The Rowans 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.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant people were protected by a positive and open approach to safeguarding. People had control over their lives and were supported by well trained, caring staff . People were fully involved, and the provider was open and transparent when things went wrong. Lessons were learned, shared and any improvements made.

This service scored 78 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Audits completed by the management team showed an exploration of any themes and trends, for example in relation to falls, weight loss and wounds.

This robust analysis of incidents had led to service improvement measures following adverse events. Detailed actions the service would take to reduce any identified risks or new potential risks for people were documented. Any lessons learned were reflected on, shared with staff both internally and externally, across the wider group of homes, to reduce the likelihood of reoccurrence.

We saw minutes from Lessons Learned Lab meetings. There was representation at these from all homes within the group. Risk issues such as nutrition and hydration, weight and falls were covered and the need for prompt and thorough record-keeping. One meeting covered safe storage of thickeners due to the potential high risk of choking if readily accessible by people.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We found the service worked collaboratively with external partners and professionals to ensure people had a safe admission to the service, or when people experienced a hospital admission.

Care plans were formulated for people following assessment and completed in more detail after admission, discussions and closer contact with the person and their relatives or representatives. Personalised care plans detailed clinical needs, medicines, past histories, risks, allergies, communication needs and contact details for people important to them. These were regularly reviewed and updated when a person’s needs changed.

A summary of this information accompanied people being admitted into hospital, whether this was a scheduled or emergency admission. This meant that clinical professionals were informed about people’s health conditions and could provide appropriate care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Ensuring people were safe and free from the risk of abuse was a priority at The Rowans Care Home. Everyone we spoke with told us they felt safe and well supported by staff. The provider shared concerns quickly and appropriately and reviewed outcomes and recommendations from partner agencies to improve care quality. Staff were supported and guided to follow policies and processes, putting these into practice to ensure people were protected from the risk of harm or abuse.

We observed people were supported in line with their risk assessments, for example we observed staff supporting people to eat and drink safely in line with their risk assessments and according to any professional guidance. Leaders told us safeguarding was included in induction, staff meetings and supervisions and training records confirmed all staff had completed safeguarding training relevant to their role.

We contacted a professional involved with The Rowans for feedback, who considered communication had improved in the service. Local authority quality officers were aware of lessons learnt throughout the safeguarding process, as the provider documented, mapped and shared these with staff. We received the following positive feedback, “The Rowans continue to engage well in the safeguarding process, raising safeguarding alerts in line with our local framework, and providing robust responses to concerns raised.”

The provider worked exceptionally well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People confirmed they felt involved in planning of their needs in relation to risks and keeping safe. The registered manager told us how risk assessments were designed in collaboration with people.

Risks were managed using the least restrictive practices to ensure people maintained their independence. The service used technology to its full advantage to help manage risk and reduce errors, including an electronic care planning system, electronic medication administration records (EMAR), PainChek, nurse call and acoustic monitoring.

This linked in with electronic devices and populated software systems, reducing duplication and freeing staff up to provide both personal and individual care for people

Acoustic monitoring involves using sound sensors to detect and analyse audio cues that may indicate a resident's need for assistance or potential safety issues. The system aims to provide non-intrusive monitoring especially during the night, allowing staff to respond quickly to potential emergencies and risk without disturbing residents' sleep. 

There were opportunities for residents to be more involved in their own care, if this was their wish. The registered manager told us how risk assessments were designed in collaboration with people and those important to them. The service supported people to effectively manage known risks. All areas of risks identified for people were clearly assessed and planned for. We found care plans contained best practice guidance for staff to follow, and staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The home management team and senior leaders ensured they actively listened to feedback or concerns from people and their relatives to improve care quality.

Records confirmed equipment safety, visual checks of the environment and reporting any concerns were completed.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The management team detected and controlled potential risks in the service. They made sure equipment, facilities and technology supported the delivery of safe care. The full-time maintenance person had recently left the home, but we received positive comments from people and their relatives about the speediness of repairs and checks done on the building; there had been no break in managing the safety of the environment. One person told us, “We had a very good handyman, but he isn’t here now. However, there is someone else who has stepped in. He is always checking doors, lights and he checks the fire alarm. If anything gets broken, it is fixed straight away.” Another commented how secure they considered the home to be and said, “My [relative] is safe here. The unit is small, with not many residents, so I know [person’s name] is getting watched carefully and is in safe hands. The security is excellent as on this unit the residents all tend to wander around and if they could get out of the doors they would. I have been here when I have heard the fire alarm being tested which is reassuring.”

The robust maintenance schedule, which ensured required environmental checks were all completed had been covered by other experienced maintenance staff employed by the provider. We saw there had been regular checks to ensure the home was safe in the event of a fire. People had Personal Emergency Evacuation Plans in place, specific to their identified needs. Records confirmed equipment safety and visual checks of the environment were completed routinely and any reported repairs were dealt with promptly.

