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 were exposed to the risk of abuse and avoidable harm and experienced periods of neglect which impacted their dignity and wellbeing. Forest Manor Care Home demonstrated a closed culture where some staff failed to report incidents of poor care practice they had witnessed despite knowing how to do this. Some staff did not receive the required training needed to be able to support people safely. In addition, trained and experienced staff failed to follow training and best practice policies to ensure people’s safety. Medicines were not managed or administered safely which resulted in people consuming unknown medicines and other people not receiving their prescription medicine. The provider and management team had failed to make significant progress and improvements since our last assessment which resulted in people receiving unsafe and inappropriate care standards and practices. 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 remained unable to explain or describe how the learning culture affected their experience in the care home. However, our observations showed lessons had not been learned and the culture of the home did not support improvements which resulted in people receiving poor experiences and outcomes.

Staff consistently raised concerns to the assessment team that their feedback was not acted upon, and this had led to a culture of incidents and concerns not always being reported. Staff were knowledgeable about what incidents were reportable but failed to follow this guidance when they witnessed incidents of concern by other staff members. For example, 3 staff members observed people being moved inappropriately in a wheelchair without footplates. The staff members did not intervene or report their concerns. This placed the person at risk of harm from skin tears and injury to their limbs such as fractures.

There had been no improvements in the learning culture of the home. Audits of incident logs continued to fail to address new concerns raised by staff. For example, we saw an incident form about inappropriate sexual behaviour from one person towards a person living with dementia. No action had been taken to investigate this incident or mitigate the ongoing risk. We raised this with the management team who started a formal investigation which remained ongoing at the time the assessment ended.

People and relatives told us there had been no improvements regarding safe systems, pathways and transitions into and out of the service. Where people had previously raised concerns about their placement within the home they had seen limited progress regarding seeking support and resolution with this. Relatives of people newly admitted to the service told us they were not given a choice over their relative’s placement. One relative said, “I didn’t want my [relative] to be admitted here but I was told I did not have an option. I know this is not the home’s fault but I’m not sure [relative] is safe here.” Following our assessment the provider ensured all residents had received a review of their placement and offered the opportunity to consider new care services and placements.

Staff continued to raise concerns about the admission process and level of support some people needed to meet their needs. The provider acknowledged this concern and had a plan in place to recruit more experienced staff but acknowledged this concern and risk remained until this support and appropriate staffing were in place.

Partners we spoke with including professionals from the local authority and the integrated care board (ICB) raised concerns about people not being supported to access medical assistance in a timely manner. One professional said, “We raised concerns about a person with a wet cough and asked that 111 was contacted for support. In 12 hours there was no action taken.”

The management did not have comprehensive oversight of the service and the level of care people were receiving. We reviewed records of the person the ICB had raised concerns about and there was no written log of their concerns or any follow up actions. This placed people at risk of harm from delayed support or missed opportunities to have health concerns reviewed.

People were not protected from the risk of abuse or harm and experienced periods of neglect which impacted their dignity, care and outcomes. From reviewing CCTV footage, we saw an incident of a person throwing a beaker at another person during a mealtime service. Despite staff being present and witnessing the incident no action was taken and no checks were made on the person who had been hit by the beaker.

When asked about safeguarding staff were knowledgeable about different types of abuse and knew the process to report their concerns. However, staff repeatedly failed to act on this process and best practice guidance to keep people safe from the risk of neglect, abuse and avoidable harm. We saw examples of staff observing other members of staff draglifting people from chairs and inappropriately restraining people without intervening or reporting the poor practices to management. This ingained behaviour from staff allowed risks in relation to safeguarding to remain.

We saw multiple incidents of neglect, for example, CCTV footage showed 3 people who were living with dementia were awake and wandering in the dining room fully dressed between midnight and 6am. Four different staff members entered the dining room on 11 different occasions during this period and did not engage or communicate with people or offer any type of support. This placed people at risk of avoidable harm from unwitnessed falls, poor continence care, lack of fluids and nutrition and sleep deprivation.

We raised concerns with the registered manager about nighttime checks, care and support and were assured that the management team completed spot checks of the service during the night. However, the management team could not provide any documentation to evidence these checks had taken place.

People’s experience relating to the management of risks had not improved since the last assessment. There was no evidence of improvement to the personal care people received. We reviewed people’s bedrooms and saw no evidence of toiletries being used for personal care. For example, toothbrushes and flannels/towels were dry in rooms where personal care had just taken place.

Staff were not knowledgeable about people, their condition or needs. We spoke with 2 staff members who were allocated to support 4 people during their working shift. The staff members were not able to tell us the health condition of any person or what their needs entailed. Inspectors asked the staff members to show them people’s health conditions within their care plans and staff were unable to do this.

Some people were living with health conditions that required their fluid and nutritional intake to be recorded. We saw multiple instances of staff failing to record information onto the electronic care planning system or logging such information incorrectly. For example, we saw 1 person was not offered a main meal at lunchtime and only offered a pudding. We reviewed the daily notes for this person and staff had recorded the person had eaten a full meal followed by pudding. This placed the person at risk of harm of malnutrition and weight loss. It also prevented accurate reviews of the person’s current wellbeing and could lead to missed opportunities to involved other medical professionals when needed.

There had not been enough improvement to the provider’s quality monitoring audits and processes since our last assessment to ensure people remained safe and were supported to manage their risks. The provider and management team were not aware of any of the issues we observed or practices witnessed by staff. They responded with an action plan to address the concerns identified.

