Forest Hospital

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• 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

This means we looked for evidence that patients were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection and assessment, the rating has changed to as 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 patients could be harmed. The service did not always detect and control potential risks in the care environment, the service did not always assess or manage the risk of infection.

However, lessons were learned from safety incidents, the service worked with patients and healthcare partners to establish and maintain safe systems of care, staff demonstrated a strong understanding of safeguarding and how to take appropriate action and staff assessed and understood risks.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Lessons were learned from safety incidents, resulting in changes that improved care for others. Staff learnt from incidents through debriefs and post incident reflective practice. Senior leaders described actions they implemented to enable improved communication with patients’ families following a serious incident that occurred at the service. Senior leaders were exploring ways to better debrief patients with dementia.

Risks were not overlooked or ignored. They were dealt with willingly as an opportunity to put things right, learn and improve. Staff focused on the antecedent to any incident to try and prevent reoccurrence. Staff looked at what was happening before an incident and reviewed the communication needs of the patient to support learning and improvement.

Incidents were appropriately investigated and reported. The provider reported 52 incidents between 01 March 2025 and 29 February 2026. Of these, 33 incidents were unwitnessed patient falls, 7 of these resulted in injury, including a fractured hip. The provider advised all patients had been or were under the falls team, all had care plans, risk assessments and policies and processes were followed which included CQC notifications, duty of candour and safeguarding reporting where necessary. There were 3 choking incidents with no harm caused. The provider advised all patients involved were referred to the Speech and Language Therapy (SaLT) team and risk assessments and processes were in place. One patient experienced 4 hyperglycaemic (high blood sugar) incidents, 1 requiring admission to hospital. We reviewed 5 accident reports from January and February 2026. These reports were completed following incidents involving physical harm or physical health events, for example, patient falls and epilepsy incidents. Staff recorded that required actions were taken as expected for 4 incidents, including completing physical observations, seeking appropriate medical input and updating care plans. For 1 incident, involving a patient falling, staff had not fully completed, signed or dated the falls risk assessment. Other incidents included safeguarding concerns between patients and physical health concerns.

The evidence showed a good standard. The service worked with patients 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 patients moved between different services.

Safety and continuity of care was a priority throughout patients’ care journey. Staff kept patients safe through effective risk management, robust oversight of observations, and clear processes that supported safe admission and discharge pathways. Staff demonstrated a good understanding of their responsibilities in maintaining a safe environment and responding to individual needs. Although discharges were infrequent, evidence from the most recent discharge showed that staff planned transitions effectively, involving appropriate external agencies and family members. Staff shared information promptly, and preparations were made to ensure the receiving service had all necessary details to continue with the patient’s care safely and effectively.

There was a strong awareness of the risks to patients across their care journeys. The approach to identifying and managing these risks was proactive and effective. During the inspection, no individuals required enhanced observations, and records showed that staff completed routine observations were completed consistently, with clear documentation demonstrating that staff followed appropriate levels and frequencies. Staff were able to describe how they would escalate concerns and implement enhanced observation levels if required, ensuring that patients at increased risk would be monitored effectively. Staff were no longer using pre-printed observations records and were recording observation times accurately.

Care and support was planned and organised with patients, together with partners and communities in ways that ensured continuity. There was a robust and thorough pre‑admission process. Care notes contained appropriate assessments and screening information demonstrating that the service only accepted admissions when it could safely meet an individual’s needs. This included gathering relevant information from referrers, reviewing clinical history, and considering environmental suitability and staffing capacity before agreeing to admission. Staff told us this process reduced risk by ensuring they could meet the needs of patients admitted to the service.

The evidence showed a good standard. The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff demonstrated a strong understanding of safeguarding and how to take appropriate action. The provider reported a compliance rate of 94% for staff training in safeguarding. Staff told us about raising a safeguarding for a patient admitted with grade 3 pressure ulcers. A support worker said they would raise any safeguarding concerns with the nurse in charge and if they did not respond appropriately, they would escalate to the hospital director.

