Rowan Court

Rowan Court is a residential care home providing personal care for up to 15 people with a learning disability, physical disability or sensory impairment and younger adults. At the time of the inspection 15 people lived at the service. The accommodation is provided in one adapted building with bedrooms across three floors.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

There were enough staff employed to ensure people’s needs were being met daily and most training by staff had been completed. However, we could not find evidence staff had been trained in some areas. People received medicines safely and were given their medicines as prescribed and supported to have regular reviews.

People were not always supported to have maximum choice and control of their lives. Some people living in the home lacked capacity to make decisions. We found not all capacity assessments or best interest decisions had been completed to ensure people were supported in the least restrictive way. possible.

Right Care

Risks assessments were not always accurate or being followed by staff to ensure safe practice. Care records were not always accurate or in place. People were supported to eat and drink enough and had a varied diet offered to them. Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.

Right Culture

The quality monitoring and auditing systems in place were not always effective. We found issues on inspection which had not been identified in the audits and actions plans were not robust. The registered manager was working with relatives and staff to improve communication and to gather their feedback. The management team and staff shared a commitment to continuously learn and worked in partnership with other professionals.

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 26 February 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

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 carried out an unannounced focused inspection of this service on 20 and 25 April 2023.

We received concerns in relation to the management of people’s care needs and staff culture. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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.

The overall rating for the service has remained requires improvement. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Rowan Court on our website at www.cqc.org.uk.

Follow up

We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Rowan Court is a residential care home providing personal care to 15 people with a learning disability, physical disability or sensory impairment. At the time of the inspection 15 people lived at the service. The accommodation is provided in one adapted building with bedrooms across three floors.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

All risks to people were not managed safely. The service was not always responsive when concerns were identified and failed to improve care quality in a timely manner. We were notified of a serious injury prior to the inspection. In response to this concern, we found the provider did not take enough immediate action to improve care quality across the service. The provider had failed to manage all risks to people safely and done all that is reasonably practicable to mitigate those risks.

The service had poor audit trails and audit systems were not robust. Governance systems failed to pick upon the issues we found during the inspection. Medicine audit tools were not robust enough to evidence what action had been taken following findings. Some actions on the wheelchair audits had not been followed up until this was highlighted to the registered manager during the inspection. The provider had not operated robust systems and processes to assess, monitor and improve the quality of the service. They had not maintained accurate and complete records.

Relatives told us people living at the service were safe. Staff had a good understanding of how to safeguard people from abuse. People's medicines were managed safely. We observed people receiving medicines in line with their care plan. Person-centred care was promoted, and relatives told us staff knew people well and responded to their needs in a person-centred way .

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.

The service applied the principles and values of Registering the Right Support and other best practice guidance. Holistic assessments and care plans had been completed which reflected the person’s needs, wishes and preferences. Staff knew people's preferences, likes and dislikes. They provided support in line with legislation, standards and guidance to achieve effective outcomes. People told us staff were kind and sensitive. A relative added, “The carers are wonderful, very professional and caring.”

Complaints were investigated and responded to. We found the service had responded to formal complaints in line with the provider’s policy. Relatives told us, “[Names of registered manager] listens to you and makes things happen,” and, “They [staff] take everything very seriously if you raise anything.”

Staff and relatives were positive about the management team and the changes the registered had made to the service. Staff we spoke with felt valued and supported by the registered manager. Staff told us, “[Name of registered manager] is incredible. They are so supportive, but you need to meet their expectations as well. They are happy to help and get involved.”

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 17 January 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to safety and the governance of the service at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Following the last inspection, we met with the registered provider and they sent us an action plan to show what they would do and by when to improve the key questions safe, effective, responsive and well led to at least good. At this inspection we checked to see whether improvements had been made and found the registered provider was not meeting the regulatory requirements relating to good governance.

