Forest Manor 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

People did not receive safe care and treatment. We observed staff using restraint with a person who had not been assessed for this type of support. During the assessment we identified a number of bedrooms with broken furniture and items stained with dirt and food debris. There were risks to people from poor infection prevention and control practices throughout the home. People, including those living with dementia, had access to unlocked store cupboards which placed them at risk of harm. However, people we spoke with told us they felt safe living at the home and that they received their medicines in line with their wishes and in a timely manner.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were unable to explain how the learning culture affected their experience in the care home. However, due the observations during the assessment and processes reviewed, we assessed that people did not always receive a positive experience.

Staff were knowledgeable of incidents and safety concerns and could describe situations appropriately which would need referral to management. Staff spoken with told us they were confident to raise concerns and safety issues with the management team. Staff also told us lessons learned were shared in team meetings. One staff member said, “We discuss concerns at our [team] meeting, and we get updates. It helps make sure things don’t happen again.”

Safety and learning culture were not always identified as a priority. The registered manager completed an audit of incidents and accidents however these audits had failed to identify safety concerns found on the assessment. For example, a wardrobe had not been re-attached to the wall following a bedroom being redecorated and radiator covers had not been identified as broken and detached from the wall. This placed people at risk of harm from scalding and objects potentially toppling onto them. These concerns were brought to the registered manager’s attention and were rectified immediately.

We received mixed feedback from people living at the home. Most people told us they had been supported and admitted to the service safely. However, some people said they lacked understanding of why they were placed with the home. One person said, “I don’t know why I’m here; I think it’s because they [funding authority] don’t know where to put me. I don’t need care so living here is hard.”

Staff told us they had concerns with the admission process the provider had in place. One person said, “We [the home] have recently starting to support people with mental health conditions, but we were not included in this decision, and I think some people living here need more specialised care.” The registered manager acknowledged that there were some inappropriate placements within the home and that they were working with the local authority to find more suitable placements. We were assured that no one had been harmed from the inappropriate placements.

Professionals we spoke with were unable to comment on Safe systems, pathways and transitions within the home. However, we saw evidence that the registered manager had contacted the local authority to discuss and raise concerns about placements.

We saw evidence that the registered manager completed pre-admission assessments with people prior to their transition into the home. However, nurses and the clinical lead were not involved in these assessments. People had hospital passports in place. A hospital passport is a document about a person and their health needs. It also has other useful information, such as their interests, likes, dislikes, how they communicate and any reasonable adjustments they might need.

Most people we spoke with told us they felt safe living at the home, however some people did raise concerns about experiencing avoidable harm. One person said, “I would feel safe except for that resident who knocked me down onto the floor, I had a big bruise over my eye. [Resident] still comes in this room and there are no staff about, it does scare me.”

Staff we spoke with were knowledgeable about safeguarding and could describe situations and incidents that needed to be referred in order to keep people safe. However, staff we spoke with did not have a comprehensive knowledge of restraint and de-escalation techniques that could be used to support people to avoid periods of frustration or crisis.

People were not protected from the risk of harm. We observed staff using inappropriate restraint techniques with a person. Staff were seen placing their hands on a person’s shoulders to prevent them from standing up from a chair. This meant that people were not supported in the least restrictive way possible, and people were at risk of harmful effects on their physical and mental health by reducing their freedom of action and mobility.

We notified the registered manager of the concerns we identified with inappropriate restraint and immediate action was taken to speak with and upskill staff. However, records reviewed showed staff had not undergone competencies checks. This meant the management team had missed opportunities to identify safeguarding concerns. Where concerns had been identified these had been raised appropriately with the relevant authorities such as the local authority and Care Quality Commission.

People told us they were not always supported to manage their identified risks. For example, one person described what support they needed to have a shower, but said, “Most of the time they support me in bed because it’s easier for them I think.”

Staff did not always support people to manage risks appropriately. One person’s care plan stated that they wanted a shower daily. We spoke to the staff member who delivered the person’s personal care on the day of the assessment and they confirmed they had not offered the person the option of a shower.

We observed a number of people living at the home, some of whom were identified as a falls risk, walking without appropriate footwear or supervision. One person was observed asking staff for assistance with finding and putting shoes on and was told they would have to wait.

