About the service: Rowans Care Centre is a 36 bedded care home providing nursing care. At the time of our inspection there were 25 people living in the care home, located in a residential area of Macclesfield. The premises provide purpose-built accommodation for 36 people in single bedrooms. It is a two-storey building and people live on both floors. Access between floors is via a passenger lift or the stairs.

People’s experience of using this service:

People received good standards of care. The atmosphere at Rowans Care Centre was welcoming, friendly and sociable. The registered manager and staff had developed good relationships with people. Throughout the inspection staff were seen to provide sensitive and compassionate care.

Staff worked together as an effective team because they benefited from having shared aims and objectives. The registered manager was highly visible in the home providing guidance and leadership, so staff were clear about their roles and responsibilities and knew what was required to ensure the service provided good care to people. Everyone we spoke to during our inspection had something positive to say about the home and the standard of care provided.

People felt safe living at the home and had confidence in the management and staff teams. Risks to people’s health safety and welfare were identified and plans were put in place to ensure risk of harm was minimised, so people were safe. Medicines were managed safely, and people received their medication at the right times. The environment was safe, and people had access to appropriate equipment where needed.

There was enough suitably qualified and skilled staff to meet people's individual needs. Staff told us that morale was good, they were very well supported and received a range of training opportunities appropriate to their role and people's needs. Staff appreciated the support and leadership provided by the registered manager. They had received guidance on the provision of person-centred care and equality and diversity. This produced a positive caring working environment where staff shared a clear vision and credible strategy to deliver high-quality person-centred care and support.

People were involved in every aspect of delivery of care. Their personal needs and preferences were reflected in care plans so staff knew how to meet their needs in a person-centred way. Staff had a good understanding of people’s individual needs and preferences and worked effectively to ensure people’s needs were met.

People received the right care and support to eat and drink well and their healthcare needs were understood and met. People who were able, consented to their care and support. Where people lacked the capacity to make their own decisions they were made in their best interest and in line with the Mental Capacity Act 2005.

Effective quality assurance process were in place.

Rating at last inspection: Requires improvement (report published 8 September 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on 30, 31 January 18 and 2 February 18 and was unannounced.

We undertook an unannounced focused inspection of Rowans Care Centre on 30 January 18. The urgent focused inspection was triggered following a serious incident which other agencies including the police were looking into. We found concerns on the focused inspection and we therefore undertook a full comprehensive inspection on 31 January and 2 February 18.

The service is a 36 bedded care home providing nursing care. At the time of our inspection there were 33 people living in the care home. There were two floors with a lift and adapted facilities.

We found concerns on this inspection related to safe care and treatment, staffing levels/deployment, care planning, person centred care and governance.

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

There was a registered manager in post. 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.

We looked into staffing levels and found they were not always sufficient to meet the needs of people. There were a high number of people remaining in bed and staffing levels were inconsistent on the rotas.

A safe level of care was not always being provided. Care plans we viewed were lacking in specific detail required to safely care for people.

During our inspection we found one person had not been supported to eat and drink according to their speech and language therapist's recommendations to reduce the risk of aspiration. Aspiration is the risk of a substance entering the lungs such as food/drink debris.

Risks were not being actioned upon or escalated in a timely way to always protect people from harm. For example, the registered manager was aware there were some areas within the care home where the call bell system was not working but had not escalated this to be repaired in a timely manner.

Staffing levels were inconsistent. The dependency tool was not being used in conjunction with other methods of assessing an appropriate staffing ratio in line with National Institute of Health and Care Excellence and Royal College of Nursing guidance.

The system of communicating important clinical information to care staff was at handover or to ask the nurse in charge. We were therefore, concerned care staff were not provided opportunities to read the care plans to appraise themselves of the important details they needed to know to care for a person. Care staff were seen asking the nurse in charge their queries and were not seen accessing the care plans.

The premises were in the process of some refurbishment. The garden/exterior of the care home was not being utilised. Its design required further adaptation to meet people's needs.

People's dignity was not always being upheld. A high number of people were seen remaining in bed when some people were able to sit out but were not being encouraged to. We observed staff rushing when delivering care leaving one person with a wet top on after providing them with care.

People were not always being provided with choices. Staff were unable to provide person centred care when information in care plans had not always been kept up to date for staff to know how to best support each individual person.

There was a system of recording when deprivation of liberty applications (DOLs) were being sent to the Local Authority and approved.

Further systems of communication were needed to obtain people's views about how the service could be improved. We found only one concern had been lo

The inspection took place on the 10 February 2016 and was unannounced.

Rowans Care Centre Care Centre provides nursing and personal care for up to 36 people. It provides nursing and personal care, including care for people living with dementia. On the day of the inspection 34 people were living at the service, 33 of whom required nursing care.

Accommodation is provided on two floors, with lounges available on both floors. A passenger lift and stairs provide access to the first floor. The main dining area is on the ground floor. There is a small car park at the front. Assisted bathing facilities are provided.

