Falmouth House

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 and staff team had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

When things went wrong, there was evidence of lessons learned and of this information being shared with the staff team. Discussions took place in team meetings to ensure best practice would be followed in the future. The management team had oversight of any safety concerns. Staff told us they felt confident to speak up if anything went wrong, so that it could be corrected accordingly.

The management and staff team had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

When things went wrong, there was evidence of lessons learned and of this information being shared with the staff team. Discussions took place in team meetings to ensure best practice would be followed in the future. The management team had oversight of any safety concerns. Staff told us they felt confident to speak up if anything went wrong, so that it could be corrected accordingly.

The management and staff team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they were happy and felt safe in the service. They also said staff were kind and listened to them.

Safeguarding processes were in place to record concerns and notifications to the local authority and CQC were made appropriately. Safeguarding training formed part of staff’s induction and was discussed frequently within staff meetings. Refresher training was undertaken by staff who demonstrated a clear understanding of their responsibilities.

People were supported in line with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Where people were subject to DoLS authorisations, staff understood and followed the safeguards in place. Applications were made when required to ensure any restrictions were legally authorised and kept under review.

The management and staff team worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were in place and contained person-centred information. They were detailed, so staff knew what to do to ensure the care they provided met people’s needs appropriately and safely. Staff told us they knew people well and how to best and safely support individuals. Daily records evidenced people were being supported safely.People told us they felt safe with the care being provided.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was well-maintained with regular servicing and maintenance completed. Staff reported problems which were addressed by the maintenance staff member who also worked as a member of care staff meaning repairs were promptly undertaken.

The environment was welcoming and homely with a calm and relaxing atmosphere. People’s bedrooms were personalised and designed to meet their needs. There was an ongoing refurbishment and redecoration plan in place to ensure the home’s décor was updated. The registered manager told us, before people moved into the home, their room would be decorated in preparation.

Environmental risk assessments were in place to protect staff and people. Risk assessmentswere clear and well documented. Personal emergency evacuation plans were in place andstaff knew what to do in an emergency to safely support people. Relatives told us that Falmouth House was clean, safe and maintained.

The management team 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.

The provider had a robust process in place that made sure there were enough skilled and experienced staff. The management team followed safe recruitment systems and processes. The provider ensured all staff were provided with appropriate training and were up to date with that training. Refresher training took place, when required and staff told us they received the appropriate training to be able to undertake their roles effectively.

There were procedures in place in the event of staff absence. Managers were available through the week and on call at weekends and out of hours, with senior staff on shift when managers were not. Staff told us the management team was on site each day.

Staff told us they had regular supervision, which was supportive and helpful. They said they could speak with the manager quickly if they had any concerns. Staff were confident the manager would listen and take action to resolve concerns. Staff told us they felt listened to and valued.

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

Staff were trained in infection prevention and control (IPC) and the appropriate usage of Personal Protective Equipment which was available for staff to use.

Bathrooms were shared spaces and the staff team sought advice from the local IPC team about how to manage the ongoing issue of paper tissues being disposed of incorrectly. As a result, each person now used their own colour-coded towels, which were kept in their bedrooms rather than in the communal bathrooms. This approach had been in place for some time and was working well.

Regular IPC checks were undertaken, and the management team undertook regular audits to maintain good IPC compliance.The service had received the highest rating following a food hygiene inspection.

Domestic staff were employed to work across the week with care staff undertaking additional domestic duties on a weekend and evening shifts if required.

The management and staff team 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’s medicines were managed safely. They were stored safely and securely. Care plans detailed people’s medicines and there was guidance to staff on possible side effects. Clear instructions were set out for staff to follow. The staff team had a close and effective working relationship with the local GP surgeries and pharmacy.

The provider had an effective medicines administration system. Staff understood how to give and record the administration of medicines. Staff carried out weekly audits to identify and correct any errors. The deputy manager completed additional audits ensured there was good management oversight.

People told us they received their prescribed medicines when they needed them and that staff supported them where required. Staff described processes in place for the management of controlled drugs and for people who wished to self-administer their medicines. At the time of our inspection, these processes were not in use.