CQC report explained · a residential care home
What the CQC found at Rowan Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments were not always accurate or followed, including for skin damage, vomiting and seizures. Medicines, safeguarding, staffing and infection control were found to be safer areas.
- Effective?
- Requires improvement
- Some capacity assessments and best interest decisions were missing or out of date. Staff training was incomplete, including core training and autism training, and there was no evidence that all staff had been trained to use specialist equipment.
- Caring?
- Good
- This key question was not assessed during this focused inspection.
- Responsive?
- Requires improvement
- This key question was not assessed during this focused inspection.
- Well-led?
- Requires improvement
- Audits and improvement plans did not reliably identify or resolve problems. Feedback from relatives and staff about management and communication was mixed.
What inspectors found, June 2023
Rowan Court is rated Requires Improvement; inspectors found unsafe risk management, incomplete legal decisions and weak quality checks.
This was an unannounced focused inspection. Inspectors visited on 20 and 25 April 2023 and reviewed information up to 2 May 2023. They spoke with staff, a person using the service and relatives, and checked care records, medicines records, staff files and management records.
There were enough staff to meet people's daily needs. Medicines were given safely, safeguarding arrangements were in place, infection control was satisfactory and people were supported with food, healthcare and visits. However, some risk assessments and care records were inaccurate or missing, and staff training was incomplete in some areas.
Inspectors found that capacity assessments and best interest decisions had not always been completed for restrictive equipment. Management audits had not picked up important problems, and improvement plans were not robust. The overall rating remains Requires Improvement, as do Safe, Effective and Well-led.
Medicines
Inspectors found that medicines were managed safely and given as prescribed. Staff administering medicines had completed training and competency checks.
“Medicines were managed safely. Medicine training and competency assessments had been completed by all staff administering medicines.” from the report
Staffing
There were enough staff to meet people's needs each day. Recruitment checks were also in place.
“Rotas confirmed there were enough staff employed to ensure people's needs were being met daily.” from the report
Safeguarding
Safeguarding procedures were in place, and staff understood how to recognise and report abuse or poor care.
“Staff understood their responsibilities to protect people from possible harm or abuse.” from the report
Health support
The home worked with health and social care professionals, including physiotherapists, occupational therapists, nurses and GPs.
“The home worked with multiple health care professionals to ensure people's needs were being met.” from the report
Risk assessments not followed
seriousStaff did not always follow people's risk assessments, and some assessments were inaccurate or lacked important guidance. This included risks linked to skin damage, vomiting and seizures.
“People's risks were not being managed safely as staff did not always follow risk assessments.” from the report
Missing legal decisions
seriousCapacity assessments and best interest decisions were missing for some restrictive equipment, including chest harnesses, foot restraints and bed rails. One assessment had not been reviewed since 2020.
“Specific decisions about people's care had not always been recorded to show the decisions made were in people's best interest.” from the report
Incomplete staff training
needs fixingOnly 75% of staff had completed core training and 62.86% had completed autism training. Inspectors found no evidence that staff had been trained to use specialist equipment safely.
“The registered manager had no evidence that staff had been trained to use a Covene.” from the report
Weak audits and records
seriousAudits did not always identify problems found by inspectors. Care records were sometimes incomplete or inaccurate, and action plans did not cover all the issues found.
“The quality monitoring and auditing systems in place were not always effective.” from the report
Weekend management cover
needs fixingSome staff and relatives were concerned that there was no management presence in the home at weekends. Feedback about communication with management was mixed.
“However, there was some concern from staff and relatives that there were no management in the home over the weekends.” from the report
- 01What has been done to make sure every person's risk assessment is accurate and followed by all staff?
- 02How are capacity assessments and best interest decisions recorded and reviewed for restrictive equipment?
- 03What percentage of staff have now completed core, autism and specialist equipment training?
- 04How do you check that care records, repositioning records and feeding records are complete and accurate?
- 05Who is responsible for management cover and responding to concerns at weekends?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and do not have current ratings in this report. This explanation was written from the published report of 29 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2020
Rated Requires Improvement; inspectors found kind and effective care, but safety risks and weak records were not dealt with quickly enough.
This was an unannounced inspection on 13 and 14 January 2020. One inspector observed care, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was rated Good for Effective and Caring. Staff knew people well, supported their choices, treated them kindly and helped them with communication, health care, eating and activities.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Inspectors found that wheelchair risks were not followed up properly after a serious injury. Records and audits were incomplete or weak, including medicine and wheelchair checks.
The overall rating remained Requires Improvement, as it had been at the previous inspection. The provider was still in breach of two regulations, although it had improved its handling of statutory notifications.
Kind, respectful care
Inspectors saw staff treating people with kindness and respect. Relatives also spoke positively about the care.
“The carers are wonderful, very professional and caring.” from the report
Person-centred support
Care plans recorded people's needs, wishes, preferences and daily routines. Staff knew people's likes, dislikes and communication methods.
“Holistic assessments and care plans had been completed which reflected the person's needs, wishes and preferences.” from the report
Choice and independence
People were supported to make choices and take part in everyday activities. Staff encouraged independence in daily tasks.
“People's views and decisions about care were incorporated in their care plans.” from the report
Staffing and training
Inspectors found suitable recruitment checks, relevant training and enough staff on duty during the inspection.
“There are enough staff around, someone is always available to help and answer any questions.” from the report
Communication and activities
The home used communication aids and accessible information. People took part in activities such as music, baking and rebound therapy.
“Staff used a variety of means of communication to support people's understanding, which included, pictures, objects of reference, some symbols and communication aids.” from the report
Wheelchair safety risks
seriousWheelchair faults were not reported and followed up promptly. After a serious injury, the provider had not taken enough immediate action to reduce the risk of another incident.
“We found systems were either not in place or not robust enough to demonstrate risks to people were managed safely.” from the report
Weak records and audits
seriousMedicine records had missing signatures, and audits did not always show what action had been taken. Some regular audits had stopped, including commode audits.
“They had not maintained accurate and complete records.” from the report
Slow response to concerns
needs fixingFormal complaints were handled according to the provider's policy, but inspectors found the home was not always quick enough to improve care when concerns were identified.
“The service was not always responsive when concerns were identified, had failed to improve care quality in a timely manner” from the report
- 01What action has been completed to check every wheelchair and deal promptly with any faults?
- 02What changes have been made since the serious wheelchair-related injury to prevent a similar incident?
- 03How do you now check that medicine records are signed correctly and that audit findings are followed up?
- 04Have the missing regular audits, including commode audits, been restarted and kept up to date?
- 05What progress has been made against the action plan sent to CQC?
This was an unannounced planned inspection covering all five CQC questions, including the care provided and the home premises. This explanation was written from the published report of 26 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Rowan Court
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- January 2019Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Kirklees
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Most charge £980 to £1,260 a week. 86 can care for a couple. 11 years' experience on average.
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