We inspected Headingley Hall on 22 February 2016. The inspection was unannounced which meant the staff and registered provider did not know we would be visiting.
Headingley Hall is a large converted property with a modern extension attached. The service provides care and support for up to 57 older people and is accommodation for people who require personal care. The service is close to all local amenities.
The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found systems in place for the management of medicines were not robust or effective in ensuring people received their medicines safely.
There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Appropriate checks of the building and maintenance systems were undertaken to ensure people’s health and safety. Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Where changes were made to people’s care following incidents the information was not always transferred into the care plan documentation. Staff were able to tell us verbally the changes that had been made.
The call bell system in the old part of the building cannot be heard throughout the service. The registered manager told us they would implement a risk assessment to ensure staff members were available in this area so call bells would be answered effectively until a new system was installed.
We saw staff had received supervision on a regular basis and an appraisal. Staff had been trained and had the skills and knowledge to provide support to the people they cared for.
People told us there were enough staff on duty to meet people’s needs. We were reassured people were protected by safe recruitment process.
Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.
We saw staff treated people with dignity and respect. Staff listened and were patient with people. Observation of the staff showed they knew the people very well and could anticipate their needs. People told us they were happy and felt very well cared for.
We saw people were provided with a choice of healthy food and drinks which helped to ensure their nutritional needs were met.
People were supported to maintain good health and had access to healthcare professionals and services.
We saw people’s care plans were very person centred and written in a way to describe their care, and support needs. These were regularly reviewed but at times updates needed were not always reflected in the care plans. We saw evidence to demonstrate people were involved in all aspects of their care plans.
We saw there was a supply of activities and outings. Staff encouraged and supported people to access activities within the community. There was a current vacancy for the activities worker which had affected the level of activity on offer at the time of our visit.
The registered provider had a system in place for responding to people’s concerns and complaints. People were regularly asked for their views. We saw there was a keyworker system in place which helped to make sure people’s care and welfare needs were closely monitored. People said they would talk to the registered manager or staff if they were unhappy or had any concerns.
There were systems in place to monitor and improve the quality of the service provided. We saw there were a range of audits carried out both by the registered manager and senior staff within the organisation. We saw the frequency of audit was not based on risk or procedure meaning some high risk areas such as medication had less frequent audit.
We found that the registered provider had breached The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see the action we told the provider to take at the end of this report.