The inspection took place on the 29, 30, 31 August and 1 September 2017 and was unannounced to the care home and announced to the domiciliary care part of the service. Rowan House Residential Home provides care and accommodation for up to 26 people who may be living with dementia. On the day of the inspection 23 people were living at the care home. Rowan House also provides a personal care service to people living in their own home. On the day of the inspection 30 people were supported by the agency with their personal care needs in their own home.

We carried out an unannounced comprehensive inspection of this service on 14 and 15 July 2016 on the care home only. Breaches of legal requirements were found and enforcement action was taken. This was because the provider did not ensure that risks relating to people's nutrition, skin care, medicines, the environment and the recruitment of staff, were effectively managed. We also found concerns in relation to staff training and to how the quality of the service was monitored. After the comprehensive inspection the provider submitted an action plan to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook a focused inspection on 17 November 2016 to check that they had followed their action plan and to confirm that they now met legal requirements. We found that action had been taken to improve the service. However we could not improve the rating from Requires Improvement because to do so requires consistent good practice over time.

At this inspection we found these improvements had been maintained.

The residential service and the domically service each had a manager in place. Though neither manager was currently registered with the Commission there were exceptional circumstance which we are aware of and except. We have now received an application to register a manager.

A registered manager is a person who has registered with the 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.

One person living in the service said when asked; “The care in here is fantastic." Another said; “We are like one big happy family." While another commented; “It just reminds me of living at home." A relative said; “Couldn’t ask for better for her.” A professional spoken with felt people were well cared for and safe living in the service.

People from the domiciliary service said; “The care I receive is excellent, I'm very happy" and “Everybody is so helpful.” A relative said: “Their care is first class."

People’s medicines were managed safely. Medicines were stored, and disposed of safely. Senior staff administered medicines. They confirmed they had received training and understood the importance of the safe administration and management of medicines.

People were protected from harm as staff had completed safeguarding training. Staff understood how to report any concerns and what action they would take to protect people. Staff told us they felt confident any incidents or allegations would be fully investigated.

People were protected by safe recruitment procedures. Staff were supported with an induction and ongoing training programme to develop their skills, and staff competency was assessed. People, staff and relatives said there were sufficient staff to care for people.

People who did not have capacity to make decisions for themselves were supported by staff to make sure their legal rights were protected. Staff worked with other professionals in people’s best interests. The managers worked in the service most days and had taken action where they thought people’s freedom was being restricted. Applications were made and advice sought to help safeguard people and their human rights.

People were satisfied with the care the staff provided. They agreed

We carried out an unannounced comprehensive inspection of this service on 14 and 15 July 2016.

Breaches of legal requirements were found and enforcement action was taken. This was because the provider did not ensure that risks relating to people’s nutrition, skin care, medicines, the environment and the recruitment of staff, were effectively managed. We also asked the provider to make improvements to staff training and to how the quality of the service was monitored.

After the comprehensive inspection the provider submitted an action plan to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook this focused inspection on 17 November 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Rowan House Residential Home on our website at

www.cqc.org.uk

The service had a manager who was in the process of applying to be registered with the Commission. 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.

People's medicines were managed and monitored effectively to help ensure they received them safely. Systems were in place to help ensure effective communication regarding medicines within the staff team, and monitoring checks by the manager and provider helped to highlight when action or improvements were required.

People's care plans had risk assessments in place to provide guidance and direction to staff about how to minimise risks associated with their care. Risk's relating to people's nutrition were effectively managed to help ensure their needs were being met and to enable prompt action to be taken, when necessary.

People's environment was assessed and monitored to help ensure it was safe. Fire testing was carried out in line with the provider’s policy and the manager took time to walk around the service each day, to carry out visual checks of fire exits and equipment.

People were protected by the provider's recruitment practices to help ensure staff employed were safe to work with vulnerable people. Risk assessments, when required, were in place relating to staffs’ Disclosure and Barring Service (DBS) checks. Staff employment history was recorded and references from previous employers were sought.

The manager and provider had worked hard to improve the quality of the service. There was a culture within the service of openness and transparency, and a willingness to learn from mistakes. There were systems and processes in place to help monitor the quality of care people received and the registered provider visited the service weekly to monitor quality and engage with staff.