At our last inspection we found that some of the more vulnerable people who lived at the home were at risk of their needs not being met because of a lack of management oversight and poor communication between staff. Risks were not being managed effectively and medicines were not always stored and administered safely. There were processes to monitor the quality of the service but these were not being used effectively so problems were not always identified or addressed in a timely manner. There was a lack of attention to nutrition and hydration for those who required assistance and care was not carried out in accordance with people’s care plans. The provider had also failed to notify us of two significant events they were required to.

At this inspection we found that all these issues had been addressed.

The service had a registered manager in post who had worked at the home for about a year and a half. 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.

Prior to this inspection we received feedback from the local authority contract monitoring team, who said that the home had been subject to an improvement plan but the actions required were completed. We looked at the carehome.co.uk website and saw the following review from October 2016, left by a relative of someone who used the service: “There is an unhurried pace to The Rowans, not regimented, residents choose how to spend the day, not all placed in the lounge at 9.00am. The rooms, activities, garden, vegetable plot are all well kept and the staff are caring and fond of the residents in my experience.”

We found that the service provided good care and support to people enabling them to live fulfilling and meaningful lives. People that were able to talk to us said they were happy in the home and with the people they lived with. The interactions we observed between people and staff were positive.

People told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. Comments included: “I have no concerns at all, I am happy here”; “I have been here a year and I find it fine”; “All X’s needs are catered for and X is happy here”; “I get everything I need”; “This place is like a proper home to my Mum and when I come it’s not like visiting a business it’s like I am coming to her home”.

The staff ensured people’s privacy and dignity were respected. We saw that bedroom doors were always kept closed when people were being supported with personal care.

People remarked that the food was good and there was plenty of it.

People could choose how to spend their day and they took part in activities in the home. The home employed activity organisers who engaged people in activities in small groups and individually during the day. They also occasionally took people out in the local community.

People’s needs were assessed and care plans were developed to identify what care and support people required.

People's health and well-being needs were well monitored. There were regular reviews of people’s health and staff responded promptly to any concern

When we visited the Rowans Care Centre on the 28 November 2013. We found improvements were needed to protect people from receiving inappropriate or unsafe care. Following our inspection in November 2013 the manager wrote to us in January 2014 and told us that the required improvements in the planning and delivery of care had been made.

Quality assurance officers from the local authority's adult safeguarding unit visited the home in February 2014 and identified further concerns regarding the planning and delivery of care. The provider informed us of a change in management at the home and the appointment of a peripatetic manager. The provider developed a more detailed action plan which indicated that improvements would be made by the end of April 2014. This included strengthened quality assurance arrangements, overseen by the regional manager who monitored and supported the home's progress and development.

Quality assurance officers from the local authority carried out further audits in March, April, May and June 2014. They identified that whilst further improvements were required in some aspects of provision including staff training, and record keeping progress had been made in the overall management of the home and the planning and delivery of care.

We were informed that a new manager was appointed and started work at the home during the second week in June 2014 and the peripatetic manager would remain at the home in support of the new manager for the foreseeable future.

We carried out a further inspection on the 13 and 17 June to follow up on action taken by the provider to ensure people were receiving safe and appropriate care.

We identified that there were still a number of issues and made compliance actions against outcome 1, Respecting and involving people who use services, outcome 2, Consent to care and treatment and served warning notices against outcome 4, Care and welfare of people who use services and outcome 21, Records.

Following the inspection the provider sent us an action plan which explained how and by when the compliance actions and warning notices would be complied with.

This visit was undertaken to confirm the issues identified had been dealt with appropriately and to assess if the service was now compliant.

During the inspection we spoke with 10 of the people using the service, four visiting family members and a total of seven staff members including the regional manager.

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

We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with the people who used the service, their relatives, the staff members supporting them and from looking at records.

Is the service safe?

We found that the people who lived at the home were now receiving safe and appropriate care and support and could see that improvements had been made in the delivery of care since our last inspection. We saw examples of good practice, particularly in the way staff interacted with the people living in the home.

People were receiving care in accordance with their assessed needs and the records being maintained were protecting them from receiving inadequate or unsafe treatment and care.

Is the service effective?

Everyone we spoke with was positive about the quality of care being provided, however we did receive some negative comments regarding the high use of agency staff at night. One person we spoke with described it as, “The weak link”. We discussed this with the regional manager who confirmed that she was aware of this and was trying to address it as soon as possible. A new night carer was due to start, they were actively recruiting staff and staff from another home that was due to close would be transferring to the Rowans in the immediate future.

Is the service caring?

Comments from the people using the service included, “The girls are very good, they always treat us with respect and dignity and don’t talk over me”, “Staff are very good”, “The staff are very nice” and “The staff are good, I have no concerns”.

We also spoke to four visiting relatives during our visit. Comments included, “Staff are wonderful, treasures, I have no complaints and they look after my relative really well”.

Is the service responsive?

