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 assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant people were not always safe and were at potential risk of avoidable harm.

At our previous assessment, the provider was in breach of legal regulations in relation in relation to safe care and treatment, medicines management and safeguarding. We found improvements in medicines management, but the provider remained in breach of regulations regarding safe care and treatment and safeguarding.

This service scored 53 (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.

There remained 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. For example, the management team advised that previously, incidents which had occurred during a night shift or over a weekend, were delayed in being reported to the CQC or to the Local Authority as required. The management team had implemented a new process for reporting and review of incidents, but this required embedding for us to be fully assured this was robust and improved safety at the service.

The provider and management team had worked hard to improve the culture within the service since our last assessment. The management had changed, with the provider actively recruiting a registered manager and a significant number of staff had left the service. We could see the improvements in the staff culture and work ethic, although some staff expressed apprehension around the ongoing changes.

People and their relatives expressed feeling the changes were positive. One person said, “The staff seem to be ok now, as they had issues with keeping people before and some weren’t very patient.” A relative told us, “I’ve noticed a difference in the past few months, and they do seem more proactive. They previously seemed to do the bare minimum.”

Staff we spoke with did now feel able to speak up if they had a concern. Staff were more confident in the new management team and felt they would be listened to if they raised any concerns.

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 could still be improved; to ensure positive experiences and safe transition from other services. Most people and relatives we spoke with couldn’t remember if they had an assessment prior to moving into the service. Records we reviewed showed important information supplied by external teams had not been always used to develop robust care plans and risk assessments. Daily records detailing professional visits were disorganised and were not being used by the management team to improve care plans and risk management. An external health professional we spoke with told us, “Communication with our service is markedly improved, however the internal communication remains poor. We are aware methods have been and are being implemented to assist however this seems to be a continued area of weakness.”

Handover meetings within the staff team were used to identify where a person may require monitoring for a change in presentation. The daily handover meetings between staff shifts were now being attended by the management team, to ensure any concerns were escalated.

We found people who required external review for their specific needs had now been 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. However, where reviews had taken place, this information had still not been fully updated into people’s care plans or risk assessments.

Only one relative we spoke with could recall any involvement with care planning and people were still not routinely being involved in review of their care plans. One person said, “I’m not aware of any information held about me, no one has said anything."

The management team did not always 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 always share concerns quickly and appropriately.

There was an understanding of safeguarding and how to take appropriate action shown by the interim management team, but safeguarding had not always been 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.

The provider’s safeguarding policy and falls protocol had been updated, to include a clear process and contacts for the relevant local authority. These policies required embedding fully into practice to provide assurance the service were following best practice.

Staff we spoke with showed increased confidence that the new management team would act appropriately if they raised concerns. Staff were now confident in using whistleblowing processes if 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.

Care plans and risk assessments had not been reviewed and updated in a timely manner to ensure risk was mitigated. The action plan submitted by the provider after our last assessment indicated this was a priority. However, we found the care records lacked evidence of review and completeness for some people. We recommended the provider focussed on updating these records as a priority. The provider responded to us with a plan for reviewing and updating care plans and risk assessments for all people. They allocated staff to complete this work, to ensure information could be migrated onto their electronic care planning system.

A person who had experienced injuries from 2 recent unwitnessed falls had no clear risk assessment in place for their mobility. Concerns were shared with the CQC by relatives and the NHS ambulance service that provided emergency and urgent care services to the East Midlands region, in regard to the support in place for this person. The service’ falls risk assessment had identified the person as high risk. The risk assessment did not describe what risk mitigation measures were in place. The related mobility care plan had been reviewed monthly and stated the person was, ‘independently mobile and walks with a frame’. This left the person exposed to the risk of further harm from falls.

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 documented. 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 ensure that equipment, facilities and technology supported the delivery of safe care.

The management team had ensured they addressed the previous risks identified, to ensure the service was safe in the event of a fire. However, there remained a lack of clear, individualised, processes in place for how to respond in an emergency. Each person had a Personal Emergency Evacuation Procedure in place (PEEP). However, we found these documents were inaccurate, in relation to the mobility support needs for some people in the event of an emergency. This shortfall was due to the inaccuracy of the information contained within people’s care plans and risk assessments. We requested the management team reviewed and updated these during our assessment.