There were effective systems, processes and practices to make sure patients were protected from abuse and neglect. Senior leaders described the processes for reporting safeguarding concerns, including referrals to the local authority, reporting to the police and notifying CQC.

Staff demonstrated a clear understanding of the Deprivation of Liberty Safeguards (DoLS), and this was only used when it was in the best interest of the patient. All 7 care records reviewed showed a clear understanding of the Deprivation of Liberty Safeguards (DoLS). DoLS applications were only made when considered to be in the patient’s best interests. Relevant documentation, including assessment outcomes and best‑interest decision‑making records, was present in the care files of those subject to an authorisation.

Mental Capacity Act

• The provider reported 94% of staff received training in the Mental Capacity Act.
• Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles
• The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.
• Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
• Staff took all practical steps to enable patients to make their own decisions.
• For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.
• When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the patient’s wishes, feelings, culture and history.
• Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The service had arrangements to monitor adherence to the Mental Capacity Act.
• Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

The evidence showed a good standard. The service worked with patients to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. They provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

Staff assessed and understood risks. We reviewed 7 care records which showed that risks to patients’ health, safety, and welfare were identified, monitored, and managed effectively. Staff used a range of recognised risk‑assessment tools, including the Health of the Nation Outcome Scales (HoNOS) to support understanding of behavioural and mental health needs. These were used alongside other assessments such as Waterlow pressure area risk assessments, moving and handling assessments, choking risk assessments, and wheelchair‑user assessments. Records showed that risks were regularly reviewed and updated, ensuring patients received safe care based on ongoing assessment and effective risk‑management practices. The provider completed risk assessments for all activities taking place at the service, with appropriate mitigations where required.

When patients communicated their needs, emotions or distress, staff managed this in a positive way that protected their rights and dignity and maximised learning for the future about the causes of their distress. Staff used a trauma informed care approach when supporting patients in distress. This was focused on getting to know patients, utilising past experiences and using de-escalation techniques. Staff described diverting and deescalating techniques used. For example, 2 patients that were previously labourers will start moving furniture angrily when distressed, staff will intervene and ask them to help them to move the furniture. The provider reported no use of rapid tranquillisation for the last 7 years. Rapid tranquillisation (RT) is the use of medication to quickly calm or lightly sedate an acutely agitated individual. It is a last-resort restrictive intervention used only when de-escalation fails and the patient poses an imminent, serious risk of harm to themselves or others. The provider reported no use of seclusion or long-term segregation.

Restraint was only ever used as a last resort. If staff used restraint, it was lawful, for a legitimate purpose, safe and necessary, and staff always followed best practice. Data showed that staff had used deescalation techniques on 319 occasions, disengagement techniques were used 6 times and staff used restraint on 7 patients 15 times between 01 September 2025 and 28 February 2026.

We reviewed restraint incidents for January and February 2026. We found that staff used holds to deliver essential personal care to patients 52 times in February 2026, this was an increase from 50 in January 2026 We saw evidence in these records that staff used deescalation techniques to diffuse situations when patients were distressed. The provider had not reported any use of restraint as a safety intervention in the records reviewed.

Senior leaders worked with staff to ensure that they worked in line with guidance when using restraint to provide personal care to patients who were refusing this support. Staff included family in completing care plans for patients who required the use of restraint to deliver personal care. The plans included regular staff providing this support to ensure consistency. The provider advised staff only used low and medium level holds. Low and medium level holds are used to guide patients and often involve staff guiding someone by the elbow or holding their arm. The provider advised staff never restrained patients in the prone (face down) position.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Arrangements to monitor the safety and upkeep of the premises were not always effective. Although the provider completed thorough risk assessments of the environment, with appropriate mitigations in place, we found the accessible bathroom had an exposed sharp edge created by broken tiling and a broken access panel to the pipes below the sink. We also noticed some of the paving slabs in the garden were loose and uneven, which created a potential trip hazard. We escalated these concerns to senior leaders, who took immediate action to make the accessible bathroom safe. They advised the uneven slabs would be reported to maintenance staff for action. Senior leaders completed ligature risk audits with maintenance and health and safety staff. Potential ligature points were identified and mitigations put in place. These included anti ligature fittings, staff assessments of patients’ risks, use of enhanced observations, alarm systems and care plans. Leaders addressed previous concerns of staff not taking action when medicine fridge temperatures went above an acceptable level. This included the implementation of new documentation which made it clear to staff action that was required.

Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly. However, medical equipment was due to be checked the day before our site visit and had not been completed. Staff completed this whilst we were on site.

The evidence showed a good standard. The service 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.

There were appropriate staffing levels and skill mix to make sure patients received consistently safe, good quality care that meets their needs. Leaders advised the baseline staffing was n 2 Registered Mental Nurse (RMN) in the morning and 1 RMN in the afternoon plus 3 Healthcare assistants (HCA) for the day shift and 1 RMN plus 2 HCA at night. Funding for additional staffing for specific patients could be accessed when required. The provider had no vacancies for qualified, unqualified, medical, therapy or ancillary staff. Between 22 March 2025 and 22 March 2026 the provider reported using agency staff to fill less than 1% of all shifts (qualified and unqualified) and used bank staff to fill 7% of shifts (2% qualified shifts and 5% unqualified shifts).

The average sickness rate was 2% between 01 March 2025 and 28 February 2026. Due to the closure of a ward 36 staff left the service and moved to the care home. This resulted in a 67% turnover for the year, the previous year turnover was at 12%. This year’s turnover reduced to 24% at the time of the inspection and was anticipated to continue to reduce.

Staff received training appropriate and relevant to their role. The compliance rate for staffs mandatory training was 96%. Staff accessed 44 different specialist training courses between 01 March 2025 and 28 February 2026. These included training on dementia awareness, understanding Huntingdon’s, positive behavioural support, trauma informed care and acquired brain injury.

Staff received the support they needed to deliver safe care. This included supervision, appraisal and support to develop. 94% of staff were up to date with supervision (management and clinical) and 100% were up to date with appraisals. Staff told us about opportunities to develop including accessing training for approved practitioner (AP) and occupational therapy assistant (OPA) roles.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection.

The approach to assessing and managing the risk of infection was not always effective. We reviewed paper cleaning records, which were up to date and indicated when areas received a deep clean. However, during our site visit we observed several areas that were not clean, including hairs in the bath, a dirty lap strap on the hoist, and dirty handrails in the main corridors. These findings indicated that cleaning checks were not always effective in identifying or addressing Infection Prevention and Control (IPC) concerns. This presented an avoidable infection risk and highlighted gaps in both day‑to‑day cleaning oversight and the reliability of the assurance processes in place. Otherwise, the ward was generally clean, well maintained and furniture was in good condition. We observed staff to be bare below the elbow and staff told us about using personal protective equipment (PPE) and hand-washing regimes. The provider addressed previous concerns relating to the medicines cupboard not being clean. Leaders implemented a new process that included nightly cleaning of the cupboards with an in-depth overview once a week.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Patients’ medicines were usually appropriately prescribed, supplied and administered. We identified 1 patient whose prescribed medicines were not always available or administered as prescribed, and delays in obtaining clinical guidance led to altered dosing without clear escalation or contingency planning. Between the 16 February 2026 and 28 February 2026 there was no stock of a statin medicine for a patient. the hospital had taken all possible actions to rectify the situation, including a referral to the local authority safeguarding team. This patient was also prescribed another medicine that staff had not administered on 11 occasions as the patient was asleep. A nurse told us changing the administration time had been discussed with the responsible clinician (RC), but they had since left the service without making any changes. Following the inspection the provider shared documentation of a ward round carried out in January 2026 which records the RC advising staff to try to administer the patient’s night time medication earlier and to continue to review the situation. There were no recent updates provided.

Patients’ behaviour was not inappropriately controlled by medicines. There were appropriate arrangements for the safe management, use and oversight of controlled drugs.