites of wounds.

People told us they felt their care was safely managed and staff worked with partners to deliver good levels of care. One person’s relative said, “We really feel [Person] is in safe hands here and I can't thank the carers here enough for how [they]are kept safe and looked after.” A second relative said, “The fact [Person] can no longer walk has to do with the deteriorating condition not the care they are receiving. The only thing I would say is [they] might benefit for getting up a bit more, like I don't think it's good for [them] to be in that chair all the time.” Our findings during this assessment demonstrated that care was not always safely managed or monitored for all people. For example, lack of pressure monitoring, inappropriate use of bed rails and a lack of personal care delivery. Some people were not supported to access external services such as dentist or specialist services. One relative said, “We sort [Person’s] eyes out by getting our own optician in, the same with other personal needs, [Person] hasn't seen a dentist yet.”

The home manager told us initial assessments were completed by themselves or the senior team. Deputy managers or unit managers were responsible for then developing the ongoing risk assessments and care plans. The provider told us they were aware that care plans were not currently fully complete and did not describe people’s clinical, social or personal care needs robustly. Care staff were not included in formal reviews of people’s care which meant the care plan did not include the information they knew about, so it was reflective of people’s choices, preferences, social and personal care needs and choices. Through this assessment we were told by the provider that additional training was being implemented and that a holistic approach would be taken to reviewing people’s care across all levels of staff.

Feedback from professionals was variable. It demonstrated that staff engaged with professionals when needed, although not always in a timely manner, or when concerns were identified or delayed. For example, we were told that the Fastrack pathway had not been used and staff had, relied on the GP to do so. The fast-track pathway should identify individuals who need to access NHS continuing healthcare quickly with minimum delay. Referral to the GP inevitably causes a delay when speed to meet their needs is most important

Concerns were raised by visiting professionals regarding the number of people cared for in bed. One visiting professional informed us that a person’s relatives were frustrated that their relative was not assisted out of bed. Another professional had assessed them and considered they could be out of bed daily for a few hours. This had not been acted upon. We found similar concerns following this feedback where people’s health and quality of life may deteriorate as a result of being unnecessarily cared for in bed 24 hours a day.

A system was in place but not operated effectively to identify and mitigate the risks to people. Guidance to support people with complex health needs including pressure/wound care, constipation, safe moving and handling of people, or distressed behaviour were not always in place or sufficiently detailed to inform staff how to support people safely. The provider failed to ensure effective processes were operated by staff when a person was found to be at risk of entrapment. An audit of one person’s mobility and use of bed rails found conflicting information in the care records. The record stated rails were not to be used but were in place. The person could remove the bumper and there was a risk of injury from doing so. The audit asked for this to be reviewed, but it was not and on the following day the person was found with an injury from entrapment in the rail.

We found evidence in people’s care plan of health professionals being involved in managing people’s health in the home. There was also a GP visit during our inspection with the nursing staff, and the GP reviewed some people whose health needs had changed. Care records and relative feedback however demonstrated that staff did not consistently refer people when needed and were prompted to call the GP to discuss a health change observed by a relative not by staff.

Any injuries staff observed like bruising, skin integrity concerns, had been referred to the GP or other specialist health care professionals and staff followed their advice in managing people’s health. Some care plans had information about the pre-assessments and how staff doing these assessments considered people’s needs before admission.

Overall people and their relatives said they felt safe living at Forest Place. We received comments such as, “We feel [Person] is safe with the friendly and helpful staff.” “We really feel [Person] is in safe hands here and I can't thank the carers here enough for how they keep them safe and looked after.” However, we have reported elsewhere in this report that some people’s rights and freedoms were not adequately protected. Some people experienced increased intrusive checks and restrictions without appropriate authorisation. People had experienced harm, which was preventable, such as from falls, moisture lesions, bed rail entrapment and injuries.

Staff said they would raise concerns to the unit manager or nurse in charge. They said the concern would then be investigated and reported to the home manager and relevant local authority if this was a safeguarding concern. However, this process had not always occurred. The provider carried out an audit of the electronic reporting system after our visit. They found that the system had been set up, so managers did not see the outcome of incidents when reported. Examples were which although recorded by staff, had not been raised with managers or the provider. The provider could not be aware of the types, frequency or severity of incidents recorded as they were not required to sign these off to complete the process.

