Archived: Rowena Court

Updated 25 August 2020

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 Care Act 2014.

Inspection team

This inspection was carried out by two inspectors.

Service and service type

Rowena Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The nominated individual is responsible for supervising the management of the service on behalf of the provider. The nominated individual was also the registered provider and registered manager for this service. Registered persons are legally responsible for how the service is run and for the quality and safety of the care provided. We refer to the nominated individual and registered manager as the ‘registered provider’ or ‘provider’ within this report. The provider attended the inspection for a short time.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We liaised with the local authority and professionals who work with the service. We checked for any feedback available through Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with five people who lived at the home and observed the care and support people received. We met briefly with the provider and we spoke with six staff members including the deputy manager, two senior support workers and three support staff members. We held discussions with local authorities and health professionals involved in people’s care throughout our inspection and enforcement processes.

We reviewed a range of records. This included records related to each person living at the home and one person’s medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

During and after our inspection, we continued to share information and the concerns we had identified with the local authorities and professionals involved in people’s care. We continued to seek updates and assurances from the provider including through formal requests concerning the quality and safety of the service. We also requested evidence about recruitment processes related to three staff members.

Updated 25 August 2020

About the service

Rowena Court is a care home which is registered to provide personal care for up to six people with mental health needs. There were six people being supported at the time of our inspection.

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

Although people told us they felt safe using the service, we found people were not protected from the risk of harm and abuse. The provider failed to appropriately escalate allegations of abuse, including where current staff were named as alleged perpetrators. Staff were not trained and equipped to respond appropriately to suspicions of abuse. This was a breach of the regulations.

We identified a second breach of the regulations due to the inadequate management of people’s risks, including poor learning from incidents at the home. Medicines management systems failed to ensure people would always be safely supported.

The provider started to improve recruitment processes after our inspection and staff felt staffing levels were safe. The home was clean and further improvements were underway, prompted by the local authority, to ensure good infection control.

We identified a third breach of the regulations because staff did not have adequate training and guidance to carry out their roles effectively, and staff deployment was not appropriately managed. We identified a number of shortfalls in how people’s needs were assessed in addition to a lack of training for staff. People were supported to access healthcare support, but this guidance was not used to appropriately inform people’s care. This all prevented adequate, effective support being provided to always meet people’s needs.

Although areas of the service were homely, the design and décor of the service failed to show regard for all people’s needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Although we saw some positive interactions with people from staff and people spoke positively about staff, established routines at the home, and the provider’s poor oversight such as their response to incidents, failed to ensure people were always well supported. We found concerns that compromised people’s dignity, respect and positive experiences. People did not have routine and planned opportunities to discuss and review their care to ensure this always met their needs.

We identified a fourth breach of the regulations as established routines at the home failed to ensure people’s individual needs and wishes were always taken into account. Furthermore, care planning processes failed to identify all people’s needs were appropriately identified and met including communication needs and end of life support.

People had been advised how to complain but no formal complaints had been submitted. People were supported to maintain community links and were encouraged to do some group activities at the home.

We identified a fifth breach of the regulations due to the provider’s poor governance systems which failed to adequately assess, monitor and improve the service. We found widespread concerns which had not been identified and addressed and which the provider had failed to notify relevant partner agencies as required. We identified a sixth breach of the regulations because the provider did not meet their legal requirement to notify CQC of specific incidents and events. Despite our urgent prompts during inspection and enforcement activity, the provider failed to act on the serious concerns we brought to their attention which placed people at ongoing risk of harm and failed to protect staff.

Rating at last inspection

The last rating for this service was Good (published March 2018).

Why we inspected

The inspection was prompted in part due to concerns about the provider’s governance systems and oversight of the quality and safety of care provided, identified through our inspection activity at another two services registered with the provider. We decided to inspect and examine those risks.

We identified serious concerns and breaches of the regulations at this inspection. We found evidence that people were at risk of harm as a result. Despite our urgent prompts and enforcement activity, the provider did not take enough action to mitigate those risks. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

At this inspection, we identified six breaches of the regulations. This was because the provider failed to protect people from abuse and ensure any allegations of abuse were immediately investigated. The provider failed to adequately assess and mitigate risks to people’s health and safety. The provider failed to ensure there were sufficient numbers of suitably skilled and competent persons deployed to safely meet people’s needs, including that staff received appropriate support and training. The provider failed to ensure people received person-centred care and treatment that met people’s needs and personal preferences. The provider failed to notify CQC of all events and incidents as required and failed to operate effective systems and processes to assess, monitor and improve the quality and safety of the service.

After our inspection, we took urgent enforcement action to require the provider to immediately address significant concerns that placed people at immediate risk of harm. We informed relevant partner agencies of our serious concerns. The provider failed to take enough action to ensure people’s safety which continued to place people at immediate risk of harm. We continued to liaise closely with the local authorities and other relevant partners.

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

During and after our inspection processes, we requested information from the provider about what action they were taking to address our serious concerns. We also worked alongside the relevant local authorities in light of the immediate and urgent concerns we identified. We carried out urgent enforcement action in relation to this service. During our enforcement processes, we continued to monitor the service for any further concerning information to help inform our inspection activity.

Special Measures

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 of 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.