Archived: Rowan House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

People did not consistently receive care that achieved good outcomes. Care plans and assessments were incomplete, inaccurate, or missing. Staff did not have the information needed to manage health conditions safely, leaving people at risk of harm.

Staff were not familiar with nationally recognised tools for monitoring deterioration. Chronic conditions, including diabetes, epilepsy, and asthma, were not managed safely. Staff failed to recognise early signs of people’s deterioration, contributing to preventable risks.

People’s human rights were not consistently upheld. Restrictive practices were in place without appropriate safeguards and the provider failed to comply with the Mental Capacity Act 2005.

The provider was in breach of regulations relating to consent and the provision of safe care and treatment.

This service scored 33 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing, and communication needs with them.

The provider failed to conduct thorough, accurate, and up-to-date assessments of people’s health and care needs. Care plans were inconsistent, incomplete, or generic, leaving staff without guidance to provide safe and effective care. Staff were unaware of people’s individual needs due to missing or misleading information.

Three people with conditions including diabetes, epilepsy, asthma, and dementia had incomplete or unsafe records. For example, 1 person with epilepsy had no care plan, risk assessment, or protocol for managing partial focal seizures. Staff incorrectly stated that no one in the home was epileptic, and the manager noted this was because the person had not had a seizure since admission. Another person’s care plan inaccurately stated the person had a Libre monitor, a device used to continuously monitor blood glucose levels in people with diabetes. However, this was not in place. The person required daily insulin for their diabetes, but no diabetes care plan or emergency protocol was available. This meant staff did not have the information on how to respond safely to emergencies.

People were placed at serious risk due to insufficient information and guidance. Staff were not managing people’s health conditions effectively. This increased the likelihood of preventable harm, missed care, or delayed responses to people’s clinical deterioration.

The provider took actions in response to our feedback. This included booking training, reviewing seizure protocols, and acquiring an anti-suffocation pillow. There was no evidence of proactive assessment, monitoring, or review of people’s needs prior to the inspection.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Staff observed and reported changes in people’s wellbeing, but the provider did not implement systems to deliver care in line with evidence-based standards, leaving people at ongoing risk of harm.

The service did not use recognised assessment and monitoring tools for skin integrity, nutrition, or hydration, and the manager was unaware of recommended practices. RESTORE2, which is a physical deterioration and escalation tool for care homes aimed at helping staff recognize when a resident is becoming unwell, had been completed inconsistently. The provider was unable to explain how to use this tool in practice.

Post-fall observations and body maps were incomplete, and dependency assessment tools were not applied to review changing needs. This meant early warning signs that people’s health was deteriorating were not identified.

People were exposed to preventable harm due to delayed or inadequate identification of clinical deterioration, dehydration, malnutrition, and skin deterioration. The lack of structured assessment, monitoring, and escalation protocols increased the risk of unsafe care and compromised health outcomes.

The provider did not consistently work effectively across teams and services to support people. They did not always share assessments of people’s needs when individuals moved between different services.

The provider failed to ensure effective communication and information sharing across staff teams and with external healthcare services. Handovers were informal, records were outdated, and essential information about people’s health and care needs was not consistently shared.

People’s hospital passports, a document intended to summarise people’s essential health and care information, were not regularly updated. Two people’s passports did not accurately reflect their current needs. Night-time handovers between staff did not include all the relevant information about people. Communication with agency staff relied on outdated summaries of people’s needs and incorrect bedroom allocations.

Healthcare partners feedback highlighted good working relationships with the service and the team. However, people were placed at risk of unsafe or inconsistent care due to ineffective communication and poor information sharing.

The provider did not implement structured systems to ensure accurate, up-to-date communication between staff and external services. Staff and agency workers lacked the guidance needed to deliver safe, coordinated care, leaving people vulnerable to preventable harm.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People told us they had meaningful conversations with staff. However, there was no evidence of activity programmes or initiatives to encourage independence and self-management.

People experienced long periods of inactivity and minimal stimulation. One person reported concerns about weight gain due to lack of exercise.People’s general feedback highlighted how their physical and mental wellbeing had been compromised. People told us that limited opportunities for engagement and stimulation contributed to their reduced mobility, decreased cognitive activity, and heightened risk of deterioration. Inconsistent health support reduced opportunities for people to maintain or improve their health and independence.

The provider did not implement structured systems to support proactive health promotion, engagement, or preventative care. People were reliant on reactive support from staff, leaving their long-term health and wellbeing at risk.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

One person who had been unwell for several days, was only tested for COVID-19 after CQC intervention and feedback. They subsequently tested positive. Another person had experienced a choking incident prior to the inspection that required hospital admission. Following their discharge, there was no incident review completed to understand the circumstances of the person’s choking incident. There was no subsequent monitoring of the person’s food and fluid intake, and no referral made to the Speech and Language Therapy (SALT) team. This lack of follow-up and review meant that opportunities to monitor the person’s needs and implement measures to prevent further incidents were missed. This person’s care plan was not updated, and the choking risk assessment still stated “no risk of choking” with no review since January 2025. During inspection, this person experienced vomiting and became unresponsive. Inspectors had to prompt staff to carry out observations in line with the RESTORE2 escalation tool .

Staff failed to provide accurate information to the ambulance service, including the person’s blood pressure readings.

People were placed at serious risk of preventable harm, delayed treatment, and poor health outcomes. Failure to monitor, escalate, and respond to clinical deterioration, including a COVID-19 infection, compromised safety and increased the likelihood of avoidable adverse events.

The provider failed to implement systems to identify, record, and respond to people’s clinical deterioration. Staff did not consistently monitor health changes, escalate concerns, or follow recognised protocols for acute illness or infection.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The provider failed to obtain, record, and act upon people’s consent for care, interventions, and living arrangements. Staff demonstrated limited understanding of how to assess capacity, seek consent, or implement supported decision-making frameworks. Restrictive practices, including bedrails, were applied without people’s or representative’s consent, Mental Capacity Assessments (MCAs), or Best Interest Decisions (BIDs). Shared rooms were used without documented agreement between people or their representatives.

One person told us they had recently signed a form for flu and COVID vaccinations, but inspectors found no consistent evidence of mental capacity assessments to support decision-making. People were unable to explain why they shared bedrooms with another person. Staff reported verbally checking with people before delivering care but staff told us they lacked confidence in capacity-related decisions. Three staff members confirmed they did not feel confident making decisions about consent and escalation. Restrictive interventions, such as bedrails, were applied routinely without legal or clinical justification.

Care and living arrangements were implemented without lawful consent, leaving people’s rights unprotected. The absence of structured consent processes increased the risk of inappropriate or restrictive care. The provider did not comply with the Mental Capacity Act 2005 or associated frameworks for consent. People’ rights were not upheld, meaning people were disempowered and exposed to abuse.