Headingley Park Care Home

Headingley Park is a care home. It can accommodate up to 40 people in a purpose-built building. It comprises of 2 units providing accommodation and personal care for older people, including people living with dementia. There were 33 people using the service at the time of the inspection.

People’s experience of using this service:

People told us they felt safe. Staff understood safeguarding and whistleblowing procedures. Relatives said their family members were kept safe. Staff knew people well and risks were identified.

Staff told us there were enough staff on duty and staffing levels had much improved, which meant needs of people could be met. We observed there were sufficient staff employed to meet people’s needs. There was a safe recruitment process, which ensured only staff suitable to work with vulnerable adults were employed.

Accidents and incidents were effectively monitored, which ensured staff learned when things went wrong. People were protected by the prevention and control of infections. Medication systems were in place and followed by staff to ensure people received their medicines as prescribed. Some minor issues were identified in regard to medicines and IPC, these had already been picked up by the managers quality monitoring system and were being addressed.

Staff were very knowledgeable about people needs. We observed that care provided was person-centred and individualised. Staff received effective training to ensure their knowledge was up to date. Staff were supervised and supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People had access to health care professionals, staff worked closely with professionals to ensure people's needs were met. We observed interactions between staff and people who used the service these were positive, inclusive, respectful and person-centred, promoting people’s well-being.

There was a quality monitoring system in place. The manager and the provider had identified areas of improvement. Audits were undertaken to ensure improvements were sustained and embedded into practice. Relatives felt listened to and said staff and management were approachable. People we spoke with told us their views were obtained to continually drive improvements. Feedback from staff was extremely positive about the new management team and felt communication had improved and the new manager was approachable, visible, listened and took appropriate action. Staff said they worked better as a team and were well supported.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was requires improvement (published 22 February 2023) there were breaches of regulation and we issued a warning notice. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected:

This focused inspection was carried out to follow up on action we told the provider to take at the last inspection. For those key questions not inspected, we used the ratings awarded previously to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow Up:

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Headingley Park is a care home providing accommodation and personal care. It can accommodate up to 40 people. Some people using the service were living with dementia. There were 33 people using the service at the time of the inspection.

People’s experience of using this service and what we found

We observed care and support to be task orientated, institutionalised and not person centred. Care staff were not directed or managed effectively. There was a dependency tool used to determine staffing levels. However, it was not clear if there was adequate staff effectively deployed to meet people’s needs. We observed staff were not always present in communal areas and did not always respond in a timely way to peoples support needs. We found staff were not always competent or experienced to meet people’s needs. The service was using high numbers of agency staff, we saw these staff sat watching television and on personal mobile phones. People we spoke with told us staff did not know them and had to wait for assistance and very rarely got a bath or shower. One person said, “There’s not enough staff, when I was at home my carers would shower me every other day, here is about once a week, if you are lucky.”

Infection prevention and control (IPC) practices and policies were not always followed. We found many areas that were not clean and areas that were not well-maintained to be able to be effectively cleaned.

Medication systems were in place. However, we found many errors with recording and although most appeared to be missed signatures, we found some that did not tally. It was not evident if medicines had been given as prescribed. We also found topical medicines were not always given as prescribed.

Systems and processes used to ensure the service was running safely were not robust or effective. During our inspection we identified shortfalls that had not been identified as part of the providers quality monitoring. For example, IPC practices, person centred care and staff deployment. Staff did not feel supported and said they were not listened to.

Feedback from people varied, we received some very positive comments about staff. However, most said staff were rushed and there appeared not to be enough staff on duty. One person said, “The buzzer can be a bit hit and miss, sometimes you are waiting ages [For staff].”

Incidents and accidents were reviewed to ensure lessons were learnt and predominantly risks to people were identified and managed effectively by the registered manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (Published 14 April 2021)

The service remains requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned focused inspection. However, the inspection was prompted in part due to concerns received from the Local Authority about staff culture and risks regarding care and support. A decision was made for us to inspect and examine those risks.

