Larchfield Manor

On this page

• 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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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

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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Managers reviewed accidents, incidents and near misses to identify any lessons that could be learned, or improvements that could be made.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. However, records relating to people using the service were not always accurate, complete or consistent. We identified contradictory or incorrect information within care plans and assessments about people’s assessed needs, support requirements as well as incorrect names. Some records had not been updated to reflect people’s current circumstances.

Inaccurate and inconsistent records increased the risk that staff might not always have access to clear, current and reliable information when providing care. The provider took action during the inspection to review and update records and introduced additional checks to improve the prompt identification of errors.

Staff demonstrated an understanding of people’s needs, and people told us they received care that met their needs. We found no evidence that people had experienced harm.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Safeguarding systems and processes were in place. Staff had received safeguarding training and understood their responsibilities to report concerns. Deprivation of Liberty Safeguards (DoLS) applications had been made where required.

People told us they felt safe with staff and living at the home. People said, “I do feel [person] is safe” and “Yes, I am safe here, I love my life here.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People we spoke with told us they were encouraged to maintain their independence and take positive risks safely. Staff supported people to do the things that mattered to them while helping them manage any associated risks. For example, a person told us they regularly went out independently and staff would check what time they expected to return so they could respond appropriately if there were any concerns about their well-being.

Regular checks of the building and equipment were undertaken. However, we identified unsuitable window restrictors, and some wardrobes and radiator covers which had been fixed to walls, had become loose. These issues had not been identified promptly through the provider’s environmental checks and presented a potential risk to people. The provider took immediate action during the inspection to rectify the defects and strengthen the arrangements for identifying environmental concerns.

Fire safety checks and evacuation arrangements were in place. However, the provider could not demonstrate that a suitably trained fire marshal was available on every shift, as identified in the fire procedures. This had not been identified through the provider’s routine oversight processes. The provider acted during the inspection to review staffing arrangements, arrange additional fire safety training and ensure appropriate fire safety cover.

Some areas of the home were in need of updating. There was a detailed plan in place for the ongoing refurbishment and redecoration of the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Recruitment checks were in place prior to staff starting to work at the home. Staff received effective training, support and supervision.

The service had recently experienced a number of staff vacancies. People told us this had resulted in staffing shortages at times and an increased reliance on regular agency staff. The provider also redeployed some staff to cover alternative roles. However, vacancies had been filled, and new staff were in the process of joining the service. At the time of the inspection there were enough skilled and experienced staff deployed to provide people with timely support. A family member said, “I think there are enough staff, from what I have seen. I think [person] is getting their needs met. There is a combination of staff; agency and permanent. I think they are getting more and more permanent ones now.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home and equipment were clean, and risks associated with infections were assessed and well managed. The laundry did not have a handwashing sink within the immediate working area. We discussed with the nominated individual the arrangements for staff hand hygiene and the appropriate use of personal protective equipment. The provider took action to review these arrangements.

People told us staff wore personal protective equipment (PPE) appropriately and the home was always kept clean. A person said, “Yes, it’s clean they are pretty good. The bathroom is clean and they are always cleaning. The cleaners here are nice, they talk to me.”

Medicines were managed and administered safely. The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

A person told us, “The staff who do the medication I can’t fault them, they are really good. They do keep you up to date, if they change your pills. I know them so well and they know me.”