We observed that people had restrictions applied to their freedom without establishing if this was in their best interest and whether they had the capacity to consent to them. For example, inappropriate use of bed rails, walking frames placed out of reach, and excessive periods of time in bed with a lack of positional changes to promote healthy skin care. Despite this, we also saw kind and warm interactions from care staff with people, and examples of staff engaging with people when unsettled to provide them with reassurance and comfort. People we saw were comfortable in the presence of staff, interactions between staff and people living in the home were kind and respectful.

However, systems for caring for people on a 1:1 basis were not all supported in the least restrictive or intrusive way. For example, people when agitated were placed on 15 minute observations when there had been incidents of distress. However, staff were in people’s bedrooms at all times, not observing in line with the care plan. These observations were about watching a person and did not seek to meaningfully engage to assess their emotional or mental state. Records did not clearly state the reason for the enhanced observations, what the aim of the observations were, and when they might be reduced. This ongoing approach did not demonstrate a least restrictive approach.

We found staff recorded incidents, injuries or safeguarding concerns. However, leaders in the home did not then follow the provider's safeguarding policy to investigate and report all safeguarding concerns. The investigation by leaders including the home manager did not consider whether the person had been at risk of harm or had in fact experienced harm. The management team failed to act to make sure people were safe living at the service. For example, they could not demonstrate they had reviewed the safe use of bed rails following incidents, explored the unnecessary development of moisture lesions and pressure wounds, risk assessed the environment to reduce falls. They had not implemented the recommendations of previous substantiated safeguarding outcomes. We further identified poor systems where a staff member investigated a concern and signed it off as the manager without this being reviewed.

Because detailed analysis of incidents, injuries, wounds safeguarding concerns were not completed ongoing risks were then always not identified. This meant the management team were not aware of the ongoing risks as these had not been escalated. They did not raise safeguarding concerns with the local authority or report them to CQC as required.

When safeguarding alerts were made to the local authority these were not always reported in a timely way.

People and relatives told us they felt safe with the care received. However, we have reported elsewhere in this report that care was not consistently provided in a way that safely met people’s care needs.

Staff feedback about meeting people’s needs in a supportive way was mixed. One staff member told us they felt the lack of training and support had led to the incidents or injuries identified through this inspection. They said, “In the last 8 or 9 months, the management has not observed my competency in any areas. I know that the carers have received support from head office [in the last couple of weeks] with training and competency assessments for personal hygiene, skin care and manual and handling. I believe this should have been done earlier to prevent issues and incidents.”

We observed significant number of people, around 50, were cared for in bed. Most received limited time with staff for personal care and in many cases received no personal care despite it being within their plan of care and assessments. We reviewed people’s daily care records for a 14 day period prior to our visit. People’s care records identified that they preferred to be out of bed, washed and dressed yet for many of these people they did not receive this care. Some people refused their morning personal care, but staff did not return later to offer a wash or change of clothes.

Records showed that 31 people were prescribed at least one antipsychotic medicine. Most people were referred to the GP following an incident such as agitation or aggression. These were clinical decisions and the care staff who supported these people daily were not involved. Staff did not have the necessary training or awareness around the behavioural and psychological symptoms of dementia or ways to engage people positively so could not demonstrate they had looked at alternative person centred approaches.

Risk of people developing skin integrity concerns were not managed well. The provider ensured that the right preventative equipment was in place, however people’s personal hygiene needs were not always met. We found significant gaps in people’s personal care records and some people only had a full body wash in a 24-hour period although they had incontinence. This lack of personal care was confirmed with the provider as not being provided. This likely contributed to the moisture lesions and further skin concerns we identified. Those moisture lesions were recorded by staff in people’s care records; however, these were not always reported to management so they could monitor this more closely. The provider told us at the inspection they were aware of one lesion, however when we asked for this to be reviewed, we found there were more in place.

People who needed to have a specific air-filled mattress in place to prevent or aid the healing of pressure related injuries were left at risk by the mattress pump not being set at the pressure indicated by their weight.

