Archived: Rowena House Limited

Updated 2 March 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Three inspectors carried out this inspection over two days. One of these was a night-time inspection.

Service and service type

Rowena House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Rowena House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

This inspection was carried out over two days. After the first day of the inspection we received information about potential risks relating to people’s night-time care. A decision was made for us to inspect the home during the night and examine those risks. Across both inspection days we spoke with three people using the service, seven care staff, the registered manager, and the registered provider. We reviewed a range of records. This included seven people’s care records and four medication records. We looked at three staff files in relation to recruitment and staff supervision, a variety of records relating to the management of the service, including risk assessments and monitoring checks were reviewed.

Updated 2 March 2024

Rowena House Limited is a residential care home providing personal care for up to 22 people aged 65 and over in one adapted building. There were ten people living at the home on the first day of the inspection and fifteen people on the second day of this inspection.

People’s experience of using this service and what we found

Risks to people were not always assessed and managed. Staff were not always aware of the risks to people they supported. Suitably qualified, competent, skilled and experienced persons were not deployed to meet people’s needs at night. Appropriate checks were not always carried out before staff started to work at the service. People’s medicines were not always safely managed.

The providers systems for assessing, monitoring, and improving the quality and safety of the service were not operating effectively. They failed to identify issues we found at this inspection. There were safeguarding vulnerable adults’ procedures in place however the registered manager failed to notify the CQC about safeguarding allegations and police visit in respect of these concerns.

People had individual emergency evacuation plans which highlighted the level of support they required to evacuate the building safely. The provider and staff were following government guidance in relation to infection prevention and control. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff said they received good support from the registered manager. The provider took people’s and their relatives’ views into account through meetings and feedback was used to improve the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 7 October 2021).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe and Well-led which contain those requirements. The second day of the inspection was prompted in part due to concerns received about potential risks relating to people’s night-time care. A decision was made for us to inspect the home during the night and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to assessing and planning for peoples care needs and managing people’s identified risks, managing people’s medicines safely, protecting people from abuse, recruitment records, training and inducting staff and the overall management of the home.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.