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

This meant the service was not always well managed and well-led. Leaders and the culture they created, promoted person-centred care.

At our previous assessment, the provider was in breach of legal regulation in relation to good governance. At this assessment, we found that, although improvements had been made, the processes in place were not fully embedded. The provider remains in breach of the legal regulation in relation to good governance.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Whilst the management team had a shared direction to improve, this was not yet fully embedded. The management team showed a willingness to take actions where any shortfalls were highlighted, but still needed to apply their new systems and action plan to deliver on this. We saw the management team were open, positive and actively working to improve their relationships with health and social care partners. The manager explained how shocked they had been to read the previous assessment report, and how this had given them the drive to improve. Where people and their relatives had been upset or expressed concern about previous shortfalls, the manager had ensured they had spoken with them personally.

Staff felt the changes in management and staffing had improved the service. One staff member said, “The change to electronic systems has been good. I think it is the right way for us to go. I previously went through a period of time of not wanting to be at work, but I don't get that feeling any more. The manager and all the new staff are lovely too.”

The provider had 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The new manager showed drive, passion and ambition to ensure Falcon House was a safe, inclusive place for everyone. They acknowledged areas where improvement was still required, and ensured they were open and transparent with people and their relatives about any shortfalls. One relative told us, “Previously, staff use of mobile phones was rampant, it isn’t any more. The new management team are more hands on; they were previously very disconnected and are much more involved now.” Another relative spoke of the improvements under the new manager, they said, “It feels a lot quieter and more peaceful, since the changeover of management.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Where complaints or concerns had been raised with the management team, there were records showing how these had been addressed. For example, there were copies of investigation reports and correspondence showing the duty of candour had been followed with relatives.

Most of the people and relatives we spoke with had not felt the need to raise a formal complaint. However, relatives we spoke with felt the new manager was available and had listened to them. One relative told us, “I am very comfortable raising things with the management.”

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 are good. The manager is really good and supportive. If I have had any problems, I have gone to them, and they have sorted it straight away. They are really approachable.” A relative gave positive feedback about the changes in staffing, they told us, “The agency staff are good, and they are clearly taking their time to recruit the right staff."

The provider did not always have clear responsibilities, systems of accountability or 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 fully embedding to provide full assurance the service was managed safely and improvements were embedded. We will review the actions taken at our next assessment.

Whilst the management team had taken action to address the findings of the last assessment, we found some shortfalls remained, because systems and processes had not been in place long enough to be embedded. We found continued gaps in care plans and risk assessments. We found not all incidents and safeguards had been reported effectively to learn lessons. The management team had an action plan to address these or took action when we raised this with them, but this meant the changes had not been fully embedded.

The management team had improved their processes for the recording of accidents and incidents and had ensured these had been reported as required. However, the documents used to record outcomes lacked completeness. For example, the outcome of safeguarding investigations was not being routinely recorded on the documents.

The manager had carried out regular monthly audits to look for themes or to inform staffing. The manager acknowledged the record keeping for incidents required improving and embedding and supplied an action plan detailing how they intended to achieve this moving forwards.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The management team were working hard to improve and strengthen their relationships and communication with external agencies. The management team showed a willingness to co-operate, engage and work on consistently improving the service.

Following our last assessment; the management team had improved the policy and processes in place to ensure people were supported to access emergency health care if needed. For example, following a fall where an injury had been sustained.

The provider focused on learning and improvement across the organisation and local system. They encouraged ways of delivering equality of experience, outcomes and quality of life for people.

The manager was open and honest about the need to ensure their auditing and quality improvement processes were fully embedded. Staff had been given extra training to ensure they were familiar with and trained on the new electronic systems. We were assured that the quality management systems in place would allow the manager to have full oversight of all documentation and to ensure any improvements needed or lessons learned could be implemented. However, these systems required fully embedding to ensure the governance and oversight of the service was robust.

Staff were positive about the approach of the new manager, and the positive changes they had implemented in a short space of time. One staff member said, “Things are much better, they have improved a lot. The transition to the electronic system makes recording better, but we are still having to report on some paper forms. It is quicker, but it does require us remembering to document it all.”