Headingley Hall Care 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff reported safety events and lessons were learnt to continually identify and embed good practice.

After an accident or incident, the manager reviewed what happened and shared key learning with staff to help reduce future risks. One member of staff told us, “We are updated when an accident or incident happens and make changes where we can.” For example, people identified as being at high risk of falls were provided with sensor mats by their beds to alert staff when they moved, which helped reduce the likelihood of further falls.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Management assessed people’s needs before they moved into the service to ensure the home could meet their requirements. Once people had moved in, staff continued to work closely with healthcare professionals to promote safe and consistent care. One person told us, “The doctor does come in here if you need one. I had a problem with my lip, and they gave me some ointment, and it has improved. The dentist came to see me earlier on.”

When people were moving on from the service, external professionals were invited into the home to complete their own assessments, supported by staff who knew the person well. This helped ensure all relevant information was shared and that transitions were planned safely and smoothly, reducing the risk of gaps in care.

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.

People we spoke with did not raise any concerns about their safety. One person told us, “I do feel safe here. There is always somebody around if you need anyone. I have always felt safe since I’ve been here.”

When safeguarding incidents occurred, the manager responded promptly and appropriately. Staff we spoke with understood what constituted abuse and were clear about the processes for reporting safeguarding concerns. One member of staff told us, “I would report anything I thought was not right. At the end of the day, I’m here to support people. If I see something, I’m more than happy to raise it to the CQC or whoever else.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had access to the equipment they needed to help keep them safe, such as sensor mats and walking frames to support their mobility. One relative told us, “The training is excellent. They understand him. I said, ‘You would think [person] would get used to being hoisted,’ and they said each time is like the very first time for [person]. I thought that was very good. The person in charge of the dementia unit is very good and knows [person] very well, and so do the staff.”

Management regularly reviewed care plans and risk assessments. Staff knew people well and understood how to support them safely. One member of staff told us, “We can access all the information we need, and I have read the care plans. I think all the staff know people well.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Although the environment was well maintained and safe, we identified that one window did not have a restrictor in place. This was addressed immediately, and on our return, we confirmed that the window restrictor had been fitted.

Regular safety checks of the environment were carried out to ensure the premises remained safe, well maintained and fit for their intended purpose. These routine checks included hot water temperature monitoring, legionella controls and fire safety systems. Staff completed these checks consistently and recorded the outcomes, which meant any issues could be identified and addressed promptly. This proactive approach helped ensure a safe environment for people living in the service and reduced the risk of avoidable harm.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The manager used a dependency tool to assess and maintain safe staffing levels. We received mixed feedback from people who used the service. Some people told us there were enough staff, while others felt that at times staffing levels were occasionally insufficient and staff could appear rushed. Comments included, “Usually they have enough staff during the day, at night and weekends. When it’s really busy, they could do with more staff, like at lunch time,” and “Yes, they do look after me well. In the dining room at lunch time, they can be pretty well pressed, and you sometimes have to wait for twenty minutes.”

From our observations, staff were busy but able to respond to people in a timely and supportive way. Staff reflected similar views, with one member of staff telling us, “It depends on the day. Sometimes we have enough staff, sometimes I feel we are short and it depends on the residents.” Another member of staff said, “On occasion when it’s really busy, we could do with more staff but having said that it’s managed well with the staff we have. The senior team are very supportive because they can see when we need help and they offer support.”

New staff were recruited safely, following appropriate recruitment procedures, including Disclosure and Barring Service (DBS) checks and verification of relevant employment history. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

During our visit, we observed that the environment was clean, well maintained and visibly hygienic. Staff were seen wearing appropriate personal protective equipment (PPE) when required and used it correctly, demonstrating good awareness of infection prevention and control practices.

The kitchen demonstrated high standards of cleanliness and food hygiene. However, we did identify some confusion regarding the dating of jugs of water and juice. This was addressed promptly and had been rectified by our second visit.

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

At the time of assessment, creams were stored in peoples’ personal bathrooms, which posed a risk for people living with dementia. This was fed back and action was taken by the provider; the service immediately began installing safes to people’s rooms to ensure creams were stored securely.

When non‑medical creams such as moisturisers and emollients were applied, staff recorded this on the electronic care system. However, it was sometimes unclear which creams had been used, particularly for residents with multiple prescribed products.

For one person prescribed ‘as and when required’ (PRN) medicines did not always have up to‑ date protocols in place to guide staff on their appropriate use‑. Some protocols remained active for medicines that were no longer prescribed.

When a dose of medication was not administered—whether because it was inappropriate or refused—the documentation was sometimes unclear. The service was introducing new individual medicine specific sheets to improve clarity, replacing the previous‑ single shared sheet.

Medication administration records (MARs) looked at during the assessment had no missing documentation, so all doses were accounted for. Medicines were stored in drug trolleys within locked treatment rooms, and stock levels were correct. Temperature monitoring was completed by staff daily to ensure medicines were being stored in the correct environment.

Controlled drugs, which require extra storage and documentation requirements, were checked weekly and all stock levels were correct and recorded appropriately with two staff signatures.

Medicines prescribed for Parkinson’s disease were administered on time to support optimal health outcomes. People prescribed patches had rotation charts to ensure correct application sites, and daily checks confirmed patches remained in place.