Rowan Garth Care Home

The following is CQC's published account of its assessment, published 10 December 2025. References to “we” mean CQC. It describes findings at that time.

Date of assessment – 25 June to 17 July 2025. Two visits to the home were conducted on the 25 June and 3 July 2025. The assessment concluded on the 17 July 2025. This was a responsive assessment based on intelligence CQC held about the service and potential risk. During the assessment, 5 regulatory breaches were found in respect of safe care and treatment, the need for consent, person centred care, staffing and continued breach of good governance. Rowan Garth Care Home provides accommodation for up to 150 people who require support with nursing or personal care. Accommodation is provided across 5 separate units. A unit manager was in charge of each unit under the direction of the registered manager. At the time of the inspection, only 3 out of the 5 units were open and 82 people lived in the home. Some people living in the home lived with autism or a learning disability. Although this service is not registered as a specialist service, we still assessed the service against ‘Right Culture, right care, right support’ guidance. This was to check if the provider guaranteed people with a learning disability or autism respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. People’s needs and risks were not properly assessed, and staff did not have accurate and sufficient information on how to care for people safely. People’s care did not always adhere to best practice guidance. There were gaps in the delivery of people’s care and some people received care and treatment which was unsafe or insufficient. For example, some people’s continence records showed they were wet through and in need of a change of clothes on multiple occasions, indicating people’s continence care was insufficient. People’s behavioural needs and risks were not managed in a safe way to prevent physical harm or abuse towards other people and staff. Wound management did not follow best practice guidance recommended by the Royal College of Nursing. Dementia care planning and the environment in which people lived did not adhere to best practice guidance issued by NHS England. People’s health conditions and clinical needs were not managed and monitored in accordance with National Institute of Health and Social Care Excellence and other associated guidance. The management of medicines was unsafe. People did not always receive the medicines they needed at the right time or in a safe way to prevent ill-health or the unwanted symptoms of the conditions the medicines were prescribed to treat. Staff did not have sufficient clinical guidance on people’s clinical risks and medicines for complex health conditions such as diabetes and epilepsy. People’s medicinal care was not person centred and the checks in place to ensure people were not given medicines they were allergic to, were not robust. Medicines were not always stored at the right temperatures which increased the risk of them being ineffective. The organisational tools used by the provider to determine safe staffing levels were not based on robust or reliable information about people’s needs. During our assessment the number of staff on duty was not always sufficient to meet people’s needs. Staff spoken with confirmed this. An agency nurse told us, “From a nurse’s point of view, there are not enough nurses, agency nurses don’t like coming back. It is too much”. People’s consent was not always obtained in accordance with the Mental Capacity Act 2005 (MCA). Some restrictions on people’s lives were put in place without due consideration of the Deprivation of Liberty safeguarding legislation, designed to protect people’s human rights. The environment in which people lived was not adequately maintained. Some people did not have access to a working bath or an accessible call bell to ring for staff support when needed. Infection control standards were poor. Used personal and protective equipment (PPE) and other debris were found in the car park and other areas of the home. Furnishing, fittings and equipment was not always clean or in a good state or repair. The checks in place to monitor for the risk of Legionella bacteria in the home’s water system were not always completed. Staff were recruited safely and had access to an induction and training. However, staff did not always receive regular supervision or an annual appraisal of their skills and abilities for the provider to be assured of their competence. Governance arrangements to monitor the quality and safety of the service were not robust. The provider and senior management team did not have effective oversight of the service to ensure risks to people’s health, safety and welfare were mitigated. Staff knew what action to take in the event of an accident and incident and told us they would report any concerns conduct to the manager should they suspect potential abuse. The overall rating for this service is ‘Inadequate’. The service has been placed in ‘special measures’. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.