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

Rowan Court is part of Holly Bank Trust which is an organisation specialising in providing education, care and support for young people and adults with profound complex needs. It was registered with the Care Quality Commission to provide accommodation for people requiring nursing or personal care, for up to 15 people. At the time of our inspection it was providing this service to 15 young adults.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. The service was delivered in line with these values.

A registered manager was not in place, as they had left the service in 2017 and not yet de-registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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. The service had been managed by a manager from another service run by the same provider, and they had applied to register with CQC. They had also left the service in October 2018 after a period of absence and the home was being managed temporarily by a second manager from another service.

Relatives told us they felt their family member was safe at Rowan Court.

Medicines management had improved and a safe system was now in place. Staff had training in safe administration of medicines and staff competency checks on the administration of medicines had been refreshed in the last year. Incidents related to medicines errors were analysed and action taken to prevent future risks to people.

Staff had a good understanding of how to safeguard adults from abuse and who to contact if they suspected any abuse and safe recruitment and selection processes were in place.

Emergency procedures were in place and staff knew what to do in the event of a fire. Risk assessments were individual to people’s needs and minimised risk whilst promoting people’s independence.

Detailed individual behaviour support plans gave staff the direction they needed to provide safe care.

The required number of staff was provided to meet people’s assessed needs.

Staff told us they felt supported. Staff had received an induction and role specific training, which ensured they had the knowledge and skills to support the people who lived at the home.

People were supported to eat a balanced diet, and meals were planned around their tastes and preferences. They were supported with diets of different consistencies and nutritional intake was monitored.

People were supported to maintain good health and had access to healthcare professionals and services. They were supported and encouraged to have regular health checks. The registered provider employed a team of therapists to meet people's complex needs and the home also worked in partnership with community professionals to ensure good outcomes for people.

The service was adapted to meet people’s individual needs, with specialist furniture and fittings. Technology was used to promote independence for people, support communication and enable people to live fulfilling lives.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. We saw evidence of good practice involving people with complex communication needs in decisions about their lives. Evidence of consultation with people’s representatives in their best interests, where required, was not always available. We made a recommendation about this.

Positive relationships between staff and people who lived at Rowan Court were evident. Staff were caring and supported people in a way that maintained their dignity, privacy and diverse needs. People were supported to be as independent as possible throughout their daily lives.

Systems were in place to ensure complaints were explored and responded to in good time, however this system was not always operated effectively.

Care records contained detailed information about how to support people and included measures to protect them from social isolation. People engaged in social and leisure activities which were person-centred. The relatives we spoke to were concerned about a recent reduction in outings related to transport issues and plans were in place to resolve this.

Thorough and timely responses to concerns and feedback from family members and others was not always evident. The absence of a registered manager had left some gaps in governance, which the registered provider and senior staff at the service were in the process of addressing. Some statutory notifications had not been submitted to CQC as required by legislation.

Relatives told us they were concerned that the management of the service had been unsettled in recent years, but were hopeful this would improve with the appointment of a new permanent manager.

The registered provider had made some improvements to the systems of governance and audits within the service and quality assurance processes were being further reviewed and improved.

Feedback from staff was positive about the current management team. People who used the service and their representatives were asked for their views informally, and formal feedback methods, specifically related to Rowan Court were beginning to be implemented by the registered provider.

We found a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the registered provider to take at the back of the full version of the report.

Rowan Court is provided by Hollybank Trust, an organisation specialising in education, care and support for young people and adults with complex needs. Staff at the home refer to people who use the service as ‘adults.’ The premises were purpose built and located in the grounds of Holme Valley Memorial Hospital, in Thongsbridge. The home provides care and accommodation for up to 15 people; at the time of this inspection 15 people were using the service. The building has three floors and five people live on each floor; all rooms are ensuite.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. 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.

At the last inspection in June 2016 we identified a breach of regulation relating to good governance, as risk assessments were not always reviewed by the stated review date, and the manager at the time lacked oversight of safety and quality at the home. A second breach of regulation we identified related to staffing and was the result of issues with training. The home had been rated as Requires Improvement in the key questions of Safe, Effective and Well-led, and Good in Caring and Responsive.

