Headingley Park 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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to managing risks posed to people and managing medicines.

This service scored 56 (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. Accidents and incidents were recorded, monitored and action taken to mitigate risks to people. This included an analysis of falls within the service. Where required incidents were reported to external agencies.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Some care plans contained conflicting information about people's needs, such as current pressure wounds and recent falls. People had pre-admission assessments in place prior to using the service, which involved people and their relatives.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately. Most people told us they felt safe. A person said, “Yes, I feel safe here. They [staff] lock the room door here when I go to bed which makes me feel safe.” Staff understood their responsibilities to report concerns and told us they felt able to whistle-blow on poor practice. A staff member said, “The [registered] manager is lovely. I have never had to report concerns, but I could if needed.” At the time of our assessment the service was working closely with the local authority about some safeguarding concerns. Appropriate action was taken by the management team, including staff performance reviews.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The service was working within the principles of the MCA. People had their capacity assessed and DoLS authorisations were in place where required.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people. Whilst we found no harm to people, improvements were required about how staff managed risks posed to people. For example, we found where people required pressure care, there was conflicting information in care plans about their current pressure wounds. We also found several pressure relieving beds to be showing a fault, not switched on and a lack of records relating to what setting the beds should be set at. Where people were on modified diets and fluids, information available to staff was conflicting, and care staff lacked knowledge about people's needs. This placed people at risk. We did however find people received their repositioning to relieve pressure points and received input from district nurse teams. We also found people received their meals in line with their assessed needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service had recently undergone several fire safety checks and made structural changes to meet the fire safety regulations. Maintenance checks of the environment were in place, including lifting equipment, electrical equipment, and bed rails. However, we found several pressure relieving mattresses to be faulty or switched off. We spoke with the registered manager about this during our assessment, and routine checks of mattresses were put in place following our assessment. Where people were at risk of falls, fall safety equipment and sensor alarms were in place.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective supervision and development. We could not be assured people were supported by enough staff. Whilst a dependency tool was in place to calculate staffing hours required, all staff we spoke with told us more staff were required to the dementia unit. A staff member said, “There isn’t enough staff on 1 unit. There are people who require 2:1 support and we are shattered. We have told managers about this, but nothing happens.” We received mixed feedback from people and relatives, some felt enough staff were available. Whilst others felt more staff were required. A person told us, “I don’t think there are enough staff at weekends, most of the staff seem to be from agencies.” A relative said, “There are times when they are busy, but they do keep [name] clean and dry mostly, but, when I come to visit and I find they are wet, I ask staff to change [name], which they do. I do think they’re overworked.”

On the day of our assessment, inspectors observed several people who appeared unkempt and requiring a shave. Inspectors also observed a lack of engagement between some staff and people.

Staff were recruited safely, and all appropriate pre-employment checks were in place prior to people starting work. Staff were trained to carry out their roles, this included training about dementia, diabetes and falls.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Improvements were required to how the service and staff promoted safe infection control practices. Whilst we found some areas of the service to be clean. We also found some infection control concerns. This included some areas to be cluttered, stained mugs, toiletries stored inappropriately, soiled chairs and limescale and rust to several plugholes and taps. We saw some staff wearing long sleeves, which is not in line with best practice guidance. We also found some food in a kitchenette are to be out of date. Staff had access to personal protective equipment (PPE) and we saw staff wearing PPE appropriately.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We could not be assured controlled drugs were appropriately stock checked, we found several controlled drugs with a stock discrepancy. This was later found to have been a recording concern, however this meant staff had not appropriately checked stock as required. Where people received 'as required' medicines, protocols were not always in place, about how and when staff should administer these. We also found several creams in people's rooms and in medicines trollies which did not contain open date labels. We found some people had creams and ointments belonging to other people within their rooms, and creams charts with several gaps. Medicine audits were in place, and had recognised some concerns we found, however these remained an issue at the time of our assessment, such as several gaps in temperature checks where medicines were stored.