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 assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant there were shortfalls in leadership. Leaders and the culture they created did not always ensure the delivery of high-quality care.

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

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have an embedded and clear shared vision, strategy and culture which was based on transparency, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Although the provider had equality and diversity policies in place, these were not being consistently applied by the management and staff team. People were not always respected as an individual, who was at the centre of their support when decisions about their lives were being made.

We saw the management team were open, positive and wished to improve their relationships with health and social care partners. We received feedback from an external partner, who told us, “We feel the home are really trying, although there is a long way to go. The atmosphere in the home has improved hugely, there is a much more welcoming culture and senior leadership are striving for better. The management structure has seen some changes, which has caused instability once again, but the culture is starting to change to one of openness; the management are welcome to feedback and constructive criticism.”

Staff indicated the culture of the service was improving and they felt confident in the new management team. One staff member told us, “The management team are more approachable now, and they listen.” Where safeguarding and incidents had not been promptly notified to the local authority and the CQC; the management team were now undertaking review and ensuring retrospective referral. This meant lessons could be learned to continually improve care quality.

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 interim management team showed an openness, commitment and drive to improve the service. The provider and the management team had responded to the concerns identified at our previous assessment and had a clear plan in place to address this. However, the progress made towards this had not been embedded sufficiently to provide assurance that the service was safe, well led and involving people as partners in their care.

Staff we spoke with were passionate about improving the quality of care at Falcon House. Staff we spoke with felt more supported by the new management team in place at the service now. One staff member told us, “I didn’t want to be here after the last assessment. Things are settling now, and new staff are here, which is great.”

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

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. Where complaints or concerns had been raised with the management team, there was a lack of detail recorded as to how these had been addressed. For example, there were no copies of investigation reports, correspondence or of duty of candour being followed with relatives.

Most of the people and relatives we spoke with had not felt the need to raise a complaint. Only one person we spoke with could recall raising a formal complaint. This relative told us, “I’ve pointed things out before like muddled up laundry, my family member not looking clean or not much happening. Mostly things will get done, or I’ll just ask more forcefully.”

Staff understood how to whistle blow if they felt the management team had not satisfactorily responded to them or people. Staff gave feedback they felt more positive in speaking up under the new management.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed staff from overseas and from diverse backgrounds, with strong skills and knowledge. The new management team were aware of the strengths of the staff team and had sought to utilise their skills by delegating specific tasks. Staff now felt able to any concerns through the provider processes, due to the improving culture. One staff member told us, “Things have been very busy, and difficult, but are definitely improving.”

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider and management team had a service improvement plan in place, to address the previous lack of oversight and quality monitoring in place at the service. This plan required embedding to provide full assurance. We will review the actions taken at our next assessment.

The provider had taken prompt action following our last assessment. They made significant changes to the management and staff team and provided regular updates on their actions to the CQC and the commissioners of the service.

We saw processes in place for monitoring the safety of the environment and equipment had improved. For example, the management team had documented their regular checks around the building. The management team had a service improvement plan which was rated in order of need. The management team were clear of their regulatory responsibility. Acknowledging the lack of notifications submitted by the previous manager, they arranged to review incidents of concern and ensure these were reported to us and the local authority.

The management team did not fully 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 were working hard to improve their relationships and communication with external agencies. The management team showed a willingness to engage and improve the service. One partner told us, “Communication to us as a service is markedly improved, however the internal communication remains poor. We are aware that methods have been and are being implemented to assist this, however this seems to be a continued area of weakness. Meaning there is often limited information to feedback to influence patient care clinically.” We found the management team had implemented regular handovers and a communication book. However, this information was not always used to inform care planning and risk management.

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

Themes from any incidents or complaints had not been robustly analysed by the management team to look for trends. Actions taken by the service had not been reviewed or shared in team meetings with staff for them to embed learning and improve care outcomes for people. For example, there were 2 recent incidents where people sustained scalds from hot drinks 6 days apart. Lessons learned had not been implemented to manage risks. The second scald required hospital admission.

The management team had improved their recognition of the skills of the staff team. One staff member told us, “I have had a recent supervision, which went really well, and I received positive feedback.” However, people were still not involved in recruitment processes to employ staff members who echoed the qualities sought after by people.