At this inspection we set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service, relatives, and the staff supporting them and looking at records.
If you wish to see the evidence supporting our summary please read the full report.
Is the service safe?
Care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. Each person's care plan did not clearly identify the areas where people needed support and gave little or no instructions of how to assist the person. There were risk assessments in place for people, which identified areas of risk associated with their care. However they did not direct staff how to care for the person so that these risks could be minimised.
There were not always enough qualified, skilled and experienced staff to meet people's needs. We observed staff and some appeared to be rushed, therefore not able to spend the time required to complete tasks at the pace of the person who used the service. We also observed that some people requiring assistance were at times left unsupervised as staff had been redirected to assist on another unit.
People who used the service were not protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent it from happening. We asked to see a log of safeguarding concerns which detailed actions taken following safeguarding concerns. The manager could not produce this. She only had information relating to one safeguarding concern; however the actions taken and lessons learned were not clear.
We asked to see the policy and procedure for safeguarding and the manager was unable to locate this. This meant that there was no procedure on site that staff could use if they needed to.
We have asked the provider to tell us how they will make improvements and meet the requirements of law in relation to safeguarding people from abuse and risks associated with their care
Is the service effective?
We looked at seven care records and found inconsistency and confusion as to what the persons needs were and how these were to be met. We spoke with the senior care worker and other care workers who were unsure how to care for people.
We saw that some people required food and fluid intake to be recorded. However, this was not consistently completed and we found gaps where food had not been recorded as eaten or offered. Food charts were not stored in a methodical order. This meant that not all food charts we asked to see could be found. Therefore the food charts could not be used to monitor intake as they were unavailable.
We have asked the provider to tell us what they are going to do to meet the requirements of law in relation to assessing and recording people's needs.
Is the service caring?
We looked at care plans and found that they did not always reflect the needs of the person who used the service. Care delivered was therefore not in line with the care plan.
People's needs were not always followed up. For example, one person needed referring to a dietician due to losing weight and not eating much. This had not been actioned. Another person required a sensory mat, but one month after the occupational therapist had advised this, it was still not in place.
An activity co-ordinator was employed by the home but was not on duty the day of our inspection. We saw that staff were only engaging with people who used the service when delivering care tasks. This meant that there was a lack of social interaction.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to planning care for people.
Is the service responsive?
We observed times when one lounge was left without staff for periods of time and people in the lounge required assistance. We spoke with staff about what we had observed and they told us that they were assisting people on a different unit.
We saw that care plans were reviewed regularly but changes were not made to ensure people's needs were met.
We have asked the provider to tell us what they are going to do to meet the requirements of the law.
Is the service well-led?
We saw that audits had been completed but where actions had been identified we found no record of what had been done to resolve the identified concern.
The system of assessing and monitoring the quality of service provision at Headingley Park was inadequate. Whilst some audits and checks had identified areas in which improvements were required, actions had not been taken to make and sustain improvements to protect people and this could put them at risk of harm.
We saw no evidence that people had been assessed for equipment such as pressure relieving items and wheelchairs. This meant that it was unclear what equipment each person required.
There were areas of the home which felt cold and people were complaining they were cold. No audit had picked this issue up. People told us that it had been like this for some time, two how many told us they did not want to complain in case it reflected badly on them.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to auditing the quality of service provision.