- Care home
Archived: Rowan House
Assessment report published 2 February 2026
Contents
Ratings
Our view of the service
We carried out an inspection of Rowan House on 8 and 9 October 2025 following concerns about end-of-life care, staffing, training, and governance. This inspection found serious and widespread concerns placing people at immediate risk of harm.
The provider was in breach of regulations in relation to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding, premises and equipment, good governance, staffing, fit and proper persons employed and notification of incidents.
Person-centred care was not always provided. Care records were inaccurate, incomplete or misleading, particularly for people with complex conditions such as diabetes, epilepsy and asthma. Staff did not have access to reliable information to deliver safe, individualised care. People’s dignity and privacy were not consistently protected.
The provider did not obtain valid consent or apply the Mental Capacity Act 2005 appropriately. Four people shared bedrooms without evidence of consent being sought, mental capacity assessments completed or best interest decisions being made in line with legislation. Bed rails were used without risk assessments or documentation confirming consent.
Care and treatment was unsafe. Medicines were not managed safely and as prescribed. Staff failed to recognise or respond to signs of deterioration, and a COVID-19 outbreak was identified only after inspectors prompted testing of unwell people. Safeguarding incidents that resulted in harm, injury or hospital admission were not recorded, reported or investigated.
The environment was unsafe and unclean, with poor infection prevention and control and unaddressed fire safety risks. Leadership and governance were ineffective. Both the provider and managers wereunaware of their legal responsibilities. Records were inaccurate, audits incomplete, and statutory notifications were not made as required. The provider acted only when prompted by external agencies.
Staffing arrangements were unsafe. There were not enough trained and competent staff to meet people’s needs.
Despite these systemic failures, people and relatives spoke positively about staff kindness and compassion.
During the inspection we identified an issue with the provider’s registration which meant they were unable to continue providing a regulated activity. Due to this issue, CQC was unable to take further enforcement action in response to concerns identified on this inspection. Following identification of this issue, all people living at the home were supported to find alternative placements.
People's experience of this service
Rowan House is a care home supporting adults over 65 living with dementia and mental health conditions, registered for up to 16 people. At the time of inspection, 10 people lived at the service. We spoke with 6 people and 6 relatives.
Three people and 3 relatives reported that the home provided limited structured or meaningful activities, leaving people with little to do. One person said, “I used to do a lot here, but now just sit.” One person using the service and 1 relative said the management team did not act on feedback about boredom, limited engagement, and inconsistent care. People and relatives’ awareness of care plans, safety measures, and leadership roles varied. Few had seen care documentation or participated in formal reviews. Some relatives were unsure whether call bells or safety equipment, such as sensor mats, were in place. While most people said their food and hydration needs were met, 1 person found the menu repetitive and 1 relative questioned whether staff consistently monitored hydration.
Regardless of these shortfalls, most people living at the service described Rowan House as warm and friendly. One person enjoyed helping in the kitchen, and 2 others enjoyed being encouraged to reminisce about their past. People highlighted staff’s kindness and the sense of familiarity within the home with one person describing it as their “second home.” People reported that staff were caring, with some forming relationships with team members who knew their preferences and interests. Relatives described the home as family-oriented and most said their loved ones appeared settled and content.
People and relatives valued staff dedication and the home’s familiar atmosphere. At the same time, recurring concerns about limited activities, inconsistent care, and gaps in oversight demonstrated, despite staff commitment, systemic failings continued to place people at risk of avoidable harm and impacted on their wellbeing and quality of life.