Archived: Rowan House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

People were exposed to avoidable harm due to unsafe care practices. Staff did not recognise or respond appropriately to signs of health deterioration. Medicines were not managed safely, with “as required” (PRN) medicines misused and staff lacking competency to administer medications safely. A COVID-19 outbreak in the home went undetected until we prompted testing, placing people at risk of preventable illness.

The provider failed to protect people from abuse and harm. Multiple incidents, including falls, choking, unexplained bruising, hospitalisations, and police involvement, were not recorded, investigated, or reported to the local authority. People at risk of harm were not safeguarded in line with statutory requirements. Staffing arrangements were unsafe. The home relied on untrained, unsuitable, and unskilled staff to provide care. Staffing levels were insufficient to meet people’ needs safely. The environment and equipment were unsafe. Risk assessments were incomplete or missing, fire safety arrangements were inadequate, and equipment was not always checked or properly maintained to keep people safe. These failings increased the likelihood of preventable incidents and injury.

The provider was in breach of regulations relating to safe care and treatment, safeguarding, staffing, premises and equipment.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider and staff did not reflect on incidents or use them as opportunities for learning or improvement. Minimal action followed the local authority’s quality team visit in June 2025, although risks to people’s safety and wellbeing had been identified. Leadership failed to analyse incidents meaningfully or follow up when things went wrong. Staff lacked understanding of lessons from past events and could not describe any improvements resulting from prior incidents.

Serious incidents requiring people’s hospital admission and police involvement were not documented or reviewed. Missed health observations and safeguarding shortfalls were not analysed. One family member reported raising informal concerns about falls, lack of engagement, and poor responsiveness, but these were not recorded or acted upon.

The absence of a learning culture placed people’s safety and wellbeing at risk. Repeated opportunities to prevent avoidable harm were missed. Staff were not clear about expectations, which contributed to inconsistent and unsafe care practices across the service.

The provider had not implemented any structured system for incident review, staff debriefing, or dissemination of learning, leaving the service without a mechanism to improve care or prevent future harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider failed to maintain consistent, safe systems for managing care and transitions. Staff did not always have access to accurate information about people’ needs or risks, limiting their ability to provide safe and person-centred care. The service did not formally reassess people when they were admitted, discharged from hospital, or transferred between services.

Initial assessments completed prior to people’s admission did not capture key information about their medical history, preferences, or individual risks. Key risks, such as choking, were undocumented or recorded inaccurately with no follow-up. Staff could not rely on written records to guide safe care. People were at risk of harm due to gaps in information, failure to monitor key risks, and lack of reassessment during transitions between other services. This increased the likelihood of avoidable incidents and unsafe outcomes for people.

The provider had not implemented robust systems to ensure continuity of care, maintain accurate records, or monitor risks across admissions and transfers, leaving people exposed to preventable harm.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider failed to ensure timely reporting, investigation, or review of safeguarding concerns. Staff had a limited understanding of their safeguarding responsibilities, and the provider did not establish systems to manage or escalate risks effectively. Safeguarding procedures were reactive rather than preventative.

A serious choking incident for one person requiring first aid and hospitalisation was not recorded or reported to safeguarding authorities. Other incidents, including falls resulting in harm, unexplained injuries, and events involving the police, were also not escalated. There was no evidence of internal investigation or review following these events.

People were exposed to preventable risks. Serious incidents went unreported, preventing safeguarding partners from intervening to protect people. The provider’s response to safeguarding concerns was reactive, minimal, and insufficient, failing to ensure that people were protected from harm and neglect.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People with long-term conditions, including diabetes, epilepsy, and asthma, did not have risk assessments or protocols describing how to manage hyper- or hypoglycaemic episodes, seizures, or respiratory distress. People could freely access hazardous areas such as stairwells and the kitchen, increasing the likelihood of falls, burns, or injury. Risk assessments were not regularly reviewed or updated, and opportunities to prevent incidents were missed.

People faced significant and avoidable risks due to the lack of structured, proactive risk management. Staff were unable to provide safe care consistently, and people were placed in unsafe situations, increasing the likelihood of harm.

The provider responded to our feedback by completing new risk assessments and arranging condition-specific training.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider failed to maintain a safe environment and did not identify or mitigate hazards effectively. Fire safety and evacuation arrangements were inadequate, and environmental risks remained unassessed.

