Falcon House 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

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 Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulations in relation in relation to safe care and treatment, medicines management and safeguarding.

This service scored 38 (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.

The management team did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Records showed that communication between the care home and external health and social care teams was acceptable but could be improved; to ensure positive experiences and safe transition from other services. Most people and relatives we spoke with could not remember if they had had an assessment prior to moving into the service. Records we reviewed showed important information supplied by external teams had not been used to develop robust care plans and risk assessments. Daily records detailing professional visits were disorganised and were not being regularly reviewed by the management team to improve care outcomes for people. Handover meetings within the staff team did not identify where a person may require monitoring for a change in presentation. These records lacked detail and gave care staff little information on any change in support needs for people. Although some staff showed a good knowledge of which health and social care professionals supported each person, we found some people had not been reviewed by external teams when their needs had changed.

We found some people who required external review for their specific needs had not been promptly referred by the service when concerns had been identified or after a specific incident had taken place. For example, after sustaining an injury following a fall or when people had expressed distress behaviours towards themselves or others.

Nobody we spoke with had recollection of being involved in regular reviews of their care plans.

The management team did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

There was some understanding of safeguarding and how to take appropriate action, but safeguarding was not always given sufficient priority or applied consistently at Falcon House. We found the management team had not always made timely notifications to the local authority safeguarding team or the CQC to ensure that incidents could be promptly investigated.

Not all staff we spoke with understood how to respond to allegations of abuse. One staff member struggled to explain the process in place for reporting concerns to the Local Authority or the CQC if the management team were not present. Other staff were clear about the process and told us they would report incidents themselves if the management team had not acted. The provider’s safeguarding policy lacked details of the service or contacts for the relevant local authority.

Staff we spoke with lacked confidence that the management team would act appropriately if they raised concerns. One staff member told us, “I feel like incidents are not reported, it feels more like they are covered up.” Another staff member felt that management blamed staff for incidents, rather than management accepting responsibility and looking at improvements needed.

Staff were not confident in using whistleblowing processes as they felt concerns were not being responded to by the management team.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The management team showed understanding towards people, and the staff team showed empathy and kindness when engaging with people. However, we found previous incidents had not been reviewed to ensure risk management was robust and people’s individual risk assessments were updated. For example, where people lived with behavioural support needs; incidents between peers had not been reviewed or risks updated within people’s care plans.

People’s needs were not clearly documented in their care plans, so staff lacked clear guidance on a person’s mental, physical and social needs. People’s communication needs were not clearly recorded. This left staff with a lack of understanding of people’s needs and wishes to support them to stay safe.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The home was not safe in the event of a fire. The management team had been served with an enforcement notice by Nottinghamshire Fire Rescue Service on 12 July 2024. We saw minimal actions had been taken to achieve compliance with this. Corridors and stairwells were not clear of all blockages, which would allow people to follow planned escape routes. There was a lack of clear and individualised processes in place for how to respond in an emergency. Each person had an individual Personal Emergency Evacuation Procedure in place (PEEP). However, we found these documents were inaccurate, in that they had not been updated when a person’s support needs had changed.

Some areas of the premises placed people at risk of injury, particularly those who were independently mobile. Wardrobes were not always secured to walls to reduce the risk of harm from falling furniture or entrapment. Mattresses were not safely positioned on bed bases to reduce the risk of harm from falling or shearing of skin. Equipment used to safely move people was in need of deep cleaning, with slings used for the hoist not marked for personal use by people.

Windows were able to be opened wide, due to the lack of restrictors in place. This safety feature should prevent people from falling or climbing out and is in line with guidance from the health and safety executive (HSE).

Staff were not confident that the building was well maintained to ensure people were kept safe from the risk of harm. One staff member described the poor quality of furnishings, saying, “Some people are sat on the chairs all day, they are very uncomfortable. People should have more of some things, like nicer bedding, more personalisation.”

The management team did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not all received relevant training on how to support people’s individual needs. Some people at the service required support for managing diabetes. We saw the kitchen staff team had not received training in diabetes management, to enable them to effectively support people with their identified dietary needs.

We raised concerns with the registered manager around the competency assessments completed for medicines administration. Some staff we spoke with showed a lack of understanding of specific medicines and their potential impact on people’s wellbeing. The service lead for medicines management lacked proficiency with the new electronic medicines administration system. This person was responsible for assessing competency of senior staff. This left the senior staff team with shortfalls in their skills and knowledge to ensure people’s identified needs were effectively met.

The service had sufficient staff available to support people, we saw that staff used their understanding of people as individuals to respond to people’s needs, rather than effective care planning. Everyone we spoke with thought staff were well trained and providing a good standard of care. However, one person we spoke with suggested there might be a problem with staffing. They said, “I’m not sure if there are enough staff, they don’t always have time to recharge their batteries.”

The management team did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some areas of the service were unclean and unhygienic. The service was not being effectively deep cleaned to ensure people were protected from the risk of infection.

The management lacked oversight of housekeeping documentation. Cleaning schedules which had been completed by the domestic team had not been reviewed. This shortfall led to a lack of oversight of the cleanliness and safety of people’s bedrooms and bedding. Areas of the home were visibly dirty in parts, with stains and malodour observed on some carpets and equipment. Multiple pressure cushions within the service were found to require deep cleaning or replacement, with observed stains and a strong malodour. The lack of effective pressure cushion audits in place, meant this had not been identified as a risk prior to our inspection. This left people exposed to a risk of harm from cross contamination and infection.

Personal protective equipment (PPE) used by staff was found to be incorrectly disposed of in communal waste bins. The yellow disposal bin for staff to discard their used PPE was found to be situated on a stairwell which would be used in the event of a fire or emergency evacuation. This yellow bin placement presented a risk of cross contamination and a risk of being unable to exit the building effectively in the event of an emergency.

One person we spoke with felt the service was clean, and said, “It always seems very clean to me and staff wear aprons and gloves.”

The management team did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

The service used an electronic medicines administration system. The information held in this system lacked accuracy and showed incorrect stock levels of medicines. Some medicines were incorrectly listed in the system and prescribing information was not being followed by the staff team. Prescribed topical creams were found to be stored unsecured within people’s en suite bathrooms. These topical preparations had no date of opening or associated body map detailing application sites and frequency. They presented an ingestion risk to mobile persons, and a risk that people were not receiving their medicines as prescribed. Where people were prescribed ‘as required’ medicines, there was a lack of detail on why this had been given, with no associated pain scales for people who might struggle to communicate.

Staff were unable to fully explain how they supported people to take their medicines safely. One staff member we spoke with struggled to explain the possible side effects of specific medicines they were administering and the signs to look out for. The lead for medicines in the service did not follow best practice when administering medicines for people. Some people at the service were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw staff had followed legal requirements by storing these medicines in an extra secure place. However, the documentation for these medicines was poor, showing a lack of regular audits by the management team.

Some staff lacked understanding of who to report medicine concerns or errors to. For example, if they felt a person’s medicine was no longer effective, there was a lack of documentation to support this. Information showing which health professionals had been involved in these decisions was not always transferred into a person’s care plan or medicines risk assessment.

Medicines care plans lacked person-specific details and were generic copies. This left people exposed to the risk of harm from staff not having clear guidance on prescribed medicines for people.