Longmead Court Nursing Home

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 safe care and treatment.

This service scored 56 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and reported safety events. However, Lessons were not always learnt to continually identify and embed good practice.

Staff generally shared safeguarding concerns with relevant agencies and partners. However, inspectors identified 2 safeguarding incidents that had not been notified to the Care Quality Commission (CQC) as required by regulation, and 1 allegation that had not been reported to the local authority. The service submitted these notifications promptly once inspectors highlighted the omissions.

Staff recorded incidents relating to behaviours of concern, accidents, falls, and safeguarding. While the service produced individual emotional support reports, it had not analysed incident data to identify themes, trends, triggers, emerging risks, or the effectiveness of interventions, including the use of ‘as required’ (PRN) medicines. Strengthening oversight and analysis would support the service to review interventions, embed learning, and improve outcomes for people.

Records showed staff informed relatives when incidents occurred and shared learning to reduce the risk of recurrence. For example, managers facilitated a group supervision session following an incident to reinforce best practice in moving and assisting people. Feedback from relatives was mixed regarding the timeliness of actions taken in response to safety concerns. One relative told us, "I feel as if what I am saying and what [Person] is saying is ignored."

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Although we saw a service user guide was available to outline important aspects of the service when moving into the home, including key contacts and expectations, relatives told us they had not always felt fully informed or involved during admission. A relative told us “I was expecting someone to talk me through everything [when Person moved in]. They didn’t”. During the inspection process, the Registered Manager and Nominated Individual (representative on behalf of the provider) acknowledged the need to strengthen engagement with relatives throughout people’s care journeys.

People were supported to access healthcare services when required, and where there was input from other services this was documented. We received positive feedback from healthcare partners including the general practitioner, tissue viability team and community mental health team in relation to partnership working. They told us they had a good working relationship with the home and felt their guidance was routinely followed to ensure safety and continuity of care. Although they told us referrals were sent promptly, we identified one delayed referral to speech and language therapy (SALT) for a person assessed as being at risk of choking. Staff submitted the referral 19 days after the risk was identified and did not update the person’s care plan promptly to reflect their assessed dietary needs. People’s records included a multi-disciplinary log to capture important discussions with other health services involved in their care and treatment.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff told us they felt able to share safety concerns and they felt confident they would be investigated. Relatives also told us they felt their relatives were safe at Longmead Court. Staff had received training in safeguarding practices and demonstrated a strong understanding of safeguarding, including how to report concerns. A staff member said, “I would tell my manager (about safeguarding concerns). I can report to CQC and the council. We have things on the wall with the details for Essex County Council.”

There was a system in place for recording, investigating and analysing safeguarding concerns, however, as outlined in the ‘learning culture’ section of this report, we identified some incidents that were notifiable to CQC, however, these referrals had not been completed. Systems of governance and oversight had not identified these omissions in reporting.

People were supported to understand what keeping safe means. Posters were displayed in the service, which meant important information such as internal and external safeguarding contacts were available to staff and people living at or visiting the service should they need to share any safeguarding concerns about themselves or others.

Where people were deprived of their liberty, DoLS (Deprivation of Liberty Safeguards) applications were submitted to ensure this was done lawfully, and a tracker was in place to maintain oversight of pending and authorised applications.

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

A comprehensive range of risk assessments and care plans were in place and regularly reviewed, however we saw some care plans contained contradictory information in relation to people’s health conditions and their associated risks. For example, 1 care plan identified a person as requiring insulin to manage their diabetes, but listed their diabetes as being diet controlled in another section of their care plan. Another had not been updated to reflect a person’s dietary needs following a recent choking assessment. There were also omissions in recording, which made it difficult to evidence care was being provided in line with peoples identified risks, for example in repositioning and fluid intake. Repositioning charts were used to document people’s movements to reduce the risk of pressure damage, however there were gaps in the completion of these charts and poor recording of refusals in this area. We saw a care plan for 1 person who was refusing repositioning; the care plan did not evidence the person had been fully involved in discussions to ensure they understood the related risks. The home used daily fluid targets to improve people’s fluid intake, but we saw people’s fluids had frequently been recorded as much lower than their target daily intake, this increased the risk of dehydration and associated risks. The Registered Manager and Nominated Individual told us this was a known issue with recording rather than the actual provision of fluids, and low reporting of associated conditions such as Urinary Tract Infections (UTIs) supported this, however a lack of accurate and contemporaneous recording made it difficult to assess whether people’s associated risks were being managed appropriately.

