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Inspection carried out on 3 May 2018

During a routine inspection

The inspection took place on 3 and 8 May 2018 and was unannounced.

Rowan Lodge is a care home service with nursing. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided. Both were looked at during this inspection.

Rowan Lodge is registered to provide accommodation and support to 60 people across three floors. The home had a large garden with tables and chairs, which was regularly used by people. At the time of the inspection there were 47 people living at the home.

The service was last inspected on 25 and 30 August 2016 when it was rated overall as 'Requires improvement'. This was because although improvements had been made to staff training, people and their families were more involved in care planning, action had been taken to ensure consent to care and treatment was gained lawfully and quality assurance systems had been improved, not enough time had passed for these changes to be fully embedded into staff’s practice. At this inspection, we found the provider had made the necessary improvements to achieve a rating of overall ‘Good’.

The service had a registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

There were systems in place to protect people from avoidable harm and abuse. Staff had received safeguarding training and were knowledgeable about actions to take if they suspected abuse. Sufficient numbers of staff were deployed to meet people’s needs and keep them safe.

There were safe recruitment processes in place to make sure the provider only employed workers who were suitable to work in a care setting. Medicines were stored, recorded and administered safely.

People received care from staff who had appropriate knowledge and skills. Staff were given regular supervision and training to help develop their knowledge.

Staff were aware of the legal protections in place to protect people who lacked mental capacity to make decisions about their care and support.

People were supported to eat and drink enough to maintain a balanced diet. Snacks and drinks were available to people at all times. People were supported to access care from relevant healthcare professionals.

Staff had caring relationships with the people they supported and knew them well. Staff encouraged people to communicate their needs and promoted their privacy, dignity and independence.

Care plans reflected care and support that people required and were written in partnership with people and their families.

The provider had processes in place for investigating and responding to complaints and concerns.

The provider had plans in place for delivering end of life care for people. Staff had undertaken end of life care training and an end of life register was used to assist staff in monitoring people if they were in need of end of life care.

Systems were in place for monitoring efficiency and quality within the service so that improvements could be made. These needed to be developed to reflect all actions taken to improve the service.

The provider worked in partnership with healthcare professionals to drive improvements in the service.

Inspection carried out on 25 August 2016

During a routine inspection

Rowan Lodge is a nursing home for up to 60 older people. When we visited there were 48 people living in the home, including people living with dementia. The home is a purpose built nursing home over three floors.

The inspection took place on 25 and 30 August 2016 and was unannounced. This was a comprehensive inspection that was carried out to check on the provider's progress in meeting the requirements made following our inspection on 24, 25 and 30 November 2015 which resulted in the home being rated Inadequate. As a consequence of this judgement the home was placed in special measures and we took enforcement action in response to this failure to meet the required standards. The provider sent us a monthly update of progress made against their action plan.

The previous inspection on 24, 25 and 30 November 2015 identified seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider had action taken to address the concerns we had identified. Sufficient improvement had been made for the provider to meet the requirements of all seven previously breached regulations. More time is required for the provider to complete their action plan and test out the robustness of the improvements and systems in place to ensure it will be able to continue to provide an improved service when new people are admitted. The provider would need to sustain the improvements made before people could always be confident that they would receive a high standard of quality individualised care that always met their needs and ensured their safety. Following this inspection the service has not been rated as inadequate for any of the five key questions and has therefore been taken out of special measures.

Rowan Lodge did not have a registered manager in post on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had made changes to the management of the home following our previous inspection in November 2015 and the current manager had been in post since July 2016. They had started their application to be registered with the Care Quality Commission to ensure the provider would meet their registration requirement to have a registered manager in place. The provider had also employed an operations manager and a service manager to support the manager with the day to day running of the home and to monitor the quality of care delivered to ensure regulatory requirements would be met.

People, their relatives and staff told us the changes in the management team had been unsettling but they were seeing improvements in the service people received and needed some time to build a relationship with the new manager. We found the new management team had a good understanding of the home’s improvement plan and implemented the principles of good quality assurance to drive improvements. The provider had reviewed the home’s quality assurance systems and additional checks had been put in place to support the manager and staff to continually evaluate the quality and risks in the service. We found these systems had been effective in improving for example, the management of medicines, staff training and supervision and staffing allocation in the home. Sometime was needed to ensure these systems would be implemented consistently to sustain improvements made in the home.

At our previous inspection in November 2015 we found people did not always receive the appropriate care and support they required to keep them safe. At this inspection we found people's risks to their health and safety had been identified and arrangements had been put in place to keep people safe. Staff understood pe

Inspection carried out on 24, 25 and 30 November 2015

During a routine inspection

We carried out an unannounced comprehensive inspection of Rowan Lodge on 24, 25 and 30 November 2015.

Rowan Lodge is a nursing home for up to 60 older people. When we visited there were 55 people using the service, including people living with dementia. The service is a purpose built nursing home over three floors.

We inspected the service following concerns received about the safety and welfare of people. We found the registered provider had failed to meet the required legal standards of care and welfare for people who used the service.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service is required by a condition of its registration to have a registered manager.

At the time of our visit a full and effective governance system to monitor the quality of the service and identify the risks to the health and safety of people was not in place. A programme of audits had not been completed and the registered manager had not identified all the areas of concern we had found. Sufficient action had not been taken to improve the quality of care and treatment and ensure the safety of people. The registered manager lacked clarity in their overall responsibility to meet and sustain all the legal requirements of a registered person to ensure the safety and welfare of people.

We found safety concerns in relation to the management of medicines. People had not always received their medicines as prescribed and medicines were not always available when people needed them. The risks of people not receiving their medicines had not always been identified. Systems were not in place to ensure medicine errors would be reported and investigated to prevent them from re-occurring.

When people fell their care plans had not always been reviewed to ensure they reflected the support people required to safely move about in the service. Falls policies did not provide staff with clear guidance on the routine checks they needed to complete to identify and act on any post fall complications.

The rights of people who could not consent to their care and treatment or a deprivation of their liberty were not protected. Decisions about people’s care had not been guided by the principles of the Mental Capacity Act 2005 (MCA) when supporting people who lacked capacity. The provider did not meet the requirements of the Deprivation of Liberty (DoLS) safeguards.

People, their relatives and staff gave us mixed views when we asked if they felt sufficient numbers of staff with the necessary skills were deployed to care for people. From our observations there seemed to have been sufficient staff numbers. However, keeping people safe at the current staffing level was not clearly assessed against people’s individual support needs or risks. The skills and knowledge required by staff to meet people’s needs were not considered in determining the staffing skill mix for each shift. In the absence of an evidence based staffing tool we could not be sure sufficient staff was always deployed to meet people’s needs.

Staff had not always received the required training and regular supervision to enable them to always meet people’s needs. We could not be sure that all staff would be able to identify signs of abuse or understood their responsibilities under the MCA. Temporary nurses who worked at the service regularly, had not received a thorough induction into the service. Nursing protocols were not always available to nurses to ensure they provided care and treatment in line with current good practice guidance.

The required pre-employment information relating to care workers employed at the home had not always been obtained when care workers were recruited to evidence safe recruitment practices had been followed.

People’s care records were not always up to date, accurate or sufficiently comprehensive to ensure staff would have all the information they required to meet people needs, wishes and preferences.

Complaints had been investigated but people could not be assured that action taken in response to their concerns would lead to sustained improvements in the care they received and the service as a whole.

People were supported to stay healthy and the service worked closely with the local GP surgery and other health professionals. We made a recommendation to support the provider to further develop an effective food and drink strategy that addresses the nutritional needs of people using the service.

The provider told us that they had become aware of concerns and shortfalls in the service. They had appointed a new Operations Manager to oversee the quality assurance of the service. She told us she would be completing an assessment of the service as a matter of urgency. The provider has also voluntarily made the decision not to admit people to the service until the required improvements had been made and sustained.

We found seven breaches of the Health and Social Care Act 2008 (Regulations) 2014. You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures

Inspection carried out on 22 May 2014

During a routine inspection

The inspection team consisted of two adult social care CQC inspectors. On the day of our inspection 57 people used the service. We spoke with seven people who use the service and two people�s relatives, five care workers and one nurse, ancillary staff including the chef and activities coordinator, head of care for the service, the registered manager and operations director.

We observed how staff supported people, and looked at documents including care plans and management reports. People were cared for in units over three floors. This ensured they were provided with care appropriate to their needs, such as nursing or dementia care.

Information of concern had been brought to our attention regarding staffing levels and appropriate nutritional support for people. We considered these concerns as part of our inspection. We considered all the evidence we had gathered under the outcomes we inspected, and used this information to answer the five questions we always ask;

� Is the service caring?

� Is the service responsive?

� Is the service safe?

� Is the service effective?

� Is the service well led?

This is a summary of what we found.

Is the service caring?

We observed staff supported people with patience, respect and care. They treated people with dignity and promoted their independence. People and staff laughed together. One person who uses the service told us �I couldn�t have a better life. They [the staff] take very good care of me and my family don�t have to worry about me�.

Staff told us they treated people as members of their family, and enjoyed coming to work to spend time with them. The activities coordinator told us �The senior staff here live and breathe Rowan Lodge. They treat the residents like they are relatives. It�s a pleasure to be part of something so positive and that improves people�s lives�. The chef commented �The people here are like my family and it is a great pleasure for me to prepare food for them and see them enjoy it�.

Care plans reflected people�s needs and preferences. We saw staff followed guidance to ensure people were supported as they wished. They encouraged people to make choices, for example about meals, clothing and activities, and listened to their responses.

Is the service responsive?

The service responded promptly to ensure people were supported appropriately. People and their relatives were involved in setting up their plan of care, and reviewing this to ensure it remained up to date. Staff ensured care was provided as people wished. One person said �The staff here are very polite and couldn�t be more helpful. They always knock on the door and check that I�m alright�.

We saw people had access to a wide range of activities, held in the home and local community. People were supported and encouraged to attend. The local community was invited into the service for coffee mornings, and the minister from the local church held services on site for those unable to attend their church.

As people�s needs changed we saw care plans were updated to reflect the additional care required, for example to support people with reduced mobility or to address nutritional concerns. The provider�s complaints policy provided a formal opportunity for people to raise concerns. A relative explained how the manager had quickly addressed a concern they had. They said �The management is responsive because they certainly wasted no time getting to the bottom of what happened and dealing with it�.

Is the service safe?

We saw people were relaxed, and appeared to enjoy the company of staff. This indicated to us that people felt safe with staff. A relative of someone who uses the service said �We have no issues with X�s care so far. We have absolute confidence in their [the staff] commitment to looking after X and keeping them safe�. Another relative told us �In general X feels safe and is very well and happy here. Sometimes they get a bit anxious but the staff are all lovely and they take good care of them�.

Risks were identified, and actions put in place to reduce the risk of harm to people and others who use the service. For example, staff were trained to support people safely if they needed assistance to mobilise. Appropriate checks and equipment were in place to reduce the risk of pressure sores for those identified at risk of developing them. People�s needs were regularly assessed to ensure changes were identified promptly. This meant the service was aware of appropriate actions to take to maintain people�s health and wellbeing.

At the time of our inspection there were sufficient staff on duty to support people safely. The registered manager explained how they identified people�s support needs, and planned staffing numbers to support this. We saw a rota for May 2014 that appeared to indicate staffing levels were sufficient to meet people�s needs. Additional staff were sought through an agency to cover identified staffing gaps.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS). This applies to services such as Rowan Lodge. The registered manager was aware of the appropriate actions to complete to assess the need to apply for DOLS, and we saw applications were made in accordance with the local authority procedure.

Is the service effective?

The service sought feedback from people, their relatives and staff. Regular meetings and comments books provided opportunities for raising concerns and sharing information.

Care plans detailed people�s care needs and wishes. There were reviews and audits in place to ensure changes in people�s care needs were identified and responded to appropriately. People�s nutritional requirements were understood, and appetites and health conditions were monitored to ensure people received sufficient food and drink to maintain their health. The chef explained �I respond to information from the doctor and nurses about people�s weight. I can suggest and provide low fat options or fortified drinks and meals�.

Staff received training to ensure they could safely support people. One person told us �The staff all know what they are doing and they look after me well�. A care worker told us �They take training very seriously here. It�s definitely the best of any company I�ve worked for�.

We saw staff performance was monitored and supported through supervision, appraisal and practical assessment. New staff attended a thorough induction programme that included formal training and shadowing of experienced care workers. They had the opportunity to request additional training or shadowing before they worked alone. Staff were encouraged to develop their skills through additional training, such as attaining the Health and Social Care diploma.

Is the service well led?

We observed the registered manager operated an �open door� policy. People, visitors and staff readily sought guidance and support from the manager. A relative told us �We have a good relationship with the manager and trust them. That makes the situation much less stressful knowing that X is in good hands�.

One care worker told us �The care here is brilliant and the management are efficient. They have done everything they said they would to support me�. Another care worker said �I just love working here. The staff work well as a team. The priority is the residents, and that�s how it should be�.

We saw checks and audits were in place to provide assurance that the service operated effectively. For example, staff training was monitored to ensure training was refreshed in accordance with the provider�s policy. Fire alarms and water temperatures were checked weekly, and accidents and incidents were monitored to identify any trends. Care needs and risks were assessed to ensure people were supported safely. Action was taken to implement changes to reduce the risk of potential harm.

Inspection carried out on 4 March 2014

During an inspection to make sure that the improvements required had been made

We last inspected Rowan Lodge in November 2013. We found the provider was not meeting two of the essential standards of quality and safety. On the 4 March 2014 we undertook a further inspection of Rowan Lodge. We reviewed seven care plans and spoke with five members of staff.

We found people were asked for their consent before care and treatment was provided. Consent forms were completed and signed in all of the care plans we reviewed. The provider had ensured that mental capacity assessments were completed for people living in the home. However, we noted that the assessments were not always related to specific decisions. We also found that best interest decisions and meetings were not always recorded appropriately.

We reviewed the care plans and found these were accurate and fit for purpose. We noted that support plans were complete and people�s personal history, like and dislikes were recorded. End of life wishes and preferences and �Do not attempt resuscitation� forms had also been added to people�s care plans following our last inspection.

Inspection carried out on 6 November 2013

During a routine inspection

At the time of our inspection the provider did not have a registered manager in post. We spoke with the manager who was currently in the process of registering with the Care Quality Commission. They explained that there was a delay in their registered manager application because their Disclosure and Baring Service check had expired. We advised the manager and provider that they needed to take immediate steps to ensure that the registered manager application was processed as a matter of urgency, to avoid legal action.

People were asked for their consent before any care and treatment was provided. However, we found that consent to care and treatment forms were not found in any of the care plans we reviewed. Staff were also unaware of their responsibilities in relation to the Mental Capacity Act and determining people�s capacity to make decision.

People�s care was assessed and planned in line with their wishes. People received good care from kind and caring staff. One person said "the care is excellent and the care staff are so kind to me�.

We found people were protected from the risk of abuse because staff understood their responsibilities to identify and report abuse. Staff had also received appropriate training. Rowan Lodge had reported several safeguarding concerns to the Care Quality Commission and the local authority in the previous six months. These were all investigated appropriately.

There were enough qualified, skilled and experienced staff. We reviewed the rota�s for the previous month and found appropriate staffing levels on each shift.

People�s views and feedback were sought on a regular basis. Staff were able to tell us about concerns and issues raised by people and how they resolved these. There were suitable systems in place to monitor the health, welfare and safety of people.

Records were not always accurate and fit for purpose. We found care plans which were not completed in full and that information was not always recorded consistently.

Inspection carried out on 19 December 2012

During a routine inspection

We spoke with three people who lived in Rowan Lodge and some of their family members. They told us that they were happy and well looked after. People told us that they or their representatives were involved in planning their care. One person said �you can do what you like, no restrictions�. They also said �the food is good and there is lots of it, when ever you want!� They told us they got the support they needed and were happy to ask if they wanted anything else. Another person said that the food was good but �a bit unadventurous�; they also said they had no real complaints.

Medicines were ordered, kept and administered safely. Nursing staff had recently been nominated as clinical leads for specialist areas such as catheter care and syringe drivers. This meant that there was experienced support for people requiring specialist care and also for other less experienced members of staff.

We spoke with six staff including the management team. They all told us they felt supported. They told us the training was good, although one person did say they felt it could be more challenging. There was an open door policy and staff felt that any issue raised would be dealt with accordingly.

There was an effective complaints policy. We followed a complaint through and saw that it had been fully investigated and actions had been taken to improve the service as a result.