• Care Home
  • Care home

The Rowans

Overall: Good read more about inspection ratings

266 Eastgate, Louth, Lincolnshire, LN11 8DJ (01507) 608081

Provided and run by:
Boulevard Care Limited

Report from 21 June 2024 assessment

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Well-led

Good

Updated 1 August 2024

The registered manager was currently working at the service and an interim manager was in place. Whilst well-meaning and keen to learn, the manager was inexperienced and did not yet have the required qualifications for the role. They were being supported by the provider to obtain those qualifications and to manage the home. Auditing processes, where, overall, effective, but they had not identified the issues we raised during this inspection. However, people’s health and safety had not been impacted. Staff performance was robustly monitored. Work was needed to ensure staff were informed of and worked towards the provider’s aims, values, and strategy. Staff felt able to speak up and raise any concerns. They felt able to do so without fear of recrimination. The registered manager had an ‘open-door’ policy that welcomed feedback from staff.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture

Score: 3

Staff and management spoke highly of the company they worked for and felt proud that they contributed to improving the lives of the people they cared for. A staff member said, “I like to work here, it's a great place to work. I feel proud of the role that I and the other staff do." Staff felt able approach the manager and senior staff to discuss anything that could affect their role, or the care provided. The manager and senior team leader felt supported by the provider to enable them to provide high quality care and support for people. They felt valued and respected. The manager told us there was an ‘open-door’ policy and all staff were encouraged to speak with them should they have any issues. We observed staff talking with the manager and discussing people’s care discreetly and confidently.

The provider’s aims and values were placed on the wall in the manager’s office. This document was not present in any other parts of the home. When asked, management and staff were unaware what the official aims and values of the provider were. The manager acknowledged this and stated that work was currently being completed by the provider to have specific aims and values for each of its homes as well as collective ones for all within the provider’s group of services. The provider had an ‘Our door always open’ document on the wall in the entrance hall. This also provided the phone numbers for head office and senior staff should people, relatives or staff wish to raise any issues in private. The manager had a basic understanding of the CQC’s ‘Right Support, Right Care, Right Culture’ guidance. The CQC expects health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Although this document was not readily available for staff to review or for the manager to refer to, we did find that the provider was providing care in accordance with the three key aims. People’s care was personalised, they received the appropriate support needed to lead fulfilling lives and the culture within the home provided people with equal opportunities to succeed and thrive. People were active members of their community.

Capable, compassionate and inclusive leaders

Score: 3

The registered manager was not available throughout this inspection and will be away from work for a significant period of time. A senior team leader had been asked to carry out this role in their absence. Care staff told us the interim manager was capable and approachable and in the short time they had been in post they had carried out their role effectively. The interim manager told us they felt they had the skills to carry out their role effectively. They were kind, caring and had a passion for ensuring their staff provided the best possible care for people.

The manager whilst caring and passionate in their role was inexperienced in managing a home like this. They were currently completing their Level 3 diploma. The qualification covers the knowledge and skills required to work in a lead adult care worker role in a range of settings and supporting individuals with different needs. There is an expectation that managers of care homes would have the Level 3 diploma completed and either be working towards or having completed their Level 5 diploma. This qualification focuses heavily on leadership and management. We were informed by the manager that they will be focusing on completing their Level 3 and then their Level 5 as a priority. We were offered assurance by a representative of the provider the manager was capable and would be provided with the support needed to carry out their role effectively.

Freedom to speak up

Score: 3

Staff spoken with felt able to raise any concerns they had and were confident they would be acted on. A staff member said, “An issue I raised recently was dealt with appropriately and I felt comfortable doing so.” Staff were aware of the whistleblowing procedure.

The provider had a number of systems in place that enabled staff to report any concerns they had about their role and/or the safety of people. Staff were encouraged to report any accidents and incidents, and these were analysed by senior management to help identify any themes or trends. If the provider was found to have been at fault for an accident or injury, there were processes in place that ensured the person was apologised to formally through a written letter.

