CQC report explained · a residential care home
What the CQC found at Longmead House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Longmead House was rated Inadequate and placed in special measures; inspectors found serious safety and management failures.
This was an unannounced inspection on 18 July 2023. Inspectors spoke with people, a visitor, staff and professionals. They reviewed care records, medicines records, staff files, incident records, audits and safety checks.
Inspectors found people were at risk because some risks were not assessed or managed. They saw unsafe moving and handling, medicines errors, poor cleanliness, an open fire door and incomplete recruitment checks. Incidents were not properly reviewed and lessons were not learned.
People were not always treated with dignity, and activities did not meet their needs. Care plans had not been reviewed regularly. The home’s checks had failed to find these problems. The overall rating fell from Good in 2018 to Inadequate, and the home was placed in special measures.
Kindness from staff
Several people said staff were kind, respectful and friendly. Inspectors also saw some kind interactions.
“The staff are very kind and look after me very well” from the report
Safeguarding arrangements
Staff had safeguarding training and knew how to report abuse. The home notified the local authority about safeguarding concerns.
“There was a safeguarding policy and procedures in place and staff were aware of these.” from the report
Fire safety knowledge
Fire checks were up to date and staff had suitable fire safety training. One staff member correctly explained what to do if the alarm sounded.
“There were up to date fire checks undertaken and the staff received appropriate training in fire safety.” from the report
Communication support
People’s communication needs were assessed and recorded, with care plans explaining how staff should support communication.
“People's communications needs were assessed, recorded and met. Care plans specified people's mode of communication and how staff should meet these.” from the report
Unsafe moving and handling
seriousInspectors saw two staff members use an unsafe moving and handling method. The person’s risk assessment did not explain how they should be supported.
“We witnessed 2 staff members undertaking an unsafe moving and handling manoeuvre with a person.” from the report
Medicines were not always safe
seriousMedicine records contained unexplained discrepancies, missing entries and unclear information. Medicines audits were also irregular.
“People did not always receive their medicines safely and as prescribed. We found some discrepancies during our inspection.” from the report
Poor cleanliness
seriousInspectors found a persistent strong smell, dust, dirt, stained carpets, food residue and damaged pressure cushions. This created infection and cross-contamination risks.
“There was a strong malodour in most areas of the home which persisted throughout the day. Carpets were stained and worn.” from the report
Limited activities
needs fixingPeople said they were bored. Activities were limited and were not planned or delivered in a way that met people’s needs.
“I get bored. We have to make our own amusement.” from the report
Care plans not kept up to date
needs fixingCare plans and risk assessments had not been reviewed regularly. Some information was inconsistent or did not explain how to support specific needs.
“Because people's care plans and risk assessments were not regularly reviewed, there was a risk the staff would not have up to date information and people's needs might not always be met.” from the report
Weak management checks
seriousAudits and monitoring were infrequent and had not identified serious problems with safety, cleanliness, medicines, dignity or activities.
“Systems to monitor and improve the quality of the service had been ineffective and standards had deteriorated since the last inspection.” from the report
- 01What immediate changes have you made to moving and handling assessments and staff practice since the inspection?
- 02How do you now check that every person receives medicines as prescribed and that medicine records are accurate?
- 03What cleaning work has been completed to deal with the smell, dirt, damaged furnishings and infection risks?
- 04How often are care plans, risk assessments and weight records now reviewed?
- 05What regular activities are now available, particularly for people living with dementia?
This was a focused inspection prompted partly by a safeguarding concern and covered Safe, Caring, Responsive and Well-led; Effective was not inspected and its previous rating was carried forward. This explanation was written from the published report of 1 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Good overall; inspectors found kind, safe care, but rated well-led Requires Improvement because important records were inconsistent.
This was an unannounced inspection on 12 April 2018. Inspectors observed care, spoke with people, relatives, staff and healthcare professionals, and checked care plans, medicines, staff files, training and quality audits.
Inspectors found enough trained staff, safe medicine storage, good hygiene and suitable checks to protect people. They also found kind and respectful care, personalised support, good activities and access to healthcare.
The main weakness was record keeping and oversight. Some risk assessments and care plans were incomplete or not updated, mental capacity decisions were not always recorded correctly, and some as-needed medicine protocols were missing.
The home was rated Good overall and Good for Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement because the improvements made since the previous inspection had not yet been applied consistently or shown to be sustained.
Kind and respectful care
Inspectors saw warm relationships between staff and people. Staff adapted their communication and respected people's choices, privacy and routines.
“People were treated with kindness and care, respect and dignity.” from the report
Personalised support
Care plans included people's histories, interests and preferences. Staff knew people well and supported individual routines, faith and independence.
“People's care plans reflected personal history and interests and were holistic.” from the report
Enough trained staff
Rotas showed that shifts were covered, and inspectors saw staff responding promptly to people's needs. Recruitment checks were also in place.
“People were cared for by a sufficient number of trained staff.” from the report
Good healthcare support
Staff worked with GPs, pharmacists, community nurses and other healthcare professionals. Inspectors found evidence that people's changing health needs were followed up.
“We found evidence of good working relationships with local GPs, the pharmacist and community nurses.” from the report
Incomplete decision-making records
needs fixingMental capacity assessments and records of decisions made for people were not always completed correctly. This was especially important where restrictions or supervision were being considered.
“The recording of mental capacity assessments were not always completed correctly in relation to the Mental Capacity Act 2005.” from the report
As-needed medicine records
needs fixingPeople taking as-needed medicines did not have individual protocols. Three liquid medicine bottles also had no opening date, so staff could not tell when they might become out of date.
“People who had 'as required' (PRN) medicines did not have a protocol in place.” from the report
Inconsistent incident records
needs fixingIncident records did not always explain the outcome or what had been done to prevent a repeat. This made it harder to identify patterns and monitor whether actions worked.
“It was not always easy to identify what the outcome of an incident was and what action staff had taken to avoid reoccurrence.” from the report
Care plans not always complete
needs fixingSome people's risk assessments and care plans had not been updated after incidents or were incomplete when people moved in. The manager said they would address the examples found.
“Improvements had not been fully or consistently implemented.” from the report
- 01How do you now check that every person's risk assessment and care plan is complete and updated after an incident or change in need?
- 02Does each person who has an as-needed medicine now have an individual protocol explaining when and why it should be given?
- 03How do you check that liquid medicines are dated when opened and that the homely remedies policy is regularly reviewed?
- 04How are mental capacity assessments and best-interest decisions recorded, especially before restrictions such as locked doors or constant supervision are used?
- 05How do you record incidents and track the actions taken to prevent them happening again?
This was an unannounced inspection covering all five key questions, including care, staffing, medicines, records, incidents and quality checks. This explanation was written from the published report of 6 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Longmead House
3 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- September 2023Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2018Goodstayed GoodSafe: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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