Forest Place Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

There was a poor culture at the service with inconsistent leadership. Staff were not consistently supported to develop their knowledge and understanding of people, to discuss a shared vision or to improve people's lived experiences. The service was not being managed well and governance systems in place were not effective. Leaders in the service lacked skills and knowledge and were not empowered to use their skills and knowledge. This lack of oversight had led to poor experiences for people.

The provider failed to ensure they informed Care Quality Commission of notifiable events at the service where they are legally required to do so.

The providers governance systems failed to recognise shortfalls in people’s care and the service. Actions had not been taken to address previous shortfalls that had been identified by stakeholders, professionals and Care Quality Commission.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke about a culture that valued people and placed them at the centre of the care provided. For example, one staff member told us, “The culture and values of Forest Place are centred around providing respectful, compassionate, and personalised care for each resident. We prioritise our residents needs and ensure they feel comfortable and valued.” However, our findings as noted throughout this report demonstrate that people did not always experience the culture and intentions described by staff. Our findings showed that the staff team themselves were committed to providing care that was centred around people, but the way the service was managed and overseen by the provider and senior leaders did not facilitate this.

Managers did not ensure that the vision, values and strategy have been developed through a structured planning process in collaboration with people who use the service, staff and external partners. Systems in place to ensure that the culture of the service was positive were not always effective. Care records, daily notes, and feedback from staff demonstrated that some of the care people received was institutionalised. For example, there was shower schedules for people to wash, which is not person centred, people were unlawfully restricted, and some were not able to choose how they spent their day. There was a risk of closed culture because of the lack of effective and implemented systems that were consistent, clear and proactively recognised poor practices. These failings made it harder for staff to demonstrate they meet people’s needs on a day to day basis.

Discussions with some staff demonstrated an outdated approach to describing people’s support needs. For example, staff frequently referred to people as having ‘Challenging behaviours.’ This term places labels, pre-judgements, and assumptions on people, as opposed to describing the emotion of feeling specifically. This use of language by staff supported our findings that the senior leadership team did not promote an inclusive environment.

Staff spoke about management changes, a lack of leadership in the home and managers not being connected to the staff and the people being supported. One staff member said, “From my perspective, there is always room to enhance how management supports both residents and staff. As a dedicated team, we work hard every day, and it would be beneficial if managers could spend more time on the floor, engaging with us in the daily challenges we face.” A second staff member said, “Staff should receive regular support, not only when problems arise.”

Leaders within the home did not have the appropriate knowledge, and skills to lead the service effectively. They were not supported by the provider to ensure they had all the necessary skills to lead the home. This meant both had not identified the significant and widespread issues highlighted within this assessment

We noted that communication with staff was often task based and did not offer opportunities to discuss matters. Documentation did not demonstrate there was a considerate and understanding approach from leaders.

The provider did not have effective processes in place to demonstrate it listened to and acted upon concerns, were open and responsive to suggestions, and used systems to drive improvement to ensure an open and transparent culture was in place. Managers, particularly deputy managers had not been provided the necessary training and knowledge to perform in their role. For example, a widespread lack of awareness about the need to carry out a root cause analysis to identify the cause of increasing incidents within the service.

Managers did not look to find ways to support staff with challenges. For example, exploring why staff were not undertaking required training and looking at ways to work with staff to improve. The lack of effective systems for management and oversight contributed to the closed culture that we found developing in Forest Place. In some cases, opportunities to minimise poor health and care outcomes for people, including human rights breaches such as abuse. For example, during a 6 week period to 27 February 2025 there had been 21 safeguards raised by the home to the local authority. Similar themes and trends suggest lessons learned were not central to mitigating risks and improving the quality of care.

Following visits from the local authority safeguarding review team, further concerns continued to be raised following similar themes.

Overall, we found there was a failure in leaders’ ability to demonstrate a compassionate, capable and inclusive response to risks within the service.

Staff told us they were encouraged to raise concerns about the service internally but not all confident to do so. This was usually through daily meetings on the separate units they worked on. However, records did not demonstrate to show where staff had raised concerns, and these had been acted upon. Staff feedback was variable with some staff feeling confident to speak out, and others chose to not answer. One staff member did say, “There is encouragement to speak up, though some staff may feel hesitant.”

Supervisions were not held regularly for staff to share their views and raise concerns. Meetings for care staff were not held with managers or the provider. Clinical meetings were held but outcomes were not escalated from these meetings to the wider staff team for discussion.