We carried out an unannounced comprehensive inspection of this service on 14 and 15 July 2016.

Rowan House Residential Home provides care and accommodation for up to 26 people who are living with dementia or who may have physical difficulties. On the day of the inspection 23 people were living at the care home. The home is on three floors, with access to floors via stairs, a stair lift or lift. Some bedrooms have en-suite facilities. There are shared bathrooms, shower facilities and toilets. Other areas include three lounges, a dining room, and garden. The service also provides domiciliary care services to adults within East Cornwall. Our inspection was carried out only in respect of the care home.

Prior to our inspection the Commission had received some whistleblowing concerns. These included issues relating to staffing levels, the management of the service, the competence of staff, and the safe recruitment of staff. We were also told staff did not always treat people with dignity and respect, that there were poor infection control procedures, and ineffective safeguarding, whistleblowing and confidentiality practices. As part of our inspection we looked at the concerns which had been raised.

There was no registered manager in post, however a new manager had been appointed and was in the process of applying for registration. 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.

At our last inspection on 4 and 5 November 2015 we asked the provider to make improvements to how people’s care was documented and reviewed, the involvement of people in decisions relating to their care and how people’s mental capacity was assessed. Improvements were also required in relation to the management of medicines, the effective monitoring of people’s nutrition, infection control practices, and the assessment of risks associated with the environment. The provider had also been asked to improve how they assessed and monitored the ongoing quality of the service, and to ensure they notified the Commission of significant events in line with their legal obligations. Following our inspection the provider sent us an action plan telling us they would make improvements by 30 April 2016. During this inspection we looked to see if these improvements had been made and we found that some action had been taken, but further improvements were still required.

People’s medicines were not always managed and monitored effectively to ensure people received them safely. People were not always protected by staff who had been recruited safely to ensure they were suitable to work with vulnerable people. People’s environment was not always assessed and monitored to ensure it was safe, for example fire checks had not always been carried out.

People’s risks associated with their care were not managed effectively. Risk assessments in place did not always provide guidance and direction to staff, about how to minimise risks associated with peoples care. For example, when they were at risk of chocking or skin damage. People’s nutrition was not always managed effectively to ensure they were eating and drinking enough so responsive action could be taken. Following our inspection the provider told us immediate action was being taking to rectify the areas identified as requiring improvement.

People told us they felt safe living at the service. People were protected from abuse because staff knew what action to take if they thought someone was being abused, mistreated or neglected. People were cared for by sufficient numbers of staff, and the manager was responsive in making changes to staffing levels when people’s needs changed.

People told staff were well trained, however the manager

We carried out this inspection to check if the compliance actions set at our inspection in July 2014, in relation to care plans, risk assessments and the systems to check the safety of the building had been met. During this inspection we spoke with four members of staff and the registered manager.

At this inspection, because of the limited areas we looked at, we were unable to answer all of our five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

The registered manager had started to update care plans using a new format. The plans were detailed and informative. Information was relevant to people’s specific, individual needs. Staff members told us they found the new care plans easier to use.

Risk assessments were included with the care documentation. Although these defined risk there was little information to guide staff on how to minimise risk. We discussed this with the registered manager and following the inspection visit they sent us a revised risk assessment. We saw this was clear, detailed and concise. The registered manager told us they would develop all risk assessments.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager told us they had contacted the local authority’s DoLS team for advice and guidance around the legislation. We saw 12 applications for DoLS had been made. This showed us people’s human rights were protected.

Since our last inspection a new system had been introduced to monitor the safety of the premises. We saw this was being adhered to.

We were able to make a judgement that Rowan House was a safe service in respect of the areas we looked at.

We gathered evidence against the outcomes we inspected to help answer two key questions: Is the service safe? Is the service caring? We gathered information from people who used the service by talking with them.

This is a summary of what we found-

Before our inspection we received some anonymous information of concern about the service, the areas of concern related to the choices people had with regards to getting up in the morning, the ethos and culture of the home, medication training and the standard of the homes care documentation.

Is the service safe?

At the time of our inspection we did not find the service to be safe.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The recent judgement made by the Supreme Court on 19 March 2014 places a responsibility on providers to ask two key questions; is a person subject to continuous supervision/control? and is the person free to leave? If a person is subject to both continuous supervision/control and is not free to leave, then a person is being deprived of their liberty and a DoLS application should be in place to state that this is in the person’s best interests.

