Larchwood Grove

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.

This is the first assessment for this newly registered service. This key question has been rated 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 service was in breach of legal regulation in relation to people’s safe care and treatment and medicines management.

This service scored 47 (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. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents had been reviewed and actions taken. For example, people had received medical assistance when they had injured themselves in a fall. Staff told us incidents were discussed in meetings and when accidents had happened. The accidents and incidents were reviewed to look at lessons learned. A staff member said, “Whenever an accident happens, we look at it and reassess the risk assessments. We are always proactive and look at hazards and remove them before something happens.”

A person told us when they fell and hurt themselves, they went to the hospital to get checked.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They had not always made sure there was continuity of care, including when people moved between different services.

When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital. However, when a person had attended a routine hospital appointment in June 2026, they had not taken a hospital passport. The person’s medical needs changed whilst at the appointment which led to them being admitted. This meant that the hospital did not have all the information they needed and they had to call the service to ask a number of questions about the person’s medical history, diagnosis and care and support.

The service had referred people to Speech and Language Therapy (SaLT) and other healthcare specialists when required.

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

Safeguarding and whistleblowing policies were in place and were accessible to staff. These policies gave staff the information they needed in terms of reporting. However, we provided guidance to the registered manager about additional guidance and signposted them to the local authority safeguarding information which all providers need to follow. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Staff told us they were confident to speak up if needed. A staff member said, “I would report abuse to the manager, I would document it, of course [registered manager] would deal with it. I can report it to CQC, the district nurses, the GP and social services.” Although staff understood their responsibilities to report a safeguarding concern, these were not followed through by the provider. Systems had not always ensured allegations of abuse had been reported to the local authority and CQC.

Relatives told us their loved ones were safe. A relative said, “No sign of feeling unsafe when [person] comes to see me.”

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. DoLS authorisations were appropriately applied for and overseen.

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

Risks to people were not always identified and risk assessments lacked enough detailed information for staff to know how to keep people safe. For example, people with epilepsy had no risk assessments in place detailing how staff should safely work with them when supporting them with a seizure, which included risks associated with bathing/showering, sudden unexpected death in epilepsy (SUDEP) and injuries. After the assessment, the registered manager created a risk assessment for people who had a diagnosis of epilepsy.

People at risk of constipation who were prescribed laxative medicines did not have risk assessments in place to detail what action staff should take if the person had not opened their bowels within specific time periods. A person’s care records had no risk assessment in relation to a known presentation which impacted their food intake. We observed them impacting their food intake during the inspection. This put the person at risk of weight loss and also was an infection control risk. A person was diabetic; there was no diabetes risk assessment in place to detail what staff should do if the person had high or low blood sugars and when they should call for medical assistance. Staff were able to tell us what action they would take when a person had low blood sugars. However, new staff and staff who did not know the person well would need to know and understand how to support them safely.

A person told us they did not feel safe at the service. We reported this to the registered manager who made contact with their local authority social worker. The person had already told someone else before we visited who had reported the concerns as a safeguarding concern. The person told us they did not feel well, and their mental health was in decline.

Relatives told us their loved ones were safe at the service. A relative said, “Yes I do (think it is safe), she is well looked after.” Another relative told us, “I’m not there 24/7, I can’t say too much about it, as far as I know he is okay.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, we observed window restrictors to some upstairs and downstairs windows which had been unhooked. This meant that windows were not restricted at all, which put people at risk. We reported this to the registered manager who clipped the restrictors back on the windows.

Maintenance tasks had been completed in a timely manner. Planned maintenance was in progress. The provider had just completed some modernisation works within the service. A person told us, “Since the new owner things are better, the old owner was very strict, the new design is more easier for walking with our frames.” People told us they liked the new shower room.

Bedrooms were clean, tidy and had been personalised in accordance with each person’s wishes. People were proud to show us their bedrooms and talked about their likes, which we saw were reflected in their décor and soft furnishings. The provider had systems and processes in place to detect and control potential risks in the care environment.

Essential servicing and maintenance of the service, utilities and equipment had taken place. Relatives told us that the service and grounds were well maintained. A relative said, “It’s been undergoing maintenance, changing furniture and new dining room, lots going on.”

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They worked together to provide safe care that met people’s individual needs.