Risk assessments were developed for different areas, for example, bedrails, falls and choking. However, risk assessments and the care plans were not detailed enough to demonstrate what was in place to mitigate such risks. For example, bedrails were in place for some people who had agitation and lived with dementia. The Health and Safety Executive [HSE] guidance warns against using bedrails in these circumstances due to risk of falling or climbing over the rails. The risk assessments or care plans for these people did not include these recommendations. For people at risk of choking and prescribed modified diets, their care plans gave little detail as to how staff needed to support them safely.

Care plans were also conflicting in information recorded. For example, for one person the care plan indicated the person needed repositioning every 2 hours. At the end of the same page it stated the same person needed repositioning every 4 hours.

People spoken with did not comment on the environment, facilities or use of equipment to deliver safe care. However, we have reported elsewhere in this report that people were not consistently protected from the risks associated with the use of equipment, such as bed rails or hoists.

Staff told us they were not aware of any risks in the environment. They raised no concerns when asked about equipment. Given the concerns identified by this assessment this demonstrated a lack of understanding and awareness of potential risks and impact on people being cared for.

Risks presented by the use of equipment to support people were not always thoroughly assessed or recognised. For example, we observed ill-fitting bedrails in use, where gaps between the end of the bed and rails were bigger then recommended by the Health and Safety Executive [HSE]. Bumpers were placed over the bedrails to minimise the risk of entrapment and injuries; however, these were also ill fitting in some cases and left a considerable area of the metal bedrails uncovered. This increased the risk of injuries to people. We identified one example where a person had become entrapped recently and sustained bruising.

The provider was aware of more recent changes in HSE guidance about using special beds and bedrails for people whose height or body mass index (BMI) were considered atypical (smaller or lower than average height and weight of an adult). However, records and practice did not show this guidance had been followed. For example, one person had a BMI of 17 was being cared for in a standard specialist bed and standard bedrails. There were no risk assessments or reference in the care plan of how the risk was mitigated sufficiently for this person not to have a bed and bed rail as detailed by HSE guidance.

Pressure mattresses in use were not set to the correct pressure setting placing people at increased risk of skin breakdown. Pressure wounds acquired had occurred within the service for people who were cared for in bed for extended periods.

We observed hoists stored in corridors where people had access, and this presented a trip hazard.

There was a plan of scheduled maintenance in place. Health and safety checks including fire were undertaken to reduce risks to people. However, the provider had not taken action to minimise environmental risks of injury. Bedrails and bumpers were not fitted in line with health and safety requirements placing people at risk of entrapment. An audit identified this risk and asked staff to act, but we found an incident where a person had trapped themselves within the bed rail and mattress. The provider had taken action to address the air pressure mattresses being incorrectly set. They asked staff to regularly monitor through the day and night. However, we found a number continued to be set incorrectly. Systems to review incidents were not always robust. For example, it had not been explored whether hoists left in a corridor could have contributed to a person’s fall which resulted in injury. Staff noted this person had been close to the hoists stored in the corridor prior to the accident.

Peoples experience of staffing levels was variable. Some people said there were enough staff, others were less positive. One relative said, “Staff wise they seem to be enough around.” A second relative said, “These carers seem well enough trained, have a good attitude and go about their jobs confidently and well.” However, one person said, “Sometimes when I ring my bell, I have to wait a long time before anyone comes to help me.” A relative said, “My perception is they're short staffed I think they're shorthanded even though you see a lot around.”

Feedback from staff around training and supervision was variable. Some staff felt training met their needs and felt supported, others were not as positive. One staff member said, “Yes, I receive supervision every few months, where we discuss workload, challenges, and development needs.”

A second staff member told us, “I believe it would be beneficial to have more frequent face-to-face training in areas like syringe driver use, end-of-life care and medication. Additionally, it would be helpful if we can have additional training for carers, for example, challenging behaviours and dementia, those to include the care staff as well with end-of-life care and medication.”

A third staff member told us that although they received training, they found staffing deployment challenging and said management did not support them through regular reviews. They said, “Yes, we receive regular training, in areas such as dementia care and safeguarding. Staffing levels vary, but at times, we do experience shortages, which can make it difficult to provide the highest level of care.”

