CQC report explained · a nursing home
What the CQC found at Rowan Garth Care Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, June 2023
Rated Requires Improvement; care was kind and safer than at the last inspection, but management systems and some aspects of daily care still needed fixing.
This was an unannounced follow-up inspection on 12 and 17 April 2023. Inspectors spoke with people living in the home, relatives and staff. They observed care and checked care plans, medicines records, staff files and management records.
There had been clear improvement since the previous inspection, which was rated Inadequate. Risk management, safeguarding, medicines, staff training and infection control had improved. People were generally treated kindly and with dignity, and the caring rating improved to Good.
The home still needed improvement in its management oversight. Inspectors also found inconsistent mealtime experiences, limited activities for some people, gaps in care records and inconsistent communication with people and staff. The home was no longer in Special Measures, but it remained in breach of Regulation 17.
Kind and respectful care
People were generally treated with kindness, dignity and respect. Inspectors saw staff knocking before entering bedrooms and explaining care to people.
“During the inspection we observed staff respect people's privacy and dignity by knocking on closed bedroom doors before entering and speaking and explaining to people before delivering an aspect of care.” from the report
Improved safety systems
Risk assessments, accident reviews, safeguarding procedures, medicines management and environmental checks had improved since the last inspection. The home was no longer in breach of Regulations 12 and 13.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Support with health needs
People had access to GPs and other health services when needed. Staff worked with other agencies to provide care.
“Records confirmed people were supported to access their GP and other health services when required.” from the report
Improved consent practice
The report found improvements in applying the Mental Capacity Act. DoLS applications had been made where needed, although some had not yet been authorised.
“At this inspection we found they had made improvements.” from the report
Inconsistent mealtimes
needs fixingFood quality and service varied between units. Some people were not offered condiments or napkins, menus were not accessible, and there was not always enough choice for modified diets.
“The quality of service and food available varied between units.” from the report
Risk of social isolation
needs fixingSome people, particularly those spending time in their rooms or in bed, did not have enough activities or conversation. The provider was asked to create a varied activity plan for everyone.
“We recommend the provider engages with people who use the service to ensure a varied plan of activity is available to everyone which reduces the risk of social isolation of those people cared for in their bedrooms.” from the report
Weak management oversight
seriousThe home did not have a registered manager at the inspection, and the new manager had been in post for two months. Management systems were not fully embedded and records were not always kept consistently.
“Governance systems were not always effective to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Limited confidence in leadership
needs fixingMost people did not know who the new manager was. Staff meetings and supervision had also been inconsistent, leaving some staff feeling unsupported.
“Most people told us they didn't know who the new manager was.” from the report
- 01What specific changes have been made to improve food quality, food temperature, menu access and choice for people with modified diets?
- 02How will you make sure people who spend time in their rooms or in bed receive regular activities and conversation?
- 03How are you addressing the Regulation 17 breach, including gaps in care records and management audits?
- 04How will the new manager build regular relationships with residents, relatives and staff?
- 05How do you check that agency staff receive a proper induction before providing care?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control under Safe, after the previous Inadequate rating and Special Measures. This explanation was written from the published report of 23 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, November 2022
Rowan Garth Care Home was rated Inadequate and placed in special measures; inspectors found serious safety and leadership failures, despite kind staff and safely managed medicines.
This was an unannounced focused inspection on 13 and 15 September 2022. Inspectors looked at Safe, Caring and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was not keeping people safe. Risk assessments and care plans were often incomplete, inaccurate or not followed. Some safeguarding concerns were not referred or properly investigated, and accidents were not always recorded or used to prevent further harm.
Inspectors found staff were kind and patient, medicines were managed safely, and infection control measures were in place. However, the home was not always person-centred, some relatives were not involved in care planning, and strong smells were present on some units.
The overall rating fell from Requires Improvement to Inadequate. Safe and Well-led were rated Inadequate, while Caring was Requires Improvement. The home was placed in special measures because significant improvements were needed.
Medicines
Inspectors found that medicines were managed safely, given as prescribed, and checked through regular audits.
“Medicines were managed safely and administered as prescribed.” from the report
Kind staff
Staff were observed to respond kindly and patiently. People said staff were respectful and explained what they were doing.
“Staff were kind in their response to people and their approach was observed to be patient.” from the report
Infection control
The home was clean, staff had suitable protective equipment, and infection control policies and procedures were in place.
“We were assured effective infection prevention and control (IPC) policies and procedures were in place at the home.” from the report
Outside support
Staff made referrals to other professionals when people needed extra support with their health and wellbeing.
“Staff made referrals to other services, such as dieticians, for additional input, advice and support when necessary to support people's health and well-being.” from the report
Risk management
seriousRisk assessments were missing, inaccurate or not followed. This included risks of falls and pressure sores.
“People were exposed to serious risk of harm due to a lack of person-centred risk assessment.” from the report
Safeguarding
seriousSome safeguarding incidents were not referred to the local authority or investigated properly. Not all staff understood their safeguarding responsibilities.
“Multiple safeguarding incidents had not been referred to the local authority for investigation to ensure people were protected from abuse.” from the report
Care planning
needs fixingCare records did not consistently show that people's needs and preferences had been met. People and relatives were not always involved in care decisions.
“Records of care delivered were inconsistently completed and did not always show people had been supported with their needs or preferences.” from the report
Leadership and checks
seriousThe provider's quality checks did not reliably identify or correct risks. This was the third consecutive inspection where the provider was in breach of regulations.
“Systems to monitor the quality and safety of the service were not used consistently or effectively.” from the report
Strong smells
minorInspectors found strong smells on some units on both inspection days. Some relatives had also noticed this.
“However, there were strong malodours present on some of the units on both days of the inspection.” from the report
- 01Which risk assessments were found to be incomplete or inaccurate, and how are you now checking that staff follow them?
- 02How do you make sure all safeguarding concerns are reported to the local authority and properly investigated?
- 03What evidence can you show that accidents and incidents are now reviewed and used to prevent repeat incidents?
- 04How will my relative and our family be involved in creating and reviewing the care plan?
- 05What has been done about the strong smells found on some units, and how are you checking that this problem has been resolved?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected, and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 10 November 2022 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 Garth Care Home
5 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2022Inadequatedown from Requires improvementSafe: InadequateCaring: Requires improvementWell-led: Inadequate
- February 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- March 2020GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2019
Registered with the Care Quality Commission on 6 March 2019.
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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