About the service: Forest Place Nursing Home is a care home with nursing. There are two separate buildings where people live and receive care. Different areas of the home specialise in supporting people with nursing care needs or dementia. There were 70 people living in the home when we inspected.

People’s experience of using this service:

People experienced compassionate care from kind, dedicated staff who made them feel important and valued. People told us they felt they were treated with respect. However, people who were unable to leave their bedrooms did not always have opportunities to engage with activities and told us they were bored and lonely. While some areas of the home environment were well maintained, and created a pleasant and welcoming atmosphere, the appearance of other areas of the home had deteriorated over time and were cold. There were lots of inconsistencies in how well people’s care needs and preferences were recorded which meant there was a risk that people may not always receive care in line with their needs and preferences. People gave examples where agency staff had not known how to support them properly. While people and relatives told us they found staff and the management team open and approachable, their systems were not operating effectively to improve people’s experience of living in the home.

Rating at last inspection: The service was rated Requires Improvement at its last inspection in October 2017.

Why we inspected: This was a planned inspection based on previous rating.

Enforcement: Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will continue to closely monitor the service and require an action plan from them.

At our previous comprehensive inspection of the service in August 2016 one breach of the regulatory requirements was made in relation to Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that improvements were required in relation to the registered provider’s arrangements for medicines management, care planning, the management of risk; and where people lacked capacity to give consent and assessments had been carried out, people using the service and others were not always involved in the decision making process.

At this inspection whilst improvements were noted since our last inspection in relation to complaints, medicines management and enabling people to be involved with making decisions, further improvements were still required pertaining to care planning and ensuring risks were managed appropriately.

Following the inspection there was a serious incident which is subject to a police investigation. The inspection did not examine the circumstances of the incident, however we reviewed all information received and concluded the service had acted appropriately to ensure people using the service were safeguarded and any risks to people’s safety and wellbeing were mitigated.

Forest Place Nursing Home provides accommodation and personal care for up to 90 older people. Some people also have dementia and complex nursing related needs. The premises consist of Kingfisher Unit for people living with dementia and Maple Down and Maple Loft for people living with complex nursing needs. At the time of our inspection the service was undergoing extensive building works to the premises and we were advised that these works would be completed in 2019.

This inspection was completed on 29 and 30 October 2017 and there were 71 people living at the service when we inspected.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Although a lot of work had been done, further improvements were required to the quality assurance system to drive improvement and ensure that all aspects of the service are clearly monitored for potential risks. This related to people’s care records and risk assessments. Risks had not always identified and mitigated so as to ensure people’s safety and wellbeing. Suitable arrangements were needed to ensure staff followed people’s care and support needs so as to ensure their safety and wellbeing. We did not see any impact on people due to these documentary shortfalls during our inspection and the registered manager was responsive to addressing any concerns noted during our visit.

Minor improvements were required to recruit staff safely in line with the provider’s policies and procedures, to ensure staff received a robust induction and an appraisal of their overall performance.

Systems were in place which safeguarded people who used the service from the potential risk of abuse and harm. Staff understood the various types of abuse and knew who to report any concerns to should the need arise. People living at the service confirmed they were kept safe and had no concerns about their safety. People were confident that their concerns and complaints would be listened to, taken seriously and acted upon.

Appropriate arrangements were in place to ensure people’s medicines were obtained and administered in line with the prescriber’s instructions. Improvements were required in relation to how medicines were securely stored for safekeeping at all times.

The deployment of staff within the service was suitable to meet peoples’ care and support needs. Staff described the management team as supportive and approachable. Arrangements were in place for staff to

We carried out an unannounced comprehensive inspection of this service on 1, 2 and 3 February 2016. Breaches of legal requirements were found. The service was judged to be Inadequate and placed in special measures by CQC to ensure sufficient improvements were made. A Notice of Proposal and subsequent Notice Of Decision was issued to the registered provider that no further people could be admitted to the service without our agreement while improvements were made.

In addition, the Care Quality Commission met with the registered provider on 12 February 2016 to discuss our concerns. During the meeting the registered provider gave us an assurance that things would improve and this was followed by a written improvement plan in April 2016 advising of the provider’s progress in meeting legal requirements.

