Rowanbrook Care Home

The service was not registered to provide care and support to people whose primary need was a learning disability. However, some people who used the service did have a learning disability diagnosis. We assessed the service against ‘Right support, right care, right culture’ (RSRCRC) guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the service did not consider or reflect this guidance. This left people with a learning disability at risk of not having their specific learning disability needs met. People with learning disabilities were not always treated in an age appropriate manner by the staff and effective systems were not in place to promote their inclusion within the service or the local community.

Some aspects of the service were not always safe and there was limited assurance about safety. Not all incidents, including safeguarding incidents were reported and investigated to enable learning to take place and prevent recurrence. Staff did not always have access to the information required to consistently and safely manage any risks associated with behaviours that challenged, such as aggression. People were not consistently protected from the risks associated with the environment and medicines.

People’s care, treatment and support was not always effectively monitored and reviewed to ensure they achieved good outcomes and there was no evidence to show people were supported to plan for future life events or set goals.

People did not always feel they were treated with kindness, and individual preferences were not always met. People were not always offered choices about their care and support. Effective systems were not in place to support people and their relatives to consistently be engaged in the design and feedback of the care.

Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. Governance systems were not always effective at assessing, monitoring and improving the safety and quality of care provided. Staff were not always protected from the risks associated with carrying out their roles and they did not always feel they could speak up about safety concerns.

However, there were enough staff available to provide care and support and people were protected from the risks associated with infections.

People’s physical health needs were consistently assessed and met, and people were supported to access care and support from external health and social care professionals. People’s consent was sought before care was provided and staff understood how to support people who could not make decisions for themselves in line with the legal requirements.

We identified 3 breaches in regulation relating to person centred care, safe care and treatment and good governance. We have requested an action plan from the provider to set out how they will address the concerns identified during the inspection.