Wardrobes in bedrooms were unsecured, with heavy items stored on top, creating a crush injury risk for people. Communal areas had unused mobility aids and medical equipment in which obstructed pathways. This was a trip hazard and increased the risk of falls for people. Windows had restrictors that could be easily overridden, and exposed pipework in accessible areas created scald and burn risks. Exit doors were chained, fire exits were obstructed, signage was limited, and evacuation procedures were incomplete or misleading. Medicines were stored in a cupboard under the stairs, near liquids, electrical wiring, and lift mechanisms, with the cupboard key left hanging nearby. The stairwell was the only evacuation route from the first floor in the event of a fire.

People faced significant and avoidable risks, including falls, burns, and injury, as well as restricted emergency egress. The unsafe environment compromised staff ability to deliver care safely and increased the likelihood of harm in an emergency.

Unused items and equipment were removed from the lounge on the second day of inspection following our initial feedback. However, no further actions were taken to mitigate any remaining hazards to people.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not consistently make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider did not have systems in place to identify staffing levels to meet people’s needs or monitor staff competencies consistently. Staff did not receive required training, induction, or adequate supervision to deliver safe care. Agency staff received minimal induction and relied on outdated or misleading information about people. Employment checks were incomplete, with gaps in references, right-to-work verification, and conduct confirmation.

Staffing levels were insufficient to meet people’s needs safely, specially at night. During the inspection we found that one waking night staff member and a sleep-in manager were responsible for ten people. The sleep-in manager told us they would not be physically able to support evacuation of residents should there be an emergency. This meant staffing levels were not sufficient to keep people safe in the event of an incident or an emergency. Daytime staffing consisted of only two to three staff covering all care, cooking, cleaning, laundry, and activities.

Staff were not trained in essential areas of people’s care, including asthma and epilepsy. The manager told us they did not fully understand how staffing numbers were calculated and relied on informal assessments rather than using a staffing tool that considered people’s needs. This meant people were placed at risk of not receiving the care and support they needed. This was because there were not enough staff who had the required skills and knowledge.

Following our initial feedback staff training for complex health conditions and additional staff were deployed.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider failed to implement effective infection prevention and control (IPC) measures. Staff did not consistently follow IPC procedures, and the service lacked systems to manage outbreaks or monitor hygiene standards. Audits and cleaning schedules were not effective, and there were shortfalls in Personal protective equipment (PPE) management.

There weresoiled bins left without lids, visible dust and debris under beds and furniture, and persistent malodours. Staff repeatedly reused gloves across multiple tasks, including taking people to the toilet and food preparation. Supplies of PPE were limited and some PPE wasexpired. Staff were unable to differentiate COVID-19 from other infections, and there were no effective outbreak management systems. IPC audits were completed without any resulting action plans, and cleaning schedules were unreliable

Three people were visibly unwell with COVID-19 during the inspection. However, this outbreak went undetected until we prompted the managers to undertake testing and isolation in line with current IPC guidance. Some lateral flow test kits available at the service were out of date and there were only 5 lateral flow test kits available and in date that could be used to test people.

People faced significant and preventable risk of infection. Poor hygiene, unsafe PPE practices, and lack of outbreak procedures increased the likelihood of respiratory or gastrointestinal infections spreading. The provider’s delayed recognition and response to illness put people’s health and safety at risk.

There was no evidence of proactive monitoring, routine checks, or preventative measures to protect people from infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning their care.

The provider failed to manage medicines safely. Staff administering medicines, including the manager, were untrained or had not undergone competency assessments. Systems for prescribing, recording, storing, and monitoring medicines were inconsistent and not aligned with national standards. Condition-specific care plans such as asthma and epilepsy were absent, and risk assessments for medicines were not in place.

As required (PRN) medicines were not managed safely. Medication for pain was stored in kitchen cupboards and not recorded on Medicines Administration Records (MAR) charts. People were not offered or provided with prescribed pain relief. A PRN sedative was routinely given at night to one person without clinical justification or documentation. For another person, transdermal patches were repeatedly applied to the same site, creating a risk of overdose due to skin irritation. MAR charts were inaccurate and incomplete, missing allergy details, incorrect condition listings, and inconsistent entries. No trained staff were available at night to manage emergency or PRN medicines, such as inhalers. Expired medicines were found stored unsafely.

People were exposed to preventable harm, including untreated pain, unnecessary sedation, overdose risk, and unmonitored medical conditions. The lack of competent staff and safe systems placed the service at immediate risk of serious clinical incidents.

The manager arranged a future competency assessment of medicines, but this action did not address the immediate risks in relation to medicines management. A qualified nurse was requested by the local authority to lead medicines management in the interim. The local authority confirmed widespread medication errors affecting every person following their visits to the service.