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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in continued breach of legal regulation in relation to people’s safe care and treatment, safe and sufficient staffing and consent.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Leaders stated they were open to feedback and demonstrated a willingness to make improvements. The provider was in the process of embedding systems to analyse incidents and identify learning. While investigations were undertaken when things went wrong, these were not consistently robust. Processes did not always clearly establish the root cause of incidents. Failure to identify root causes limits opportunities to reduce recurrence and increases the risk to people using the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The manager said, “I have not admitted anyone into the service, but we use preadmission forms, and I would meet the person face to face. I would ask for the medical records, find out as much information about them, talk to their families and consider their health and social care needs. When we need to send people to hospital, we ensure their information is shared with medical professionals who need to know. We provide copies of medicine records and any information appropriate. We ensure they have their night clothes and we communicate with families.”
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Whilst the manager was aware of reporting processes, we identified some incidents that had not been reported appropriately. For example, 1 person had raised a formal complaint about how a staff member had spoken to them. This was investigated and dealt with as a complaint but not identified as a safeguarding.

People told us they felt safe at the service. One person said, “I feel safe here because the staff look after me well and respond to my needs.”

The manager said, “We have done a lot of work with the local authority safeguarding team, and I have had a lot of support from them.”
A nurse said, “I would report abuse straight to the safeguarding team, I would not hesitate. After I have reported it, I would report to the manager what I have seen and what I have done about it.” A staff member said, “I would report to my line manager and if they did nothing about it, I would report to the local authority or to CQC.”

We found staff training levels for safeguarding were significantly below expectation. This means people were at an increased risk of abuse as staff may not identify and appropriately report signs of abuse.

We found there was no effective process in place to manage and assess people’s mental capacity. Where people lacked capacity to make decisions, their families had not been given the opportunity to inform the care and treatment in the best interests of their relative. We found the service was not always working within the principles of the MCA as some people's capacity had not been assessed or their ability to make decisions reviewed or recorded in their care plans.

The provider acknowledged their failure to work within the MCA and said they would put a system in place to improve this.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider failed to identify ineffective risk assessments, leaving wheelchair users without appropriate risk assessments or restraints. We identified 2 people using wheelchairs who were at risk of slipping from wheelchairs with no lap-belts in use. Furthermore, we identified these people did not have risk assessments in place for safe use of wheelchairs. This exposed individuals to a high risk of falls, injury and harm. The provider was responsive to this feedback and took immediate action to start risk assessing wheelchair users.

Families told us their views had been sought by staff completing care plan reviews.
One relative told us they work in partnership with staff and external health professionals to enable and empower their loved one to take an informed risk. In this case there was a risk to the person, they had the mental capacity to make the decision, to meet their emotional needs and preferences improving their quality of life. The family member spoke positively about this and explained their responsibilities. The care plan was very clear detailing responsibilities and how to safely manage this risk.

The provider did not always detect and control potential risks in the care environment. They did not always ensure the environment was clean.

We identified risk of hazardous substances due to the cleaning keys being left in the unit kitchen cupboards, making the cleaning chemicals accessible to people. Staff seemed to lack understanding of the potential risk to people when we brought this to their attention. Furthermore, we identified that completion of health and safety awareness training for health care assistants was significantly below the provider’s compliance expectations. This placed people at an increased risk due to insufficient staff training which could lead to potential harm.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We received mixed feedback from people and their families. One person said, “The staff change frequently and that can’t be a good thing for continuity of care. I ring my call bell and wait far too long. It can feel like years when you need them. They explain that they have been busy, which I accept, but there are clearly not enough staff if that keeps happening.”

Another said, “This is not a happy place, and the staff say they are so short staffed, I regularly have to wait for them to answer my call bell. There are so many agency staff, so they must struggle to understand people’s needs. The night staff always tell me they are too busy to cover what they need to. There is a language issue; I just cannot understand some of them, I ask them to speak louder and slower. I feel language is a potential risk here.”