The management team had been served with an enforcement notice by Nottinghamshire Fire Rescue Service on 12 July 2024. We saw actions had been taken to achieve compliance with this. Corridors and stair wells were clear of blockages, which allowed people to follow planned escape routes. However, staff had not all received training in practical fire evacuation techniques, which we asked the management team to ensure was completed promptly.

Where we previously found some areas of the premises placed people at risk of injury, the management team had ensured these were rectified. Wardrobes were now secured to walls to reduce the risk of harm from falling furniture or entrapment. Mattresses were safely positioned on bed bases to reduce the risk of harm from falling or shearing of skin. Equipment used to safely move people had been serviced and deep cleaned with slings used for the hoist marked for personal use by people.

Windows were restricted as required. This safety feature should prevent people from falling or climbing out and is in line with guidance from the health and safety executive (HSE).

The management team did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure all 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 their risk of choking. We saw the staff team had not all received training in the international dysphagia diet standardisation initiative, (IDDSI), to enable them to effectively support people with their identified dietary needs. Some staff had not completed manual handling practical competency training, which we had previously identified as a risk of potential harm for people. The management team responded to our concerns and ensured these training sessions were booked for these staff in the month ahead.

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 through effective care planning and deployment. The majority of people we spoke with thought staff were well trained and they felt safe. However, one person we spoke with suggested there may be a problem with staffing. They said, “It’s mostly ok but they could do with a few more, like at mealtimes. We have to wait.” Another person said, “I feel safer inside my room, as I can lock my door, as it’s such a quiet corridor and I’m by the stairs and anyone could come in. I’d prefer a male on at night as it can just be young females on doing the checks. But I can’t lock my door in the day and someone who walks about will come in and take any food left out or move my things. There’s one lady and a man who get up very early and walk the corridors.” A relative we spoke with was positive about the safety of the service, they told us, “My family member is safe, very safe. There’s nothing I’ve found that gives me concerns about them being here.”

The management team assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies.

The management team had ensured they addressed the concerns from our previous assessment in relation to infection prevention and control. The service was now being effectively deep cleaned to ensure people were protected from the risk of infection.

The management team had oversight of housekeeping documentation. Cleaning schedules which had been completed by the domestic team were now being regularly reviewed. A pressure cushion audit had taken place, with those which required disposal and replacement having been completed. Ensuring this was maintained was an allocated task for specific staff. This ensured people were no longer exposed to the risk of cross contamination or infection.

Personal Protective Equipment, (PPE) used by staff was found to be correctly disposed of in yellow waste bins. Staff understood the importance of wearing PPE when providing personal care or serving food.

One person we spoke with felt the service had addressed the concerns found previously around cleanliness, and said, “It always seems very clean to me and staff wear aprons and gloves,

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

Everyone we spoke with told us that their medicine taking was supervised. Although none of these people were aware of what medicines were provided and why. One person said, “I get woken quite early by the medication person. The staff will wait while I have my tablets.” A relative told us, “I’ve been here when the staff are doing the medication round and they always stand by when they give them.”

Where people were prescribed ‘as required’ medicines, there was a lack of detail on why this had been given, or how staff should identify people’s pain level if they were unable to communicate this verbally. Medicines care plans for people had been reviewed and updated since our last assessment. However, these required review alongside the care plans, to ensure a holistic approach to supporting people with their medicines.

The management team understood who to report medicine concerns or errors to. However, if staff 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.

The service used an electronic medicines administration system. The information held in this system had been reviewed and updated and now showed correct stock levels of medicines. The staff team was following prescribing information. Prescribed topical creams were found to be stored securely, to reduce any risk from ingestion for mobile people. These topical preparations had a date of opening, with an associated body map detailing application sites and frequency.

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. Staff who administered medicines had now been assessed as competent. Staff we spoke with showed an understanding of specific medicines and their potential impact on people’s wellbeing.