Falcon House 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

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question Good. At this inspection the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not ensure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 29 (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 provider lacked inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

The management team showed a lack of oversight, despite their extensive experience and long service at Falcon House. The registered manager and deputy manager showed compassion and empathy but lacked strong, capable management skills.

The provider was not present at our inspection, due to planned leave. Therefore, we could not assess how they engaged in the running of the service. People and their relatives could not recall having met with the provider and the majority of people and relatives we spoke with thought the deputy manager or the activity co-ordinator were the manager. Everyone we spoke with thought staff were kind, though none knew the name of the manager.

Staff we spoke with were passionate about providing good quality care. However, some staff felt they were not supported to continually improve their practice, or bring the best of themselves to work each day. In relation to feeling supported by the management team one staff member told us, “We are using behavioural charts, which were not previously used until a recent incident. It is unclear what the benefit is, as the registered manager does not look at them or share learning from them.”

Another staff member told us, “I have no confidence in the safeguarding processes in place here, but I personally feel confident to report any concerns directly if needed.”

The management team had not fostered a positive culture where people and staff felt they could always speak up and their voices would be heard.

Most of the people and relatives we spoke with had not felt a need to raise a complaint, apart from a historic issue a person told us they had raised, which had been resolved. This person said, “I did have a problem, although I can’t remember what it was; but it was sorted because I don’t have a problem now.”

We saw there was a lack of regular engagement with people and their representatives. This meant people were not being supported to thrive or have new experiences and live the life they choose.

Staff understood how to whistle blow if they felt the management team had not satisfactorily responded to them or people. We found the service lacked an open and transparent culture. The lack of quality monitoring in place meant there was no overall service improvement plan in place to improve care quality across the service.

The provider did not value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Although the provider employed staff from overseas and from diverse backgrounds, with strong skills and knowledge, the management team did not celebrate this.

Some staff spoke of being mocked or belittled by other staff due to their appearance or a disability. They felt unable to raise these concerns through the provider processes due to the poor culture.

One staff member told us, “I have skills and feel worthless, we are not given the support to learn or improve by the management team.”

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 understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The management team did not work effectively with people, their representatives and staff to build a culture that focused on enabling people to enjoy their lives.

Where people required referral to external health and social care partners for review, this had not been carried out. We raised concerns regarding a person who required input from an occupational therapist for equipment to support them whilst in bed. The management team had not identified this as a required action until prompted by the inspection team.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice.

Themes from any incidents or complaints had not been analysed by the management team to look for themes and trends. Actions taken by the service lacked analysis so these could be shared in team meetings with staff for them to embed learning and improve care outcomes for people.

The management team had not recognised and championed the skills of the staff team. The service did not consistently give staff opportunities for development and progression. People were not involved in recruitment processes to employ staff members who echoed the qualities sought after by people.