Headingley Park Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff had received some supervisions; however, we found several staff who had not received a supervision for a number of months, in line with the providers own policy. We also found staff meetings had not taken place for several months, this included a period of time when a new registered manager was in post. However, staff told us they could raise concerns with the management team, and most said they felt the staff team worked well together, to meet people's needs. A staff member said, “I feel like I have enough training to do my job. The [registered] manager is lovely, very nice, accommodates your needs, they help you.”

At the time of our assessment a new registered manager was in post. Staff and partners told us the new registered manager was making improvements. However, we received mixed feedback from people and relatives about the leadership in the service. A person said, “I’ve seen the [registered] manager. They are approachable. The service appears to be well managed.” Whilst a relative said, “I have spoken with managers about my concerns, but they have all been poor.” We found there was a clear management structure in place, the registered manager was supported by a senior management team and a deputy manager.

People did not always feel they could speak up and that their voice would be heard. Whilst most staff told us they felt the management team were approachable, and they could raise safeguarding concerns, several staff told us they had raised concerns relating to staffing on 1 unit and this remained a concern. This was highlighted in a recent staff survey also.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they did not face any discrimination at work, and no one had been subject to unfair treatment. Staff told us they felt supported in their roles. All staff were supported with their professional development and staff initiatives were in place to celebrate staff's achievements.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Several auditing and governance systems were in place, this included audits of people's mealtime experiences and nutritional monitoring. Whilst we found no concerns relating to the monitoring of people's nutritional intake and weights, we found concerns relating to infection, prevention and control, managing risks, managing medicines, staff interactions, activities, refurbishments required and managing risks. These concerns were highlighted in some areas on auditing systems; however, audits had not recognised all the concerns we had found, neither did they rectify or action any of the concerns we found. We found some records not to be stored appropriately, for example, one person's bowel screening kit was in a kitchen cupboard and another person's mental capacity assessment was found on a community activity trolley.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. We could not be assured staff worked collaboratively with people, due to feedback we received from some people, relatives, and the local authority. There was a lack of activities and community-based activities for people. However, people were supported to maintain contact with loved ones, and we observed several visitors in the service on the day of our inspection. Some people were also able to access the community independently.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Whilst people, staff and partners told us the service had improved since the new registered manager was in post, improvements were required about how the service monitored the quality and safety of the care people received. Plans were in place to refurbish the premises, but these were ongoing at the time of our assessment. The local authority had recently carried out a contract quality monitoring visit and had made some recommendations. The registered manager had made several improvements at the time of our assessment and was keen to ensure the concerns we highlighted were resolved. The registered manager had also introduced a new audit system and staff meeting schedule, however this required embedding into practice at the time of our assessment.