Archived: Rowan House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

Staff did not consistently provide care that reflected people’s individual needs or preferences. Care plans were generic, incomplete, or inaccurate, limiting staff ability to deliver personalised support. People had limited opportunities for meaningful activity and social engagement. Staff did not consistently provide structured or stimulating activities, leaving some people with little to do. Call systems were inadequate, reducing people’s ability to summon help. Transitions between services lacked reassessment, and communication with external health partners was inconsistent, placing people at risk of unmet health needs.

The provider was in breach of regulations relating to safe care and treatment and person-centred care.

This service scored 43 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People received care that generally met their basic needs but did not consistently promote autonomy, personal goals, or meaningful engagement. People’s experiences depended on individual staff attentiveness rather than on coordinated person-centred approaches, leaving people disempowered and with limited control over their care and daily lives.

Staff knew people’s routines and preferences but did not routinely record these in care plans or engage people in formal reviews. Opportunities for people to express views, make choices, or influence care delivery were minimal. People could occasionally make simple decisions, such as meal preferences or light household tasks, but these actions were inconsistent and not embedded in daily care planning.

The provider failed to consistently involve people in decisions about their care or daily routines. Care planning did not reliably reflect people’s current needs, preferences, or personal goals, limiting individualisation and choice. Staff interactions, while often attentive, were not underpinned by structured person-centred systems.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People generally received consistent care from familiar staff, which promoted trust and comfort. However, during periods when agency staff covered shifts, care delivery became inconsistent, and planned support was sometimes missed or delayed. Emergencies diverted staff from scheduled care tasks, disrupting people’s routines. Family members reported that staff provided proactive updates regarding medical issues, but these communications did not compensate for inconsistent daily support or fragmented care.

Inconsistent staffing and care delivery created variability in the quality of support and increased the risk of people’s needs being overlooked. People’s experienced interruptions to routines, delays in tasks, and reduced opportunities for personalised care.

The provider did not maintain systems to ensure seamless continuity of care or effective coordination between staff and services. While familiar staff supported reassurance, reliance on agency workers and weak handover processes left residents at risk of inconsistent care and unmet needs.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The provider did not have policies or systems to ensure people with communication needs received information in accessible formats. Staff did not consistently support people to understand care plans, service arrangements, or daily routines. The service’s internal and external communications contained inaccuracies and were not tailored to meet individual preferences or comprehension needs.

The service had no policy to meet the Accessible Information Standard. One person told inspectors that they wished staff would wear name badges to help them identify staff more easily, demonstrating a simple but unmet need for reassurance and orientation. Noticeboards and care documentation were basic, not available in large print, pictorial, or other accessible formats. The provider’s Statement of Purpose contained misleading information, including claims of registration for nursing care and acceptance of people aged over 55, which did not match the terms and conditions of registration.

These failings limited people’s understanding of who was providing care, what support was available, and how to access important information about the service. Confusion and uncertainty undermined confidence and reduced people’s ability to make informed choices about their care.

The provider’s response was reactive. During inspection, they acknowledged inaccuracies in the Statement of Purpose and agreed to review it, but there was no evidence of a structured approach to improving information accessibility or ensuring communications were accurate, clear, and up to date.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

People shared feedback with management about lighting, food portion sizes, and boredom, and there was no evidence this had been acted upon. A residents meeting had taken place, but 1 person reported that it did not encourage open discussion or active participation.

Relatives told us they appreciated how responsive staff were when concerns were raised informally, and inspectors saw examples of staff listening kindly to people’s day-to-day preferences. Staff told us they saw themselves as the first point of contact for complaints and said they relayed issues to the managers. While they encouraged informal feedback, few were aware of formal processes for gathering or managing complaints, and there was little evidence of feedback being recorded or used to drive improvement.

These shortfalls meant people’s views were not always sought, heard, or used to influence how care was delivered. Opportunities to identify and resolve concerns early were missed, and people were not always informed about how their feedback had been used to improve the service.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

People had contact with GPs, dentists, and opticians, but support to attend these appointments was inconsistent. One person became tachycardic (abnormally fast heart rate) and hypotensive (low blood pressure) overnight. However, night staff failed to escalate these concerns to the day team. This delay in escalation and treatment led to the person deteriorating in health further and experiencing preventable harm.

People were at risk of delayed treatment and avoidable harm due to ineffective communication and lack of proactive support. These failings limited people’s ability to receive safe, effective, and timely care and reduced confidence in the service’s ability to manage health needs.

The provider did not have systems in place to ensure equitable access to healthcare or to monitor that care and treatment needs were met promptly.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

People with physical disabilities or mobility restrictions were at increased risk of harm due to unsafe equipment and unrecognised hazards. These failings meant that care was not always safe, responsive, or equitable, and residents’ ability to move independently or safely was compromised. A person with mobility difficulties used a walking frame that had missing screws and was unstable. Staff did not recognise or report this hazard until it was fed back during the inspection. Similar gaps were observed in risk monitoring for people requiring mobility aids or additional physical support when mobilising within the home, leaving them exposed to falls or injury.

Leaders and staff did not consistently identify or act on factors that could contribute to inequitable care, particularly for people with physical disabilities or mobility restrictions.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

At the time of inspection, no one was receiving end-of-life care. Of the 5 care plans reviewed, 3 included advanced care plans that had not been completed or personalised. Staff lacked clarity about people’s decisions for the future, and there was no evidence of regular review or discussion with residents or their families.

People were at risk of receiving care that did not reflect their values or wishes. This was because the absence of completed and person-centred advance care plans limited informed decision-making and could result in care that was not aligned with people’s wishes.

The provider had not implemented structured processes to support people in planning for future care or end-of-life decisions. Without proactive engagement and complete documentation, people’s rights to personalised and anticipatory care were not fully upheld.