Rowan House Residential Home (operating both a care home and domiciliary care agency) was rated Requires Improvement overall, with a confirmed breach of Regulation 17 (Good Governance) due to unidentified financial risk, insufficient care plan guidance, and audit failures in the domiciliary service. Strengths included positive staff culture, adequate staffing, effective infection control, and a responsive registered manager who took immediate corrective action during the inspection.
Concerns (7)
criticalGovernance: “The provider had failed to assess, monitor, and mitigate risks relating to the health, safety and welfare of service users. This is a breach of Regulation 17 (Good Governance)”
critical
Safeguarding
: “One person's bank card and PIN were being used by staff to purchase shopping regularly. However, there were no checks, monitoring or audits of these transactions.”
moderateCare planning: “One person's care plan did not contain sufficient guidance and direction for staff to manage all the risks related to their physical care and social support.”
moderateRecord keeping: “In two care plans, it was recorded the individuals did not require to have decisions made on their behalf and in their best interests. Contrary to this, best interest decision meetings had been recorded.”
moderateMedication management: “On the day of the inspection, we found that some medicines did not match with the amount held. The registered manager did a complete audit and found some medicines incorrectly recorded.”
moderateConsent / capacity: “One care plan stated the person did not have the capacity to make any decisions for themselves. Later it stated they could make decisions such as what food to eat, and clothing to wear.”
minorStaff training: “Recruitment processes were not always robust. One new staff file had not had a reference requested from their last care role.”
Strengths
· People and relatives spoke positively about staff, describing them as kind, compassionate and respectful of privacy and dignity.
· Sufficient staffing levels in both the domiciliary and residential services, with adequate travel time between calls and no agency staff used.
· Staff received appropriate induction, training and regular one-to-one support from management.
· Effective infection prevention and control measures in place, including appropriate PPE use.
· Residential home had detailed, up-to-date risk assessments and a robust computerised care planning system.
Quality-Statement breakdown (31)
safe: Assessing risk, safety monitoring and management (Domiciliary)Requires improvement
safe: Staffing and recruitment (Domiciliary)Requires improvement
safe: Systems and processes to safeguard people from the risk of abuse (Domiciliary)Good
safe: Using medicines safely (Domiciliary)Requires improvement
safe: Preventing and controlling infection (Domiciliary)Good
safe: Learning lessons when things go wrong (Domiciliary)Good
safe: Systems and processes to safeguard people from the risk of abuse (Residential)Good
safe: Staffing and recruitment (Residential)Good
safe: Using medicines safely (Residential)Requires improvement
safe: Assessing risk, safety monitoring and management (Residential)Good
safe: Preventing and controlling infection (Residential)Good
safe: Learning lessons when things go wrong (Residential)Good
effective: Supporting people to eat and drink enough to maintain a balanced diet (Domiciliary)Good
effective: Ensuring consent to care and treatment in line with law and guidance (Domiciliary)Requires improvement
effective: Assessing people's needs and choices (Domiciliary)Good
effective: Staff support: induction, training, skills and experience (Domiciliary)Good
effective: Staff working with other agencies and supporting people to live healthier lives (Domiciliary)Good
effective: Adapting service, design, decoration to meet people's needs (Residential)Good
effective: Assessing people's needs and choices (Residential)Good
effective: Staff support: induction, training, skills and experience (Residential)Good
effective: Supporting people to eat and drink enough to maintain a balanced diet (Residential)Good
effective: Ensuring consent to care and treatment in line with law and guidance (Residential)Good
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirements (Domiciliary)Requires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering (Domiciliary)Good
well-led: Engaging and involving people using the service, the public and staff (Domiciliary)Good
well-led: Working in partnership with others (Domiciliary)Good
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering (Residential)Good
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirements (Residential)Requires improvement
well-led: Engaging and involving people using the service, the public and staff (Residential)Good
well-led: Continuous learning and improving care (Residential)Good
well-led: Working in partnership with others (Residential)Good