Headingley Nursing 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 requires improvement. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 an engaging, proactive and positive culture of safety, based on openness and honesty and working with people to identify where areas could improve. Staff listened to concerns about safety and investigated and reported safety events. Lessons were continuously learnt to identify and embed good practice

Staff and leaders demonstrated a positive learning culture, with incident and accident records consistently maintained and used to inform practice. There was clear evidence that learning from events was shared across the team, with staff able to describe how this occurred in practice. People told us this approach contributed to them feeling safer.

The provider worked well with people and healthcare partners to develop and maintain safe care systems where safety was actively monitored and managed. They ensured continuity of care, including during transitions between services.

Managers and staff worked in partnership with health and social care professionals to ensure people received coordinated and appropriate care and support. This included the timely sharing of relevant information when people transitioned back to their own homes or moved to other care settings.

The provider worked closely with people and healthcare partners to understand what safety meant to them and how best to achieve it. Staff focused on improving people’s lives while safeguarding their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

Concerns were escalated promptly and in line with established procedures. Staff had completed relevant training and demonstrated a clear understanding of their safeguarding responsibilities. Robust systems were in place to ensure concerns were reported and acted upon without delay. People and their relatives consistently reported feeling safe and confident in raising concerns, with one relative stating, “[Person] has been here three years. About two years ago [another family member] moved in as it’s good. They are definitely safe; they look after everyone quite well.”

The provider worked with people to take a holistic approach to understanding and managing risks. Staff delivered care that was safe and supportive while enabling individuals to do the things that mattered to them.

People were supported to make informed choices and maintain their independence, while remaining safe. Risk assessments were individualised and reflected people’s preferences. Staff were confident in supporting people with complex healthcare needs. They demonstrated an appropriate balance between managing risk, promoting autonomy, and involving people in decisions about their care.

The provider identified and managed potential risks within the care environment. Equipment, facilities, and technology were maintained to support safe care delivery. The premises were clean, well maintained, and free from hazards.

Regular safety audits were undertaken, with any identified actions addressed promptly. Ongoing maintenance was observed during the inspection visit. People told us they felt comfortable and safe in their environment, with one person stating, “It’s nice and tidy here; they regularly come to your room and clean it. They are friendly and work with you.”

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

There was a robust system in place to support safe recruitment practices. Staffing levels were sufficient to meet people’s needs. Staff received appropriate training, support, and supervision to carry out their roles effectively. Staff spoke positively about the quality of training and support provided, with one member of staff stating, “The training is great. It keeps us and the people who live here safe.” People were also confident in staff competence, with one person commenting, “The staff are well trained, and you often hear the seniors guiding the younger ones in the correct procedures.”

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. Infection prevention and control measures were robust.

Personal Protective Equipment (PPE) was readily available and used appropriately, and the home was observed to be clean throughout. Staff had completed relevant training and followed appropriate infection prevention and control procedures. People told us they felt reassured by the cleanliness of the environment and staff practices, with comments including, “Yes, it’s clean, there are cleaners around” and “Yes, it’s clean here.” Cleaning audits were carried out regularly, and any identified issues were escalated and addressed appropriately.

People received their medicines safely and in a timely way. Medicines administration was recorded accurately on people’s medicines administration records (MARs), and medicines were stored safely and securely.

Processes were in place to support the safe and effective use of medicines. Staff had access to detailed, person-specific guidance for medicines prescribed on a PRN basis, which supported consistent and safe administration. We identified one instance where a person’s PRN protocol did not fully reflect the required actions; however, this was promptly addressed and corrected on the day of inspection.

Medicines quantities and stock balances were regularly checked and found to be accurate. There were clear processes in place for recording and reviewing medicine-related incidents or errors. Staff responsible for administering medicines were appropriately trained and supported in their role. In addition, managers and suitably trained staff undertook regular medicines audits to monitor adherence to procedures and to support ongoing improvement.

We received positive feedback from the General Practitioner that works alongside the home. Their comments included, “Partnership working is positive. The weekly meeting is usually well prepared, and [staff member’s name] in particular plays a key role in ensuring this runs smoothly. [Staff member’s name] are organised and knowledgeable about residents and provides accurate clinical information that supports effective decision‑making. [Staff member’s name] is a reliable and constructive link between the home and the practice.”