The provider had ensured that the new build care home was modern and well-designed, in line with dementia-friendly guidance. There was lots of natural light and wide corridors, to help prioritise people’s safety, comfort, and ease of navigation. Each floor had multiple communal lounges and dining facilities with several smaller rooms, ideal for people with dementia, including a small lounge with sensory lighting. There were ample quieter spaces for people to spend time alone or with families and friends. The external grounds were paved and safe; we saw these being used on both days of our assessment.

The home contained safety features in line with guidance from the health and safety executive (HSE), to protect people living there. Windows were fitted with restrictors and Juliet balconies to the upper floors were fitted with glass balcony guards. Furniture was secured to walls to prevent any risk of this falling over and injuring people. Where people required specialist equipment, for example, falls sensors or air mattresses, these were in place and well maintained.

The kitchen was managed in a hygienic way to ensure people did not get food borne infections. The food standards agency had awarded the home 5 stars in 2024, this being top of the scale. This means food hygiene standards at the home are very good and fully comply with the law.

The provider made sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

We observed staff to use the skills and knowledge gained on induction, from dementia training workshops and coaching sessions when supporting people living with dementia; approaches to people were calm and help was offered in a kind and dignified manner. Staff were seen to de-escalate a situation quietly and confidently before this caused any distress for those involved. People were relaxed and comfortable and told us they felt safe. A relative told us, “My [family member] is safe here. The unit is small, with not many residents, so I know [family member] is watched carefully and is in safe hands.”

The provider had a robust recruitment process; applicants were invited to the home to attend an assessment day prior to being selected for interview. This allowed recruiters to see potential employees in a less formal setting, tackling team tasks and talking about something that was important to them. The provider used these sessions to select those with the right personal qualities and approach to proceed to the next stage of interview; it afforded senior leaders the opportunity to gain a better understanding of the skill set and compassion of potential employees.

We talked to 5 staff members who provided care; all were extremely complimentary about the recruitment journey. All staff had access to policies and procedures, had received suitable training for their role, and were within the homes’ compliance rate for mandatory training. Staff felt well trained and invested in. There was a trained dementia specialist in the service and face to face training with a bespoke dementia trainer had been sourced. Staff could reference ‘care champion’ leads for specific areas, such as oral hygiene, nutrition, wound care and dementia. Care champions promote best practices and act as a point of contact for other staff, providing information, signposting, and support. 

We spoke to 9 relatives and visitors. They had no qualms about the number of staff on duty in the households. People told us, “My [relative] is safe here. There are plenty of staff around all the time”; “‘There are always plenty of staff around; I can be alone in my room, but they will come past regularly and check I am ok” and “I have no concerns about staffing ratios. This is the third home my [relative] has been in and the number of staff on duty here at any time appears to be better than other homes.”

Robust and safe recruitment practices were in place to make sure that all staff, including any agency staff, were suitably experienced, competent and able to carry out their role.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Audits completed by the management team showed an exploration of any themes and trends, for example in relation to falls, weight loss and wounds.

This robust analysis of incidents had led to service improvement measures following adverse events. Detailed actions the service would take to reduce any identified risks or new potential risks for people were documented. Any lessons learned were reflected on, shared with staff both internally and externally, across the wider group of homes, to reduce the likelihood of reoccurrence.

We saw minutes from Lessons Learned Lab meetings. There was representation at these from all homes within the group. Risk issues such as nutrition and hydration, weight and falls were covered and the need for prompt and thorough record-keeping. One meeting covered safe storage of thickeners due to the potential high risk of choking if readily accessible by people.

The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff always involved people in planning, including when changes happened. People told us they received medicines on time, including appropriate pain relief. One person told us, “They tell me what my medication is for. I am given it every day and they watch me take it.”

Medicines were given, ordered and stored safely. Medication was recorded on an electronic system, and this was able to be documented in the daily log for each person on the Nourish system. The service had a backup plan in case of technology failure, and this was evidenced with copies of printed-out drug records stored in clinical rooms. Controlled Drugs and supplements were also stored and administered safely. Medication fridges across all the households had temperature checks completed and within set limits with no gaps in records. Locked boxes were used for drinks thickener, which contained information on the person the thickener was for and how to dispense. Medical gases, such as oxygen, were stored securely in appropriate places.

Various staff could administer medications, including registered nurses and care companions, all of whom undertook robust medication training and completed competencies with observations from senior staff. Not all care companions were trained, but training was offered to those who identified specific capabilities or those who aspired for personal development in this area.

No members of the households were able to self-administer medication at the time of our visit, and several required covert medications. Those who required covert medication had care plans in place to support this, linked to a mental capacity assessment and a best interest meeting with relatives, a GP, social care representative and staff at the care home. There were pharmacy instructions on how these medications could be given covertly, depending on the individual; these instructions were documented within electronic care plans that staff could see on handheld devices.