The assessment was carried out from 6 – 13 February 2026. We visited the service on 6 February 2026 and reviewed additional information the manager sent us electronically, following our site visit. Housing 21 – Rowan Croft is an extra-care scheme that supports adults both over and under 65 including those living with a dementia and mental health conditions. At the time of the assessment 52 older people lived at Rowan Croft, of which 32 received personal care. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. This was a planned inspection based on the previous rating and time since we last inspected. We also took into account that there had been no registered manager in post since 2023 which is a legal requirement to support accountable leadership. The manager told us that work to complete the registration process was underway and we will follow this up outside of the inspection process. The service supported one person with a learning disability. Although the service was not registered as a specialist service for people with a learning disability and autism, we assessed it against the ‘Right support, right care, right culture’ guidance to consider whether the provider ensured people with a learning disability and autism received respect, equality, dignity, choice, independence and good access to local communities. We found that the principles of the guidance were met in practice. The manager had not been fully aware of this guidance. She told us she would strengthen her understanding of the guidance going forward. There was a stable staff team, along with appropriate staffing levels and safe recruitment practices, which meant people received consistent care. Staff, teams, and external professionals worked together effectively to support people. There was a handover system in place to ensure key information was shared between shifts. Staff used an electronic system that allowed messages and updates to be sent to all staff, which helped maintain consistent communication across the team. The service was clean and well maintained. Staff had access to appropriate personal protective equipment. Whilst governance systems were in place, some systems required strengthening to fully support safe, high‑quality care. We identified shortfalls in records relating to medicines, people’s care and support, the management of concerns and the submission of notifications about events at the service. Accidents and incidents were monitored across different systems, and work was underway to improve integration between these systems. We did not identify any negative impact from these shortfalls on people’s care and support. Staff had completed core training and demonstrated good knowledge of people’s day‑to‑day needs. However, they had not completed formal training on specific health conditions to fully support people’s individual health needs. Although formal training had not been undertaken, staff had received informal guidance and support from relevant health professionals, which helped strengthen their understanding and practice. Staff told they enjoyed working at the service and they felt supported and valued. Quarterly check‑ins and meetings were carried out, giving staff structured opportunities to discuss concerns, reflect on practice and feel supported in their roles.
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Housing & Care 21 – Rowan Croft received an overall rating of Requires Improvement at its first inspection in September 2015, with three regulatory breaches identified relating to medicines management, staffing (training/supervision/appraisal), and governance. Caring was rated Good, reflecting strong staff–resident relationships, but significant shortfalls in medication records, care planning, staff training, and quality auditing require remediation.
Concerns (9)
criticalMedication management: “medicine administration records were not completed correctly as per current guidance and 'as required' medicines had not been recorded correctly.”
criticalMedication management: “the medibox was recorded on medicines administration records (MARs) as a single entry when in fact a number of medicines had been administered”
criticalStaff training: “Moving and handling records showed that only three staff had up to date training. safeguarding, medicines and infection control training were also out of date.”
criticalSupervision / appraisal: “One member of care staff reported they had never had an appraisal and another member of care staff said, "I last had it at the beginning of January 2014."”
criticalGovernance: “Overall, audits and checks, including those by the manager and the provider, were not robust.”
moderateIncident learning: “the manager told us that they currently did not keep an accident and incident log to monitor any trends forming.”
moderateCare planning: “one person's care records stated they needed to be supported with a shower. The records did not explain how staff would do this or how the person preferred to be showered.”
moderateCare planning: “A small number of people's care plans had not been reviewed recently, including one since May 2014.”
minorRecord keeping: “Staff did not have any written information [at handover], which meant that there was a possibility of relevant and important information being missed by accident.”
Strengths
· People felt safe and staff demonstrated a working knowledge of safeguarding and whistleblowing procedures.
· Staff treated people with compassion, kindness, and respect, and people were not rushed during care.
· People were encouraged to remain as independent as possible.
· Sufficient staff were in place to meet people's needs and appropriate recruitment procedures were followed.
· Staff understood the Mental Capacity Act 2005 and obtained consent appropriately.
Quality-Statement breakdown (15)
safe: Safe management of medicinesRequires improvement
safe: Risk assessmentsRequires improvement
safe: SafeguardingGood
safe: Staffing levels and recruitmentGood
effective: Staff trainingRequires improvement
effective: Supervision and appraisalRequires improvement
Housing & Care 21 – Rowan Croft was rated Good across all five key questions at its inspection on 19 December 2016, having previously been rated Requires Improvement in 2015. The service demonstrated safe staffing, strong person-centred care planning, effective governance and a positive culture under a well-regarded registered manager.
Strengths
· Staffing levels were appropriate and flexible, with absences covered internally including by the registered manager and care team leader
· Robust recruitment and selection procedures including DBS checks, references and identity verification
· Comprehensive risk assessments in place covering personal care, infection control, falls, fire safety and safeguarding
· Medication management was safe with locked storage, MAR charts, competency checks and weekly audits
· Staff were well trained with up-to-date mandatory training, Care Certificate enrolment, regular supervisions and annual appraisals
This focused follow-up inspection found that Housing & Care 21 – Rowan Croft had made improvements against three previously breached regulations covering safe care and treatment, staffing, and governance. Ratings across safe, effective, and well-led remain at Requires Improvement as consistent good practice over time is needed before an upgrade can be awarded.
Concerns (5)
criticalMedication management: “At the last inspection the provider did not have proper and safe management of medicines procedures in place. That meant people were in danger of not receiving their medicines at all, or at the incorrect time or at the incorrect dosage.”
moderateStaff training: “At the last inspection we found the provider had not given staff appropriate or sufficient training, supervision or appraisal.”
moderateGovernance: “At the last inspection we found the provider did not have robust quality assurance systems in place, including monitoring of accidents and incidents and regular audits.”
moderateSupervision / appraisal: “At the last inspection we found the provider had not given staff appropriate or sufficient training, supervision or appraisal. This meant staff had not been given the opportunity to further develop their skills.”
minorRecord keeping: “We saw that where some training had been completed, no certificates were produced by the training agent. The registered manager was looking into this.”
Strengths
· Medicines were now being managed safely following updated policy, staff training, and competency checks by senior staff.
· Staff demonstrated working knowledge of safeguarding and whistleblowing procedures; all recently trained.
· Risk assessments fully completed for individuals and working environment, including falls, malnutrition, and moving and handling.
· Accidents and incidents fully recorded and monitored for trends, with appropriate referrals to healthcare professionals.
· All staff now up to date with supervisions, appraisals, and training; competency checks fully met.
Housing 21 – Rowan Croft, an extra-care scheme in Newcastle Upon Tyne serving 31 people receiving personal care, was rated Good across all five key questions at its July 2019 inspection. The service demonstrated high-quality, person-centred care with strong leadership, robust governance, effective multi-agency working, and no identified failure themes.
Strengths
· People felt very safe and staff were well trained in safeguarding procedures
· Medicines were well managed with robust ordering, storage, administration and audit processes
· Staff delivered high-quality, person-centred care that promoted independence and dignity
· Strong partnership working with external health and social care professionals achieving positive outcomes
· Registered manager maintained thorough governance and quality assurance through regular audits
Quality-Statement breakdown (26)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
caring: Compassion, dignity and respect
Good
caring: Independence promotionGood
responsive: Person-centred care planningRequires improvement
responsive: Complaints handlingGood
well-led: Governance and auditRequires improvement
well-led: Accident and incident monitoringRequires improvement
well-led: Staff engagement and management cultureGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Staff support: induction, training, skills and experienceGood
effective: Adapting service, design, decoration to meet people's needsGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood