Rowan House Residential Home

Rowan House Residential Home provides care and accommodation for up to 26 people who may be living with dementia. On the day of the inspection 25 people were living at the care home. Rowan House also provides a personal care service to people living in their own home. On the day of the inspection 30 people were supported by the agency with their personal care needs in their own home.

The residential service and the domiciliary service each had a manager in place. The residential service had a registered manager in place and the manager on the domiciliary service had applied to be registered. However, both the residential and domiciliary service remain under the same registration of Rowan House Residential Home.

Rowan House Domiciliary Care Agency

Risks were not always identified, assessed and recorded. One person had been exposed to potential financial risk. There were no checks, monitoring or audits of staff financial transactions done on behalf of a person.

One person had specific care needs. There was not sufficient guidance and direction for staff to safely manage all potential risks associated with their care and support.

Recruitment processes were not entirely robust. We have made a recommendation about this in the safe section of this report.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. There was misleading and contradictory capacity assessments seen in two care plans.

People and their relatives spoke positively about staff and told us they were happy with the service they received.

We were told staff were friendly, they were treated with kindness and compassion and their privacy and dignity was respected. Comments included, “They are very nice,” “Marvelous,” “Such a good agency” and “They are really good.”

New staff had sufficient support during their induction before working alone with people.

There were sufficient staff employed to cover the visits required by people. Staff were provided with adequate travel time to enable them to carry out visits at the time of the person’s choosing.

Environmental risks to visiting staff were assessed. Care plans were completed for each person and contained details of the person’s needs and preferences. Care plans were reviewed regularly to help ensure they were up to date and relevant.

People told us they felt safe when being supported by staff. There were systems to help protect people from abuse and to investigate any allegations, incidents, or accidents.

There were audit processes in place at the time of this inspection. However, these audits had not identified the concerns found at this inspection.

People and staff were regularly asked for their views and experiences of the service.

The service had implemented some quality assurance systems to monitor the quality and safety of the service provided. Spot checks were carried out to monitor staff performance. Staff were well supported and asked for their views.

People were supported by staff who had been appropriately trained and were skilled in their role.

People received support to maintain good health and were supported to maintain a balanced diet where this was part of their care plan.

Staff understood the importance of respecting people's diverse needs and promoting independence. People were always asked for their consent prior to care being provided.

There were clear lines of responsibility which were known and understood by the staff team.

There was a manager who was in the process of registering with the CQC at the time of this inspection.

Rowan House Residential Home

People’s experience of using this service and what we found

People told us they were happy with the care they received, and people said they felt safe living there. Comments from people included, “I am safe, and staff help me” and “I can talk to (named registered manager).” Another said, “They are familiar faces. I don’t know all their names, but I do know their faces.” While a relative said, “I’m happy with everything and I know (named relative) is safe here.” Another relative said, “It’s wonderful, like a family, very friendly and lots of fun.”

People looked relaxed, happy, and comfortable with the staff supporting them. Staff were caring and spent time chatting with people as they moved around the service.

The environment was safe, and there was equipment available which protected people from harm and supported staff. Health and safety checks of the environment and equipment were in place.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately. Medicines were ordered, stored, and disposed of safely. However, we did find a discrepancy in the number of medicines held and what was recorded. The registered manager actioned this immediately and put additional audits and monitoring in place.

People were protected from abuse and neglect. The service used a computerised care planning system. People's care plans and risk assessments were clear. Records were accessible and up to date.

The management and staff knew people well and worked together to help ensure people received a good service.

People were supported by staff who completed an induction and received appropriate training and support to enable them to carry out their roles safely. This included fire safety and dementia care training. Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction, and an outside entertainer was in the service during our inspection. Staff knew how to keep people safe from harm.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s communication needs were identified, and where they wanted, people had end of life wishes explored and recorded.

Staff told us the registered manager was available, assisted them daily and moved into the service and helped cover shifts when some staff had been absent with COVID-19. They went on to say how the registered manager was approachable and listened when any concerns or ideas were raised. One staff member said, “Very friendly person” and another “Very approachable.” One relative said, “Yes, I’m confident in the management, they always let me know how she is and are responsive.”

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 30 September 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Rowan House Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the oversight of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We carried out an unannounced comprehensive inspection of this service on 14 and 15 July 2016 on the care home only. Breaches of legal requirements were found and enforcement action was taken. This was because the provider did not ensure that risks relating to people's nutrition, skin care, medicines, the environment and the recruitment of staff, were effectively managed. We also found concerns in relation to staff training and to how the quality of the service was monitored. After the comprehensive inspection the provider submitted an action plan to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook a focused inspection on 17 November 2016 to check that they had followed their action plan and to confirm that they now met legal requirements. We found that action had been taken to improve the service. However we could not improve the rating from Requires Improvement because to do so requires consistent good practice over time.

At this inspection we found these improvements had been maintained.

The residential service and the domically service each had a manager in place. Though neither manager was currently registered with the Commission there were exceptional circumstance which we are aware of and except. We have now received an application to register a manager.

A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

One person living in the service said when asked; “The care in here is fantastic." Another said; “We are like one big happy family." While another commented; “It just reminds me of living at home." A relative said; “Couldn’t ask for better for her.” A professional spoken with felt people were well cared for and safe living in the service.

People from the domiciliary service said; “The care I receive is excellent, I'm very happy" and “Everybody is so helpful.” A relative said: “Their care is first class."

People’s medicines were managed safely. Medicines were stored, and disposed of safely. Senior staff administered medicines. They confirmed they had received training and understood the importance of the safe administration and management of medicines.

People were protected from harm as staff had completed safeguarding training. Staff understood how to report any concerns and what action they would take to protect people. Staff told us they felt confident any incidents or allegations would be fully investigated.

People were protected by safe recruitment procedures. Staff were supported with an induction and ongoing training programme to develop their skills, and staff competency was assessed. People, staff and relatives said there were sufficient staff to care for people.

People who did not have capacity to make decisions for themselves were supported by staff to make sure their legal rights were protected. Staff worked with other professionals in people’s best interests. The managers worked in the service most days and had taken action where they thought people’s freedom was being restricted. Applications were made and advice sought to help safeguard people and their human rights.

People were satisfied with the care the staff provided. They agreed staff had the right skills and knowledge to meet their needs. People were encouraged and supported to make decisions and choices whenever possible in their day to day lives. People had their privacy and dignity maintained. Staff were observed supporting people with patience and kindness.

People had visits from healthcare professionals. For example, district nurse, to ensure they received appropriate care and treatment to meet their healthcare needs. Professionals confirmed staff followed the guidance they provided. People received the care they needed to remain safe and well. For example, people who received regular visits from the district nurses had their dressing attend to. People’s end of life wishes were documented and respected.

People were supported to maintain a healthy balanced diet. People told us they enjoyed their meals and there was plenty of food available. We observed people, who required it, being supported at mealtimes. One person said; “The food is very good.”

People’s risks were assessed, well-managed and regularly reviewed to help keep people safe and well. Whenever possible, people had choice and control over their lives and were supported to engage in activities. Records were updated to reflect people’s changing needs. People and their families were involved in the planning of their care. People’s care records were of a good standard, were detailed and recorded people’s preferences. People said they were happy living at the service. There was a calm and relaxed atmosphere within the service.

People said both managers were very approachable. A visiting professional and staff confirmed the manager made themselves available and were very good at supporting them. Staff talked enthusiastically about their roles and took pride in their work.

The managers and registered provider had an ethos of honesty and transparency. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

People’s opinions were sought formally and informally. There were quality assurance systems in place. Feedback was sought from people and their relatives to assess the quality of the service provided. Audits were conducted to ensure the quality of care and environmental issues were identified promptly. Accidents and safeguarding concerns were investigated and where there were areas for improvement, these were shared for learning. Audits on infection control had taken place. Staff had received training in infection control.

Breaches of legal requirements were found and enforcement action was taken. This was because the provider did not ensure that risks relating to people’s nutrition, skin care, medicines, the environment and the recruitment of staff, were effectively managed. We also asked the provider to make improvements to staff training and to how the quality of the service was monitored.

After the comprehensive inspection the provider submitted an action plan to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook this focused inspection on 17 November 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Rowan House Residential Home on our website at

www.cqc.org.uk

The service had a manager who was in the process of applying to be registered with the Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People's medicines were managed and monitored effectively to help ensure they received them safely. Systems were in place to help ensure effective communication regarding medicines within the staff team, and monitoring checks by the manager and provider helped to highlight when action or improvements were required.

People's care plans had risk assessments in place to provide guidance and direction to staff about how to minimise risks associated with their care. Risk's relating to people's nutrition were effectively managed to help ensure their needs were being met and to enable prompt action to be taken, when necessary.

People's environment was assessed and monitored to help ensure it was safe. Fire testing was carried out in line with the provider’s policy and the manager took time to walk around the service each day, to carry out visual checks of fire exits and equipment.

People were protected by the provider's recruitment practices to help ensure staff employed were safe to work with vulnerable people. Risk assessments, when required, were in place relating to staffs’ Disclosure and Barring Service (DBS) checks. Staff employment history was recorded and references from previous employers were sought.

The manager and provider had worked hard to improve the quality of the service. There was a culture within the service of openness and transparency, and a willingness to learn from mistakes. There were systems and processes in place to help monitor the quality of care people received and the registered provider visited the service weekly to monitor quality and engage with staff.

Rowan House Residential Home provides care and accommodation for up to 26 people who are living with dementia or who may have physical difficulties. On the day of the inspection 23 people were living at the care home. The home is on three floors, with access to floors via stairs, a stair lift or lift. Some bedrooms have en-suite facilities. There are shared bathrooms, shower facilities and toilets. Other areas include three lounges, a dining room, and garden. The service also provides domiciliary care services to adults within East Cornwall. Our inspection was carried out only in respect of the care home.

Prior to our inspection the Commission had received some whistleblowing concerns. These included issues relating to staffing levels, the management of the service, the competence of staff, and the safe recruitment of staff. We were also told staff did not always treat people with dignity and respect, that there were poor infection control procedures, and ineffective safeguarding, whistleblowing and confidentiality practices. As part of our inspection we looked at the concerns which had been raised.

There was no registered manager in post, however a new manager had been appointed and was in the process of applying for registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection on 4 and 5 November 2015 we asked the provider to make improvements to how people’s care was documented and reviewed, the involvement of people in decisions relating to their care and how people’s mental capacity was assessed. Improvements were also required in relation to the management of medicines, the effective monitoring of people’s nutrition, infection control practices, and the assessment of risks associated with the environment. The provider had also been asked to improve how they assessed and monitored the ongoing quality of the service, and to ensure they notified the Commission of significant events in line with their legal obligations. Following our inspection the provider sent us an action plan telling us they would make improvements by 30 April 2016. During this inspection we looked to see if these improvements had been made and we found that some action had been taken, but further improvements were still required.

People’s medicines were not always managed and monitored effectively to ensure people received them safely. People were not always protected by staff who had been recruited safely to ensure they were suitable to work with vulnerable people. People’s environment was not always assessed and monitored to ensure it was safe, for example fire checks had not always been carried out.

People’s risks associated with their care were not managed effectively. Risk assessments in place did not always provide guidance and direction to staff, about how to minimise risks associated with peoples care. For example, when they were at risk of chocking or skin damage. People’s nutrition was not always managed effectively to ensure they were eating and drinking enough so responsive action could be taken. Following our inspection the provider told us immediate action was being taking to rectify the areas identified as requiring improvement.

People told us they felt safe living at the service. People were protected from abuse because staff knew what action to take if they thought someone was being abused, mistreated or neglected. People were cared for by sufficient numbers of staff, and the manager was responsive in making changes to staffing levels when people’s needs changed.

People told staff were well trained, however the manager was in the process of reviewing staff training and competency because they felt some staff lacked knowledge in some areas. Some external health professionals told us the skills and experience of staff varied, which meant they were hesitant to speak with some staff.

People told us the meals were nice. The manager and chef had been working hard to improve the standard and quality of the meals. The chef was keen to obtain feedback from people and was flexible to cook other alternatives if people did not like what was on the menu.

People’s nutrition was monitored; however records did not demonstrate that people’s nutrition was effectively monitored to ensure prompt referrals to external healthcare professionals were made. Following our inspection the provider informed us that action had been taken to improve the monitoring of this paperwork and the effective sharing of information between the staff team.

People told us they were able to see a GP or community nurse and people’s consent to their care was sought in line with legislation and guidance, helping to ensure their human rights were protected.

People told us staff were kind. Staff showed through their interactions a fondness for people, and people who were distressed were shown patience. People were supported to express their views and to be involved in their care. Independent advocates were arranged as required.

People told us their privacy and dignity was respected, but staff did not always knock on their bedroom door. The manager told us she would speak with staff about this and arrange further training.

People were supported at the end of their life. The service worked in conjunction with external health care professionals to ensure a joined up approach. People had care plans in place so staff knew what people’s preferences and wishes were.

People received individualised care. People were able to choose how they spent their day and had a choice about when they got up and went to bed. The manager was making improvements to ensure people’s changing care needs were communicated more effectively amongst the staff team, to help ensure people received responsive care at all times.

People’s religious and spiritual needs were recorded and respected. People were able to participate in social activities and their family and friends were welcome at any time.

People’s complaints were listened to, valued and investigated. The manager and provider had started to audit complaints to identify themes, helping to highlight where ongoing improvements maybe required.

The manager and provider had been working hard to improve the culture of the service, to promote openness and inclusiveness. The provider was taking time to speak with staff to ensure they all knew their whistleblowing responsibilities. There were some systems and process in place to monitor the quality of the service, but action was being taken at the time of our inspection to make further improvements. For example, the provider told us he would be at the service weekly to help create and imbed new monitoring practices.

