Forest Manor Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People did not receive effective care and there had been minimal improvements since our last assessment.

We observed staff repeatedly making decisions for people without attempting to support or encourage them to make their own decisions as described with their care plans.

People’s aims and outcomes were not always supported by staff and risk assessments did not always fully reflect people’s needs. Some care plans did not contain specific care plans to support people with known health conditions which placed people and staff at risk of harm.

We took enforcement action against the provider and told them to make improvements.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While people and relatives we spoke with stated they felt included in care planning and having their needs assessed, we saw evidence in care plans that people’s identified needs were not clearly documented.

We saw examples of people’s known health needs and conditions not having supporting care plans to guide staff on how to support a person appropriately, in line with their wishes or in the event of an emergency. This included conditions such as kidney disease, diabetes and transmissible conditions. This placed people and staff at risk of unsafe and ineffective care.

We spoke with several staff members who stated they felt they were able to give feedback about care plans and people’s changing conditions, however nursing staff told us they did not assess or develop care plans in any way. This meant the opportunity to have clinical input into people’s needs was missed.

Care plans and risk assessments were not effectively developed, monitored or reviewed. Daily notes did not accurately reflect people’s fluid or nutritional intake and this also extended to their continence care, repositioning needs and daily activities. This meant that people’s needs could not be accurately assessed, which risked further professional support and referral not being sought in an effective way.

Improvements had not been made in people’s experiences of having their care and treatment delivered in line with best practice.

People were not supported to make decisions or choices in line with care plans such as meals and drinks. We observed people not being offered or receiving a meal or experiencing excessive wait times to be supported with nutritional needs resulting in cold food. People were not encouraged to remain independent with their needs, for example we saw several incidents of people living with dementia leaving full plates of food without staff attempting to encourage them to eat and staff simply removing the meal.

We raised these concerns on our last assessment with the registered manager and the same issues were identified again on this assessment. Some staff told us there was a high level of need during mealtimes which impacted their ability to support people effectively. However, through reviewing CCTV footage we saw multiple incidents of staff simply observing people at mealtimes and making no attempt to engage and support people or intervene when people began to wander.

Despite concerns being raised to the management team on multiple occasions people were still not receiving effective care and treatment. We saw no evidence of the management team being present during mealtimes or observing staff practices and processes in place had failed to identify incorrect and inaccurate recording in the care notes by staff.

People were not able to answer questions about how staff and teams worked together.

Some staff told us they knew people well and knew how and when they wished to be supported to access services such as hairdressers and chiropodists. However, other staff we spoke with did not know people’s health conditions which resulted in them not knowing what support was appropriate for some individuals.

We received mixed feedback from partners who worked with the service. For example, the local authority and integrated care board found significant issues during their own audit process and were not assured by the management team responses. However, we received positive feedback from the GP practice aligned to the home who stated the staff were knowledgeable about people’s needs and sought assistance appropriately.

We saw evidence of the registered manager evaluating people’s readmission to the home following hospital admissions to ensure this was undertaken safely and effectively. Care plans contained referrals and communication to other medical professionals involved in people’s care allowing a joined-up approach to ensure people received their care effectively.

People were not supported to live healthier lives. People were left unsupported and unsupervised for large periods of time. This impacted people’s ability to manage their own needs or have staff help them to identify their needs such as continence care.

We saw little evidence that people were supported with their personal care. For example, we reviewed CCTV footage of several night shifts. People were not supported to change into nightwear such as nightgowns or pyjamas and were not supported to go to bed. Some people remained in the same clothes for multiple days.

We observed staff members routinely waking people up and supporting them out of bed from 5.30am despite some people’s care plan stating they did not wish to get up until around 9am.

We observed poor and negligent practices from some staff members. For example, one person’s care plan stated they would place themselves on the floor and staff were to support them from the floor and to safe area. CCTV showed this person placing themselves on the floor in a corridor during the night and appearing to fall asleep for an hour after failing to locate their bedroom. 3 separate staff members entered this corridor and observed this person and did not engage with them. At times staff stepped over the person whilst walking through the corridor.

Quality monitoring and audit systems in place had failed to identify the poor care and negligence. While care plans did contain some person-centred guidance for staff about how people wished to be supported, the management team had failed to identify the poor practices displayed by staff.

People did not always experience positive outcomes. People did not always receive their care in a dignified way. For example, we observed a staff member support a person to their room to provide personal care and a change of clothes. Following this a bedroom check was undertaken and the room did not have any curtains and only a partial privacy screen on the window. This meant the person’s dignity was not respected and the bedroom did not support dementia-friendly practices such as the opening and closing of curtains to help people to identify the time of day.

We spoke with the provider about the rooms without curtains and the concerns around people’s dignity. We were advised these items had been removed due to repeated destruction. The management admitted they had not considered alternatives such as enclosed blinds or Velcro fastenings.

The provider acted on this feedback and ordered appropriate furnishing for people.

Care plans we reviewed did not support or demonstrate things we saw on assessment. For example, we were told some rooms did not contain furniture because of people’s personal preferences but the care plans did not support this.

There had been no improvement in this area since our last assessment. We observed multiple staff members making decisions for people in relation to clothing and food choices.

The management team and staff were knowledgeable about the mental capacity act, however the repeated actions, described above, we observed on the day and through CCTV did not support good practice in this area.

As found on our last assessment care plans contained mental capacity assessments and where appropriate were supported with best interest decisions that guided staff on how to support the person in their preferred way when people lacked capacity. However, the management team did not have oversight of the quality of care provided and failed to undertake competency checks with staff therefore the management team had not identified the concerns we saw through our observations.