Rowanbrook 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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We received mixed feedback from people and their relatives about the safety and learning culture at the service. For example, 2 relatives told us their loved ones had both experienced falls but described differences in the communication around any learning from these incidents. One relative said, “[Relative] had a couple of falls. They were managed well. I feel they communicated well.”. However, the other relative said, “I don’t know what they have done since to prevent it happening again, but it hasn’t.”

Staff also gave mixed feedback around the safety and learning culture at the service. Comments from staff included, “Can escalate concerns, speak to nurse first or a senior.”, “Can go to management or senior staff if something happens. Mostly investigated [but] not all the time.” and“When accidents and incidents occur, it is not escalated appropriately. Instead of pullingemergency cord when [person] fell in shower, the carer went to another floor to call staff.” This meant staff were not always confident lessons would be learned from safety events.

The systems in place to manage safety incidents in a consistent and effective manner were not always effective. Not all incidents recorded in people’s care records, were formally reported as incidents which meant incidents at the service were not consistently reported, investigated and managed to prevent recurrence and identify learning.

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

A system had been recently introduced to review and analyse safety incidents. However, this was not yet embedded or used regularly to facilitate effective monitoring of people’s safety. For example, 1 person’s care records showed they had displayed behaviours that challenged, including aggression, for a period of at least 6 weeks. However, no formal analysis of these behaviours over that period of time had been completed to identify potential triggers, themes and learning in order to improve safety.

Staff gave mixed feedback about the information made available to them when new people were admitted to the service. For example, 1 staff member said, “Paperwork comes through and [I] can access that.” Another staff member said, “Don't get much information about people when they move into the home. We have to ask questions. Information is not handed to all staff.”

However, care records showed assessments were completed before people were admitted to the service. These assessments identified people’s basic safety needs. The registered manager told us how they tried to ensure the mix of people on each floor of the home was safe by looking at how people would interact with each other. This included identifying people’s behaviours and personalities prior to and following admission.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

People and their relatives gave mixed feedback about safety. For example, 1 person told us they did not always feel safe as they had experienced some staff being unkind. They said, “I used to feel safe here, but I don’t now.” Another person told us they always felt safe. They said, “I don’t fall out with any of them. I don’t think I am safe here, I know I am safe here. They are all good to me.” Feedback from relatives was also mixed. Comments from relatives included, “[Relative’s] safe and she is clean and well looked after” and, “Overall I think he’s safe but it needs to improve.”

Care records for 1 person described a safeguarding incident that had not been recognised or reported as potential abuse by staff. This incident had caused the person distress and care records did not show any action had been taken to prevent recurrence. This had led to the person being exposed to the same risk of abuse again without appropriate action being taken to mitigate this risk. Following our inspection, the registered manager evidenced this safeguarding incident had been discussed with the local authority safeguarding team, however this discussion took place 4 months after the initial incident occurred. This showed a delay in reporting safeguarding concerns.

However, staff had completed safeguarding training and staff we spoke with were able to describe potential signs of abuse and how they would escalate this. One staff member said, “If someone being abused would report it to a senior. If feel like they’re not doing anything then [I would] go to [registered manager]. If feel like [registered manager] not doing anything, I’d have to find way to escalate it.”People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found no concerns and Deprivation of Liberty Safeguards (DoLS) were in place for people when needed.

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

Information to guide staff in how to consistently and effectively manage risks associated with behaviours that challenged, including verbal and physical aggression was not always available. For example, 3 people’s care records contained generic information guiding staff to reassure and redirect these people in the event of aggression. However, no personalised information was available to show how each of these 3 people should be reassured and redirected. Staff we spoke with about these 3 people’s needs gave us inconsistent information about how they would respond to any incidents involving aggression. This meant people were at risk of harm from inconsistent and ineffective care.

However, people told us they felt they were supported by staff to manage their risks, and they raised no concerns with regards to this. Comments included, “They hoist me out of bed. There’s always 2 staff, I do feel safe in the hoist.” and “I’ve had a shower today. I sit on a chair in case I fall and they wash me. I’m safe in there.” Relatives also felt risks were managed. One relative said, “[Relative] has both a walking frame and a stick to help her with her balance when walking around the home.”

Care records showed risks associated with people’s physical health were appropriately assessed and planned for. This included risks associated with Epilepsy, Diabetes and damage to skin.

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

On multiple occasions during our site visits, we identified some areas of the home that contained hazards to people were accessible, placing people at risk of harm. This included a sluice room and a storage area that contained personal protective equipment. Although, we saw no one accessing these areas, we could not be assured people would not be exposed to the hazards within these areas as they were not always locked.

People who required specialist mattresses to manage their risk of skin deterioration were at risk of receiving unsafe care. Care plans directed staff to check mattress settings were appropriate. However, mattress settings were not always recorded and staff were not always able to tell us how they checked these mattresses were safe to use.

Despite this, people and their relatives told us they had no concerns about the safety of the environment. One relative said, “Environment is safe and clean.”

There were systems in place to ensure the building was adequately maintained and an up-to-date fire risk assessment was in place.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support and development.

Relatives told us they felt there were enough staff at the service. One relative said, “There’s enough staff, there is always someone about. I used to get phone calls all the time from the last place about [relative’s] behaviour. I’ve had none here. I can go home and lay my head on my pillow and know she is safe.” Another relative said, “There’s more staff here than the last place, they get more attention here.” However, some people described the care as rushed at times. For example, 1 person said, “I don’t think there’s enough staff. They just don’t have enough time for us. Sometimes they have to rush getting us washed. Not all of the time though.”

Most staff told us staffing numbers were appropriate for the number of people using the service. Our observations showed staff were visible and available to support people when they needed support. For example, call bells were consistently answered promptly and staff responded very promptly to emergencies.

A dependency tool was used to identify the numbers of staff required to keep people safe. The registered manager told us they staffed the service higher than the tool recommended to ensure there were always enough staff available to support people.

Records showed staff were recruited safely and they received training that provided them with the skills required for their roles. Staff confirmed they completed training. One staff member said, “Training was good, [I] was pleased with the training.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People told us the service was clean and well maintained. One person said, “My room is cosy and clean.” Staff told us and we saw Personal Protective Equipment (PPE) such as gloves and aprons were available and used. One staff member said, “We have enough PPE.”

Infection prevention and control (IPC) audits were completed to identify, monitor and act on any IPC risks. Care records showed suspected infections were reported to health care professionals as required.

The provider did not always make sure that medicines were managed safely.

We found the records of the numbers of medicines at the service did not always match the actual numbers of medicines at the service. This meant we could not always be assured people had received their medicines as prescribed.

However, people told us they were supported to access their medicines when they required them. Medicines were stored safely, this included medicines that were temperature sensitive and controlled medicines that required additional safety storage and monitoring. People who required medicines to be administered on an ‘as required’ basis had plans in place detailing how and when these medicines should be administered.