Falcon House Care Home

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last inspection this key question was rated Good. At this inspection the rating has changed to Requires Improvement. This meant people’s needs were not always met through poor organisation and delivery.

The provider was in breach of legal regulation as people were not supported in a person-centred way.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Some staff we spoke with felt unable to speak up if they had a concern. Staff were not confident in the management team and their response where concerns had been raised.

There was a lack of accurate recording or robust processes in place for the management team to review incidents. We found this lack of review of incidents had led to required actions not being taken to improve care outcomes for people. The lack of effective review and audit tools in place did not ensure improvements could be made or learning could be shared widely across the staff team.

There were some shortfalls in how the management team understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Where people were receiving care from an external health team, we saw care plans and medicines records did not indicate this. For example, those people who were receiving healthcare input from the district nursing team for wound or diabetes management. The professional visit records within people’s care records lacked information and left people exposed to the risk of not having clear guidance on their care needs.

The management team did not display a positive attitude towards effective partnership working with external teams. The management team lacked understanding of it being imperative to embrace partnership working to ensure seamless care delivery and best outcomes for people. The risk assessment tools used in care plans showed best practice in care and support, for example, skin and weight management tools. However, the lack of effective implementation of these tools, and a lack of oversight from the management team left people exposed to the risk of having unmet needs.

The management team did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Support plans and records were not captured in ways that met people’s requirements for meaningful communication and decision-making. Therefore, people were not enabled to be active participants in their care.

The service had not followed the five steps to meet the Accessible Information Standard, (AIS). Care plans detailed people’s individual communication needs, such as language, aids such as glasses or hearing aids, but lacked clarity on how staff should support people with these requirements. Where people had a preference not to use their hearing aid or wear their glasses, their care plans lacked guidance on how staff should support and encourage people to understand any risks to their personal safety.

There was a lack of additional resources such as writing aids, picture aids or technology required to assist people. The service had not produced literature for people in different font sizes, easy read formats or audio versions to assist in sharing information for people.

The management team did not always make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The service had a, ‘You said, we did’ board displayed on the corridor. However, this was not written to be clearly accessible for all people and relatives. Where shortfalls had been raised, we saw required actions had not been addressed. For example, the food quality and lack of activities for people.

There was no support in place for people who could not verbally communicate or understand complex documents. There was a lack of ensuring advocates were involved in people’s lives to support their independence and decision making.

The management team did not always make sure that people could access the care, support and treatment they needed when they needed it.

Residents’ meetings were held infrequently, so people were not actively involved in shaping the service. A lack of trips and tailored activities in place left people without meaningful stimulation. One person was heard repeatedly saying they were ‘bored’ and being given biscuits by staff to placate them rather than engaging in conversation or an activity of their choice.

The service provided had not produced information for people in different formats. There was no access to easy read documents, such as how to raise a complaint or explaining how to place a vote.

Staff and leaders did not always actively listen to information about people who were most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

People were not always supported to access community facilities, understand voting and lead a full, enriched life at Falcon House. The service had a dedicated activity co-ordinator, who currently was employed 2 days each week. Although the registered manager advised a new activity co-ordinator was due to commence employment, we found a lack of planned activities of interest to people.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The service did not effectively support people at the end of their lives. The management team had not ensured care plans were reflective when a person was receiving end of life care. Care plans and related dependency tools were contradictory and had not been updated when a person’s needs had changed. One person’s dependency tool stated they were independently mobile and required no support with meals. However, this person was being cared for in bed, being supported by the district nursing team with pain relief, and unable to eat or drink without support. This person had no clear guidance for staff to follow to ensure their comfort, or details of increased welfare checks required. This left the person at risk of not receiving effective, compassionate care at the end of their life.

We found people’s advanced decisions and what mattered to people were not clearly recorded in their plans of care. Staff had not supported people and their relatives to create detailed care plans. We saw some people had information on funeral plans where they had chosen to discuss this. Where people did not wish to discuss the end of their life, there were no clear plans in place to revisit the subject in the future in a different way.