Workforce equality, diversity and inclusion

Score: 3

Staff felt they were treated equally and did not face discrimination at work. All staff spoken with told us they enjoyed their roles and were supported by the management and the provider should they have any concerns, including any issues in their private lives.

Policies and procedures were in place to support staff to carry out their roles to the best of their ability. Staff retention was high, and this was reflected in the positive approach of staffing carrying out their role. Staff had access to external support networks both internally and externally. This included counselling services should they wish to discuss any issues they may be having in their private lives.

Governance, management and sustainability

Score: 3

The staff we spoke with praised the way the service was managed. They felt they were encouraged and supported to carry out their role effectively. Staff told us they received supervisions of their role and competency assessments; they found this to be a useful process that helped them to identify any areas of improvement in their work. The manager told us they had a strong and stable core team of staff in place, and they were confident that people were provided with the care they needed to lead happy and fulfilling lives.

The provider had a number of quality assurance and auditing processes in place that were designed to support the continuous review and assessment of the care provided and staff wellbeing. The audits assess the effectiveness of the management of medicines, quality of care plans, staff performance, accidents, and incidents and much more. However, it is concerning that these audits had failed to identify the inconsistent controlled drugs process and the missing epilepsy care plans for two people. Effective auditing processes, completed by suitably skilled and experienced staff, should have highlighted these issues. This could place people’s safety at risk. The manager had a basic understanding of the statutory notifications that must be provided to the CQC including, serious incidents resulting in harm, safeguarding and police involvement. The manager admitted their knowledge was limited on this process and guidance was provided during the inspection on what was expected of them. People’s electronic and paper-based records were secured. Access to people’s records was restricted. Any unauthorised access would be identified quickly, and action taken to address any security breaches.

Partnerships and communities

Score: 3

People told us they felt an active part of their local community. People were supported to visit many local attractions and amenities, some of which were specifically for people with a learning disability and/or mental health conditions; but also those were other members of the public visited. This support was provided following the CQC’s ‘Right Support, Right Care, Right Culture’ guidance.

Staff actively encouraged people to be active members of their local community. Throughout the inspection we saw people with support of staff going out to local shops, activities and in one case a music concert. Staff spoke passionately about the support they provided. People were encouraged to make new friends at local discos and other events and staff told us this had helped people to develop improved social skills. The manager felt they had a good working relationship with external partners such as the local authority. They said, "Every external relationship we have doesn't make me feel threatened, we are a team and all work together."

Prior to this inspection the local authority raised some concerns with us about the provider of this group of services. At The Rowan’s we did not find any evidence of poor practice.

Staff and leaders engaged with people, communities, and partners to share learning with each other that results in continuous improvements to the service. They used these networks to identify new or innovative ideas that can lead to better outcomes for people.

Learning, improvement and innovation

Score: 3

Staff felt they contributed to development and improvement of the home. They felt their views were valued and respected and where required, action was taken to address any issues. Staff felt involved with the review process following the use of physical restraint. Staff welcomed the opportunity to discuss this process and to learn from any potential errors and embrace more effective ways of supporting people. The manager told us they had a team of staff that were ready to learn and embraced change. The manager felt supported to implement new ideas that would benefit people’s lives.

Regular team meetings, staff supervisions and spot-checks took place to ensure that staff were always aware what was required of them. Where staff performance may drop below the expected standard, processes were in place to address this to ensure there was no or minimal impact on people due to poor staff performance. Innovation was encouraged, staff were actively supported to think of new ways to improve the quality of care and support people received. Staff provided numerous examples where they had tried different approaches to the care and support provided and the positive impact this had on people. For example, some staff have learned to use Makaton as a way of communicating with people who can’t always express their views verbally. Makaton is a unique language programme that uses symbols, signs, and speech to enable people to communicate. It supports the development of essential communication skills such as attention and listening, comprehension, memory, recall and organisation of language and expression.