Headingley Court 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 66 (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 listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Processes were followed to ensure all accidents, incidents, safeguarding concerns, and complaints were appropriately investigated and actioned. Lessons were learnt to continually identify and embed good practice. Relatives fed back that people were safe. One person said, “I feel safe and get on well with all the staff and other residents no worries. I have had no falls or accidents. I would not want to be anywhere else.”

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.

Information was shared with agencies to ensure continuity of care. We found staff and leaders made appropriate referrals to external professionals and staff followed their guidance. Assessments of people’s needs prior to moving in were carried out and the service sought support from the GP practice, and health and support team where necessary. One person said, “I have been here for a few months now, I came here on respite and I feel very safe.”

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 comfortable to whistle-blow on poor practice and the management team would listen to them and act. A staff member said, “When I have raised concerns in the past and immediate action was taken by management.” The provider shared concerns quickly and appropriately. Notifiable incidents were reported externally as required, such as to the local authority and the CQC. People and relatives told us they felt safe. A relative said, “[Name] is absolutely safe and absolutely well looked after.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that appropriate DoLS applications had been submitted where required, and authorisations were in place. Records showed that conditions attached to authorisations were being met, and staff monitored these effectively. This meant the service was acting lawfully and protecting people’s rights while ensuring their care needs were met.

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 risks to them assessed, and risk assessments were incorporated within their care plans. They enabled staff to prevent or minimise the identified risks. This meant staff had up to date information about the action they should take to manage those risks. The systems enabled, and supported staff to report concerns, incidents, and accidents in a timely way, minimise risks, and avoid them being repeated. The management team completed regular audits and care plans were updated if new risks were identified.

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 found two bedrooms in need of deep cleaning and redecoration; however, plans were already in place for this work to take place.

We found several issues within the environment posing potential risks to people’s safety. For example, equipment was not stored securely, and a high-risk area had been left unlocked. Some windows were not secured in line with the provider’s policy and health and safety guidelines. In addition, some slings had no visible labels, meaning it was not possible to confirm they had been laundered correctly. We found a gap at the bottom of one of the fire escape doors, which meant the door would be unlikely to hold back smoke or fire effectively in the event of an emergency. The registered manager was proactive in addressing any concerns raised and took appropriate and immediate action to begin resolving the issues identified.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

There were enough staff on shift, and staff received regular supervision to support them in their roles. The provider did not ensure all staff had the training and competence needed to meet people’s needs safely. While nurses carried out delegated clinical tasks and therefore had the background to reduce risks, care staff had not received all the necessary training required. For example, care staff had not completed epilepsy awareness training, meaning they may not have identified early signs of seizure activity or known when to seek support from nurses or emergency services. Not all staff had also not received training in dysphagia, which limited their ability to recognise swallowing difficulties or respond safely at mealtimes. However, we found no evidence of negative impact on people, and the risks were reduced because staff knew people well and were attentive to their day-to‑day presentation. Staff could describe people’s usual behaviours, triggers, and health needs, which helped them recognise when someone might be becoming unwell. The provider was also proactive and took responsive action once the training gaps were highlighted, including arranging additional training and reviewing competency requirements.

Training records showed that all staff had completed enhanced training in learning disabilities and autism. This meant staff had a clear understanding of the lived experiences of people with a learning disability or autism and applied this in their daily practice. Observations during the site visit showed staff responding promptly to requests for support and staff spent meaningful time engaging with people throughout our site visits.

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. The systems and training were efficient and maximised infection control which ensured a clean, hygienic environment for people to live and staff to work in. We observed the home to be clean, tidy and hygienic.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had systems in place to safely store, administer and record the use of medicines.Topical creams were stored in unlocked cabinets in people’s bedrooms.This issue was addressed during our visit. Medicines used to thicken fluids for people with swallowing problems were not recorded when they had been used. Some people were prescribed a medicine administered via a patch. There was no process in place to indicate the site of application to prevent the patch being placed on the same site too frequently.

We checked the quantities and stock balances for 12 people and found them all to be correct. The service had individual fire risk assessments in place for people who were prescribed paraffin-based skin products. Instructions for medicines which should be given at specific times were available. Detailed guidance specific to each person on how to administer medicines prescribed ‘as and when’ people required them, known as “PRN” was available to staff. When people were prescribed a medicine with a variable dose, for example 1 or 2 tablets, there was information available to support staff to know which dose to give.

Some residents were unable to take their medicines by mouth. Guidance was in place to enable trained staff to safely administer appropriately prescribed medicines into a stomach tube percutaneous endoscopic gastronomy (PEG).

The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. Handwritten MARs were signed by two members of staff to confirm dosage instructions.

There were appropriate arrangements in place for the management of controlled drugs and staff completed regular balance checks. Temperature records to ensure the safe storage of medicines were completed in accordance with national guidance.

There was evidence that there was a process in place to record medicines related incidents or errors. Staff told us they had completed a training and induction process for medicines management.

Audits to make sure that procedures were followed had not identified the issues found during the assessment.