The Rowans 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. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance.

This service scored 36 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Our observations confirmed that staff were task focused, and the culture of the service was not always positive for all people. The provider was aware of the shortfalls at the service and had recently implemented a new governance system to support the required improvements. However, a lack of understanding from the management team showed the new governance system was ineffective and did not identify the concerns found at this inspection.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The registered manager lacked understanding of their role and the importance of quality monitoring at the service. Where concerns were raised or identified, appropriate, timely action was not taken to address issues and prevent reoccurrences. The registered manager was open and honest during the inspection and was a visible presence at the service. However, some people and their relatives were unclear who managed the service and often referred to the administrator of the service as the manager.

People did not always feel they could speak up and that their voice would be heard. People and their relatives felt they could approach the registered manager with any concerns. However, they were not confident to do so. One relative told us, “Sometimes frightened to rock the boat as [person's name] will suffer.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt able to raise concerns, however they did not always feel their concerns were listened to. They described a culture that was them [management] and us [staff]. One staff member said, "Tensions in the home with the staff are very high, and that has come from the top from the manager."

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate. Governance systems had not identified serious shortfalls and failure within the service found during this assessment. Overall, the service had not been able to sustain their compliance levels since the last inspection, resulting in multiple breaches of the regulations being identified. The registered manager told us about new governance systems that the provider had implemented in January 2025 to improve the oversight at the service. We reviewed quality assurance records for February 2025 and found that where audits had been completed, they were not fully completed nor did they contain any actions for improvements where concerns were identified. The widespread issues we identified during this assessment had not been identified by the providers own governance processes. This lack of effective governance systems in place at the service placed people at risk of harm. The lack of oversight required from the provider and management team resulted in people not having their basic care needs met.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The service failed to address actions and improvements identified by partner organisation. For example, a stakeholder had reviewed the management of medicines at the service. The actions identified during this review remained at the time of our assessment.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. There was a lack of systems in place to ensure continuous learning and improve the care people received. The provider's own quality assurance was ineffective and had failed to identify shortfalls found at this assessment. Audits that were completed had not identified common trends; or reflect required improvements. Where issues were identified within audits, no action had been taken to reduce the risks to people's wellbeing.