Archived: Rowan House

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

Care did not always uphold people’s dignity, privacy, or individual preferences. Whilst staff interactions were often kind, compassionate, and familiar, delays in personal care, the use of shared rooms, and unsafe equipment undermined people’s experience of respectful care. People were sometimes left in distress or discomfort. Staff were not consistently able to maintain person-centred standards.

The provider was in breach of regulations relating to dignity and respect.

This service scored 45 (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 did not always treat people with kindness, empathy and compassion, or respect their privacy and dignity. Staff did not always respond appropriately in situations that compromised people’ modesty, comfort, or emotional wellbeing.

We observed a person who had been unwell, become distressed while walking. Staff assisted the person safely onto the floor but left their underwear exposed until we fed back to staff the person’s dignity was being compromised. On another occasion, a staff member discussed a person’s personal care needs aloud in a communal area. Four people shared bedrooms with commodes separated only by portable dignity screens, providing limited privacy.

While staff were familiar with people’s routines and preferences, people experienced distress, and exposure, undermining their dignity and sense of personal safety. The provider did not consistently ensure care protected people’s dignity, privacy, or individuality. People’s rights to respectful and compassionate care were not fully upheld.

The provider did not always treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. They did not always take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

Care plans were generic and inaccurate, omitting personal routines, likes, and dislikes. People’s cultural and social needs were not consistently addressed in care documentation or daily activities, limiting their ability to maintain identity and wellbeing. However, staff knew of people’s preferences in day-to-day interactions.

Some people participated in decisions about meals or light household duties, such as folding napkins. One person told us staff took a call from their relative in another country with warmth, discretion, and attentiveness, demonstrating personalised care in practice.

Staff showed awareness of people’s preferences in daily interactions, but the provider did not embed personalised approaches consistently into care planning or practice. People’s individual needs and choices were not fully recognised or supported across the service.

The provider did not always promote people’s independence, so people did not always know their rights and have choice and control over their own care, treatment and wellbeing.

People were not always informed about their rights or included in planning their care, which undermined their rights. Opportunities for meaningful engagement were very limited, and no structured activity programmes were in place to support participation or promote independence. Some people occasionally took part in light duties around the home or meal choices, but these were inconsistent and not part of a coordinated plan to maintain or develop people’s skills. Staff did not routinely encourage people to make decisions about how they spent their day or maintain independence in personal care or health management.

People experienced reduced control over their daily lives and limited opportunities to exercise choice. The absence of structured approaches to promote independence left people reliant on staff, reducing their independence and engagement in meaningful activities.

The provider did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

The provider failed to ensure people could summon help when needed or receive timely support for urgent needs. Call systems were inaccessible or absent in communal areas and in one ground-floor toilet, limiting people’s ability to alert staff.

Staff didn’t always recognise or respond promptly to visible distress or acute health deterioration.One person was repeatedly smacking a table and calling for attention, but staff did not intervene promptly, leaving the person anxious on 2 occasions. Another person was bent over in bed, crying and shouting for help, visibly in pain and staff did not respond until we raised this with staff. Staff further delayed calling an ambulance for this person for over thirty minutes, misattributing their symptoms to chronic knee pain.
People experienced serious, preventable risks, including delayed treatment, mismanagement of acute illness, and potential deterioration of health. Lack of timely response to urgent needs compromised safety, wellbeing, and confidence in staff support.

The provider did not maintain systems or practices to ensure people’s immediate needs were recognised and met. People could not rely on staff to respond safely or promptly, leaving them vulnerable to harm.

The provider did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care.

The provider failed to establish systems that promoted staff wellbeing, competence, and confidence. Structured supervision, reflective appraisals, team meetings, and opportunities for feedback were absent or ineffective. Staff were not consistently supported to develop skills or manage residents’ complex needs safely.

Supervision for staff, when provided, consisted of brief messages rather than meaningful support or development. New staff and agency workers received only basic information, such as people’s names, without guidance or risk management instructions. Staff were required to perform multiple roles simultaneously, including care, cleaning, cooking, and laundry, with no dedicated domestic support. Night staff were scheduled to work alone with sleep in support increasing pressure and isolation during emergencies.

Some staff reported positive relationships with people and satisfaction in their roles, but the provider did not maintain systems to support workforce wellbeing or capability.