Forrester Court

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. This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider conducted investigations when incidents occurred and took appropriate action to prevent recurrences. Staff attended regular meetings, which helped ensure any learning from events was shared and actioned.

The provider had policies and procedures for responding to incidents, accidents and complaints and staff we spoke with were knowledgeable about these. Staff told us they were aware of all the policies and felt confident about how to respond and report correctly.

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.

Suitably trained staff completed and regularly reviewed assessments of people’s health and well-being, risks and wishes, to make sure they accurately reflected their needs.

Care plans were developed and shared with health and social care professionals when required, such as GPs, dietitians, physiotherapists and community mental health teams, to ensure people’s well-being was supported and maintained. Staff worked effectively with health and social care professionals to make sure people received appropriate support that met their needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Information was on display throughout the service that reminded staff how to speak up and report any concerns and to also inform people and visitors to the service. People and their representatives told us they felt safe and well cared for. Comments included, “I am safe from harm” and “I do feel my [loved one] is safe at Forrester Court.”

The provider had safeguarding policies and procedures in place. Staff were knowledgeable about recognising potential abuse and harm. Staff told us they had completed training for safeguarding adults and said they were confident that any concerns raised would be managed appropriately. Staff confirmed they always report any concerns and told us they would also follow the whistleblowing policy if needed.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments with people and care plans were developed to mitigate identified risks. For example, nutrition and hydration, falls risks and skin integrity. People’s risk assessments and care plans were regularly reviewed to ensure they continued to reflect people’s needs and remained effective in helping people to keep safe.

People’s representatives told us they were happy with the way their loved ones were supported to manage identified risks. One person told us, “[Name] is very frail, but they [staff] have put things in place to keep [Name] safe.”

Physiotherapists undertook risk assessments on people which enabled them to exercise on the appropriate gym equipment safely.

The provider was aware of potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were clean, safe, well maintained and meeting people's needs. People told us, “Nothing wrong with safety” and “Health and safety is one of their priorities.”

People enjoyed living in well designed premises and had access to amenities which provided a safe and relaxing environment.

For example, a new coffee shop had recently been created. Additional facilities included a gym, a multi-faith prayer room and a refurbished hair salon, in which the pictures of hair styles were modelled by people living in the home. Historical photographs of the local area decorated the walls in the corridors and a person told us, “It’s reassuring to see these photos from when I was a child”. People living in the home, as well as visitors and staff all expressed how much they appreciated this improved environment.

There was also a Namaste room, which is a dedicated, multi-sensory space designed for people to benefit from sensory stimulation and meaningful interactions. The provision of the Namaste approach was also available for people who were unable to leave their rooms.

The maintenance person told us they regularly assessed and maintained the environment and equipment. We saw servicing records for the fire alarm system, portable appliances, gas safety and legionella testing. Checks and audits were also carried out on slings and hoisting equipment, baths, the call bell system and regular fire drills were conducted.

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.

Some people and their representatives commented that they felt the home could sometimes do with more staff. A person’s representative told us, “Sometimes there have been staffing issues, but the new manager seems proactive and is making improvements.” However, the majority of people told us they received prompt support. We noted that senior staff regularly assessed people’s dependency levels and used this information to determine staffing levels. At the time of our assessment, the rotas and our observations showed the home to be sufficiently staffed in order to meet people’s assessed needs. A clinical lead told us that, due to good staff retention, the home only used agency staff for people who required 1:1 support.

People felt the staff were well trained. A person said, “Staff are really good and know what they are doing.”

The provider had safe recruitment practices to help ensure suitable staff were employed. All necessary pre-employment checks were completed before staff began working in the home. Nurses kept their registration up to date.

Staff completed regular training, to make sure they had the knowledge and skills to carry out their duties. The management team monitored the training matrix to make sure staff remained up to date. Staff confirmed they received regular support and supervision and all spoke highly about the quality of the training and support they received.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and free from offensive odours. The provider employed a dedicated domestic team and everyone we spoke with complimented the home on its cleanliness with comments such as, “It’s a big place, so keeping on top of the cleaning is a mammoth task. It’s always so clean and fresh. The housekeepers do a brilliant job” and, “Can’t fault it. Everywhere is kept spotless.”

There were hand gels available throughout the home and we saw that staff had sufficient supplies of personal protective equipment (PPE), which they wore and used appropriately. Staff completed training for infection control and regular audits were effective in identifying any areas for improvement, which were actioned promptly.

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

There were multiple instances where records on the eMARs (Electronic Medicines Administration Records) were not transcribed accurately and therefore did not match the medicines being administered or prescribed. In 1 instance, there was an error with transcribing that led to an incident where a medicine was administered when it should not have been. The provider investigated the incident and put in place measures to prevent this from happening again.

Care plans did not always contain information regarding medicines risks. For example, information about the risks related to high-risk medicines, or information on the management of medical emergencies for people with certain medical conditions. We discussed this with the management team who took action to update the care plans.

The GP carried out regular medicines reviews with people. PRN (as required) medicine protocols were detailed. PRN medicines used to manage agitation and anxiety were not excessively used to control behaviour.

Staff completed training to understand how to handle medicines safely. Managers assessed their competencies. Medicines were stored appropriately.

People gave positive feedback about their medicines, with comments such as, “I have no concerns when it comes to medication” and, “Medication is administered efficiently.”