A family member said, “The staff are changing constantly and that must make it hard to ensure the care is top quality. Added to that is the fact some staff have a poor grasp of English, I worry what if they misinterpret what a person says to them. The other day a person in the lounge was calling out, but no one responded by coming to check on them. There was another occasion when someone was struggling to get up and no staff helped.”

Another family member said, “I can say with confidence that there are insufficient numbers of staff to cover the needs of people staying here. If my relative needs someone, there is likely to be a wait.”

Three out of 4 families spoken to, told us they sometimes need to ask staff to assist their loved ones with incontinence care.

On the day of the assessment, we observed one person waited 21 minutes for staff to be available to assist them to their room. Staff attended 4 times to say they are waiting for a second person to assist. We also observed another person had been sat in the lounge and not moved for a minimum of 4.5 hours. When staff supported them to stand, it was clear they had been doubly incontinent. Staff did not shield the person as they walked to preserve dignity.

At the last assessment we found the provider failed to implement effective robust processes to identify and address poor staff training through effective oversight. At this assessment we found there were continued significant shortfalls in the management of staff training, supervision and professional development.

We identified widespread and significant shortfalls in staff training, this included mandatory training as well as essential training giving staff the skills to meet people’s individual care needs. For example, we identified staff provide care for people with epilepsy, we also identified only 2 staff had received epilepsy training. Furthermore, we identified 2 staff members with only 2 modules of training in date and another staff member with only 4 modules of training in date. There were significant shortfalls in training including first aid, safeguarding, infection control and prevention, fire awareness and food safety.

This meant that people were at risk as staff were not trained to meet their needs and provide safe care.

The local management team failed to provide staff with a supportive space for professional development, emotional well-being, and accountability reducing burnout while increasing confidence through one-to-one reflective practice. We found significant shortfalls in staff supervision. For example, 27 health care assistants and 9 nurses have not had supervision in 12 months. Where one-to-one supervisions had taken place, they lacked clear objectives, personal elements, and failed to address training concerns.

This puts people at risk of receiving care from staff that have not received appropriate support, training and professional development to carry out the duties they are employed to perform.

The provider told us they have made significant investment in staff training; however, we could not see evidence of this. The provider also said, “Going forward we want to get this right, we will make a commitment to improving staff supervision, improving morale and address training.”
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found poor standards of housekeeping in some bathrooms, this included dirty shower trays and soiled toilet brushes. The provider was responsive to this feedback and took immediate action to reduce risks.

This meant people were placed at risk of harm from infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were systems and processes in place to order and administer medicines, however, these were not always robust. The GP practice ordered the medicines in bulk from the pharmacy without input from the service. This meant people were not always receiving their medicines due to the service not having appropriate oversight of the ordered medicines. This was not in line with national guidance which states the service must retain responsibility for ordering medicines from the GP practice.

The service had been working with the pharmacy to prevent people going without prescribed medicines, but the issue remained at the time of the assessment. Staff used homely remedies [medicines available over the counter] to support people.

There was no process in place to monitor when people’s antipsychotic medicines were due for review. The service worked with the local mental health team; however, staff told us they were concerned about these medicines being prescribed too often and how long it took to get them reviewed by the mental health team. A stakeholder visiting the service had also raised concerns about the impact of these medicines on a person’s health. We discussed these concerns with the provider and recommended they took action to ensure people were being prescribed their medicines appropriately and reviewed regularly.

Staff had received medicines training and an induction to carry out their role, however; this was not always completed in a suitable time frame. One staff member said they had been given 3 days to complete their induction and competency assessment. Although the competency assessments were detailed, this was not enough time to ensure staff felt confident to administer medicines independently.

Medicines were stored and disposed of safely and in line with legal requirements. However, staff were not recording quality assurance checks for blood glucose monitoring machines. Homely remedy audits were not always completed and not all the medicines listed were stocked on all units.

Care plans contained information to support staff to care for people with health conditions such as diabetes and seizures. Where people had medicines administered via a percutaneous endoscopic gastrostomy [PEG] or covertly [medicines hidden in food and drink], there were detailed instructions in place for administering the medicines as well as mental capacity assessments and authorisations and assessments from health care professionals in line with national guidance.