Falcon House Care Home

On this page

• 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 assessment this key question was requires improvement. At this assessment the rating has remained requires improvement. This meant people’s needs were not always met through good organisation and delivery.

The provider remained in breach of legal regulation in relation to how people were not supported in a person-centred way.

This service scored 46 (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 always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People and those important to them were not fully engaged or actively involved with decisions about the care and support which they received. The ‘life story’ section in some people’s care plans remained blank, with no information regarding things which are important to them. People had not been routinely consulted when changes were made to their care plans. The daily menu blackboard in the upstairs dining room was not positioned where people could easily view this.

People explained they were offered meal choices by the staff. One person said, “I enjoy the food and they’re quite obliging and will do something different for me if I ask. I can ask for a yoghurt or fruit between meals if I’m peckish.” Another person said, “It’s lovely and they tell us the choices. I can’t eat a certain meat, as it upsets my tummy, so they’ll do anything else I ask for.”

Care plans remained lacking in person-centred details. This showed a lack of understanding of personalised care planning and left people at risk of not receiving their care as they wished.

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 health care input from the district nursing team for wound or diabetes management. The professional visit records within peoples’ care records had improved but outcome from the visits had not always been updated into care records. This left people exposed to the risk of not having clear guidance on their care needs. An external partner told us, “Recording of information at Falcon House has historically been inconsistent. Due to this, there is a wider need for learning and understanding with documentation. The result of this being information recording on bowel charts, food and fluid charts and body maps has been of poor quality. Body maps are improving; however, bowel charts remain poor. This often leads to a delay in clinical decision making whilst we, as a service, obtain the information required.”

The management team displayed a positive attitude towards partnership working with external teams. People with the most complex needs had now been reviewed at the request of the management team. This had been carried out by the covering GP practice regular weekly ward round, or by external health and social care teams. However, the lack of effective implementation of their guidance, and poor recording in records, 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 wearing 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.

A display board within the service, ‘You said, we did’, had not been updated since our last assessment visit in March 2025.

There was no support in place for people who could not verbally communicate or understand complex documents. Although some people had recently been referred onto independent advocacy services; there was a lack of ensuring advocates were routinely involved in people’s lives to support their independence and decision making.

We did find that where shortfalls had been raised, the management team had taken measures to address these. For example, the food quality and lack of activities for people.

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. Although the new management had a planner in place for more regular meetings to take place in future. A lack of trips and tailored activities in place left people without meaningful stimulation or interaction during their day. One person said, “I’m left to do things by myself and come and go, but it means I don’t see people unless it’s at meals.”

The service 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 are 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 currently had no dedicated activity co-ordinator, although recruitment was underway. We found a lack of planned activities which were of interest to people.

People were not always effectively 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 always provide effective support people at the end of their lives. The service worked with external health professionals who supported with people’s palliative care needs. However, the management team had not ensured care plans were reflective of 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.

We found people’s advanced decisions and what mattered to people was 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 future in a different way.