Forest Manor Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The home was not well-led and displayed a closed culture which did not encourage people or staff to speak up. Poor practices observed by the CQC and other professional partners were not identified by managers at the home, through existing quality monitoring systems and placed people at risk of harm and neglect. 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.

Whistleblowing concerns from staff and from feedback received from staff during the assessment demonstrated their concerns over a closed culture. A closed culture is described as a poor culture in a health or care service that increases the risk of harm. This includes abuse and human rights breaches. The development of closed cultures can be deliberate or unintentional – either way it can cause unacceptable harm to a person and their loved ones. Staff told us CCTV was used to monitor them inappropriately. For example, a staff member said, “The [Name] was not on site and they phoned me to ask me what I was doing and said and told me they were watching me, it makes you paranoid.”

We raised the concerns with the provider and registered manager. We saw evidence that the CCTV was not accessed excessively from the main office, however there was no report that covered remote access to the system.

We received mixed feedback from staff. Some staff said the managers and provider were open and accessible and would listen to feedback and concerns. However other staff told us they did not feel the managers were approachable. One person said, “You never know what mood or reactions you are going to get, sometimes they are supportive, other times I’ve been sworn at or seen them shouting and crying. It’s easier just not going to them.”

We discussed our concerns with the provider and gave examples of staff feedback, such as staff being concerned about nicknames used to describe managers which invoked fear. The provider was not aware of these concerns and took immediate steps to investigate and improve the experience for all staff and to ensure they had access to required support.

Staff told us that while they knew how to speak up and were aware of whistleblowing policies, they were not confident to use them. One staff member said, “I wouldn’t speak up, when CQC were here last time and found issues, [Name] shouted at people they thought were responsible in front of other staff. It was horrible and there was no support.”

Again, we raised these concerns with the provider who took immediate action to ensure people received a supervision and opportunity to give feedback. They also put an action plan in place to ensure this support was ongoing.

While some staff told us they believed staff were treated equally some staff told us it was not an inclusive place to work.

The provider and management team did not take action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion for people or staff.

Through observations of staff practices and conduct we observed significant concerns that the management team acknowledged were poor practice as they reviewed the CCTV footage with the assessment team.

There had been no improvement in the quality monitoring processes since our last assessment. Audits such as competency checks were still not routinely undertaken and the provider and management team did not have oversight of the quality of care people were receiving. Where audits such as domestic checks and daily walk rounds had been completed these had not identified the issues found on inspection meaning people were consistently exposed to risk of harm and poor care.

People were unable to comment as to how the service worked in partnership with others or within the community. However, from issues identified on inspection we were not assured that people were kept safe following the recommendations from partners and other professionals.

The management team and the provider were responsive to all feedback and engaged with the assessment process. They took immediate steps to implement an action plan for improvement.

Professionals who had visited the service and undertook audits had repeatedly raised concerns about infection prevention control (IPC) within the home. They told us that, despite receiving feedback from the provider and giving them recommendations and time to implement changes, issues consistently remained with the standard of cleanliness and safety within the home. This issue remained on this assessment.

As at our last assessment, the registered manager had completed an action plan to address concerns raised and in relation to issues raised by external partners and professionals, however issues still remained within the home environment and staff practices.

Lessons had not been learnt from our previous assessment and feedback as well as that of other professionals and partners the home worked with. There had only been minor improvements in some area as demonstrated throughout this report.

The culture of the home and oversight processes in place to monitor the service failed to identify concerns, poor staff conduct and unsafe care. This showed that learning and improvement had not been embraced by managers or embedded into the service.