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. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s Safe Care and Treatment, Staffing, Safeguarding and Management of medicines.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Accidents and incidents were not always recorded and opportunities to learn lessons and prevent similar incidents from happening again, were missed. For example, we found evidence of incidents reported to CQC that were not recorded within auditing records.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Care plans, risk assessments, daily records and monitoring charts did not always reflect the care people received, and they did not always serve to effectively monitor people's health and wellbeing. This meant any information provided to health care partners was at risk of not been accurate.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately. The provider failed to ensure risks to people were managed effectively. Risk assessments in place did not contain information on how to mitigate risks or identify any control measures to keep people safe. During the assessment we made 4 safeguarding referrals to the local safeguarding team. These referrals were in relation to the safe management of medicines and people’s care requirements. Systems and processes in place to support the provider to identify concerns at the service had not been completed. A number of staff had not completed up to date safeguarding training.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider did not assess and manage risks relating to people's specific needs and health conditions. People were exposed to risks as the provider did not always ensure risk assessments completed for people contained detailed information or provide sufficient information on how to manage risks.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The provider had systems and processes in place to manage the safety of the service. However, these were not always followed by the management team.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. The provider failed to deploy enough staff to provide people with the care and support they needed. Staff told us they did not feel staff levels were adequate to meet people's basic care needs. Comments included, "There is not enough of us. Not everyone has had personal care yet this morning", "The staffing is very poor" and "We can't bath them, there isn't enough staff." The registered manager told us they did not feel the tools used to support safe staffing levels at the service was adequate, however no action had been taken to address this. Staff were not always effectively supported within their role. Gaps in mandatory training in relation to fire safety, safeguarding and health and safety were identified at this assessment. People and their relatives felt there was enough staff at the service.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. PPE was available around the service for staff to use. However, clinical waste bins were minimal and staff had to walk through the service to the nearest sluice room to dispose of incontinence aids.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. Processes in place for monitoring the safe management of medicines was not followed. People did not always receive their medicines as prescribed. For example, people who were prescribed 'as and when' required medicines were given these on a regular basis, without any consultation from a health professional. Records to support the safe administration of medicines were not completed correctly by staff. Some staff responsible for administering medication had not had their competency checked in over a year. Processes were not always robust for supporting people that required controlled drugs in line with the providers policy.