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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained as inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in continued breach of legal regulation in relation to good governance.

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.

The provider did not have a shared vision, strategy and positive culture. The provider was open and transparent with CQC explaining that the culture of the service needs and improving and said they are committed to making the changes.

Effective systems were not in place to promote a positive culture, transparency, learning and improvement. The provider had not ensured that the systems and processes ensured people and their representatives were engaged, included, and involved in the arrangements of their care and treatment and to the improvements of the service as whole. There were no processes to ensure that staff supervisions, team meetings and resident’s meetings were meaningful and effective.

One staff member said, “The staff who have been working the longest, care the most for people and always put the residents before anything else. New staff need to not only do the training but apply it to their work, so they reduce skin tears and bruises. It is a really nice place, but we need to improve the quality of care from having staff with no experience. I am happy, I love my job. We are improving daily.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

At the time of the assessment the manager was not registered with CQC and has since left the organisation. A stakeholder said, “I also feel they currently have a very good manager who has made significant positive changes within the home, and this has made a noticeable difference to the service overall. To maintain and continue this progress, I feel the manager would benefit from additional and continued support from the owners.”

The provider told us the leadership team comprised of the manager, deputy manager, clinical leads, unit managers, operational manager and chief of operations. The provider also said, “We have invested in 3 external professionals to support the manager to make the changes needed and it has been frustrating to hear improvements are not as we would have hoped.”

Leadership roles and responsibilities were not clearly defined, and there was no coherent plan outlining tasks and required improvements. The leadership team did not always act in a timely way when concerns were found. For example, nurses completed regular medicines audits which identified areas for improvement with associated action dates. However, we found not all areas of concern we identified at the inspection had been recognised by staff, and there was not a clear follow up system in place for completed actions to ensure these were being completed and embedded in practice.

This meant the provider failed to have effective and robust systems in place where responsibility led to accountability.

Improvements were required to demonstrate consistently capable leadership that lead by example and ensured risks and oversight of the service were well managed. There were significant shortfalls relating to learning when things go wrong, risk mitigation and safe and suitable staffing which were not addressed by the management team. The extent of the concerns we raised were not known or identified through the providers auditing and quality assurance processes which were poor.

The provider had a complaints policy in place; and complaints were formally responded to and investigated. However, we found the provider failed to act on staff feedback. For example, in the 2025 staff survey 73% of staff felt supervision was not helpful and did not help them develop. We found the provider and leadership team did not address this issue and staff continued to go without supervision.

This meant there was not an open and transparent culture where people feel they can speak freely and be listened to, without fear of judgement.
 

The provider valued diversity in their workforce, However, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The manager was able to tell us about workforce equality, inclusion and diversity. This included staff being treated equally and having equal rights.

Systems were not in place to seek staff feedback in areas such as the setting up of the rota, to promote fairness amongst the staff team. However, the provider told us they are in the process of implementing a fare rostering system that includes staff in the planning process.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The manager told us they did not have oversight of the fundamental areas of running a safe service and gave the rota as an example. The manager told us the rota is managed by a central office team and as a result the manager is not always aware of who is working.

The leadership team told us they have oversight of the service; however, they failed to identify and address the significant and widespread concerns highlighted within this assessment. The manager told CQC, lessons learnt reviews had only been completed for the month of March, despite this being on the provider improvement plan for over a year.

The provider failed to implement a robust quality assurance process which effectively analyses incidents and identifies what went wrong.

This meant the provider did not always have oversight of accidents or incidents which took place in the service and did not always take action to mitigate potential risk and harm to people. Lessons were not always learned to reduce the risk of reoccurrence.

Not all notifiable incidents had been reported to CQC or the local safeguarding team. We identified reportable incidents through complaints where the leadership team had failed to recognise the complaints amounted to safeguarding referrals.

At the last assessment published August 2025, 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.

While some improvements were noted, the provider failed to make adequate or timely progress in strengthening governance. In some instances, governance systems were not robust enough to identify issues that we found during the assessment.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We received mixed feedback from stakeholders, one saying the provider does not always respond to well to feedback. Another said, “Communication with staff has been positive and professional. They are approachable and willing to discuss concerns or provide updates when needed. We have worked together as multi-disciplinary team regards several people and there are good communication lines between us,the care home and the GPs.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider failed to have systems in place to encourage creative ways of delivering equality of experience, outcome and quality of life for people.

There were significant and widespread concerns identified during this assessment. The leadership team could not evidence that action had been taken to learn and improve the quality of the service.

The provider failed to implement a consistent approach to measure outcomes, utilise best practice guidance and monitor the impact and quality of care for people.

The lack of systems to monitor effective practice in areas such as staff training and risk mitigation put people at risk of harm. For example, people were at risk of choking, and not all staff had completed the appropriate training to safely support people with eating and drinking.

The senior leadership team carried out audits of safe eating and drinking; however, they had not received the relevant training. When asked why this was, and how they can effectively carry out the audit without the necessary knowledge, a member of the leadership team said, “We need to ensure the staff handling the food receive the training first, then the leadership team will follow.”

This means people were at increased risk of staff and leaders lacking the knowledge and training to provide safe and appropriate support.