While records we reviewed showed risks were assessed and reviewed regularly these checks did not always identify people’s needs or reflect people’s needs and choices. Where needs had been identified there were no quality management checks completed, such as staff competency checks, to ensure people received care and support in line with their wishes or identified needs.

While people told us they felt safe living at the home, the experience people received did not always meet required standards. During the assessment we identified risks to people from equipment. For example, we observed slings used to assist people with moving and handling that had not been quality checked appropriately to ensure they were safe to use.

Staff we spoke with acknowledged that there were safety concerns with broken items in people’s rooms and stated they had made management aware. One staff member said, “We have reported our concerns, and we have a really good maintenance team but there are still a lot of broken items that need fixing.”

We observed wheelchairs, which were in daily use to support people with their moving and handling requirements, which did not have footplates attached. Furniture in people’s rooms had not been maintained to a high standard. We observed drawers hanging from chest of drawers and some rooms were missing basic equipment like chairs for people to be able to sit in their bedrooms. This meant people were at risk of harm from an unsafe environment.

During the inspection we identified several pieces of broken equipment including hospital beds. Audits completed by the registered manager had failed to identify these concerns. We brought these concerns to the registered manager who took immediate steps to rectify the risks identified.

People and their relatives felt there weren’t always safe and effective staffing levels within the home. One relative said, “My [relative] has 1 to 1 staff support but today have a new staff member with them and they don’t appear to know how to care for [relative].” A person living at the home said, “I want to go to dining room, but I can’t until staff are about to let me through the doors.”

Staff we spoke with told us they felt there were enough staff to support people in the home. One staff member said, “It can be really busy in a morning when everyone is getting up but there is enough of us.” Staff told us they received regular training that was relevant to their role. A staff member said, “We have online and face to face training and we do refresher training every year to make sure we remember everything.”

We observed large periods of time where people were in unsupervised communal areas of the home with no way to gain staff attention or support should this have been required.

We reviewed the training matrix and saw that staff had completed mandatory training relevant to their roles, however there were several annual refresher training requirements out of date. The registered manager confirmed this would be arranged immediately to ensure people remained safe. The home had a dependency tool in place and staffing levels matched this requirement. We discussed our concerns with the registered manager about unsupervised communal areas and they agreed to review staff deployment in the home as a priority.

People did not experience good infection prevention and control. We undertook checks in people’s bedrooms and found stained mattresses and bedding in multiple rooms. Carpets were heavily stained and had a strong odour of urine. Furniture was chipped and broken which presented a risk of spread of infection.

There was a dedicated domestic team who had checklists to support them with what cleaning tasks needed to be completed daily. Staff told us at times they struggled to complete these tasks especially if another staff member was absent. One staff member said, “It can be hard, if some are off sick, we have to try and cover their work too and it’s not always possible.”

We observed chairs in communal areas stained with dirt and food debris. We saw pressure cushions in use that had rips and tears. We found wheelchairs had not been cleaned for an extensive period and were dirty and contained dried food debris. We brought these concerns to the attention of the registered manager who took immediate action.

While the registered manager acted on the feedback we gave, we saw evidence that the provider had been made aware of similar concerns during audits by other stakeholders and had not actioned this feedback prior to our visit. Quality monitoring audits, such as daily walk rounds had failed to identify and address the concerns we saw on the assessment.

People told us they were supported safely and effectively with their medicines. People told us staff were responsive if they requested pain relief and they did not experience excessive wait times for this medicine. One person said, “Yes, they [staff] are very good, they know what all my tablets are and make sure I take what I need.” Relatives supported this feedback, “The staff are great, they always update me if medication changes, or if they are concerned.”

Clinical staff we spoke with were knowledgeable about people’s needs and their medicines. Staff actively engaged in the weekly ward round with the GP, and this promoted early detection of risks to people. Staff told us nurses and nursing assistants were responsible for medicines but stated they felt confident in raising concerns to them and managers if they felt people needed medicines for pain or illness.

Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed. Further checks such as storage temperatures were recorded which ensured people remain safe from the risk of harm. Some people required ‘as needed’ medicine and staff had clear written guidance on how this should be administered. Although clinical staff were responsible for administration of this medicine, guidance was clearly written in care plans, so all staff knew how and when to help someone request a ‘as needed’ medicine.