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 inadequate. At this assessment the rating has changed to 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.

At the last assessment the provider was in breach of regulations in relation to governance. 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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider and manager were fully aware of the improvements still required at the service and were working in a proactive way to address all areas that still required improving upon. The new governance system had been implemented and was supporting the service to improve.

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

The manager had applied to register with CQC and was passionate about creating a culture in line with the values of the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider had recruited a new manager to support the service with the shortfalls that were identified at the last assessment and improve the quality of the service. Whilst a lot of work had been completed to address some of the areas identified, there were still areas that required further time to make the required improvements. The provider and manager understood systems and processes required further time to be fully embedded to support them to monitor the overall quality of the service.

During this assessment we acknowledge that a large amount of work had been completed at the service to make improvements since the last assessment. However, we did identify some remaining concerns in relation to staff deployment, training, infection control practices, management of medication and record keeping.

The provider and manager also acknowledged the service was not quite where they wanted it to be but were confident and committed to making further improvements to the quality of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Everyone we spoke with as part of this assessment expressed significant improvements had been made at the service. People told us, "It is much better here now, the new manager is lovely and comes to see me all the time" and "I like the new manager, things are definitely improving, we are much more involved." Relatives comments included, "The new manager is more visible and approachable always saying hello when I visit. I would be happy to approach them, if I had any concerns" and "The manager and their team are amazing and have made a big difference, the staff are more relaxed and without a doubt the atmosphere in the home is better."

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

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.

Staff told us the service had improved greatly. One staff member told us "We [staff] all feel much more supported in our roles. There is a clear pathway now not too many spoons stirring the pot. We get more feedback from the management, and they are involved in the daily running of the service and it really helps us." Another staff member said, "There has been a lot of positive changes and it is making the home a better place. The new manager always offers to help and are consistently communicating improvements with staff. They are is always present in handovers and they will go through the days objectives and uses data to support us to do our job the way it should be done."

Discussions held with the manager during the assessment provided evidence that further improvements were planned to improve staff confidence and skills. This was also recorded on the service overall action plan.

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

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider and manager were open and transparent throughout the assessment. Systems and processes were in place to support the service on their improvement journey.

Audits monitored the quality of the service and action plans were created from these audits. However, actions recorded did not always contain sufficient detail on how these would be addressed and evidence this would be completed in an appropriate timeframe.

We fed this back to the provider who stated they would add to this and provide further information.

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.

The manager routinely worked with visiting health professionals to ensure people received the right support. Information of concern regarding service delivery had been shared with the local authority and improvement plans were in place to ensure required improvements were recorded, monitored and actioned.

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

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Whilst the main focus at the service was making the improvements to the areas identified at the last assessment, the manager was also researching and looking at innovative ways to further improve the service. An air conditioning unit had recently been installed and future plans included the new electronic medication system and the implementation of a new state-of-the-art technology to support in falls prevention.

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