Forest Lodge Care 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 was good. At this assessment the rating 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.

We could not be assured that a pressure mattress used to support a person who was prone to pressure ulcers was working and constantly monitored. There was important information missing from a risk assessment we reviewed. We saw instances of violence and aggression by a person including threatening staff with a knife which had not been added to the risk assessment. There was a lack of information included in people’s plans which detailed the management of violence and aggression and clear descriptions of how this presented itself and how staff should effectively respond. This constituted a breach of regulation 12 safe care and treatment.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff told us how the manager was willing to listen and could be approached if there were concerns. There was evidence that the service worked closely with the local authority and learnt from each event that occurred in the service. We heard how this learning was addressed at various levels in the organisation and where information that would benefit the practice within the service and how this was disseminated down from senior members within Bramley Health Limited.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. We saw how the provider assessed people before coming into the service and about the criteria which determined whether it was deemed suitable for a person. We saw evidence of people moving between hospital and the service and how this was managed to ensure people received the care they needed.

We heard how the clinical lead nurse was responsible for visiting people and services to carry out assessments of people who could potentially move into the service. The clinical lead nurse told us how they liaised with other colleagues working for Bramley Health Limited to discuss their findings and share possible concerns before progressing with potential referrals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. One professional told us how the provider reached out when they required support with regards to a person’s wellbeing. Another professional told us, “The staff, in particular the nursing team, have been reciprocative to advice about people’s care.”

Staff we spoke to were clear about what posed safeguarding risks to people, the types of abuse and the signs they might see. They knew the people both within the organisation and the statutory bodies such as the local authority and the Police they could talk to if they had concerns.

Owing to the safety needs of people living in the service, restrictions were necessary to be placed on people which included their use of the community. We saw for people in their care the provider had followed the correct procedures required by law to restrict people’s liberty and that these applications were all up to date.

The provider did not always work well with people to understand and manage risks. For example, where people required pressure relieving mattresses to reduce the risk of pressure ulcers. We found the pressure mattress for one person was unplugged. We were unable to determine how long this had been unplugged for, this posed a risk to the person's skin integrity

Risk assessments did not always cover the level of risks posed by people. We saw a risk assessment relating to verbal aggression. However, incident reports during a two week period indicated 5 separate incidents of violence and aggression to either staff or other people living in the home including 1 occasion where a member of staff was threatened with a knife the person was using to eat with.

Risk plans called positive behaviour support plans (PBS) lacked detail of the violence and aggression people could, at times, display. We saw incidents where staff had been assaulted on occasions, including where a staff member was slapped and headbutted. The plans did not describe the types of behaviour they might encounter or the description of methods they had been taught to manage this. We raised this with the provider and during the inspection process they addressed this lack of detailed information immediately and send us updated plans to evidence this.

During our visit we observed people who required support to eat and drink during mealtimes. Best practice guidelines suggest staff should be sitting, whilst supporting people with this. We saw occasions when staff were standing to supporting people to eat and drink. We raised this with the provider, and they took immediate action at both service and organisational level

The provider had processes in place to identify potential risks in the care environment and mitigate any risks they may pose to people living in the service. During a tour of the premises, we saw the lift was not working which the provider had told us about and were working to get this fixed as quickly as possible. Access to the service was restricted with locked outer and inner doors which kept people safe. The provider had effective systems in place to check when repairs were required, and we noted people on site attending to maintenance issues during our visit.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff received training to be able to carry out their jobs and were knowledgeable about the people they supported and the care they needed. Rotas indicated that staff had regular days off to prevent them working excessively, ensuring they had adequate rest.

During our visits we saw a great deal of positive interactions between the staff and people living in the service, with staff offering people the support they needed. The provider had robust processes in place to ensure that staff were recruited safely. This included checks on right to work and disclosure and barring service (DBS) who provided information including details about convictions.

The families we spoke to had mixed views about the staff. Some families talked about a turnover of staff but most views were positive. One family member said, “At one point it did not seem as though there were enough staff but that has changed, you see the same faces time and again and I think the staff are happy.”

The provider assessed and managed the risk of infection. There were policies and procedures regarding infection prevention and control in place. We observed that that overall standards of hygiene and cleanliness throughout the service was good.

There were adequate stocks of Personal Protective Equipment (PPE), including gloves and aprons throughout the home. Staff demonstrated an understanding of when they were expected to use PPE. There were occasions during our visits where we found there was a lack of either soap or hand drying facilities in the bathroom. When checked again, we noticed that the service addressed this as required.

The provider did not always make sure that medicines and treatments were safe. A person living in the home used patches placed on their skin in different places each day to alleviate pain. The recording of these patches was inconsistent in the dates they were administered and the location where they were placed. We raised this with the provider who addressed this at service and organisational level. Medicines were stored safely in locked cabinets within locked and temperature controlled rooms. Medicine administration records we looked at did not contain any gaps.