We found people who lived at Rowan House were not subject to restriction. However, it was not clear from people’s care plans how the provider had considered this having regard to the DoLS legislation particularly as some people who lived at Rowan House had a form of dementia. It is important that people’s care plans are individually reflective of such care needs to ensure that staff are aware of how to meet a person’s needs without imposing restrictions.

People’s needs were assessed, but care and treatment was not always planned in line with their individual care plan. We found care plans for people were not always reflective of their current care needs, and the information in risk assessments was not always clear. Care plans did not always give clear direction and guidance to staff. It is essential care plans give clear direction to enable staff to be able to understand how people’s individual health and social care needs should be met.

Is the service caring?

At the time of this inspection we found the service to be caring.

People who lived at Rowan House were complementary of the care and support they received from staff. Comments included, “I can’t speak highly enough of them, caring and love that are the two words I would use to express my feelings about this; my home” and “they are very, very kind”.

We spoke with a relative who told us, “I’ve got tremendous praise for the home”.

One relative told us, “X [the manager] has a sense of fun which I think is really infectious”. They also told us, “I think Rowan House is just wonderful my X has just thrived there” and “I’ve got nothing other than praise for Rowan House”.

During our visit we met most of the 19 people who lived at Rowan House, spoke to five people and two relatives. We spoke with three staff at Rowan House including the registered manager and reviewed five care files. We spoke to five people who used the homecare service on the telephone, met and spoke with the manager of this service, spoke with five of the community staff on the telephone and reviewed five care files of people being supported in the community.

People told us “My choices are respected”; “Yes, they respect my privacy and dignity” and “The care is excellent, staff brilliant, choices are respected, they check people are okay and safe, Dad’s never been happier.”

We found people had their choices respected and were treated with dignity and privacy. We spoke with staff who were mindful to ensure people’s personal preferences were honoured such as what they liked to wear and how they liked their hair and make-up done.

We found people had their needs assessed prior to admission and people’s care plans gave detailed information about their care and support needs which ensured their safety and well-being.

People had their nutritional needs met and staff were aware of people who required additional support and monitoring to maintain a good diet.

People felt safe at Rowan House, staff were trained in recognising the signs of abuse and knew the procedures to follow to report abuse and protect people.

Rowan House had a complaints policy and people felt able to raise concerns and felt listened too.

We (the Care Quality Commission) carried out this inspection as part of our scheduled inspection programme.

We talked with four people who lived at the home and four visitors. People using the service told us “staff are as good as gold” and “it’s wonderful here”. Visitors told us “I honestly would not want my relative anywhere else” and “they keep me up to date with all changes and how they are”.

We spoke with five staff who told us that Rowan House was a good place to work with friendly and caring staff. They told us that “There is lots of training” and that they felt the management of the home were very supportive.

We looked at the care provided and records relating to three people in the home and two people in the community. Records relating to people’s care were detailed and personal to each person. The details enabled staff to meet people’s individual needs.

People using the service felt there were sufficient staff with the right skills, to meet their needs.

We looked at the domiciliary care provided to people in the community. We spoke by telephone, with three people receiving care. They told us staff were punctual, stayed the right amount of time and were kind and friendly. Staff working in the community told us that they had information and support from the office staff at Rowan House.

We spoke to people living at Rowan House Residential Home and staff. There were no issues raised by anyone, all were very positive about the care provided and the staff providing the care. People who use the service were moving freely around the home and staff were seen to interact well with them. We saw that people who use the service were very happy to approach any member of staff. We saw staff and people who lived at the home chatting with each other throughout the visit.

People we spoke with confirmed that they chose how to spend their days, and that they could do what they liked.

We saw that people were spoken with in a respectful and caring way. People told us that the staff were “lovely”, “wonderful” and that “it was a wonderful place to live”. On the day of our visit some people were making Easter cards, others were involved in a card game and some were reading books or newspapers.

People told us they were happy with the care and support they received at Rowan House Residential Home.

People said that the staff were “all lovely” and that they “loved them all”. People told us about the activities that they enjoyed.

We saw that people who use the service were happy to approach staff. People told us that they felt safe and that could discuss anything with any of the staff.