Where people exhibited behaviours that communicate a need, emotion or distress, we saw care plans were in place. They contained clear information about signs of distress and guidance for staff to follow to support people. Although records were completed to document any behavioral incident that expressed a need, they were not fully completed to show what had worked or not worked, to improve outcomes for people in the future.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We identified multiple concerns with the environment during our inspection, which posed a risk to people’s safety. Multiple bedrooms contained wardrobes which had not been secured to walls, exposing people to the risk of injury or entrapment. A door to a sluice room was unsecured, allowing people access to extremely hot water and exposing them to the risk of burns. The kitchen was cluttered and there was a build-up of cooking residue in areas, we also found food products which were not stored or labelled in line with best practice. Once raised by inspectors, all the issues were rectified promptly to ensure immediate safety.

Environmental checks were being completed regularly, including checks of window restrictors, water temperatures and gas safety. However, we could not be assured that all checks were completed effectively, as we saw evidence of some checks being signed off ahead of time. The monthly carbon monoxide checks and checks of firefighting equipment for both June and July had been signed off as completed, despite our review of records taking place in June. The environmental concerns we found had not always been identified by the service’s own audits and checks, and where they had been, prompt action wasn’t always taken to remedy the issues.

Fire safety was not given sufficient priority to ensure people’s safety. Records from fire drills and false alarm evacuations in March and June 2026 had highlighted multiple concerns, however no action plan had been implemented to show how the concerns were addressed and followed up to ensure a safe evacuation in the event of a fire. The home’s own checks had identified multiple fire resisting doors as unsafe, however no immediate action had been taken to respond to this risk. Although the leadership team queried the accuracy of the judgement made about the fire doors, no independent checks had been arranged to provide assurance until it was raised by inspectors. An independent survey of the doors during the inspection period identified 7 doors were unsafe. A risk assessment was put in place by the provider in the interim and works scheduled to replace the unsafe doors. Personal Emergency Evacuation Plans (PEEPs) are used to ensure that everyone can be evacuated safely and quickly in emergency situations. PEEPs records contained inaccurate and outdated information. The list of people residing at the home had not been updated as people moved in and out of the service, and it was not kept up to date with information of people who were temporarily absent from the service, for example due to hospital admissions.

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 did not always work together well to provide safe care that met people’s individual needs.

Although we observed staff were readily available during our inspection, we received mixed feedback about staffing levels. One relative said “I don’t know about general staffing levels. There are times when I have to go and find people to help. Sometimes they (staff) can’t help as there is only 1 person in the communal areas.” A dependency tool was used to determine safe staffing levels but had not always resulted in the appropriate staffing numbers being scheduled on the rota. The Nominated Individual told us they had experienced ongoing issues with the dependency system used despite this being in place since 2024 however a new system had not been procured. There were gaps in staff training which had not been identified prior to the inspection. Bank care assistants had not been allocated the same range of training modules as other staff members to ensure they could respond to people’s specific risks, despite carrying out the same role. This included training in key risk areas including diabetes, food and nutrition and food and texture modification.

Staff received support in their roles via appraisals and supervisions and there was a tracker in place to monitor these. Most staff were positive about the system of supervision. A staff member said, “I receive regular supervision, annual appraisals, training updates, and can speak to senior staff whenever I need advice.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified areas throughout the service which posed an infection prevention and control risk. We saw furniture which was torn and worn in areas, equipment such as shower chairs and pedal bins which were rusty, preventing effective cleaning. A worktop in a kitchenette was observed to be degraded and showing signs of wear. Damaged surfaces can harbour dirt, moisture, and microorganisms and may prevent effective cleaning and disinfection. The provider had identified staff to act as infection prevention and control champions, and lead on IPC management, however no additional training had been offered to staff to support them in this role. This contravened the provider’s own policy.

The home was generally clean and tidy, and feedback from people and their relatives was positive in this area. Although we identified some issues with cleanliness on the first day of our inspection, for example in bathrooms and bedrooms, this appeared to be due to short staffing on the day of the inspection. The domestic staff demonstrated a sound understanding of how they prioritise key areas such as touch points and bathrooms for cleaning, and all areas were cleaned to a good standard by the end of the day. We saw personal protective equipment (PPE) was available throughout the home, and staff told us there were ample supplies available.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and as prescribed. Staff had received training in the administration of medicines, and checks had been carried out to ensure they were competent in doing so. Staff we spoke to demonstrated good knowledge of medicines management. People’s medicines were generally stored safely; however, we found waste medicines which were not stored in line with best practice guidelines, which requires them to be stored securely, out of sight and not accessible to unauthorised individuals.

People had care plans in place, which contained clear information for staff to follow to enable them to administer medicines safely and in line with people’s preferences and capabilities. Where people were supported by staff to take their medicines, care plans showed they had been involved in discussions around this. There were capacity assessments in place where people were unable to make this decision for themselves. For people prescribed antipsychotic medication, a specific review focusing on antipsychotics is necessary to ensure the appropriateness, safety, and ongoing need for these medicines. Although we saw general medicines reviews were completed 6 monthly, separate reviews were not taking place specifically for those on antipsychotic medicines, in line with best practice guidance.