Archived: Rowan House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. 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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

Management and oversight were ineffective, reactive, and lacked transparency. Leaders did not ensure staff competence, safe staffing levels, or consistent adherence to fundamental standards.

Systems to monitor quality, safety, and compliance were not effective. Incidents, safeguarding concerns, and staff feedback were not consistently reviewed, reported, or used to improve care. Audits and care reviews were incomplete or inaccurate, providing insufficient assurance that people received safe, effective care.

The provider was in breach of regulations relating to governance, fit and proper persons employed and notification of incidents.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Leaders had not established a consistent organisational culture that prioritised safety, human rights, or person-centred care. Staff relied on individual knowledge of people rather than structured guidance, policies, or oversight. Unsafe practices, such as poor medicines management, unreported environmental hazards, and delayed recognition of health deterioration, persisted. Opportunities for engagement with people, relatives, or staff were informal, inconsistent, and lacked structured feedback mechanisms.

There were no scheduled meetings or systems to promote shared learning, reinforce organisational values, or embed safety as a cultural priority.

People experienced inconsistent, reactive care. Individual preferences and rights were not consistently respected or applied. The absence of a coherent vision or culture limited the provider’s ability to sustain safe, equitable, and person-centred care. Staff lacked clarity on expectations, contributing to variability in practice and reduced accountability.

Without a clear, shared direction and robust culture, the service was unable to promote equity, inclusion, or consistently uphold people’s rights.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

Leaders lacked the skills, knowledge, and experience to lead effectively, and did not demonstrate integrity, openness, or transparency. They were unaware of their legal obligations to report incidents resulting in harm to safeguarding authorities, and were unfamiliar with nationally recognised assessment tools or evidence-based care standards. Leadership failed to address serious, ongoing risks, including unsafe medicines management, missed clinical deterioration, poor infection control, unreported safeguarding incidents, and unsafe environments and equipment.

Decisions and actions were reactive, prompted by inspections or external interventions, and at times influenced by cost considerations rather than people’s safety. Staff had insufficient guidance, supervision, or oversight, and no credible internal leadership existed to drive improvement.

People did not feel they could speak up and that their voice would be heard. There was no evidence of a whistleblowing culture or accessible mechanisms for staff, people, or relatives to report unsafe practice, abuse, or concerns about care.

The service lacked formal structures for raising concerns. Staff relied on informal communication rather than established reporting channels, and there was no clear process for people or relatives to escalate issues. Safeguarding concerns and serious incidents, including a choking episode and police involvement, were not reported to the relevant authorities, demonstrating a culture of under-reporting and limited accountability. Staff hesitated to escalate concerns formally, and the absence of clear pathways contributed to ongoing unsafe practices.

The provider did not foster an open and transparent culture. Without a structured and trusted process for speaking up, risks went unrecognised, unsafe practices persisted, and people’s safety and rights were compromised.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service lacked structured systems to support staff development, supervision, and competency assessment. There were no formal strategies or initiatives to promote equality, diversity, or inclusion. Staff appraisal, training, and team meetings did not include a focus on creating an inclusive culture or identifying inequities in opportunity or workload distribution.

The lack of formal equality and inclusion frameworks limited staff support and resilience. While staff reported they felt treated fairly, the absence of organisational oversight meant that inequalities could go unrecognised, workloads were uneven, and staff wellbeing and performance were at risk.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. This lack of oversight contributed to serious and repeated failures in care that placed people at immediate risk of harm.

Multiple people experienced preventable deterioration, unsafe medication administration, delayed medical interventions, and exposure to unsafe environments.

There was no effective auditing or review of clinical incidents and care plans and records were inaccurate or misleading. For example, one person’s care plan incorrectly included a person was using of a continuous glucose monitor. The service’s Statement of Purpose included the home provided nursing care provision and accepted people aged over 55, however, the service was registered for personal care only and adults over the age of 65.

Dependency tools were not used to assess the staffing level needed. This left staffing levels and people’ needs inadequately assessed. Medication audits did not reflect our findings during inspection, which included unsafe management of medicines and medication errors affecting every person.

Staffing levels were insufficient and skill gaps extensive. Staff were untrained in essential knowledge areas including asthma, epilepsy, diabetes, PRN medication, and infection control. Competency assessments were not completed to assess staff knowledge, including for the managers. From our discussions, it was clear that they lacked knowledge and understating of the regulatory requirements.

These failures left people’s health and safety severely compromised. Delayed emergency responses, incorrect treatments, and unsafe practices occurred repeatedly. The service relied heavily on external oversight to prevent further harm, highlighting the provider’s inability to manage risks, safeguard people, or sustain improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Some collaboration with community services was evident, including regular engagement with the district nursing team, and the community independence services. Relatives reported being kept informed about medical concerns. However, hospital passports were not regularly updated, safeguarding concerns were often unreported, and external agencies were repeatedly required to intervene to address serious issues. Participation in local multi-disciplinary teams (MDTs) and wider system forums was limited, meaning opportunities for coordinated, proactive care were missed.

While people occasionally received consistent care from familiar staff, gaps in communication and collaboration contributed to delays in recognising deterioration, responding to risks, and ensuring continuity of care. The provider’s engagement with partners was reactive rather than proactive, prompted by our inspection or external agencies rather than embedded in everyday practice.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There were no effective systems to review incidents, evaluate practice, or implement lessons learned. Audits were incomplete or absent, and there was no evidence that care failings, safeguarding issues, or clinical errors led to meaningful improvements.

Paper-based systems for people’s care records, risk assessments, and care monitoring were not effective.Recommendations from the local authority to implement better monitoring systems such as electronic care planning, to improve accuracy and accessibility were not implemented.Staff reported that although team meetings encouraged feedback, requests for additional night staffing were not acted upon, highlighting gaps between feedback and action. Staff felt that more formal mechanisms for learning and reflection would support continuous improvement.

The impact on people was significant: unsafe practices, delayed interventions, and inconsistent care persisted due to a lack of learning culture. The provider’s response remained reactive, reliant on external prompting, and driven by financial implications rather than safety, demonstrating a profound failure to foster continuous improvement, innovation, or the delivery of high-quality, safe care.