“I have not had regular supervision [for six months], and if I recall correctly, the last supervision was [not with my line manager], During that meeting, they asked if there was anything they could help or support with, but the main purpose seemed to be for them to get to know me better. Unfortunately, I did not feel that it was particularly helpful or supportive.”

Staff were very busy during the site visit element of the assessment. We observed people being supported by staff, however deployment over the floors and units was inconsistent. On one unit there were no staff present in communal areas other than one housekeeper. All other staff were supporting people in their bedrooms on the same floor. In this area people had been identified as being at risk of falls. The service had an increase in falls, but staffing levels had not been considered as a way to reduce those risks. We observed a person who was nearing the end of their life and would have benefitted by being monitored and supported more closely, however this was not factored in the staffing deployment.

Staff did not have the skills, knowledge and competence to support people in line with their care plans and risk assessments. For example, care staff did not undertake skin integrity, pressure care or moisture lesion training. We found examples where having this awareness may have alerted the nursing team sooner. Training that was provided, was not sufficiently detailed to give care staff confidence in supporting people. For example, dementia training was delivered at an awareness level. The care home states it is able to for provide dementia care as a specialist service type. Given staff daily support people living with a complex dementia, then training that reflected this complexity would have resulted in less incidents as care staff could pro-actively intervene. Training was completed mostly via an online platform. Staff were not paid to complete training and most completed this at home. The provider did not have competence assessments in place and therefore could not assure themselves the training was effective, or that that all staff members had completed this.

The provider did not operate a dependency tool to measure staffing levels against the changing needs of people using the service. The provider did not look at themes or trends within falls, incidents, call bell responses or injuries to consider whether staffing levels were sufficient. Many people ultimately spent their day in bed, through no choice of their own, or did not receive sufficient personal care. Incidents and accidents reoccurred and were not minimised as far as possible because the provider did not have processes to monitor, assess and review safe staffing levels, skill mix, competency and training.

People did not comment on the cleanliness of the service, or the staff practises around the management of infection prevention. Whilst on relative commented that they were happy with the cleanliness. The site visit for the inspection found malodours throughout, equipment not cleaned and some other areas of cleanliness needing improvement.

Staff confirmed they had received training around infection control, and they had access to personal protective equipment as part of following safe practice. However, we also found at this assessment that they did not undertake skin integrity, pressure care or moisture lesion training. We found examples where having this awareness may have alerted the nursing team sooner reducing risks of infection or wounds developing. We also observed examples where staff practice had not supported robust infection prevention processes, which suggested staff awareness was not sufficient.

We observed a person eating their lunch and as they ate their meal, staff placed their catheter bag on their pillow next to them as they ate. This did not promote this person’s privacy and dignity. In addition, the catheter bag presented a risk of infection and cleanliness. Unclean areas presented a risk around cross infection/control, for example, some of the hoists had food stuff in the joints and footplates, several toilets had heavy staining around the start of the U bends and scaling present. The first floor had a strong malodour present throughout the duration of our assessment. However, staff wore appropriate personal protective equipment [PPE] when providing personal care and domestic staff were seen to use the appropriate equipment for the tasks they were carrying out.

Staff assessed and managed the risks associated with possible infection and cleanliness. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly. As noted above, processes however did not always identify day to day hygiene concerns, for example the continued presence of malodours or some areas of cleanliness noted during our visit.

People said they received their medicines when they needed them. People and relatives did not raise concerns around medicines management. People were not assessed to enable them to manage their own medicines or given the choice to self-administer.

Staff explained how they administered people’s medicines in accordance with their needs and preferences. Staff told us they received training to safely administer medicines which was annually refreshed.

The provider did not always make sure medicines were being given as prescribed. People’s time critical medicines were not administered when required. Medicines did not allow sufficient spacing between administration. We saw no PRN (as required) protocols to instruct staff when to administer as needed medication for people who may not be able to communicate their needs. 31 people were prescribed at least one antipsychotic medicine to control their mood or behaviour. These medicines were not reviewed following national guidance.

Systems were in place to order, store, record and dispose of medicines. Medicine Administration Records (MAR) were all signed to indicate when people had received their medicines. Body maps had been completed for people indicating where topical creams and pain-relieving patches needed to be applied.