Since our last inspection the provider had responded to concerns we raised and had taken action address them. A visiting relative told us, “It has a lot more order. I feel more relaxed and can see improvements”.

The staff members we spoke with were also positive about the changes that had been implemented since the last inspection, these included, “Things are improving”

Since our last inspection the provider had responded to concerns we raised and had taken action address them.

Is the service well led?

The provider has responded to the concerns raised previously and the regional manager plus peripatetic managers have worked hard to address them. The manager appointed in June left shortly after the inspection took place so the service had no registered manager in place at the time of our inspection. We were informed that a new manager had been recruited and would commence at the home in the near future. This person will continue to be supported by the regional manager in order to ensure that the improvements made are sustained.

When we visited the home we spoke with eight of the people who lived there. Some of the people we spoke with were able to discuss the way their care was provided. We asked them about their experiences of how the service involved them and kept them informed. They told us that they were treated with respect and were always involved in making decisions about their care and support.

We received many positive comments about the staff and the standard of care provided, including:

• One person told us told us that they had a long history in the service industry and said they “found that the staff were attentive and caring”. They told us that the staff behaved in a way that showed regard and respect for people “which created a genuinely nice atmosphere”. They told us how the manager had assessed their needs and made them feel involved with the whole process so they were confident that their needs would be met when they moved in. They told us that staff understood and respected their rights to make decisions and gave examples as to how this and helped them settle in and feel at ease in the home.

• Another person said the “care provided at the home is second to none”, the staff are beautiful, they are excellent”. A visitor to the home spoke highly of the home and the standard of care provided they said “it is excellent and they were very pleased their Mum had moved in”.

• Two other people told us how they had been encouraged and helped to personalise their bedrooms so they felt at home. We asked them if there was enough to do. They told about the home’s “pensioners club” where they get together play bingo, dominoes and other board games, organise outings and other activities such as jumble sales. They said “there is always something going on”.

As part of this inspection we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who may have difficulty expressing their views. We found that the home had a relaxed, sociable and welcoming atmosphere. We could see that the people who lived at the home were treated with respect and enjoyed good relationships with staff.

We could see that staff recognised the importance of helping create a relaxed and sociably atmosphere. They engaged people in activities at every opportunity and demonstrated genuine affection, care and concern for the people who lived at the home. One person received special attention because it was their birthday which was celebrated with cake and singing “happy birthday”, which all participants were seen to enjoy.

We observed staff engaging people in conversation frequently, listening to them, and acting on their requests with courtesy and respect. The staff showed their knowledge of each person's individual needs and preferences by the way they assisted and supported them.

The inspection was unannounced and took place on the 26 May and 23 June 2015.

The Rowans Care Centre is a care home providing nursing and personal care which is located in a residential area of Macclesfield. The premises provide purpose built accommodation for 36 people in single bedrooms. It is a two storey building and people live on both floors. Access between floors is via a passenger lift or the stairs. On the first day of our inspection there were 32 people living in the home.

Rowans Care Centre has 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.

When we started our inspection we found that the registered manager was absent and management arrangements for the home were inadequate to ensure the wellbeing of the people. Staff told us that the registered manager had left the home and a replacement manager had been appointed to manage the home in April but they too had left on the 1 May 2015. We were not formally notified of these changes until 1 June 2015 when we received notification that the registered manager had left the home on the 8 May 2015 to take up a new position in the organisation. When we returned to complete our inspection on the 23 June 2015 we found that the registered manager had returned to manage the home until a suitable person could be deployed to replace them.

Whilst many of the people spoken with told us that they were well cared for we found that some of the more vulnerable people who lived at the home were at risk of their needs not being met because of a lack of management oversight and poor communication between staff. Some people were not getting the support they needed to take fluids until late in the day, risks were not being managed effectively and medicines were not always stored and administered safely. There were processes to monitor the quality of the service but these were not being used effectively so problems were not always identified or addressed in a timely manner.

People received visitors throughout the day and we saw they were welcomed and included. Visitors told us they could visit at any time and were always made to feel welcome.

We could see that staff ensured people’s privacy and their dignity was respected. We saw that bedroom doors were always kept closed when people were being supported with personal care.

People told us that they enjoyed the food and could choose how to spend their day. The home employed an activity organiser and volunteers who supported people to take part in activities in small groups during the day evenings and on occasion weekends.

Staff received specific training to meet the needs of the people who lived at the home including safeguarding vulnerable people from abuse. All staff spoken with were confident that any allegations made would be fully investigated to ensure people who lived at the home were safe.

Some people who used the service did not have the ability to make decisions about some parts of their care and support. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

Following our inspection we were informed that a suitably qualified, experienced and competent person had been appointed and deployed to manage the home. This person told us that they were in the process of applying to the commission for registration as manager. This will help to ensure that the people who live at the home receive safe, responsive and effective nursing and personal care.

We identified breaches of the relevant regulations in respect of safe care and treatment, person-centred care, meeting nutritional needs and good governance. You can see what action we told the provider to take at the back of the full version of the report.