Forest Lodge Rest 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to risk management, medicines, infection prevention control, safe environment and staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety. Risks to people were not always used to learn and improve. For example, incidents within the home were not always recorded. Therefore, the service could not effectively monitor for themes and trends. However, we found the management team were open and transparent and wanted to drive improvement at the service.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service worked with external professionals to ensure rehabilitation for people to support with progression into independent living.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People mostly told us they felt safe at the home. However, 1 relative told us they felt the mix of people living at the home caused some conflict and they did not feel their relatives were in a suitable placement.

The service did not work well with people to understand and manage risks. Risk assessments relating to the health, safety and welfare of people using the service were not always completed. This meant plans were not always in place to support people to manage risks. For example, where people were at risk of falls, risk assessments were not always in place to mitigate further risks to the person and to maintain their safety. Communal areas were not always supervised to reduce risk to people.

The service did not always detect and control potential risks in the care environment. Where there were risks in the environment, such as, a smoking room, appropriate risk assessments were not completed. During our first visit to the service, there did not appear to be appropriate ventilation within the smoking area. The provider took prompt action to resolve this.

The service had enough staff. However, the provider did not always ensure staff received sufficient training for their roles. For example, where people had specialist needs, such as, a learning disability or epilepsy, staff had not received training to support these people safely. This placed people at increased risk of harm. However, the provider did ensure staff received effective support, supervision and development.

The service did not always assess or manage the risk of infection. During our first visit to the service, we identified several areas of concern with regard to cleanliness and food hygiene. We also received negative feedback from a visiting professional regarding the cleanliness of the home. On our second visit to the service, we found improvements to the cleanliness and food hygiene practices. Personal protective equipment was readily available to staff.

The service did not always make sure that medicines were stored, administered and managed safely, in accordance with prescriber instructions and best practice guidelines to make sure that people who used the service were not placed at risk. We found issues with medicine stock levels and found some controlled drugs which were not stored or being administered in line with the prescribers’ instructions. The provider was responsive and took immediate action to resolve issues found by inspectors.