On the first day of inspection we identified concerns with the way medicines were managed and administered. We fed this back to the registered manager the same day. On the second day of inspection, four days later, we found no improvements had been made.

Accidents and incidents at the home were not always recorded on the provider’s electronic system. Those which were on the electronic system did not always contain information about how they had been investigated and what measures (if any) had been put in place to prevent reoccurrences.

The provider and registered manager lacked oversight of safety and quality at the home; this was a concern at the last inspection in June 2016. The system of audit at Rowan Court was not fit for purpose.

The registered manager did not fully record how complaints had been investigated and resolved.

People’s care files contained a range of person-centred risk assessments. All but one we saw had been updated according to the stated review date. This was an improvement from the last inspection. Risks to people posed by the building, equipment and utilities had been managed.

People’s relatives, staff at the home, and other healthcare professionals told us sufficient staff were deployed to meet people’s needs. Our observations supported this.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. However, there was no consistent approach to mental capacity assessment at the home.

Staff had access to the training, supervision and support they needed to provide people with effective care. This was an improvement from the last inspection.

People liked the meals cooked by staff at the home; risk assessments and guidance was in place to ensure people were supported to eat and drink safely. We found one person’s food and fluids charts had not been completed fully.

The building had been purpose-built for people with complex physical needs. People had specialist equipment which they had been assessed for and staff had the guidance they needed to support people with this equipment safely.

Records showed people had access to a range of healthcare professionals to help them maintain their holistic health. Feedback we received from healthcare professionals about the home was positive.

People indicated staff were caring and treated them with respect. Relatives and healthcare professionals who visited the service were also complimentary about the support workers.

Support workers helped people retain and build their independence; they also respected people’s privacy and dignity. Our observations showed staff knew people very well as individuals.

People’s records did not evidence how they had been involved in designing and reviewing their care plans, although support workers could describe to us how they did this. The registered manager said conversations with people about their care and support would be captured in future.

People’s care plans were detailed and person-centred. Support workers could describe people’s care needs in detail, although we did observe one intervention when support workers did not follow a person’s plans.

People had access to a range of activities and were supported to go on holiday with support workers they chose, if they wanted to.

Feedback about the registered manager was positive. He had taken action to try and improve staff culture and morale.

Senior support workers had regular meetings with the registered manager; those held for other support workers were sporadic. The registered manager had created a newsletter to help keep staff up to date.

Forum meetings were held for people who lived at Rowan Court, and the provider organised relatives’ meetings on a regular basis. A regular newsletter was sent to people’s relatives to let them know about activities and events at the home.

We found breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Rowan Court is part of Holly Bank Trust, which is an organisation specialising in providing education, care and support for young people and adults with profound and complex needs. It is based in purpose built premises on the grounds of Holme Valley Memorial Hospital, close to Huddersfield. It provides care and accommodation for up to 15 people. At the time of our inspection 15 people were using the service.

There was a manager in place but they were not a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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. The manager was leaving the service at the end of June 2016 and a new manager had been appointed.

Risks to people using the service were assessed and plans put in place to minimise the chances of them occurring. However, we saw that risk assessments were not always reviewed by their stated review date. Risks to people arising from the premises were regularly reviewed.

Emergency plans were in place to support people safely in emergency situations, though they were not easily accessible. There was a business continuity plan in place to help provide a continuity of care in situations where the service was disrupted.

Accidents and incidents were monitored by the manager and registered provider and steps taken to minimise the risk of them occurring.

There was a safeguarding policy in place and staff understood the types of abuse that can occur in care settings. The safeguarding policy contained guidance to staff on indicators of abuse and how they should report any concerns they had. Staff confirmed there was a whistleblowing policy in place and said they would use it if they had any concerns.

People’s medicines were managed safely. People’s medicine support needs were set out in a medicine care plan. Protocols were in place providing guidance to staff on people’s ‘as and when required’ medicines. Controlled drugs were securely stored and regularly monitored.