Staff told us they received supervision and support. Most staff had completed mandatory training to meet people’s needs. However, staff had not been provided with detailed guidance and training on epilepsy, despite supporting people living with epilepsy. Staff responses around how they would support people having seizures showed a lack of training and understanding in this area. No staff had completed Makaton training despite providing support for people who used Makaton (which is a form of sign language) to communicate. Staff had completed level 1 of learning disability and autism training but had not completed level 2 which was required as part of their role. The registered manager told us this training was not available with their training provider. We also identified that staff had not completed allergen training despite preparing, cooking and serving meals.

The provider told us, required staffing levels were maintained on each shift and were planned around residents’ assessed needs and activities. There appeared to be suitable amounts of staff deployed to meet people’s needs. However, relatives told us they felt more staff were needed to support people to get out and about in the community. We observed that people were able to go out for short periods, however this was 1 person at a time. Relatives told us they felt more staff were needed to support people to get out and about in the community. Staff supported people to access the community, however staffing levels only allowed for this to happen 1 person at a time.

Staff had been safely recruited. All required checks had been carried out, and documents were all in-date. The information helps employers make safer recruitment decisions.

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. However, we observed hand soap and hand towels were not stocked in people’s ensuite toilets and in communal bathrooms. Staff told us this had been put in place to prevent paper towels being placed in the toilet. On day 2 of our site visit we observed that towel dispensers had been filled.

The service was cleaned by the care staff, cleaning schedules were in place which included deep cleans. Night staff also carried out some cleaning within communal areas. Staff carried out the washing of clothes and bedding in the laundry. People told us they were not really involved in the cleaning and household tasks, staff confirmed this. A person told us, “The lady is cleaning my floor upstairs. I don’t do any of my cleaning.” Another person said, “Sometimes I do some cleaning in my room, I clean the mats (place mats) in the dining room every day, I like doing that job.” A relative said, “It is very clean. Whoever cleans does a very good job.” The nominated individual for the provider told us, people were encouraged and supported to participate in cleaning their own rooms and other appropriate household tasks according to their abilities, preferences and willingness on the day.

The provider had plenty of personal protective equipment (PPE) in place to keep people and staff safe. We observed that the staff were using PPE effectively and safely. Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “We have gloves, aprons and masks. We have more than enough.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider had systems and processes in place to manage medicines, but these were not always effective. Medicines were not well managed.

We could not be assured people had received their medicines as prescribed as medicines stock counts did not tally up with electronic records. The registered manager told us this could be an issue with the electronic medicines administration system (EMAR) syncing and raised this with the system provider.

The temperature of non-fridge medicines had not been checked to ensure it was stored in line with manufacturers guidelines. We observed the temperatures on both days of the assessment to exceed 25 degrees Celsius in the room where medicines were stored. Storing medicines at higher temperatures can break down their chemical structure and make them less effective.

Medicines records showed some people had not had their prescribed medicines as it was out of stock. The provider had a medicines policy which was not always being followed, staff had not been recording creams administered on the topical medicines charts. Some medicines had not been given in line with the prescribers’ instructions. Levothyroxine medicine had been given at the same time as other medicines which was not the prescriber’s instructions. Taking Levothyroxine with certain medicines, foods and drinks can change how well the body absorbs or processes the thyroid hormone. People did not have PRN (as and when required medicine) guidance for constipation medicines and staff did not have adequate guidance to support people with their constipation.

After the site visits the registered manager carried out their own medicines stock count, raised concerns with EMAR provider and put in place paper medicines administration records as a backup until the issues could be resolved. The registered manager also told us they would ensure staff attended medicines refresher training and complete updated staff competency checks.

Medicines were stored securely. Despite the evidence above, most people and relatives gave us positive views about their medicines support. Comments included, “He has them in the morning 2 heart tablets and another 1 for iron, he has got a few tablets. He gets them when needed, they give them to him before breakfast” and “She needs a lot (of medicines), I have got no problems with that, no one said they have not been given to her."

The provider’s medicines policies showed they had regard for STOMP. STOMP stands for stopping over medication of people with a learning disability and autistic people. STOMP is a national project to reduce prescribing and administration of psychotropic medicines. It is about helping people to stay well and have a good quality of life. We observed that people were not over medicated and received regular medicines reviews with their GP.