The Larches - Tiverton

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, including medicines and infection control, staffing, recruitment and safeguarding.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was not a culture of safety and learning. There was a lack of learning from events that had put people and/or staff at risk of harm. Known environmental risks were overlooked or ignored. For example, there was a known risk of potential entrapment in the lift door, this had not been addressed. Incidents were not always appropriately recorded and reported in a timely manner. For example, falls and medicine errors. There had been a breach of regulation relating to safe care and treatment at a previous inspection in 2024.

Lessons had not been learnt and sustained from previous CQC enforcement action in 2024. For example, recruitment was unsafe at the service as the provider failed to adopt a thorough and timely approach to ensuring staff were suitable to work with people living with dementia. For example, they had not requested a reference from a previous care employer or ensured appropriate police checks had taken place. There had been a breach of regulation relating to recruitment at a previous inspection in 2024. Improvements were seen at an inspection in 2025 but this had not been sustained.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

External agencies, including CQC, did not always receive requested information from the provider in a timely manner. This included the service improvement plan and evidence on how food was purchased by the service. This made it difficult at times to monitor how the service was being run and how concerns were being addressed by the provider. External agencies, including CQC, had arranged meetings with the provider, which the provider then did not attend.

Delays in the provider sending documents to demonstrate how they maintained safe systems of care and monitored people’s safety meant agencies became concerned around the systems and governance of the service. When documents were received, they were of poor quality with multiple gaps and lacked evidence on how people and staff members’ well-being was maintained.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were worried about the number of staff who had left in the last 4 months, which included the registered manager and the deputy manager. These staff changes made them feel less secure. Relatives were concerned about the impact of staff changes including the service being without a consistent manager for approximately 4 months. They worried the resignations of experienced and knowledgeable staff might compromise the safety of their relatives.

People said they felt safe with the staff group, who they described as kind and caring, although they felt more comfortable with permanent staff who knew their care needs well, rather than agency staff.

The new manager understood their safeguarding responsibilities, including the requirement to report them to an external agency such as the Care Quality Commission (CQC), which they had demonstrated during their short time in post. For example, appropriate safeguarding alerts had been made to the local authority linked to medication errors, with steps taken to improve staff practice. However, the provider had not demonstrated a similar understanding and previous safeguarding notifications had not been sent to CQC in line with legal requirements. This meant we did not have a reliable overview of safeguarding incidents in the home to help us measure risk in the service.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found applications were made appropriately.

The registered provider did not establish a robust system to manage and safeguard people’s personal money in accounts held in the main office. There was no second staff signature to help protect service users from staff error or to protect staff from allegations of misappropriation.

The provider did not always work well with people to understand and manage risks. However, staff did provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had not ensured staff met with people and their relatives to review their care. People and their relatives told us they had been involved in care planning initially but were not invited to review how risks to their health or safety were being managed on an on-going basis. This concerned some relatives who were worried their relative was falling more or at increased risk of severe constipation. Therefore, the provider could not demonstrate how people were involved in making decisions about their care and support or supported to understand and manage risk.

People were at ease with the staff supporting them. Staff were mindful of people’s safety, ensuring they did not face unnecessary risk when moving around the building. We observed attentive staff used equipment safely to assist people to move and reminded people to use walking aids. One person took a regular walk around the home with a staff member to build their confidence and strength and reduce their risk of falls.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People were put at risk of harm because the provider had not acted upon known risks such as a lift door that was identified as needing fixing in July 2025 but had not been actioned. This placed people at risk of entrapment.

Risks relating to fire safety were not safely managed. During our site visits staff were unable to locate a current fire risk assessment. The latest version available to us was dated March 2025. This fire risk assessment showed actions from previous fire risk assessments had not been satisfactorily addressed by the provider.

The provider had not ensured there were adequate systems and processes to ensure staff completed fire safety practice and drills to keep people safe in the event of a fire. The fire logbook showed no planned fire drill had been completed since 31 January 2025.

We saw unsafe practice linked to cleaning chemicals which were not stored securely. For example, the laundry was unlocked, the cleaning cupboard was left unlocked and a trolley with cleaning chemicals on it was left unattended. There was a burn risk from exposed hot pipework in an unlocked boiler cupboard. There was no record of hot water temperatures being checked in January 2026.These examples placed people living with dementia at risk of avoidable harm.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Recruitment processes were not operated effectively or safely. CQC had been contacted prior to the inspection by people raising concerns about the provider’s recruitment process.

Recruitment records showed the provider had employed staff without obtaining all the relevant information required under the Health and Social Care Act. We reviewed the pre-employment checks for 3 staff and found key information was incomplete or missing. The registered provider could not demonstrate all staff employed were fit and proper to perform their roles. This exposed people to the risk of receiving care from unsuitable staff.

The provider had not ensured their recruitment systems and processes were compliant with the relevant regulations despite CQC providing them with information and guidance and directing them to the relevant regulations.

Some people and relatives felt there were not enough staff. People shared examples of the impact of this including not being able to go outside on a regular basis and increased falls at night for a person. Following our inspection in 2025, staffing had been increased at night from 2 to 3 staff. However, this had since been reduced back to 2 staff members. Staff were not able to explain why this had happened, and relatives’ expressed concern as they felt this increased the risk of people falling at night.

We were informed night staff did not have access to working radios so they could not communicate with each other if they were in different parts of the building. This meant potentially there were delays to responding to falls or incidents if 2 staff were needed.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People were not always kept safe because infection risks were not safely managed. We saw red bags containing soiled laundry piled on a communal landing. These were not stored safely and were left unsupervised for over an hour.

The laundry was not kept locked despite signage stating it should be locked. There was no permanent member of staff overseeing the room. Therefore, soiled laundry in red bags was accessible to people living with dementia. Due to the size of the laundry, there was no clear separation between soiled and clean laundry which increased the risk of cross infection.

There were 2 bathrooms in the home; 1 containing a shower and 1 containing a bath. Both had rusty or mouldy equipment, and the grouting and skirting boards were dirty. We also saw stained carpets in 2 people’s bedrooms; the new manager asked staff to address these issues. Several relatives felt bedrooms could do with a deeper clean on a regular basis.

However, staff wore personal protection items, such as gloves and aprons appropriately, and this equipment was accessible and available around the home to help control cross infection. The home smelt clean.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

We found people were not always kept safe and pain free because of recent medicine errors. Some involved the use of patch medications, and their application. For example, there were no records of where patches were applied, so it was not possible to tell whether the site was being rotated in line with manufacturer’s guidance. There were no checks patches were still in place in between applications. This lack of effective management of patch medicines meant we could not be assured people always received their medicines correctly, as prescribed for them.

Medicines needing secure storage were poorly managed. Records were incomplete, so some balances appeared incorrect, and witnesses were sometimes signing the register before the administration details had been entered.

If medicines were prescribed to be taken ‘when required’ there was information in people’s care plans to guide staff when these might be needed. However, the time of administration of ‘as required’ medicines was not always recorded. This meant staff could not ensure there was an adequate safe interval between doses. Medicines administration record (MAR) charts were not always clear. This meant we could not be sure people were receiving their medicines in the way prescribed for them.

Medicines were stored securely. However, the temperature for medicines needing cold storage was not consistently monitored. This meant records did not show they were always stored according to the manufacturer’s instructions to make them suitable for use. Medicines with a limited life, once opened, were not always suitably dated, meaning we could not be sure all preparations were safe for use.