These were missed opportunities to identify trends and to take appropriate actions to address them and improve staff, and people’s experiences.

Staff felt the provider valued diversity within their workforce. Staff raised no concerns about discrimination at work and spoke positively about working within a multicultural workforce.

The workforce was diverse, although training did not support this diversity within the team. There was little evidence to demonstrate how the provider incorporated creative ways of bringing the staff team together in a positive way to celebrate diversity and learn about the wide range of cultures in the staff team to foster an inclusive work environment.

Staff spoken with gave variable feedback. Some staff felt the management team were approachable and supportive. Others said that managers were disconnected from the service and did not provide leadership. Staff were not always aware of the areas of risk within the service as managers did not meet them to discuss these. Staff could not comment on the improvements needed within the service because the provider did not share with them findings from their own internal audits, or from external stakeholders.

The governance systems in place had failed to ensure a consistently good service was delivered and had not identified the widespread shortfalls identified at this assessment. The provider did not have oversight of the service. Two provider audits were completed prior to this assessment. They lacked the quality or insight as they failed to identify long standing risk and concerns about the quality of care provision Audits had not been completed robustly, or at all, often failing to identify and address the numerous and at times significant concerns identified throughout this assessment period.

There was a lack of analysis and lessons learned to support continuous improvement. There was a basic analysis for accidents and incidents, but on reviewing records we found these had not considered incidents noted in daily records. The outcome of incidents, injuries or safeguarding concerns were not used effectively to drive improvements through shared learning. The provider completed their own audits on a monthly basis however these did not identify the issues identified in both this report.

Significant events were not notified to the Care Quality Commission or local authority safeguarding team. The responsibilities, roles, systems of accountability needed for good governance were not working effectively. This compromised the ability to deliver good quality, consistent care, treatment and support.

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People were not supported to stay in touch with their community, to go out for trips or visits to the local town, forest or events. People’s relatives were encouraged to visit, and during these visits could take people into the community. However outside of these opportunities little was organised within the home.

The manager and staff told us staff were asked for their ideas for learning and improvements. However, there was no documentation to evidence of this, or the actions taken as a result. Staff told us meetings and supervisions were not always regular and did not offer the opportunity to discuss learning.

Health professionals told us staff raised referrals when needed and were responsive in following their instructions. However, the local authority said that the home leadership did not report safeguarding concerns in a timely manner. Investigations completed were not robust and did not demonstrate an open and transparent approach to learning lessons and improving the quality of care.

The service has not demonstrated they are sharing information, learning and collaborating with partners to improve their services. For example, safeguarding concerns were not always raised or were not done in a timely way with the local authority. This did not ensure protection and safety of people living at Forrest Home. Safeguarding is a process which enables the cause of the harm to be established, and for staff to learn from the incident and make improvement. The management team did not use external support networks to identify new or innovative ideas. This lack of external support and scrutiny contributed to the closed culture that we found developing in Forest Place.

The provider failed to involve people, their representatives, and staff in developing and improving the service. Despite being given opportunities and support from the local authority for improvement, the service had not used these to ensure people’s experiences and care provision was safe of high quality they should expect. Staff, although positive about working in Forest Place generally said they did not have the structured support or leadership to continually promote their wellbeing and development. Most staff had not received supervision for a significant period of time; some examples given were in excess of 6 months. Training in most areas was basic and did not enable staff to develop and take on new opportunities to explore different ways of supporting people living with different needs. Staff told us many of them had not received regular supervision or support through training and reflection to deliver person centred care.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. There has been an organisational failing to learning, improvement and innovation. Whilst there was information available which could have been used to identify and drive improvement, they were not being used effectively. For example, the electronic care plan system recorded, falls, wounds, incidents, positional change frequency etc, but managers at all levels did not use this information to assess risks, trends, themes to identify patterns and address risks. The provider did not always support or enable staff to deliver person-centred care. Systems to ensure staff had opportunities to raise concerns or feedback were not established. Staff did not benefit from frequent structured supervision, staff meetings, feedback or embedded lessons learned discussion to reflect on practise to develop their approach to providing person centred care.

At this assessment we found the provider had failed to sustain the improvements from the previous rating and was in breach of regulations. Since 2016 Forest Place has been inspected on nine occasions and been rated Good once. This assessment found similar ongoing issues and therefore did not demonstrate learning, improvement and innovation was central to delivering a quality experience for people.