The Larches - Tiverton

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• 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 Requires Improvement. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff did not feel the provider actively engaged with them. For example, they were not kept up to date about any risks and challenges for the service that affected the day to day running. This led to on-going speculation and unease amongst the staff group.

The provider did not consult with staff about proposed changes.

There had been a period of approximately 4 months when the home had been without a manager. This had put pressure on other staff to take on roles which they did not always have the experience or knowledge to undertake. Some said this was a responsibility they had not chosen. Staff said they were extremely relieved to have a new manager in place from 15 March 2026. Staff, people and families spoke positively about the new manager’s approachability and friendly nature. Staff said the new manager’s presence was reassuring.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Staff at the service spoke positively about the new manager in post. People living at the home knew who the new manager was and commented there had been lots of changes to get used to.

However, staff told us the provider’s communication with the staff team was “dire” and finding out decisions and actions by them was “hard work.” Other staff said they were treated ‘like a slave” and “spoken to like dirt” by the provider. In contrast, 1 staff member said they were treated well by the provider. Staff told us they worried about the well-being of internationally recruited staff.

Since November 2025, the registered manager, a new manager, the deputy manager, the acting deputy, seniors, day and night staff, and a new activity staff member had resigned. This totalled at least 10 staff members. However, the provider said “We do not conduct exit interviews.” This response showed a lack of commitment to learn from staff resignations to achieve staff stability which would have impacted positively on the people living and working at the home.

People did not always feel they could speak up and their voice would be heard.

Feedback to CQC indicated longstanding issues with the provider’s approach, staffing stability and low staff morale, with concerns reported from 2023 onwards.

Staff said they were reluctant to raise concerns with the provider. They did not feel confident they would be treated with compassion and understanding, and were worried they would be blamed, or treated negatively if they did so. Some staff were reluctant to challenge the provider or correct them regarding the accuracy of information. Staff said they did not feel valued by the provider and felt business decisions were financially based as opposed to providing a safe and stimulating place for people to live.

Two families had raised concerns with the provider and were waiting for an outcome. One family said there had been delays in getting a satisfactory response and felt the goal posts were being moved regarding a resolution.

The new manager had taken time to meet and greet relatives and had plans for increased meetings to gain feedback from people and their families. Surveys had been sent to relatives in 2025 by the previous registered manager and over half had been returned. Feedback was extremely positive about the caring nature of the staff group. For example, ‘Mum is happy, well cared for and I feel confident in her being here’ and ‘Everyone we have met has been a joy to interact with.’

When we spoke with relatives as part of this assessment, they again praised the staff team but raised some concerns about the general environment, tired appearance of the building, on-going issues with the lift and the lack of secure accessible outside space. For example, they said “Considering the property they work in (staff) do a good job. It’s not a good property to work in or live in... It’s a tough place for staff to be working in going up and down the stairs etc” and another said “I think the team are working in a property that is extremely challenging compared with other care facilities. It’s difficult to get around...”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a diverse work force. People and families commented on how the staff group worked well as a team. We observed a good working relationship between team members regardless of their role. Some staff were working through sponsorships and had worked at the home for several years. Other staff members commented on how much they valued their kindness and skills. We saw people were at ease with all members of the staff team, including ancillary staff.

However, some staff remained concerned about their roles and their hours. We saw 2 staff contracts, where the hourly pay did not match memos to individual staff. These showed a lesser hourly rate. Some staff were reluctant to engage in conversations relating to their working conditions.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s monthly audits were poorly completed and did not show a progress of actions. For example, an audit dated January 2026, showed staff were not recording accidents and incidents appropriately. This meant they could not be audited, and action plans were not set up to try and mitigate risk of harm. In March 2026 we found incidents in ABC charts between people were still not logged appropriately.

Sections of the provider’s monthly audit were left blank including complaints, training and supervision matrix checks, and recruitment.

Governance arrangements were insufficient to ensure security and sustainability of the service. Staff said external agencies regularly rang to chase payment of their unpaid invoices. For example, unpaid agency staff bills which led to agencies not providing care workers when staff requested them. Staff said this was “embarrassing”. Several key invoices were unpaid. They had made the provider aware of the calls, but the calls continued from agencies chasing payment.

The provider had not established a meaningful system to show how they checked on environmental risks, such as hot water temperatures. There was no log to show they had addressed the missing January 2026 hot water temperatures or picked up on contradictory records linked to the kitchen fire door not closing effectively. The lift door on the ground floor remained unsafe despite feedback from the servicing company.

The provider did not act when records showed staff had not completed regular fire safety practice and drills to keep people safe in the event of a fire.

Many of the people living at the home were living with dementia. The provider’s service improvement plan showed planned timescales were missed. For example, dementia care sections in care plans were due to be completed on 31 October 2025. On 27 February 2026 it was noted ‘no dementia care plans had been completed.’ This work was still showing as incomplete at the time of our assessment. This meant care plans lacked appropriate guidance for care staff to meet people’s care needs in a person centred way.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff told us they had good relationships with health professionals who supported people’s care. This included the district nursing team, and a GP service, which included a weekly visit. A staff member shared examples of joint working to help people improve their mobility and regain confidence. We received feedback from a health professional which showed staff worked collaboratively with them to improve people’s health outcomes.

However, as noted previously in the report, the provider had failed to attend arranged meetings with partners. There was limited evidence they were open to collaborating with other agencies to drive improvements in the service. Information requested by CQC and other healthcare professionals was not provided in a timely manner or had not been received.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

During this assessment we identified 6 breaches of regulation in safe care and treatment, safeguarding, staffing, recruitment, dignity and respect and governance. Five of these related to the key questions Safe and Well-led, and were concerns raised at 3 previous CQC inspections starting in 2023. The provider’s governance arrangements were not adequate in ensuring the health, safety and welfare of people and opportunities to make improvements had been missed.

We were told the staff training matrix was being put into a new format by the provider. We were not able to review the staff training matrix to provide us with an oversight of how staff were updated and whether they had the knowledge and skills to meet the needs of people living at the service. Some staff said they were struggling to keep on top of their training; they were not supported by regular supervisions to help them manage this task.