Archived: Rowan Lodge

Updated 19 September 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 21 August 2017 and was unannounced. The inspection was carried out by a single inspector.

Before the inspection, we reviewed the information we held about the service, including notifications we had received from the provider informing us of significant events that occurred at the service, the last inspection report and the action plan the provider had sent to us.

During the inspection we looked at the care records of all three people who used the service, three staff files and a range of records relating to the management of the service. We spoke with all three people who used the service, the provider who was also managing the service, the operations manager and a care worker.

Following the inspection, we contacted and received feedback from three external professionals who were involved with people who used the service.

Updated 19 September 2017

We undertook an unannounced inspection of Rowan Lodge on 21 August 2017. The service was last inspected on 8 and 9 December 2015 when we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because medicines were not managed safely, recruitment procedures were not being followed robustly and the service was not being monitored so shortfalls were not being identified and addressed. The provider sent us an action plan on 2 February 2016 telling us about the improvements they planned to make by 31 March 2016. At this inspection, we found that improvements had been made.

Rowan Lodge Care Home provides accommodation and personal care for up to three people with mental health needs. There were three people using the service at the time of our inspection.

The provider is registered as an individual and as such is not required to have a registered manager in place. The provider runs and manages the service with the assistance of an operations manager who is a family member. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were activities provided at the service, however these did not always meet the needs of people.

We have made a recommendation in relation to the provision of activities.

People's individual needs had been assessed and recorded but not all care plans were regularly reviewed. Monitoring charts and records were not always updated.

Incidents and accidents were acted upon appropriately. However, records of these were not always fully completed and did not always include a management review and an action plan about how to mitigate the risk of reoccurrence.

Recruitment checks were in place to obtain information about new staff before they supported people unsupervised.

There were systems in place to ensure that people received their medicines safely and the staff had received training in the management of medicines.

There were procedures for safeguarding adults and the staff were aware of these. Staff knew how to respond to any medical emergencies or significant changes in a person's wellbeing.

Feedback from people and stakeholders was positive. People we spoke with said that they were happy with the level of care they were receiving from the service. We saw that people’s needs were met by caring and respectful staff.

People's needs were assessed and support plans were developed from the assessments. People had taken part in the planning of their care and there were regular reviews.

The manager was aware of their responsibilities in line with the requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

The service employed enough staff to meet people's needs safely and had contingency plans in place in the event of staff absence. However there was not always enough time for staff on duty to provide meaningful activities for people who used the service.

People's health and nutritional needs had been assessed, recorded and were being monitored.

New staff received an induction and shadowing period before delivering care and support to people. They received the training and support they needed to care for people.

There was a complaints procedure in place which the provider followed. People felt confident that if they raised a complaint, they would be listened to and their concerns addressed.

There were systems in place to monitor and assess the quality and effectiveness of the service, and the provider ensured that areas for improvement were identified and addressed.

People and staff told us that the management team was approachable and supportive. People and staff were supported to raise concerns and make suggestions about where improvements could be made.