This inspection took place on 11, 12, 13 and 16 August 2016. A registered manager was not in post at the time of this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had voluntarily cancelled their registration with us since the February inspection. A new manager was in post and taking steps to progress an application for registration as required.

Forest Place is registered to provide accommodation with nursing and personal care for up to 90 older people. People living in the service may have care needs associated with dementia. The service also offers palliative care. There were 67 people receiving a service on the day of our inspection, including two people who were in hospital.

At this inspection we found that although some areas required further sustained improvement, the majority of improvements had been accomplished. The service had developed more robust quality assurance processes to ensure an improved quality of service provision. However, further work was needed to ensure that processes and systems were embedded and continued to improve the care people received at the service, once the service started to re-admit people. We found that the complaints system had not been operated effectively to show that people’s complaints had been thoroughly investigated, learnt from and responded to.

Medicines management was more robust but some aspects of this, as well as aspects of care planning and individual risk assessments, needed further development. Where people lacked capacity to give consent, assessments had been carried out to ensure their rights were protected; however additional detail was needed to show that suitable people had been involved in the decisions in all cases.

Staff were knowledgeable about identifying abuse and how to report it to safeguard people. Staff recruitment processes were shown to be thorough to safeguard people. People were supported by sufficient numbers of staff that were properly deployed to respond to their need safely.

Staff were effectively trained and were clear on their role and responsibility in providing safe and responsive care. People received support from caring staff and people were treated with dignity and respect, including at the end of their life.

Arrangements were in place to support people to gain access to health professionals and services. People had choices of food and drinks that supported their nutritional or health care needs and their personal preferences.

This inspection took place on 1, 2 and 3 February 2016.

Forest Place Nursing Home is registered to provide accommodation with nursing or personal care for up to 90 people, some of whom may be living with dementia. There were 83 people receiving a service on the day of our inspection.

The overall rating for this service is ‘Inadequate’. This means that it has been placed into special measures by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not protected from the risk of harm. Risk management plans for individual people were either not in place or were inaccurate and so did not support people’s safety. Staff did not use equipment safely to limit people’s risk of injury or take action to protect people from risks in the environment they lived in. Staff knowledge of how to safeguard people varied and staff had not acted to protect people from the risk of harm. People’s medicines were not safely managed. Staff recruitment procedures were not robust to ensure staff were suitable to work with people living in the service. Staff were not always available in sufficient numbers to meet people's needs and to provide them with safe care and support. Improvements were needed to staff deployment to ensure people’s safety was consistently monitored.

Up to date guidance about protecting people’s rights had not been followed so as to support decisions made on people’s behalf and to comply with legislation. Staff did not receive suitable training and support to enable them to meet people’s needs effectively. Staff performance was not suitably monitored and appraised to ensure good practice was in place. We observed poor care practices around supporting people to eat and drink well, with moving and handling of people and with supporting people with anxious and distressed behaviours.

People were not always treated in a caring and respectful way. Records were not always available to guide staff on how to meet people's assessed care needs. People did not always receive the support required to meet their identified individual needs and to support their decisions and choices. People had limited opportunities to participate in social activities and engage in positive interactions.

The service was not well led and there were widespread shortfalls. While people living and working in the service had the opportunity to say how they felt about the home and the service it provided, action plans were not developed to demonstrate that improvements were implemented. Management arrangements to ensure accountability and communication in the service were weak an

On the day of this inspection there were 88 people living at Forest Place Nursing Home. This is a summary of what we found based on our observations during the inspection. We looked at written records, which included people's care records, staff personnel files, medication systems and quality assurance documentation. We spoke with eight people who used the service and we spoke with the manager, the deputy manager, the group development manager and four members of nursing and care staff. We also spoke with one close relative and an NHS professional who was visiting the home to assess some of the people for correct funding.

We considered our inspection findings to answer the five questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

If you want to see the evidence supporting our summary, please read the full report.

Is the service caring?

