Forest Lodge Rest 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 requires improvement. At this assessment the rating has remained 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.

At our previous assessment, we identified a breach of regulation in relation to the safe care and treatment. At this assessment, we found improvements had been made, and the provider was no longer in breach of this regulation.

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 listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents were logged, investigated and addressed, with outcomes and learning routinely shared with the team. Records were detailed, timely and demonstrated action had been taken to support improvements. Leaders were welcoming and responsive to feedback. Where we identified opportunities for improvement during the inspection, action was taken promptly to address them.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

People told us they felt safe living at the home. Comments included, “It feels safe here. There are security gates so no one can get in. I would press my buzzer if I felt unsafe.”

Staff were able to explain how to protect people from abuse. Staff understood the importance of documenting and reporting their concerns and had completed safeguarding training relevant to their role. Safeguarding policies were accessible and information on how to raise concerns was displayed throughout the home.

The provider ensured people were supported in line with the Mental Capacity Act 2005 (MCA). People’s capacity to make decisions about their care was assessed and where individuals were unable to express their wishes, relatives or representatives were consulted to support best-interest decision making. When people were subject to restrictions to keep them safe, authorisation was sought in line with the Deprivation of Liberty Safeguards (DoLS).

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.

People’s care records included guidance for staff on how risks should be managed in a way that balanced safety with individual choice. Staff supported people to take part in activities they enjoyed and make choices about their lives, while managing risks in a positive and proportionate way. Staff told us they had access to people’s care plans and risk assessments, which were easy to follow. They told us any changes to people’s needs were communicated to them through daily handovers and staff meetings. One staff member told us, “If there is any change in a resident's condition, it is recorded in their care records and discussed during handovers so that everyone knows about it and can provide the right support.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the assessment, we identified several environmental concerns requiring improvement. These included heavy internal doors that closed too quickly, a window restrictor that allowed an excessive opening, an unlocked electrical cupboard that was accessible to people living at the home, a broken and heavy plant pot outside the main entrance, and a furniture unit with missing drawer handles and exposed screws. These presented a risk of injury. We raised these concerns with the registered manager. Before the assessment concluded, we received assurances that action had been taken to resolve the issues identified. The provider also told us they would implement systems to monitor and manage the premises and equipment, including daily walk-rounds.

Health and safety checks were in place and up to date, showing the equipment had been checked, was compliant and in safe working order. There was evidence that required fire safety checks were completed and recorded.

People’s bedrooms were personalised with items that were important to them and reflected their individual preferences. This helped create a familiar environment.

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.

Our observations during the assessment found there were sufficient staff available to support people safely and in a timely way, including to support people to access the community. One person told us, “Staff are brilliant but could do with a few more during the day.” Other people, and their relatives, told us they felt the staffing levels were appropriate. Comments included, “There’s loads of staff. There’s always one around.”

Staff told us they felt very well supported and received regular supervision. Feedback was consistently positive, with staff speaking highly about working at the home and describing a supportive team. One member of staff told us, “Most of the time we have enough staff to provide safe care. There are busy periods, but everyone supports each other to make sure residents receive the care they need.”

Infection prevention and control (IPC) practices required improvement to ensure people were protected from the risk of infection. The provider did not always assess or manage the risk of infection.

We found areas of the premises were not always clean and well maintained. For example, we found several foot-operated bins that were broken, this meant staff may not have been able to dispose of waste in a way that reduced the risk of cross-contamination. In one bathroom cabinet, we found a toilet plunger stored alongside personal items, such as suncream. The light pull cords in toilets and bathroom did not have wipeable covers and could not be cleaned appropriately.

One person told us, “It’s not the cleanest place. I don’t always want to take a shower because it’s not always clean.” Other people and their relatives told us they were satisfied with the cleanliness of the home. Comments included, “Yes, it's clean. They come in my room to clean every day.”

The home employed domestic staff to help with daily routine cleaning tasks across the home. Records showed staff had completed IPC training. We observed staff using personal, protective, equipment (PPE) appropriately and there was sufficient stock available. The kitchen where food was stored, prepared and cooked was clean, and a cleaning schedule was in place to monitor standards and maintain cleanliness.

The provider was responsive to our feedback and took prompt action, including ordering replacement equipment and addressing some of the IPC concerns identified.

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

On the first day of our assessment, the medicine storage room temperature was above the recommended safe range, which meant some medicines, including insulin, could potentially be affected. Records showed this had occurred on a further 4 occasions. Although no adverse effects were identified, people were exposed to a significant risk of harm as medicines may not have remained effective.

Two people had received regular maximum doses of “as required” (PRN) pain relief for 2 months without a GP review. Although people were able to communicate their need for pain relief, an opportunity to review their medicines had been missed. We also found topical creams were not always stored safely or labelled with opening dates, meaning the provider could not be assured they were used within appropriate timescales.

Medicines were disposed of safely, staff had received medicine administration training, and competency checks were completed. We observed medicines being administered discretely and safely. However, medicine audits completed by the management team had not identified the concerns found during our assessment.

By the end of the assessment, the registered manager had taken action to address the concerns, including removing unlabelled creams, requesting GP reviews for PRN medicines and implementing measures to ensure medicine storage temperatures remained within a safe range.