Forest Manor Care Home

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

There had not been any meaningful improvements since our last assessment. People were not treated with kindness, compassion, dignity or respect and people were not always treated as individuals. People and staff told us they were not always able to respond to immediate needs. We took enforcement action against the provider and told them to make improvements.

This service scored 25 (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 not treated with kindness, compassion, dignity or respect. We observed through CCTV that people were not supported with their continence needs or receiving inappropriate support. For example, a person living with dementia had become incontinent of urine and had pulled their trousers and underwear down to their ankles. Staff walked the person down the corridor without attempting to cover the person up. This did not respect the person’s dignity and left them at risk of falls from walking with clothing around their feet.

We spoke with the registered manager and provider about the concerns we found on assessment and the lack of improvement to the care and dignity provided to people since our last assessment. The provider acknowledged the concerns and took immediate steps to implement change.

Feedback from the local authority and integrated care board did not support that people were treated with kindness, compassion and dignity. Feedback said they had observed staff struggling to recognise people’s basic needs, such as a need to go to the toilet.

Observation did not show that people were supported with kindness, compassion or dignity. Multiple people wore dirty and stained clothing as seen on the last assessment. We also saw people wearing torn and ripped clothing and ill-fitting clothing that did not protect their dignity.

People were not treated as individuals and did not always receive care in line with their needs or wishes. One person said, “I am fully independent with my needs and have been here a long time but I am not allowed a mirror to shave. I have to sneak into the staff bathroom to shave.” We fed this back to the provider who acted to get the person a mirror.

Some staff we spoke with raised concerns about their ability to support people as individuals. One staff member said, “It’s hard supporting people living with dementia on the mental health extension. We can’t have items in there because of risks to some people but this means the majority don’t have access to anything to keep them occupied or entertained.”

We observed one person struggling to communicate with us because of the provider’s policy that staff and visitors were required to wear face masks. They repeatedly asked the inspector to remove their mask and talk to them. We spoke to a member of the management team who advised this was a provider policy and they were unaware why it remained in place and acknowledged some people struggled to communicate because of this. The provider has since lifted the requirement for staff and visitors to wear masks.

Care plans did contain information and guidance on how to support people in an individualised way, however, staff failed to consistently follow this guidance or were not assisted by the environment to be able to do so. There was no evidence to show how the management team ensured that this support was being given to people. Quality monitoring checks such as daily management walk rounds had not identified the concerns we found. This issue remained from our last assessment.

People told us there had been little improvement since our last assessment. One person said, “Nothing happens, there isn’t anything to do here. I go to my room but people wander in and out so I ask staff to lock me in, it shouldn’t be like this.”

Staff told us that they do support some people to go into the community but have limited opportunities to do this.

During our assessment visits we did not see any meaningful or organised activities happening. We observed the activities co-ordinator supporting with care needs and meal service rather than activities or stimulation.

Despite concerns being raised with the registered manager at our last assessment, feedback and observations showed there had been no improvement in people’s experience or access and participation in meaningful and stimulating activities.

People told us that while staff tried to be responsive to their needs, at times they could not find a staff member to support them. One person said, “Its’ hard sometimes, they are always busy. There are so many locked doors that you have no option but to wait until they are free.” Another person said, “I told [staff member] I needed a wee, I can’t find the toilet, they pointed down here, but I can’t find it.”

Some staff told us they struggled to respond to people’s immediate needs. One staff member said, “It’s hard, people have complex needs, and a lot of people need 2 staff to support them, so when staff have a break or lunch or are already supporting someone, we get delayed or communal areas can end up unsupervised.”

People’s immediate needs were not always supported or responded to in line with guidance contained within their care plan. For example, we observed a person experiencing a period of frustration who became verbally aggressive to other people in a communal lounge. A staff member walked into the lounge and did not take any action to de-escalate the situation.

Some staff we spoke with said there had been some improvement since our last assessment, but this had not been maintained. For example, a staff member said, “We had a team meeting after the last visit and more information was shared about the direction of the home but there hasn’t been any more since.” Another staff member said, “I know CQC found some concerns last time you were here, but I don’t know what they are, maybe I missed that update or meeting.”

We did see evidence of team meetings being held but from staff feedback it appeared staff who didn’t attend did not receive an update of the information or any information shared lacked clarity. The management team had started to implement competency checks on staff, but these had failed to identify the issues we found on inspection and not all staff had undergone this process. For example, the provider acknowledged only 1 staff member on the night shift had received a competency check.