Larchwood Grove

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.

This is the first assessment for this newly registered service. This key question has been rated 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 service was in breach of legal regulation in relation to governance at the service.

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.

The provider’s statement of purpose lists, ‘Residents at Larchwood Grove have the right to live a lifestyle which is geared to their personal choice and preference and to have their personal dignity respected at all times along with their values and beliefs. We take great pride in listening to our residents at all times including thoughts, opinions and attitudes respected and considered.’ We observed this was mostly put into practice in the service.

Staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “We have a good relationship as staff, we communicate as a team, communication is highly promoted”, “The culture of the service has improved since [registered manager] has been here”, “It is a very friendly home, I really enjoy my job” and “I am happy being part of the family, we are like 1 big family. We all communicate with each other. Communication is very good. We all support each other.”

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 mostly had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Services providing health and social care to people are required to inform CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. Systems were not effective in ensuring that incidents had always been appropriately reported. CQC had not been notified of DoLS authorisations. The nominated individual and registered manager were unaware this was required. During the assessment the registered manager submitted DoLS authorisations in retrospect. Safeguarding allegations had not always been reported to CQC.

The registered manager knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with a registered manager and a deputy manager. The deputy manager had left the organisation 2 weeks before we started the assessment, and the provider was in the process of recruiting to the vacant role. The service also had care staff to provide care and support as well as a cook. The registered manager told us they were well supported by the provider. Staff told us the registered manager was supportive and approachable and were confident in reporting any concerns. Relatives told us the registered manager was approachable. Comments included, “[Registered manager] is very approachable” and “I know the manager well.” A person told us, “I like [registered manager].”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistle blowing policy in place. Staff felt confident in reporting to managers and staff knew they could report outside of the organisation. A staff member said, “I would feel confident to whistle blow. [Registered manager] is very open, always willing to listen.”

Staff confirmed they had staff meetings and were encouraged to contribute. Staff told us they were encouraged to voice their ideas for improvements and any concerns.

The service had received no complaints within the last year. A person told us, “It is excellent, I have no complaints at all.” Relatives told us the registered manager was responsive. Comments included, “I have been very satisfied with the way they have dealt with things” and “If I have got a problem or [person] has got a problem, I tell her and they try to sort it out.”

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 told us they felt well supported and they felt communication was good. Staff told us there was flexible working, around childcare and religious needs. Staff said, “[Registered manager] is so good, she really helps us. She is very reliable. If I have any questions and worries I can go to her”, “Every time I need help, I get it. I am very happy” and “[Registered manager] is the most amazing soul I’ve ever met, so loving. I can speak for all the staff, she is so supportive, she’s an amazing person.”

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.

There was a lack of provider and registered manager oversight of the service. Audits and checks were not robust and had not identified the issues we found at the assessment. Audits had been carried out of care plans, medicines, health and safety and infection control. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, medicines audits had not identified the issues we found. Care plan checks had not identified that care plans did not provide staff with guidance on how to provide care and support and that essential care plans and risk assessments were missing. Audits had not highlighted the concerns around capacity and consent.

The provider had worked in early 2026 to address actions set by the local authority to improve the environment of the service. The lounge area had been renovated, new flooring had been laid throughout, new furniture had been purchased, and a shower room had been installed.

Staff were committed to the service and making any changes and improvements that were required. A staff member said, “If there are concerns, we will fix them.”

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.

We observed some people were supported to get out into the community to access day services and appointments. The registered manager told us that people were well known in the local area and utilised the local amenities such as shops, pub and a club which took place on a Wednesday. People and their relatives told us about support to attend football matches, cafes, pubs, theatre, appointments and other activities which people enjoyed.

The service produced a regular newsletter which showed people and their relatives news about the service. The newsletter had been halted when the building works had been taking place, but the registered manager planned to restart this.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider and registered manager told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions. The registered manager told us they attended support networks with other registered managers, such as local authority forums and gained support from organisations such as skills for care. The provider and registered manager told us that changes made at the service would inform changes and actions at the provider’s other registered services.