Larchmere House Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The vision stated, ‘Our aim is to provide our residents with a caring, safe, homely environment in which their comfort, well-being, individual choices and wishes are at the centre of everything we do.’ We observed this vision was put into practice when we carried out the assessment.

The staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “I really like the home, management and staff are really friendly, I can discuss everything”; “The manager is approachable, and I know where she is if I need her” and “It is a fun atmosphere. We treat people as human beings, we have a laugh with residents.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The management team knew people well and were passionate about making sure people received good quality care. The registered manager shared that they had reported maintenance and building concerns to the provider, these had been added to the provider’s action plan. There was a clear management structure in place with the registered manager and a deputy manager. Nurses provided clinical support to people, and they were supported by senior care workers and care workers to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the nominated individual for the provider; the nominated individual visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider. The registered manager told us that the provider had been investing money to renovate the service. The lounge and dining area had been completed, and a new assisted bath had been installed, other plans included replacement of the lift were in progress and subject to planning permission.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Complaints processes were available. A person told us, “If I had concerns, I can speak to one of the managers, [staff] is nice, she would listen,” Relatives confirmed the registered manager was responsive and accessible and had followed up any concerns or issues they had, and they were satisfied with the response. A relative said, “Any concerns have always been dealt with.” Staff confirmed they were invited to meetings and encouraged to contribute. They mostly felt listened to. Staff meeting minutes evidenced that these took place regularly. Staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “[Owner] is very polite and nice, and will answer the door. If I had a problem I could go to him or [nominated individual].”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The workforce was diverse, and support was in place for staff. Any issues could be discussed openly at staff meetings or during supervision. The registered manager had an open-door policy and staff told us they would not hesitate to speak to the registered manager if they needed to. Most staff reported the staff all worked together well as a team. Staff told us, “[Nurse] and [Nurse] help care staff with personal care. I feel I can speak my mind. If I disagree, I will say about it”; “If I had an issue I can email [registered manager]. I am fully supported by my colleagues” and “Nurses appear to be helpful; I mainly use the seniors and the other girls. The nurses check in with me to see how I am getting on.”

The registered manager ensured staff with protected characteristics were supported with any reasonable adjustments if required. For example, altering shifts and working times to accommodate childcare arrangements and disability and providing equipment to support staff with a disability.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had systems in place to check the quality of the service. Audits had been carried out. There were monthly audits of infection control, care plans, kitchen, clinical governance, medicines, call bells, health and safety, and wounds. The registered manager carried out occasional unannounced nighttime checks. The provider used an external company (consultants) to carry out support and additional audits of the service. They carried out visits to the service and they carried out monthly off-site support with reviewing care plans. We saw that actions had been completed to address most issues identified in the range of audits. However, it was not clear that learning always took place from audits. For example, the consultants had identified areas of concern around food and fluid monitoring which had not been taking place. We identified issues around fluid monitoring during this assessment. The management team told us that a monthly nutrition audit was conducted to look at weight loss and any actions were taken as required to address this. The consultants had also identified gaps in recording of oral care and bowel monitoring. The registered manager told us these issues had been addressed by drawing up individual care plans. However, this had not been embedded across the service as we found gaps in recording oral care within this assessment.

The audits were not always robust enough to highlight and manage shortfalls in the service. For example, the health and safety audit had not identified burns risks from accessible pipework in the hot water tank cupboard, this had left people exposed to risks of harm. Medicines audits for May and June 2025 had not highlighted the issues we identified regarding paracetamol doses.

There had been a lack of clinical and management oversight of constipation risks relating to people as systems were not in place to review bowel charts regularly. This had led to people not receiving medicines and help in a timely manner to relieve constipation.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that all incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. The provider had displayed their last inspection rating on their website and within the building.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with GPs. The service worked closely with the local community. When events took place, these were open to the local community. We observed signs outside the service as well as inside advertising an upcoming open day and event. A person told us, “I get the Parish magazine, we have 2 pages in there every monthly with pictures.”

A healthcare professional told us, “We have developed a good relationship with [Deputy Manager] who usually takes the round, and is very helpful.” We requested feedback from a range of partners and organisations but did not receive responses.

Activities staff showed us how they had been working in partnership with people and their relatives to create memory books. They explained the books prompted discussions with people and as individuals and as groups. They explained that a picture book of activities was also put together for each person over the year. This enabled people to remember what they had been involved with, and it was nice for relatives to be able to see.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions. The registered manager sent us confirmation that issues had been addressed. They detailed that additional training was being added to address shortfalls and medicines practice has been reviewed and incidents investigated.

The registered manager had taken the opportunity to attend registered managers forums run by Skills for Care and video link local forums and local and national events to liaise with others and keep up to date with good practice.