The inspection took place on 4, 5, and 27 November 2015 and 4 December 2015 and was unannounced to the care home and announced to the domiciliary care part of the service.

Rowan House Residential Home provides care and accommodation for up to 26 people who are living with dementia or who may have physical difficulties. On the day of the inspection 23 people were living at the care home. The home is on three floors, with access to floors via stairs, a stair lift or lift. Some bedrooms have en-suite facilities. There are shared bathrooms, shower

facilities and toilets. Other areas include three lounges, a dining room, and garden.

The service also provides domiciliary care services to adults within East Cornwall. On the day of our inspection 45 people were using the service. The home care service provides palliative care, as well as supporting people with physical disabilities, sensory impairments and mental health needs, including people living with dementia.

The service had 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.

At the time of our inspection the provider was managing the service in the absence of the registered manager. There was a separate manager in charge of the domiciliary care service. The provider was open and transparent about areas which required improvement and was responsive in taking action on the day of our inspection when we identified anything of concern. The provider was in the process of creating an action plan to address improvements and was keen to make changes quickly.

People received care and support from staff who were kind and caring, treated them with respect and promoted their privacy and dignity. Relatives told us they were happy with the care their loved ones received. People told us there could be more staff at busier times, such as lunch time and when people wanted to go to bed. At the time of our inspection the provider was taking action to make sure additional staff were available at such times. There were social activities available, but some people told us they would like more to do to occupy their time, such as trips out.

People did not live in an environment which promoted the principles of good dementia care because of poor signage and a lack of colour contrast. The environment was clean and free from malodours, but people were not always protected by effective infection control procedures because staff did not always display knowledge of infection control practices.

People told us they enjoyed the meals, and people were supported to eat and drink enough and maintain a balanced diet. People who were at risk of losing weight were not always effectively monitored to help ensure prompt action was taken, such as contacting the person’s GP.

People felt safe. The provider and staff understood their safeguarding responsibilities and staff had undertaken training. People were protected by safe recruitment procedures as the registered manager ensured new employees were subject to necessary checks which determined they were suitable to work with vulnerable people. However, records did not demonstrate disclosure and barring service (DBS) checks had been risk assessed to help ensure staff were suitable to work at the service. There was a whistleblowing policy in place, however, some staff told us they had not felt confident about whistleblowing in the past, but explained they now felt confident, and would report any concerns to their line manager or to the provider. The provider told us he would be having further discussions about whistleblowing with the staff team to alleviate any worries they had.

People had risk assessments in place to help staff minimise risks associated with people’s care. People had personal evacuation plans in place, which meant people could be effectively supported in an emergency. The environment was not regularly assessed and monitored to ensure it was safe at all times.

People’s consent to care and treatment was obtained, and staff asked people for their consent prior to supporting them. People’s care plans did not always provide guidance and direction to staff about how to meet people’s individual needs. People were not always involved in the creation of their care plan. External health professionals told us communication was not always effective regarding people’s changing care needs.

People’s end of life care and resuscitation wishes had not always been recorded so staff would know what to do at the end of a person’s life to ensure they received the care they wanted. People’s medicines were not always stored securely and documentation was not always in place to help guide and direct staff about the correct administration of medicines. Systems were not in place to monitor the management of medicines and staff who were responsible for medicines had not received effective training. The provider took immediate action to arrange training for staff at the time of our inspection.

People who were deprived of their liberty had been assessed to ensure their human rights were protected. People’s mental capacity was not always assessed which meant care being provided by staff was not always in line with people’s wishes. For example, people who lived with memory loss or dementia did not have care plans in place to provide guidance and direction to staff about how to support the person effectively.

People and those who mattered to them were not always encouraged to provide feedback about the service they received. People told us if they had any concerns or complaints they felt confident to speak with the staff or registered manager. People received care from staff that had been given training and supervision to carry out their role. Staff felt supported. However external health professionals felt staff required further training to improve their competence, such as identifying health care concerns promptly and recording people’s blood pressure.

The provider did not have effective systems and processes in place to ensure people received a high quality of care and people’s needs were being met. The Commission was not always notified appropriately, for example in the event of someone passing away.

The provider had an ethos of honesty and transparency. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

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