Procedures were in place to ensure safe staffing levels. During the inspection we saw that people were attended to quickly and staff were attentive to people in their own rooms and communal areas. Staff told there were enough staff employed to support people safely. Procedures were in place to minimise the risk of unsuitable staff being employed.

Staff received mandatory training in a number of areas, but was not always refreshed in line with the registered provider’s policy to ensure it reflected best practice.

Newly recruited staff completed an induction programme before they could support people without supervision. Staff we spoke with confirmed they had completed the induction programme before supporting people on their own.

Staff were supported through regular supervisions and appraisals. Staff also completed competency checks in areas such as moving and handling and medicines to see if further training was needed, and we saw records of these in staff files.

The service worked within the principles of the Mental Capacity Act 2005. Everyone using the service was subject to a DoLS authorisation. The manager kept a chart showing when these had been granted, when they expired and any conditions that applied. This helped ensure that any renewal applications were made in a timely manner. Where people lacked capacity to make some decisions they were still encouraged and supported to decide things they were capable of.

People were supported to maintain a healthy diet. Care plans also contained evidence of the involvement of other professionals such as dieticians and speech and language therapists (SALT) to help people maintain a healthy diet. People’s weights were monitored and their food and fluid intake recorded to ensure they were receiving enough food and drink. Each floor had its own food budget, and people went on a weekly shopping trip to decide how this should be spent. People were also involved in planning a weekly menu, and we saw that people had their own choice of foods in addition to that bought for everyone.

The service supported people to access external professionals to manage and promote their health. Professionals such as occupational therapists, nurses, speech and language therapists (SALT), dieticians and physiotherapists were involved in developing people’s care plans to ensure they effectively met people’s health and support needs.

People were able to communicate to us that the support they received was caring and they were happy at the service. People communicated that they got on well with the staff who supported them.

Staff used Makaton and individually tailored hand, eye and facial expression communication techniques to interact with people. Staff were committed to using techniques that worked best for the person involved.

There was a presumption that people could understand what the conversation was about even though they did not always respond, which created an inclusive and homely atmosphere. People were treated with dignity and respect and staff were attentive to people’s needs.

At the time of our inspection no one at the service was using an advocate. There was no advocacy policy in place but the manager was able to describe how they were working with the local authority to arrange an advocate for a person using the service.

No one was receiving end of life care at the time of our inspection. The manager told us how this would be arranged if needed.

Care was planned and delivered based on people’s assessed needs and preferences. Care plans were produced on the basis of people’s assessed support needs and reviewed every six months. Staff said they would be updated sooner if there were any changes to people’s support needs. Daily notes were used to record care and support delivered. This helped ensure that staff changing shift had the most up-to-date information on the person.

People were supported to access activities based on their preferences and abilities. People had an individual activities timetable, and these were also displayed in communal areas. Where appropriate, risk assessments were in place for physical activities to help people access them in a safe way.

There was a complaints policy in place. This provided guidance on how complaints would be investigated and the timeframes for doing so. There was also an easy read ‘complaints folder’ on display throughout the service. Records confirmed that investigations had taken place and outcomes had been sent to those involved.

The manager and registered provider carried out a number of quality assurance checks at the service, but these were not always effective at monitoring and improving standards. The audits had not identified the issues we found with overdue risk assessments and training. The manager did not carry out overall checks of the audits to see if they were effectively monitoring standards.

Staff spoke positively about the culture and values of the service. Staff said they felt supported by the manager, including in staff meetings where they could raise any concerns they had.

Feedback was sought from relatives of people using the service in annual questionnaires. People using the service were not asked to complete a questionnaire but throughout the inspection we saw staff asking how they were. There was an easy to read feedback folder on each of the three floors, containing charts with symbols depicting moods and feelings. This was used to help people give staff feedback.

The manager understood their role and responsibilities, and was able to describe the notifications they were required to make to the Commission.

