Larchfield Manor

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 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 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. Managers demonstrated an awareness of the service challenges and had plans in place to address identified issues. Managers and staff shared a belief and commitment to providing safe, person-centred care for people who lived at the home. A staff member told us, “I love it here. It’s small and the care is excellent.”

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. There was no registered manager in place. The provider had arrangements in place to ensure management cover while they recruited to the manager post. Staff spoke positively about the provider, managers and recent changes that had been made. Staff members told us, “We have wonderful management. At the moment I think everything is doing alright.”

A person told us, “I think they are well organised. I don’t have any concerns.”

Staff knew how to raise any concerns either within the home or to external agencies and told us they were encouraged by managers to raise any concerns.

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. Staff were asked during the recruitment process if they required any specific additional help or support to enable them to complete their roles.

Systems were in place for the governance and oversight of the service, and the provider had recently introduced measures to strengthen quality assurance. Whilst the provider had already begun to strengthen systems and processes, these improvements were relatively new and had not yet been embedded sufficiently to demonstrate sustained effectiveness.

During the inspection, we identified inaccuracies and inconsistencies in people’s care records, gaps in fire safety arrangements and environmental risks. These matters had not been identified, escalated or resolved through the provider’s existing governance processes.

Although we found no evidence that people had experienced harm, these issues presented a potential risk to people. The provider could not demonstrate that its systems were consistently effective in assessing, monitoring and improving the quality and safety of the service. Managers responded openly during the inspection and took action to address the concerns. They reviewed oversight arrangements and introduced additional monitoring.

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 service worked with external professionals and agencies to support people's care and well-being.

The provider was committed to improving the service and had introduced a number of changes to strengthen quality assurance and oversight. Managers were receptive to feedback and took prompt action where areas for improvement were identified.

However, systems had not consistently identified issues before the inspection. This meant opportunities to learn, improve and prevent recurrence had not always been fully realised.