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 Requires Improvement. At this assessment the rating has remained Requires Improvement.

This meant people and their relatives were not always fully involved, and the provider processes in place were not fully embedded to ensure people were kept safe.

At our previous assessment, the provider was in breach of legal regulations in relation to safe care and treatment, medicines management and safeguarding. At this assessment, we found improvements had been made to the management of medicines, but some shortfalls remained in risk oversight, safeguarding and learning from incidents.

This service scored 59 (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 always have a proactive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We found reviews of incidents to look for themes, lessons learned and inform improvements in care quality were not fully embedded. For example, where a person had exhibited multiple distress behaviours, the times and locations of these events were not being routinely used to inform care planning or staff deployment within the service.

The provider and new manager had worked hard to improve how concerns were raised and responded to within the service since our last assessment. The management had changed, and we could see the improvements in the staff engagement and approach. Staff told us they now felt confident raising concerns with the manager and felt they would take action when they did so.

The provider 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 had improved since our last assessment to ensure positive experiences and safe transition from other services. The new manager had made sure effective communication with people and their relatives was a priority. They explained how they were aware of the challenges they faced to continue to improve previous poor experiences.

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 experienced a change in their cognition or behaviours. However, where reviews had taken place, this information had not been consistently updated across people’s care plans or risk assessments.

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 attended and documented by the management team, to ensure any concerns were escalated.

We received mixed feedback from relatives regarding their involvement in care planning and reviews. One relative told us, “I feel things are going in the right direction. My family member is safe here. I am not involved in care planning and have not had any meetings to discuss care. There has only been one relative meeting so far.” Another relative was more positive, and told us, “There is a relative meeting in early February, and I think there was a resident meeting on Friday. The manager introduced themself at the relatives meeting, which was a two-way conversation. The management explained findings from the previous CQC visit and what they were doing to address the concerns.”

The provider 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 always 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.

The management team had implemented a new process to report and review incidents, but this required embedding for us to be fully assured this was robust and had improved safety at the service. We found some incidents lacked review, which 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, one person had experienced a fall with an injury, and the service had been advised to monitor the person closely for 72 hours. The records did not have a date when they were completed and had not been completed in full. There were no ‘normal’ ranges listed for the person on the form, to alert staff to any changes in the persons presentation. The documents were split over multiple paper formats, and had not been brought together, to look at any actions needed by the service. We discussed these shortfalls with the management team, who supplied an updated observations document, which they planned to use in line with their electronic care planning system.

The new manager had ensured they followed their duty of candour, and informed relatives where incidents had occurred. People and their relatives described feeling positive about the changes made by the new manager. One person said, “Oh yes, I feel safe. Staff do come when you need them. Staff are nice and kind, very good.” A relative we spoke with told us, “I feel my family member is safe. I’m informed of any incidents and was made aware of any falls which were dealt with perfectly. I appreciate the communication.”

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.

Risk assessments had not all 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 management team focussed on updating these records as a priority. The management team responded to us with a detailed plan to review and update risk assessments for all people immediately after our assessment.

Some information within people’s care records was contradictory and had not been promptly updated after an incident, or a change in need was identified. For example, where people lived with behavioural support needs; Incidents between peers had not been reviewed or risks updated within people’s care plans.

The management team showed understanding towards people, and the staff team showed empathy and kindness when engaging with people. People and their relatives were positive about the staff approach, and the staff team’s responses to their needs. One relative told us, “I feel my family member is safe. The staff care here. I didn’t use to be involved in care planning, but the deputy took me through the records.”

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

People were not always safe in the event of a fire. The management team had an action plan in place, to ensure remediation measures were taken to replace ill-fitting fire doors. However, these actions still required completion, due to the bespoke nature of the doors. The documents used to ensure people were enabled to safely leave the building in the event of a fire required a review and update. The Personal Emergency Evacuation Plans (PEEP), and the safe evacuation register traffic light system used by the service did not always match. For example, some people were listed as amber, but the register stated red. We raised this with the management team, who supplied updated documents the following day.

Fire evacuation plans for the service were in place and had been recently reviewed and updated.

People and their relatives were positive about the environmental changes which had been completed. One relative told us, “It’s definitely improving. There are less hazards in the home and staff keep their eye on things. There is always someone at the desk to speak with.” Another relative told us, “The manager has been good. I went to them about flooring in my family members room and it was replaced.” Another relative told us, “It has generally improved over the last 4-5 months. It’s a much more welcoming environment, staff are much more attentive and on hand. It is a much calmer environment.”

The garden area to the rear of the service required remediation work, to ensure this was a safe, accessible space for people. The provider had included this planned work in the service improvement plan. People did have access to a small outdoor courtyard, with chairs and raised beds. One relative told us, “I like the home, we would prefer a bit more garden. But it’s always clean.”

Equipment used to assist people with their mobility needs was safe and had been recently serviced. The provider had invested in an ongoing refurbishment plan, for example, to ensure any flooring identified as requiring replacement had been actioned.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We found that staff had completed the mandatory training required by the provider. However, there was a service-specific training matrix, which showed the majority of staff had not completed Parkinson’s or continence care training. We raised this with the management team, who ensured all relevant staff were booked onto this training as a priority. We were assured by their response and received a subsequent training matrix, which showed staff had completed these training courses.

Staffing and allocation was set according to the dependency tool used by the service. We saw staff were available and responsive to people during our visit. People and their relatives gave positive feedback about the numbers and skills of the staff team. One relative told us, “The staff are very good with my family member, especially recently and a couple really go the extra mile. It seems to have improved recently, they are all more communicative.” Another relative told us, “I haven’t noticed any staffing differences at the weekend. Staff feel more responsive now with a better response. I’ve never seen anything unkind.”

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

The environment was clean and tidy. Work was ongoing to fully refurbish and improve the service to a high standard. The provider had an infection, prevention, and control action plan in place, with any required actions allocated to specific team members for completion. A member of the domestic team told us, “Things have really improved, under the new manager. We are able to share our views and be listened to.” Another relative told us, “The home is always clean, no smells, I like that.”

The manager carried out a daily walk round, which identified any areas requiring attention. Any actions were then allocated to the most appropriate staff member to complete. People and their relatives were positive about the environmental improvements.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People and their relatives were confident in the management of their medicines. One relative told us, “My family members medication is much better than before. The staff are giving the eye drops now.” Another relative told us, “We have no issues with medicines, I trust the judgment of the staff.”

Medicines were managed, stored and administered safely, by staff who were trained and competent. The management team understood who to report medicine concerns or errors to. If staff felt a person’s medicine was no longer effective, there was documentation in place to support this.

The service used an electronic medicines administration system. The information held in this system had been reviewed and updated and showed correct stock levels of medicines. The staff team followed prescribing information. Medicines care plans for people had been reviewed and updated since our last assessment.

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.

Where people were prescribed ‘as required’ medicines, there were details on why this had been given, and how staff should identify people’s pain level if they were unable to communicate this verbally.

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 we spoke with showed an understanding of specific medicines and their potential impact on people’s wellbeing. We discussed the impact for some people of being given their medicines during the busy lunch service, where people may struggle to understand what staff were saying to them. The management team agreed to review this, to see if changes could be made, to enable people to be more involved in the process.