We found two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014, in relation to the effectiveness of risk assessment reviews and quality assurance processes and staff training. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We considered all the evidence we had gathered under the outcomes we inspected.

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care plans were well organised and the information was clear.

We saw that there were risk assessments in place for bathing, tissue viability and fire safety. Where someone was assessed as being at high risk, such as from a diminished swallowing reflex, then control measures had been recorded to state how the risk would be minimised.

We saw there were robust systems in place to assess and check appropriate and safe care was being delivered. These included daily and monthly internal audits. These audits included infection control and mattress quality and suitability.

The provider had appropriate security arrangements in place to protect people who lived at the service. We found that the entrance door was secure and visitors could only enter the building with the knowledge of the staff. People indicated to us they felt safe and secure in the home.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We spoke with two relatives who told us of their experience of the service. They told us the service was 'fabulous' and perfectly met both the needs of their relative and themselves. They said they felt confident that everything they and their relative needed would be provided.

Staff we spoke with were clear about the needs of the people they supported and what they told us was reflected in people's care plans.

We spoke with staff who told us they felt well supported by the manager who arranged access to regular training and development to ensure they were able to deliver appropriate care.

Is the service caring?

We saw all people at the home appeared at ease and relaxed in their environment. We saw that people responded positively to staff with smiles when they spoke with them. We observed that staff included people in conversations about what they wanted to do and explained any activity prior to it taking place. We noted staff understood people's non-verbal methods of communication and were able to respond appropriately.

We saw that people were dressed appropriately for their age and the time of year. We noted people had been supported to express their personality, for example by having their nails painted in a colour of their choice or their hair styled in a particular way.

Care staff on duty told us they were responsible for providing people with meaningful activities that they enjoyed. We saw each person had a weekly timetable of activities. A care worker told us that these were guides used by staff to encourage people to participate in activities they might find enjoyable. With the help of staff people told us of activities they had been involved with. These included going to football matches, the zoo and to the horse racing. Smiles and positive body language indicated to us that these activities were greatly appreciated.

Is the service responsive?

We reviewed three people's care records and found they all had complex health care needs and received services from a range of secondary health care providers.

Our discussions with the senior social care officer on duty demonstrated the provider was fully aware of each person's individual care needs. Care plans and risk assessments were in place to be able to respond to frequently changing health care needs.

All people had a health passport which would accompany them in an emergency to hospital. The health passport was a document containing all current relevant information about a person including allergies, communication difficulties, current medication and known diagnoses. This ensured other health care professionals had access to meaningful information to help them act safely in emergency situations.

All care plans contained a specific section on communication. Our observations and scrutiny of care plans demonstrated the provider had explored every avenue of care to ensure people with profound communication problems were not isolated through their inability to communicate by speech.

Is the service well led?

Decisions about care and treatment were made by the appropriate staff at the appropriate level. There was a clear staffing structure in place with clear lines of reporting and accountability.

The staff we met were well trained and competent to make most of the routine care decisions. They said they knew when and how to report any issues or concerns and they were confident management would provide any necessary advice or support.

There was evidence that learning from incidents and investigations took place and as a consequence appropriate changes were implemented.

Our inspection demonstrated the provider had good governance arrangements in place. The provider was recognising its accountability, was acting on lessons learned and was honest and open in seeking the best possible outcomes for people. The service was well led.

We observed staff were attentive to people's needs and appeared to know them well. Although people did not have capacity to consent to complex care decisions, we observed staff involving people in decisions. For example, asking them what they wanted to eat and drink and what activities they wanted to participate in.

We reviewed people's care records and spoke with a relative of a person living at Rowan Court. The care records we looked at were person centred and provided an accurate and up to date picture of their care needs and how their care needs were to be met. The relative whom we spoke with was very complimentary about the quality of care. They told us, "I can't praise it highly enough".

The staff we spoke with told us they provided good care and received the necessary training and support to enable them to so.