CQC report explained · a nursing home
What the CQC found at Headingley Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Headingley Nursing Home rated Requires Improvement; inspectors found safeguarding and management weaknesses despite enough staff and positive feedback.
Inspectors visited on 29 June and 5 July 2022. They spoke with relatives and staff, reviewed care, medicine and recruitment records, and checked quality monitoring systems. The inspection was unannounced.
The home had enough staff and people received medicines safely and on time. Infection control arrangements were suitable, and people and relatives said they felt safe. However, safeguarding concerns were not always reported, safeguarding records lacked detail, and some care records were vague.
The home did not have a registered manager. Inspectors found the interim management arrangements were not robust, and some audits had not led to improvements. The overall rating changed from Good at the previous inspection to Requires Improvement.
The breaches concerned safeguarding and good governance. CQC asked for an action plan and said it would continue to monitor the home and take further action if needed.
Enough staff
Inspectors found staffing levels were safe and people's needs were being met in a timely way.
“There were enough staff employed to ensure people's needs were being met.” from the report
Infection control
The home had suitable arrangements for preventing and managing infections, including the correct use of masks.
“We were assured the provider was taking steps to effectively prevent and manage infection outbreaks.” from the report
People felt safe
People and relatives told inspectors they had no concerns about safety.
“People felt safe living at the home.” from the report
Positive feedback
Staff, people and relatives gave positive feedback about the management team and said it was approachable.
“The feedback about management and leadership was positive.” from the report
Safeguarding was not reliable
seriousInspectors were not assured that all safeguarding concerns were reported. The safeguarding log also lacked enough detail, creating an increased risk that people could be harmed.
“We were not assured all safeguarding concerns were raised.” from the report
Weak management arrangements
seriousThere was no registered manager, and inspectors found that the interim management arrangements were not robust. This was a breach of the good governance regulation.
“We were not assured there was robust management of the service.” from the report
Medicine audits missed problems
needs fixingThe medicine audit did not identify people who had not received medicines at the correct time, so the checking system was not effective.
“Medicine audits were not effective in ensuring medicines were used safely.” from the report
Some risk records were vague
needs fixingCare plans contained information about managing risks, but some records were not specific enough.
“Care plans contained information for staff to manage risks to people's health and wellbeing, however some records were vague.” from the report
- 01How are safeguarding concerns now identified, reported and recorded, and who checks that none are missed?
- 02Who is currently responsible for managing the home while recruitment of a registered manager continues?
- 03What changes have been made to medicine audits to identify missed or late medicines?
- 04How have vague risk records been reviewed and made more specific?
- 05What actions were included in the provider's action plan, and what progress has been made?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other key-question ratings carried over from the previous inspection. This explanation was written from the published report of 21 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2021
Rated Good; inspectors found safe, kind and responsive care, with improvements still needed in medicines records, food and fluid records, and care planning.
Inspectors visited on 25 March 2021. They spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, training information and the home's quality checks. The inspection was unannounced and followed concerns about staffing, medicines, pressure care, food and drink, cleanliness and personalised care.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, good infection control and kind interactions. People said they felt safe and that staff knew them well.
Inspectors found some areas needing improvement. Guidance for some medicines given when needed was incomplete, and some medicine administration times were recorded incorrectly. Food and fluid records did not always accurately show what people had eaten and drunk. Care plans were being updated to include more personal detail, and the home was working to improve activity participation and end of life planning.
The home did not have a registered manager at the time. A replacement manager was completing the registration process. The previous rating was Good, published in January 2018, and all five ratings remained Good at this inspection.
Staffing and safety
Inspectors found enough staff to meet people's needs. Recruitment checks were in place, and staff responded quickly to calls for assistance.
“Enough staff were deployed to support people safely.” from the report
Kind and respectful care
People were treated warmly and with dignity. Staff supported independence and respected people's personal, religious and cultural needs.
“We observed a number of positive interactions throughout the inspection.” from the report
Infection control
The home had effective cleaning arrangements and staff used protective equipment safely. Inspectors were assured that infection prevention procedures were being followed.
“We were assured the service were following safe infection prevention and control procedures to keep people safe.” from the report
Management improvement work
The management team used audits, feedback and an improvement plan to track actions. Staff spoke positively about the current management and support.
“The home used a continuous home improvement plan to record any actions or issues identified via auditing, monitoring or feedback from people and/or staff.” from the report
Medicines records
needs fixingSome medicines given when needed did not have enough guidance for staff. Some administration times were written incorrectly, although inspectors found the medicines had been given at the right time.
“Not all 'as required' medicines; such as pain relief, had guidance in place for staff to follow, to ensure these were given correctly and for the prescribed reason.” from the report
Personalised care plans
needs fixingCare plans explained people's needs but did not always contain enough personal detail. It was also not always clear from the electronic records that people or relatives had been involved in reviews.
“Care plans explained how people wished to be cared for and supported, however, would benefit from greater detail and more personalisation.” from the report
Registered manager
minorThe home did not have a registered manager when inspectors visited. The replacement manager had started the registration process.
“At the time of inspection, the home did not have a manager registered with the Care Quality Commission.” from the report
- 01What has been done to add clear guidance for all medicines given when needed, and to make sure medicine administration times are recorded correctly?
- 02How do you now check that food and fluid records accurately show what each person has eaten and drunk?
- 03How are care plans being made more personalised, and how will you record the involvement of residents and relatives in reviews?
- 04Who is currently responsible for managing the home, and what is the current position of the registered manager application?
- 05How do you make sure people who prefer not to join group activities still receive meaningful one-to-one activities?
This inspection examined all five key questions and infection prevention and control, and followed concerns about staffing, medicines, pressure care, dietary management, cleanliness and personalised care. This explanation was written from the published report of 24 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Headingley Nursing Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019
Registered with the Care Quality Commission on 2 December 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £980 to £1,250 a week. 89 can care for a couple. 11 years' experience on average.
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