The manager was developing positive relationships with external health professionals. The manager and provider were open and honest, they responded professionally and promptly to the Commission and external agencies when required. This reflected the requirements of the duty of candour. The manager had informed us of significant events in line with their legal obligations.

We have made a recommendation about the providers monitoring systems and processes.

You can see what action we told the provider to take at the back of the full version of the report.

At this inspection, because of the limited areas we looked at, we were unable to answer all of our five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

The registered manager had started to update care plans using a new format. The plans were detailed and informative. Information was relevant to people's specific, individual needs. Staff members told us they found the new care plans easier to use.

Risk assessments were included with the care documentation. Although these defined risk there was little information to guide staff on how to minimise risk. We discussed this with the registered manager and following the inspection visit they sent us a revised risk assessment. We saw this was clear, detailed and concise. The registered manager told us they would develop all risk assessments.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager told us they had contacted the local authority's DoLS team for advice and guidance around the legislation. We saw 12 applications for DoLS had been made. This showed us people's human rights were protected.

Since our last inspection a new system had been introduced to monitor the safety of the premises. We saw this was being adhered to.

We were able to make a judgement that Rowan House was a safe service in respect of the areas we looked at.

This is a summary of what we found-

Before our inspection we received some anonymous information of concern about the service, the areas of concern related to the choices people had with regards to getting up in the morning, the ethos and culture of the home, medication training and the standard of the homes care documentation.

Is the service safe?

At the time of our inspection we did not find the service to be safe.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The recent judgement made by the Supreme Court on 19 March 2014 places a responsibility on providers to ask two key questions; is a person subject to continuous supervision/control? and is the person free to leave? If a person is subject to both continuous supervision/control and is not free to leave, then a person is being deprived of their liberty and a DoLS application should be in place to state that this is in the person's best interests.

We found people who lived at Rowan House were not subject to restriction. However, it was not clear from people's care plans how the provider had considered this having regard to the DoLS legislation particularly as some people who lived at Rowan House had a form of dementia. It is important that people's care plans are individually reflective of such care needs to ensure that staff are aware of how to meet a person's needs without imposing restrictions.

People's needs were assessed, but care and treatment was not always planned in line with their individual care plan. We found care plans for people were not always reflective of their current care needs, and the information in risk assessments was not always clear. Care plans did not always give clear direction and guidance to staff. It is essential care plans give clear direction to enable staff to be able to understand how people's individual health and social care needs should be met.

Is the service caring?

At the time of this inspection we found the service to be caring.

People who lived at Rowan House were complementary of the care and support they received from staff. Comments included, 'I can't speak highly enough of them, caring and love that are the two words I would use to express my feelings about this; my home' and 'they are very, very kind'.

We spoke with a relative who told us, 'I've got tremendous praise for the home'.

One relative told us, 'X [the manager] has a sense of fun which I think is really infectious'. They also told us, 'I think Rowan House is just wonderful my X has just thrived there' and 'I've got nothing other than praise for Rowan House'.

People told us 'My choices are respected'; 'Yes, they respect my privacy and dignity' and 'The care is excellent, staff brilliant, choices are respected, they check people are okay and safe, Dad's never been happier.'

We found people had their choices respected and were treated with dignity and privacy. We spoke with staff who were mindful to ensure people's personal preferences were honoured such as what they liked to wear and how they liked their hair and make-up done.

We found people had their needs assessed prior to admission and people's care plans gave detailed information about their care and support needs which ensured their safety and well-being.

People had their nutritional needs met and staff were aware of people who required additional support and monitoring to maintain a good diet.

People felt safe at Rowan House, staff were trained in recognising the signs of abuse and knew the procedures to follow to report abuse and protect people.

Rowan House had a complaints policy and people felt able to raise concerns and felt listened too.

We talked with four people who lived at the home and four visitors. People using the service told us 'staff are as good as gold' and 'it's wonderful here'. Visitors told us 'I honestly would not want my relative anywhere else' and 'they keep me up to date with all changes and how they are'.

We spoke with five staff who told us that Rowan House was a good place to work with friendly and caring staff. They told us that 'There is lots of training' and that they felt the management of the home were very supportive.

We looked at the care provided and records relating to three people in the home and two people in the community. Records relating to people's care were detailed and personal to each person. The details enabled staff to meet people's individual needs.

People using the service felt there were sufficient staff with the right skills, to meet their needs.

We looked at the domiciliary care provided to people in the community. We spoke by telephone, with three people receiving care. They told us staff were punctual, stayed the right amount of time and were kind and friendly. Staff working in the community told us that they had information and support from the office staff at Rowan House.