CQC report explained · a residential care home
What the CQC found at Longroyds and Pilling House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Morning medicines were given late to 7 to 8 people because an agency worker could not access the electronic medicines system. Laxative and cream records were incomplete, although the home said it had taken corrective action.
- Effective?
- Good
- People's dietary and healthcare needs were generally met, and staff worked with healthcare professionals. Formal supervision and some training had not been regular, but these issues were addressed after the inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection, so its previous rating carried over.
- Responsive?
- Good
- This key question was not inspected during this focused inspection, so its previous rating carried over.
- Well-led?
- Requires improvement
- The home had a positive staff culture and regular regional manager visits, but quality checks did not always record actions, timescales and completion clearly. It was also unclear how some negative survey feedback had been handled.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found kind and effective care, but medicines management and oversight were not consistently safe.
This was an unannounced focused inspection on 30 November 2022. Inspectors reviewed records, medicines, staffing and care, observed mealtimes, and spoke with people, relatives, staff and a healthcare professional.
The home was rated Requires Improvement overall. Safe and well-led were Requires Improvement. Effective improved from Requires Improvement to Good. The home had staff present and people generally felt safe and well cared for.
Inspectors found problems with medicines records and late morning medicines. Some risk records, staff checks, quality audits and feedback systems also needed to be stronger. The home said it had taken action after the inspection on medicines, supervision and training.
The home remained Requires Improvement, as it had at the previous inspection published on 17 August 2021. This was its second consecutive Requires Improvement rating. CQC said it would continue to monitor the home with the provider and local authority.
People generally felt safe
People and relatives said they felt safe. Staff knew how to recognise and respond to possible abuse.
“People and relatives told us they or their loved ones felt safe.” from the report
Kind and positive culture
People and relatives were mostly positive about the care. Staff described good teamwork, and inspectors saw care that supported a person's wellbeing.
“The home had a positive culture which helped to ensure positive outcomes for people.” from the report
Healthcare support
Staff worked with a range of healthcare professionals and acted when people became unwell or needed specialist support.
“Staff worked well with healthcare partners to meet people's needs, which were assessed before they moved to the home.” from the report
Food and drink needs met
People were offered meals, snacks and drinks, including support and supplements when needed. Mealtimes were generally pleasant.
“People had enough to eat and drink and dietary needs were being met.” from the report
Medicines were not reliably managed
seriousSome morning medicines were given late. Records for laxatives and topical creams were not complete, and not all medicine competencies were up to date.
“Medicines were not robustly managed at this inspection.” from the report
Safety records had gaps
needs fixingRecords did not always show how often people needed repositioning, and some repositioning records were incomplete. A recruitment check was also not recorded as followed up.
“However, repositioning records did not show how often a person needed this support, and there were gaps in the recording of repositioning care.” from the report
Quality checks were not always followed through
needs fixingAudits did not always include clear action plans, deadlines and confirmation that actions were complete. This reduced assurance that problems were being properly monitored.
“These did not always include an action plan with timescales and sign off to show actions were completed.” from the report
Family involvement and contact needed improvement
minorThere had been only one meeting for people and relatives in 2022. Some relatives reported difficulty getting through by telephone, and the home could not show how most survey feedback had been acted on.
“We were unable to see how feedback had been responded to by the provider, with the exception of feedback about a particular dining option.” from the report
Some infection control and visiting concerns
needs fixingSome staff and a contractor were not wearing face masks correctly. Three relatives who said they were essential care givers reported being unable to visit during an outbreak.
“Two other relatives who said they were essential care givers said they were also not allowed to visit the home.” from the report
- 01What has been done to make sure agency staff can access the electronic medicines system before giving medicines?
- 02How do you now check that laxatives, topical creams and other medicines are recorded correctly?
- 03Can you show us how repositioning care and other safety records are checked for gaps?
- 04What deadlines and sign-off process are now used for actions found through audits?
- 05How can relatives contact each house, and how will family feedback and visiting rights be handled during future outbreaks?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 25 February 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, August 2021
Longroyds and Pilling House Care Home: Rated Requires Improvement; inspectors found safe staffing and medicines systems, but environmental risks and management needed improvement.
This was a focused inspection of Safe and Well-led. Inspectors visited on 28 April and 15 June 2021, with inspection activity ending on 20 July 2021. They spoke with people, staff and managers, and checked care, medicines, recruitment and management records.
Inspectors found that some environmental risks had not been identified or managed. These included exposed pipes, an unsecured boiler cupboard, an open key cupboard and a stair gate that could be a trip hazard. Learning from an incident had also been missed. The provider took action during and after the inspection.
There were also positive findings. People felt safe, staffing met people's needs, medicines were managed safely and infection control arrangements were in place. Records about mental capacity and best-interest decisions had improved, so the previous breach of Regulation 11 no longer applied.
The overall rating remained Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating. The inspection did not examine the circumstances of the death following the specific incident, which was subject to a criminal investigation.
Enough staff
Staffing levels were judged to meet people's needs, and recruitment checks were carried out before staff started work.
“Staffing levels met people's needs and were monitored appropriately.” from the report
Medicines
Medicines were received, stored, given and disposed of safely. Staff handling medicines had their competence checked.
“Medicines were received, stored, administered and disposed of safely.” from the report
Infection control
Inspectors were assured about infection prevention, testing, protective equipment, hygiene, social distancing and visits.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Improved decision records
Records about mental capacity assessments and best-interest decisions had improved since the previous inspection, and the earlier breach was no longer present.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 11.” from the report
Supportive culture
People and staff found the managers approachable, and staff said they felt supported by one another.
“There was a positive culture, where staff felt supported by one another.” from the report
Environmental safety
seriousSome parts of the building and equipment had not been made safe or secured. Inspectors recommended embedding better risk management in everyday practice.
“Some risks had not been identified and managed in the environment.” from the report
Missed learning from an incident
seriousThe response to accidents and incidents was appropriate, but inspectors found that learning from one incident had not been identified and used to prevent similar events.
“We found opportunity for learning had been missed due to the shortfalls identified above.” from the report
Out-of-date training
needs fixingSome staff training had expired and was being addressed by the manager.
“Some staff training had become out of date.” from the report
Inconsistent records
minorSome medicines records were not consistent. The home had moved to a new system to improve record keeping.
“Some of the record keeping was not always consistent.” from the report
- 01Have all the exposed pipes, the boiler cupboard, the key cupboard and the stair gate been made safe, and how are these checks recorded?
- 02What changes were made after the incident to ensure learning is identified and similar incidents are prevented?
- 03Which staff training was out of date, and has all required training now been completed?
- 04What checks are now used to make sure medicines records are complete and consistent?
- 05When will the next comprehensive inspection review the Effective, Caring and Responsive areas?
This was a focused inspection of Safe and Well-led only; the other three key questions were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 17 August 2021 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 Longroyds and Pilling House Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Longroyds and Pilling House Care Home →
- August 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Longroyds and Pilling House Care Home →
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
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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