Rowanbrook Care Home

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. This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (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 shared vision, strategy and culture. However, this was not always followed which led to some shortfalls in care.

The culture of the service was not always person-centred, open, inclusive and empowering. Although the provider had set organisational aims and objectives, leaders did not always model or uphold them in practice. For example, the provider described their care as being ‘always centred around the individual’. However, as documented in other sections of our report, we found this was not always the case.

In addition, the service did not follow the statutory guidance ‘Right support, right care, right culture’. This meant the service wasn’t planned in a manner that considered and met the needs of people with learning disabilities.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always lead effectively.

People and their relatives gave mixed feedback about the leadership at the service. For example, 1 relative said, “Leadership isn’t good. It needs more attention to detail. I’ve only ever seen [registered manager] up here twice in 14 months and that is only to speak to staff.” However, another relative said, “The management is good. [Deputy manager] is very approachable. I thought she was the manager. [Deputy manager] is very approachable.”

The registered manager did not respond effectively to the feedback we provided following the first day of our inspection. This meant there was a missed opportunity to drive improvements in people’s care and experiences in a timely manner.

However, most staff described the management team as approachable, and we saw staff actively approach the deputy manager seeking advice and support on the second day of our inspection. One staff member said, “I love working here. Management are welcoming and supportive with everything.”. Another staff member said, “Management are approachable.”

People did not always feel they could speak up and that their voice would be heard.

Some people and their relatives told us they felt unable to speak up about the care. For example, 1 relative told us, “I haven’t spoken to the manager because I don’t want it to look as if I’m complaining as they may take it out on my [relative].”

Some staff also described feeling they could not always confidently speak out about care concerns. For example, a staff member told us they were aware of the whistleblowing policy but felt they couldn’t always speak up. They said, “I feel like I can speak up to a degree but not completely.”

Minutes of a staff meeting in February 2026 suggested staff had been advised not to contact CQC to share care concerns. These minutes stated, ‘Please discuss issues with your line manager or managers or company HR instead of submitting allegations to the CQC’. This indicated a closed culture was at risk of developing at the service. When we fed this back to the leadership team, the registered manager denied stating this and suggested the minutes may be inaccurate.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff told us they felt all staff were treated fairly and we saw the diverse staff group interacted positively with each other. Staff completed training in equality, diversity and inclusion.

The provider did not always operate effective governance systems.

Governance systems were not always effective in identifying and addressing safety and quality concerns. Although care plan audits had identified areas for improvement and these areas had been improved, they had not identified people’s positive behaviour support plans were not person centred or specialist mattress settings were not recorded. Medicines audits, completed by staff at the service, had not identified the stock inaccuracies we identified during our inspection, and environmental audits had not identified hazardous areas were unlocked at times.

Quality observations had been completed on 3 occasions in 2025 where positive and negative interactions between staff and people were identified. However, the action required section of these assessments were left blank, therefore we could not be assured action had been taken to address the negative interactions.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Partner agencies, including the Local Authority and Integrated Care Board, told us staff at the service engaged positively with them.

Care records showed staff at the service engaged positively with visiting health and social care professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

Effective systems were not in place to ensure consistent learning from all incidents that occurred. This meant there were some missed opportunities to learn from incidents and improve people’s care experiences.