We undertook this focused inspection to check they had continued to make improvements and confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well led. For those key questions not inspected, we used the ratings awarded previously to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Headingley Park on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment, person-centred care, staffing and leadership and oversight at this inspection.

Please see the action we have told the provider to take at the end of this report. Other information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Headingley Park is a care home providing personal care. It can accommodate up to 40 people. Some people using the service were living with dementia. There were 28 people using the service at the time of the inspection.

People’s experience of using this service and what we found

The quality monitoring systems had identified where improvements were required however, were not always effective in ensuring improvements were implemented and embedded into practice.

Risks were identified and the care plans detailed actions to mitigate and manage risks. However, we found the documentation in place did not always evidence the actions were followed to ensure the risks were managed. Safe medication systems were in place for staff to follow. However, we found topical medicines were not always recorded correctly so could not evidence they were given as prescribed. The registered manager had identified this and was addressing with staff. We have made a recommendation, that the documentation is embedded into practice.

The environment was predominantly clean, the domestic staff understood the need for additional and more robust cleaning during the pandemic. However, we identified some areas required improvement which, had been identified by the registered manager and were part of the providers action plan.

Relatives spoke highly of the care staff. However, we received mixed feedback from relatives regarding communication and management during the pandemic. The registered manager had identified this and was improving communication systems to ensure all families were kept up to date. The provider had recently sent out questionnaires to relatives to obtain feedback and drive improvements.

We observed adequate staff on duty on the day of our Inspection and staff we spoke with, said there was usually enough staff to meet people’s needs. We observed staff attended to people’s needs in a timely way, when support was required. People we spoke with told us the care staff were lovely and were always there when you needed them.

Incidents and accidents were recorded appropriately. The registered manager had introduced a more robust overview to effectively analyse and monitor these to ensure lessons were learnt. The staff team worked together with external agencies to deliver effective care and treatment and support people’s access to healthcare services. Most staff told us they felt supported and worked well as a team. There were systems in place to safeguard people from abuse.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 5 February 2020).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found some improvements had been made and the provider was no longer in breach of regulation 12.

Why we inspected

The registered manager is registered at two locations, we identified concerns at the other location and this in part prompted this inspection. It was also based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The overall rating for the service is requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. We have identified a breach in relation to governance at this inspection Please see all sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Headingley Park on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Headingley Park is a residential care home providing personal care to 30 older people, some of whom were living with dementia at the time of the inspection. The service can support up to 40 people in one large building.

People's experience of using this service and what we found

People received their medicines on time from staff who had received training in medicines administration. However, medicines were not always recorded in line with current best practice guidance.

Governance systems included audits and regular checks of the environment and service to ensure people received good care. We found these systems were not always fully effective in driving improvement. Whilst it was not evident this had any significant impact on people, it did not evidence a fully effective governance system was in operation and placed people at risk.

Staff were recruited safely. Staff, people and their relatives expressed concerns regarding staffing levels. We could not be assured they had been correctly assessed as the dependency tool took information from care plans which did not always hold the most up to date risk and care needs information. We have made recommendations in the safe section of this report regarding these concerns.

People were supported to eat a balanced diet. People currently had access to limited activities to keep themselves stimulated and active. However, a new activities coordinator was being recruited.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Each person had a care plan that contained details of their choices and preferences. People met with the registered manager or senior staff before moving into the service to check staff would be able to meet their needs. People were treated with dignity and respect. People's end of life wishes had been recorded. When required, staff worked with GP’s and district nurses to support people at the end of their lives.

Complaints had been recorded and investigated following the provider's policy. The environment was being decorated to support people living with dementia following good practice guidance. People were given information in a way they could understand.

People were supported to access healthcare services, staff recognised changes in people's physical and mental health, and encouraged people to seek professional advice appropriately.

Staff told us they enjoyed working at the service and that the team worked well together. There was mixed feedback regarding the management of the service.

Why we inspected

This was a planned full comprehensive inspection to ensure that the service was meeting the regulations of the Health and Social Care Act 2008 and CQC.

Enforcement

We have identified breaches in relation to governance and keeping people safe from abuse and harm at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk