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 inadequate. At this assessment the rating has changed to 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.

At the last assessment the provider was in breach of regulations in relation to safe care and treatment, safe staffing and management of medicines. At this assessment the provider had made improvements and was no longer in breach of regulations.

This service scored 50 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Previous areas requiring improvement identified at the last assessment had been addressed in relation to the management of risks and learning from incidents.

Staff understood the importance of recording accidents and incidents and did so in a timely manner.

The manager completed regular audits on completed records to identify any further actions needed and to share lessons learnt with staff.

While the provider has made improvements in this area, we acknowledged significant concerns were previously identified in relation to the management of risk and learning from incidents. Further work is required to ensure these improvements are sustained and embedded into everyday practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Significant improvements had been made by the service regarding information stored about people. The provider had implemented an electronic care planning system to support these improvements.

Information recorded about people’s holistic care was detailed and daily monitoring records were reviewed by the manager each day to identify any concerns or gaps in recording. The manager then addressed this with staff at daily handover meetings.

The improvements made to records, ensured accurate, up to date information was available when people required support from external health care services.

While the provider has made improvements in this area, we acknowledged significant concerns were previously identified in relation to people’s care records. Further work is required to ensure these improvements are sustained and embedded into everyday practice.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The management team followed internal and external processes to keep people safe. Staff knew what action to take to ensure people were safe and protected from harm and abuse.

People and their relatives felt the service was safe. Comments included "I am very safe here, they [staff] look after me well." A relative told us, "I am confident [person name] is safe at The Rowans. [Person's name] is happy and had made friends with both residents and staff."

We checked whether the service was working within the principles of the Mental capacity Act, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with Deprivation of Liberty Safeguards (DoLS). This meant people’s rights were fully respected. The manager kept a record of DoLS applications and authorisations, and this was regularly reviewed to make sure authorisations were current.

While the provider has made improvements in this area, we acknowledged significant concerns were previously identified in relation to Safeguarding people. Further work is required to ensure these improvements are sustained and embedded into everyday practice.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Previous areas requiring improvement identified at the last assessment had been addressed and staff had access to up to date and accurate information regarding risks to people. All care plans and risk assessments for people had been fully reviewed and re-written.

The provider and manager had engaged with staff, relatives, advocates and health professionals to ensure that any potential risks to people were identified and action to manage and mitigate these.

This ensured staff had information to support people to remain safe at the service and received appropriate support in line with their health needs.

While the provider has made improvements in this area, we acknowledged significant concerns were previously identified in relation to the management of risk. Further work is required to ensure these improvements are sustained and embedded into everyday practice.

The provider detected and controlled potential risks in the care environment. They made 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. The management team followed these to ensure safety within the service.

Regular audits were completed around the environment. Fire drills were completed on a regular basis to ensure staff knew the correct procedure to follow in the event of a fire.

Where health and safety concerns were identified, the provider acted promptly to address these.

While the provider has made improvements in this area, we acknowledged significant concerns were previously identified in relation to the health and safety of the service. Further work is required to ensure these improvements are sustained and embedded into everyday practice.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff deployment required further improvements. During this assessment we observed people sat in communal areas for long periods of time with no staff presence.

People told us that they did not always feel like there was enough staff at the service. Comments included, "Sometimes I have to wait a while before they [staff] come, but they [staff] do always come and help me. There just needs to be more of them" and "They are always busy helping someone else."

We received mixed feedback from relatives regarding the staffing levels at the service. Comments included, "Yes, I feel there is enough staff, sometimes you have to go looking for them" and "There seems to be a reduced number of staff on a weekend."

Staff felt that improvements to staff shift allocation had supported them to respond to people in a more timely manner. The manager was aware that further improvements were needed around staff deployment at the service.

The manager implemented daily checks on call bell response times and following feedback received from relatives was ensuring management would be in the service 7 days a week.

The provider carried out appropriate recruitment checks, however key information to ensure staff were suitable to work with vulnerable adults was not always available. For example, staff full employment history was not recorded or explored, and some staff records only contained one reference.

The provider and manager were aware of further improvements required relating to staff recruitment, staff training and staff support, and this was recorded on the services action plan as an ongoing action to be addressed.

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.

Some relatives raised concerns regarding the cleanliness of their loved one’s bedrooms. One relative told us, "I had to ask staff to clean [person's name] room, it was filthy."

The manager was aware further improvements were needed and regularly held staff meetings with the domestic team to address concerns and improve the cleanliness of the service.

Regular infection control audits were now completed and where concerns were identified, action plans were completed and updated when work was completed. Staff received infection control training and used personal protective equipment appropriately.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Some areas requiring improvement identified at the last assessment had been addressed in relation to the management of medicines. However, we did identify some continuing recording issues on medicine administration records and records relating to 'as and when' required medicines.

The provider and manager completed monthly audits on a regular basis; however, the issues we found were in records which had not yet been audited.

The manager was aware that further improvements were required and was in the process of implementing an electronic medication administration record to support the safe management of medicines at the service.