The provider had made some improvements since our last inspection such as replacing and repairing beds where required. However, there remained significant concerns for people surrounding their environment. Previously we had raised concerns about foul smelling carpets within bedrooms and while some of these areas had been replaced some rooms still contained carpets and were not due to be fully replaced until January 2025. This meant that people were placed at risk of a poor environment despite awareness by the provider of such risks.

We spoke with the provider at length about improvements and planned ongoing improvements. We saw evidence of a limited amount of new furniture, such as wardrobes, being sampled and ordered. However, we saw unsafe furniture remained in people’s rooms. For example, some people’s rooms contained poor quality bedside tables. These tables had loose joints and evidence of wear with screws showing through surfaces. These items posed an injury risk to people.

We observed a person’s bedroom had a urine-soaked bed and bedding. A staff member was observed supporting the person to bed and we advised them about the bedding, however the person was still supported into this bed. When the person awoke a short time later, they were supported to the dining room remaining in the same clothing that had been in contact with the stained bedding. We returned to the person’s bedroom at the end of the day and the stained bedding remained.

During the assessment we saw that a panel which displayed call bell alerts was missing and undergoing repair. This meant at times and in certain areas of the home when a call bell was pressed staff were not able to hear the call bell. The provider assured us that this had not impacted people’s call bell response time however they acknowledged this had not been risk assessed to ensure risks were mitigated where possible.

People and their relatives told us their experience of safe and effective staffing had not improved since the last assessment. People who had capacity and were able to mobilise independently told us they remained frustrated by the number of codes on internal doors which prevent them freely accessing the home which was further impacted by the availability of staff to open these doors for them. One person said, “I would love to be able to go outside and watch the birds whenever I want, but it’s so much hassle just getting downstairs and finding a staff member to let me through that I stay in my room now.”

We spoke with 2 new members of staff who confirmed that since starting work with the home they had not undertaken any training after a period of 4 months. These staff members were observed supporting people independently with their needs. This placed people at risk of harm and unsafe care from staff who did not have the required skills to support people. We reviewed training records with the management team who advised there had been a system error with a third party IT company who provided their training software however we were not provided with any evidence of this. We noted 5 new staff members who had not completed their mandatory training. The management team ensured these staff members did not work with people unsupervised again until training was completed.

We observed on assessment and through review of CCTV footage large periods of time where communal areas were unsupervised by staff members. CCTV footage also showed 4 staff members who worked nights were appeared to be asleep for large periods of time. Some of these incidents included staff members who were allocated to support people with 1-1 care and had choking and self-harm risks that required support 24 hours a day. This meant people were knowingly placed at risk of harm and neglect.

The provider and management team did not have oversight of safe and effective staffing within the home. During the assessment we found that no permanent staff member had undertaken practical manual handling training or refresher training despite the home having a staff member who was a qualified train the trainer for this course. The provider responded immediately and implemented a 7-day action plan to retrain staff. To mitigate risks to people, only staff who had completed theoretical manual handing training supported people with manual handling tasks until additional staff had been upskilled.

People remained at risk from poor infection prevention and control (IPC) methods and standards within the home. While the provider and management team had made some improvements since our last assessment, we observed reoccurring issues regarding stained bedding and mattresses and malodorous rooms.

Staff we spoke with were knowledgeable about IPC however did not demonstrate best practice guidance during their working role. Personal protective equipment (PPE) was not always worn. Where staff did wear PPE, we observed multiple occasions of this being worn inappropriately and not being changed between support for different people. There was limited access to infectious waste bins for staff to dispose of PPE which led to used items being left on surfaces and in corridors and we saw people living at the home handling these items.

We repeatedly observed on assessment and through CCTV footage people in stained and dirty clothing for extended periods, including at times people with urine-soaked clothing. This placed people at significant risk of harm from infection and damage to skin integrity from being in wet clothing. We observed staff collecting beakers which contained partially drunk fluids of people living at the home. These were placed into the fridge and given out to people later in the day. The drinks were not identified to particular people and meant beakers and fluids had been shared by multiple people. This exposed people to the risk of bacterial, viral, fungal and parasitic infections.

Quality monitoring and assurance systems put in place by the provider and management team had not identified the issues we found on the assessment. Although improvements in furniture and cleanliness of equipment such as wheelchairs had been made in some areas, significant risks remained to the safety of people living at the home.

People were placed at risk of potential harm from their experience of medicine optimisation at Forest Manor Care Home. Through observation of CCTV, we saw multiple instances of people, some living with dementia, being administered liquid medicine in beakers which were left on a table in front of them and then not observed taking these medicines. We saw other people, also living with dementia taking these beakers and drinking the contents. This placed people at risk of harm from consuming medicine that had not been prescribed to them and others at risk of not receiving treatment needed to support their health conditions.

We observed further incidents of negligent behaviour from staff members. For example, we saw a nurse leave an unlocked medicines trolley unsupervised within a corridor of the home where people, some of whom were living with dementia, were wandering unsupervised. This resulted in a person accessing and consuming an unknown liquid from the medicines trolley without staff knowledge. This placed the person at extreme risk of harm as the medicine trolley had 18 people’s prescribed medicines stored on the trolley.

While staff had completed a medicines competency before being allowed to administer medicines, spot checks on staff competencies were not completed routinely or robustly and there was no evidence of any spot checks for the night staff, therefore the negligence we observed had not been identified. We raised concerns with the provider who took immediate steps to protect people whilst a plan for improvement was developed.