Rowland House Care Home

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 remained Good. This meant people were safe and protected from avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Management had a proactive and positive culture of safety, based on openness and honesty and lessons were learnt to continually identify and embed good practice. A relative told us, “I haven’t encountered any safety concerns since the new (interim) manager has joined.”

Accidents and incidents were recorded by staff and reviewed by management to check appropriate actions had been taken in response. Learning from accidents and incidents took place as the interim manager explained, telling us, “We had a situation where processes were not being followed properly and there was no collaboration with other professionals. We had a meeting to discuss this, and it enabled us to embrace and manage the situation.”

Management worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The interim manager told us how the needs of 1 person had changed and as such Rowland House Care Home was no longer a suitable place for them. They said, “We helped facilitate the move to another service for them. We worked with external stakeholders and this ensured the result was a good outcome for this resident as well as everyone else. They are now in a safe environment receiving the correct clinical input."

Management worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. A relative told us, “He feels safe around staff.” A second said, “It has become a much safer atmosphere and peaceful since [interim manager name] has arrived.”

Staff received training in how to recognise and report abuse and put this training into practice. Safeguarding concerns had been raised with the relevant local authority safeguarding team and the provider staff had worked with this team to investigate and identify actions needed.

The interim manager explained they had raised a recent safeguarding concern of potential neglect for 1 person. They told us, “Social service asked lots of questions and we provided them with all the information they needed. The safeguarding concern is now closed.”

Management and staff worked with people to understand and manage risks by thinking holistically, although we did identify a shortfall relating to people’s pressure relieving mattresses. Despite finding 1 person’s mattress had been set correctly (according to their weight) another person’s had been set at 100kg, despite them weighing 73kg. This meant the mattress may not be effective and as such could put the person had higher risk of pressure damage. We raised this with the interim manager so they could address this.

Relative’s felt their family members were safe living at the service. A relative told us, “He is safe in the sense that staff look after him. They have done everything they can to make sure he is safe. Staff have minimised the risks.”

Staff had recognised potential risks to people and had taken action to address these to help ensure people were kept safe. For example, some people had been assessed for having bed rails in place to reduce their risk of falling out of bed and other people, where bed rails were not appropriate, had sensor and crash mats positioned appropriately to reduce the risk of injury or to alert staff if the person got out of bed.

One person had a fascination with electricity putting them at risk of electrocution. Their room had been placed on a separate low-voltage electric circuit which enabled them to continue exploring their curiosity but in a safe way.

Other people’s care plans had guidance in place for staff which included staff positioning themselves on the left of 1 person when providing personal care to keep them safe.

Management detected and controlled potential risks in the care environment although identified actions did not always take place in line with deadlines.

A health and safety review was completed in September 2025 to follow up on the review in April 2025. The outcome of this review showed some actions still outstanding. This included ensuring the house minibus being made roadworthy so it could be used, the introduction of a monthly bed rail checklist, the installation of a carbon monoxide alarm and formal bath temperature charts to be instigated. New deadlines had been given for these actions as the previous manager had failed to address them. The interim manager was taking action against these.

However, the regular health and safety checks contributed towards ensuring that Rowland House Care Home was a suitable place for people to live. We found the environment was clean and tidy and people had been provided with plenty of space to move around in their wheelchairs. A lift was available to assist people in reaching their rooms on the first floor and the kitchen was adapted so staff could adjust the worktops to make them suitable for people in wheelchairs to access.

Regular fire drills were carried out which involved all staff participating and staff received fire training to help ensure they knew what to do in the event of an emergency.

Management made sure there were enough qualified, skilled and experienced staff, who received effective support and training.

The interim manager explained they had reviewed staff rotas and reorganised them so staff were clearer on their shift patterns. They said this had helped ensure people saw consistent staff on shift during the day and it had helped improve the handovers taking place between day and night staff.

Relatives and staff generally felt there were sufficient staff on duty. A relative told us, “When [person’s name] has rung the bell, sometimes they (staff) are a bit slow in coming. But it is adequate.” Staff said, “We only have 5 people here at present, so 3 staff is sufficient. There may be the odd time when someone needs repositioning and we might have to wait for a colleague to help us, but this does not happen that often.”

Our observations during the day were that people did not have to wait for staff support. At lunchtime people received their meals promptly and where people needed support to eat this was provided quickly.

Staff received appropriate training to help ensure they were competent and confident in their role. This included face to face as well as eLearning. A relative told us, “I think staff have the right training. They take good care of [person’s name].”

New staff completed an induction programme at the head office for their first week in the role and this was followed by 2 days of eLearning as well as face to face moving and handling and medication training. A staff member told us, “The induction was comprehensive.”

Staff were recruited through good processes. This included providing information about previous employment and their performance, evidence of their right to work in the UK and their fitness for the role. In addition, staff underwent a Disclosure and Barring Check (DBS) to help ensure they were suitable to work in this type of service.

Infection prevention and control shortfalls were identified in the service. This included some broken lino in one person’s en-suite and a dirty sink and tap as well as flaking paint in one toilet. Both areas were at risk of harbouring infection. We raised these with the interim manager who told us they had already identified these areas and had plans in place to remedy them. They told us, “The downstairs toilet is being ripped out on Monday and being totally revamped. I have also reported [person’s name’s] flooring and waiting for this to be replaced.”

Other areas of the service were clean and well-presented and there were personal protective equipment (PPE) stations placed around the service. A staff member told us, “[Interim manager] had these put up. It means we have access to plenty of PPE and quickly. They are so much better.”

The laundry area had been established in an out-building. We found it was well organised and tidy and allowed for good air circulation to help prevent dampness and help ensure clothes dried efficiently.

Relative’s felt happy with the cleanliness in the service with one telling us, “[Person’s name] always looks good and clean, and his room is always clean, so I have no concerns.” A second relative said, “We did have some concerns about hygiene and cleanliness but that had improved recently, and I see staff wear gloves.” A further relative commented, “I feel the cleanliness of [person’s name] room has been significantly improved. She used to have an awful smelly carpet which has been replaced with hard flooring.”

Although people received the medicine’s they were prescribed we found the storage of medicines was not always safe. People had their own medicines cabinet in their room. Staff checked the temperate of the cabinet twice a day but we found it was affected by how warm people liked their room. For example, 1 person’s room was very warm and we saw from the temperature logs that on 12 occasions over a period of 61 days the temperature of the cabinet had gone over the safe storage temperature of 25 degrees, rising as high as 28 degrees on 1 occasion. In addition, there was another medicines cabinet in the hallway on the first floor. This contained the medicines for 2 people. Again, we read from the logs held by staff that the temperature of these had risen above 25 degrees on 41 out of 91 occasions. This put people at risk from their medicines being degraded, reducing the medicine effectiveness or rendering it unsafe.

The interim manager told us, “Medicines cannot possibly be stored in people’s rooms. I’ve told the staff that. I’ve had a medication room built on the top floor. It is all ready and fitted with air conditioning. However, the maintenance man caused damage to the door and door frame when installing the digital lock, so I am now waiting for that to be fixed before we can use it.”

Each person had a medicine administration record (MAR). We reviewed the records for 3 people and found no gaps in the records, indicating people had received the medicines they required. A relative told us, “Staff give it (medicine) to [person] and [person] takes it alright.” Another relative said, “The staff have a schedule for giving [relative] their medication.”

We also saw that each person’s MAR had a dated photograph of them, together with information on any allergies they had and details of their GP. Where people were on ‘as and when’ medication, protocols were in place which recorded why this medicine may be needed and how often it could be given.