Falcon House Residential 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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 71 (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.

Although the registered manager was relatively new to the service, they demonstrated a clear understanding of the provider's values and expectations and how these should be embedded within the day-to-day running of the home.

The registered manager told us, "When I spoke to the owners, they made it clear that the goal was passion, care and empathy." They described a culture where people were placed at the centre of the service and where staff were encouraged to build positive relationships with residents and their families. The registered manager reflected that there was a genuine sense of care from the provider and a commitment to ensuring people received compassionate and person-centred support.

The provider was visible and accessible within the service. The registered manager told us the provider visited the home on a weekly basis and was readily available by telephone for advice and support when needed. This regular involvement helped leaders maintain oversight of the service, understand the experiences of people living there and respond promptly to any issues that arose.
 

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.

Staff spoke positively about the leadership of the service and described managers as supportive and accessible. One staff member told us, “[Registered manager] is a fantastic manager, very supportive and approachable. I am very confident in my ability to approach them with any issues or concerns that I might have. I think the home is run efficiently.” Another staff member said, “I find the management approachable and supportive. I feel the home is well managed, and staff can raise concerns when needed.”

Feedback from staff demonstrated that leaders had established positive working relationships and fostered a culture where people felt listened to and valued. Staff told us they were encouraged to seek advice, discuss concerns and contribute ideas to improve the service. They felt confident that any issues raised would be taken seriously and addressed appropriately.

The registered manager was open, responsive and proactive throughout the inspection process. They provided information promptly when requested and engaged positively with the inspection team. The registered manager was knowledgeable about the service and was able to discuss both its strengths and areas requiring further development. They were honest about where improvements were needed and had already identified actions to address these areas, demonstrating an open and reflective approach to leadership and continuous improvement.

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

Staff understood their responsibility to promote good care and told us they would feel confident challenging poor practice if they observed it. One staff member said, “We are all encouraged to speak up about poor care if it is noticed.”

Staff described a culture where concerns could be raised without fear of repercussions and where leaders were approachable and responsive. They told us managers listened to feedback and took concerns seriously. Staff were aware of the processes for reporting concerns and understood the importance of ensuring people's safety, wellbeing and rights were protected.

The registered manager told us they used supervision sessions to build trusting relationships with staff and create opportunities for open discussions. They said, “I am doing this in supervision, letting them know they can trust me. If they have something to tell me, we take the right route.” This demonstrated a commitment to ensuring staff felt listened to, supported and confident to raise concerns through appropriate channels.
 

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 consistency of feedback from staff demonstrated that inclusion was reflected in their day-to-day experiences. Staff spoke positively about working at the service and described an environment where they felt accepted, valued and treated fairly regardless of their background. This helped to foster positive working relationships and created a sense of belonging amongst the workforce.

The service actively celebrated diversity and encouraged people living at the home and staff to learn about and appreciate different cultures. Staff and residents told us about international and cultural celebration days that were held within the service. These events included themed activities, information sharing and opportunities to enjoy food from different countries and cultures. One staff member told us, “We have introduced culture days that offer a variety of menu choices from different places around the world.”

The provider had governance systems and processes in place to monitor the quality and safety of the service and support the delivery of care. Leaders understood their responsibilities and were able to discuss risks, performance and areas for improvement within the service. The registered manager was open and responsive throughout the inspection and worked proactively to provide information requested by the inspection team.

However, governance processes were not always fully effective. Some records and documentation were disorganised, and historic information had not always been appropriately archived. This meant information was not always readily accessible and additional time was required to locate some records during the inspection. While most documents were eventually found and provided, record management systems did not consistently support efficient oversight and retrieval of information.

The registered manager recognised the need to improve the organisation and archiving of records and had begun reviewing documentation to ensure information was current, accessible and appropriately stored. Despite these shortfalls, leaders were able to provide the majority of records requested and there was evidence of ongoing monitoring of key aspects of the service. Improvements were needed to strengthen governance arrangements and ensure records were consistently well organised, accurate and easily retrievable to support effective oversight of the service. Audits were in place for most processes.
 

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 service had positive working relationships with relevant health, social care, safeguarding and commissioning organisations. They understood when information needed to be shared, when specialist advice was required and when concerns needed to be escalated beyond the service. A professional told us, “Overall, I have no significant concerns regarding the care I have observed at Falcon House.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Although the registered manager was relatively new to the service, they had already identified several areas for development and had begun implementing changes to improve the quality of care and the effectiveness of governance systems. This included reviewing care planning documentation, improving the organisation of records and strengthening oversight processes.

The registered manager promoted a culture of learning and reflection and encouraged staff to identify opportunities for improvement. Staff were supported to reflect on incidents, concerns and near misses through discussions and lessons learned exercises. This helped staff understand what had worked well, what could be improved and how practice could be developed to achieve better outcomes for people.