Rowan Garth 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 requires improvement. 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 provider was in breach of the legal regulation, good 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 long-term strategy for ensuring service delivery and operational practices reflected the mission and values of the service at all times. They did not understand the challenges and the needs of people and their communities which impacted on quality and safety.

Provider oversight of the service was poor. The provider did not have robust governance systems in place to underpin a clear shared vision, strategy or culture. The management of the service did not demonstrate a consistent and proactive responsibility for ensuring the quality and safety of the service met regulatory standards. There was also an inconsistent safety culture with regards to care and treatment which meant the provider could not be assured people’s care was safe and appropriate.

The provider had put a service improvement plan in place in December 2024. This action plan identified improvements with care plans, medicines, environment, staffing and governance were required. At the time of our assessment 7 months later, no effective action had been taken to complete the required improvements. Inspectors found serious concerns in all of the areas identified by the provider in December 2024. It was clear the provider did not have an effective strategy in place to deliver the necessary improvements.

During our assessment, the management team operated a transparent culture around the shortfalls in the service and acknowledged improvements needed to be made.

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.

At the time our assessment, a new senior management team had been in place for approximately 7 months. During this time, some of the concerns identified during assessment had already been identified by the senior management team, however little effective action had been taken to drive up improvements.

During discussions with the senior management team, the registered manager and unit managers, they failed to demonstrate a clear understanding of people’s needs, care and the context in which care was delivered. They did not demonstrate they fully understood the potential risks associated with the shortfalls in service delivery and did not demonstrate a proactive approach to addressing them in a timely manner.

People and staff told us unit managers were approachable, friendly and easy to talk to. People felt staff treated them kindly and with compassion.

People living in the home felt they could speak up and that their voice would be heard. The voices of staff however were not always listened to or acted upon.

There was little evidence the provider promoted a positive safety culture where lessons were learned, and improvements made. In the provider’s 2024 staff survey an area for improvement was “Improve communication and listen to employees”. At the time of our assessment the provider 2025 staff survey was still in progress. A small number of returned surveys indicated some improvements had been made in this area. However other elements of staff feedback had not been responded to appropriately. For example, the 2024 survey indicated staff had spoken up about poor staffing levels and retention. During the assessment, this remained a concern and there was little evidence any robust action had been taken to listen to staff in this area.

People’s felt able to speak up about any concerns and felt they would be listened to.

Staff told us unit managers were approachable if they had any concerns.

There were appropriate whistleblowing and safeguarding policies and procedures in place to guide and reassure staff on how to speak up.

The provider valued diversity in their workforce but did not always promote an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff told us they felt valued by the provider and fairly treated. Equality and diversity was reflected in the workforce. The provider had policies and procedures in place to promote workforce equality, diversity and inclusion. This included ensuring staff with protected characteristics under the Equality Act 2010 had equal opportunity and equity in their working life.

The systems in place to create an inclusive workforce however were not fully utilised. Staff meetings were not always completed regularly to foster a sense of belonging. Supervision and staff development systems were not maximised to ensure staff were able to meet their full potential with equal opportunities for further training and development.

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.

The senior management team, the registered manager and unit managers were aware of their roles and responsibilities. However, they were not always able to demonstrate an understanding of good quality care, best practice or good governance. The senior management team did not demonstrate they had effective oversight of the service or adequate systems of accountability.

The provider’s governance processes were not used effectively to mitigate risk and drive up improvements in the quality and safety of the service. There was a lack of managerial and clinical oversight of people’s care including nursing care and medicines. People’s care records contained gaps and anomalies that had not been explored to ensure people’s care and treatment was safe. Processes were not sufficiently robust to detect the missing and/or contradictory information we identified in care records or to ensure people’s care was person centred.

Staffing levels were not always sufficient to ensure people’s needs were met and staff had the capacity to deliver person centred care. Record keeping was not contemporaneous and records in relation to the people’s daily care were often duplicated which made it difficult to read and understand. The governance systems in place failed to take any action with regards to these shortfalls.

Processes were not effective in identifying or addressing ongoing serious concerns with the management of medicines, environmental concerns or ensuring the Mental Capacity Act legislation was followed appropriately at all times.

The provider’s quality and safety audits showed a repetitive cycle of shortfalls from one month to the next indicating the action taken to address them was insufficient and ineffective. It also showed a lack of accountability by unit managers and other leaders within the organisation to ensure improvements were made.

The provider was unable to act on the best information about risk, performance and outcomes, as the systems and quality of record keeping in place were poor.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They had shared information about the service with CQC and other partners when appropriate.

The service worked in partnership with a range of health and social care professionals, including the Local Authority. Referral processes were in place to help people access the additional support they needed, and records showed some people received this support. Care plans were not always updated consistently however, with any professional advice given, and care records were not always clear or accurate. This impacted on the reliability of the information shared with partners to support seamless pathways of care for people.

Statutory notifications to CQC in respect of incidents occurring at the service were reported CQC and the Local Authority appropriately.

The provider had some processes in place to share learning and improvements ideas across the organisation. These systems were not effective and did not demonstrate a focus on continuous learning or that robust action was taken to drive up improvements. They did not actively contribute to safe, effective practice and research.

A culture of continuous improvement was not fully embedded at the service. A Local Authority Quality Assurance Visit had taken place in June 2025 with improvements in wound care, catheter and bowel care identified. This visit and the provider’s own audits had identified a repetitive cycle of shortfalls in the delivery of people’s care and the management of the service. For example, care planning, monitoring and provision of care, medicines, infection control, environment, staffing, accident and incidents, staff support and governance. The systems in place to drive up improvements were not effective as there was little evidence any robust action was taken to make the necessary improvements. This meant similar shortfalls were found again during CQC’s assessment of the service.