We spoke with eight people who used the service and one close relative. One person said to us, "I am very well looked after here. It's very nice; they treat you well." Another person said, "I have no complaints at all. The staff are always wonderful." One close relative said, "It is an awkward journey for me to get here, but I would not want [my relative] cared for anywhere else as this place is perfect. It's incredible just how kind the staff are."

We observed the care and attention people received from staff. All interactions we saw were patient, respectful and friendly and there was a calm atmosphere throughout the home. People's dignity and independence was respected.

Is the service responsive?

We saw that care plans and risk assessments were informative, kept up to date and regularly reviewed. The manager responded in an open, thorough and timely manner to complaints. Therefore people could be assured that complaints were investigated and action was taken as necessary. Staff told us the manager was approachable and they would have no difficulty speaking to them if they had any concerns about the home.

Is the service safe?

The accommodation was adapted to meet the needs of the people living there, was suited to caring for people with limited mobility and was properly maintained. The home was warm, clean and was personalised to the people who lived there.

People were protected by effective staff recruitment systems. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines. There were proper process in place in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS).

Is the service effective?

People we spoke with were satisfied with the care and support they received. No one raised any concerns with us. All of the staff we spoke with were knowledgeable about individual people's care needs, and this knowledge was consistent with the care plans in place.

Is the service well led?

Staff said that they felt well supported by the manager, there was a good team ethic and they were able do their jobs safely. The provider had a range of quality monitoring systems in place to ensure that care was being delivered appropriately by staff, that the service was continuously improving and that people were satisfied with the service they were receiving.

During our last inspection on 14 November 2012 we found the provider did not conduct sufficient assessments of people’s capacity to make decisions, they were not protecting people from infection nor ensuring that records were stored securely. We asked the provider to take action to improve matters.

During our inspection on 24 May 2013 it was clear staff had a good relationship and communicated well with people living in the home. We spoke with five people who lived in the home. They all said that they were involved in the planning of their care and gave their consent for any care to be given. One person told us, "It's nice here, the staff are lovely, they always ask me how I like things to be done". All the people we spoke with told us they felt safe and would raise any concerns with the manager.

We observed staff supporting people in a kind and calm manner. Communication was positive and staff spoke respectfully with people.

The home was clean, staff were well trained and there were systems in place to ensure people were protected from infection.

Records relating to both staff and the people who lived at Forest Place Nursing Home were appropriate and were securely stored.

All staff had been trained in the Mental Capacity Act. Staff demonstrated to us that they had knowledge of the people they were caring for, meaning they knew what assistance an individual would require to make a decision or give consent.

People we spoke with told us that they were satisfied with the service and the care they received at the home. They told us that had been involved in the admission and assessment process and had been given information when they arrived at the home. They said that staff were friendly, helpful, listened to them and offered them choices. They said that they were, "Looked after very well" and, "Staff are generally all very nice." Most people were happy with the level of social activities provided.

Where people were unable to provide a verbal response or tell us about their experiences we saw that staff interacted positively with people, supported them respectfully and explained what they were doing to give reassurance to them. However we saw no evidence that appropriate assessments of the mental capacity of the people had been carried out.

We found that the personalised records of people who live at the home and staff members were not always stored securely when left unattended. We also found that the record of training and updates for all staff showed that the ongoing education in the prevention and control of infection associated with the provision of health and social care had not always happened

People with whom we spoke told us they were satisfied with the service overall and the care provided there. They had been involved in the assessment and admission process and had been given some information about the service when they arrived at the home.

People told us their privacy and dignity was respected at Forest Place and that staff were friendly and helpful. People felt well cared for, said that staff offered them choices and listened to them, and responded to them when they needed assistance. Most people felt that there was an acceptable level of social activities provided.

Where people were unable to provide a verbal response or tell us about their experiences, for example as a result of limited verbal communication or poor cognitive ability, we saw that staff interacted positively with people, supported them respectfully and explained what they were doing to reassure people.

People using the service and visitors felt that people living at Forest Place were safe. People told us they would feel able to tell staff or the manager if they had any worries and told us that staff treated them well.