CQC report explained · a residential care home
What the CQC found at Headingley Park Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Headingley Park Care Home rated Good; inspectors found safer staffing and management, with minor medicines and infection-control issues still being addressed.
This was an unannounced follow-up inspection on 25 July and 4 August 2023. Inspectors spoke with people, relatives, staff and other professionals. They observed care and reviewed care, medicines, recruitment and management records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found enough staff, safer recruitment, suitable risk assessments and improved systems for medicines and infection control. Some minor issues had been identified by the managers and were being addressed.
The home had previously been rated Requires Improvement, with breaches of regulations and a warning notice. Inspectors found enough improvement and said the home was no longer in breach. This was a focused inspection, so other question ratings were carried forward from the previous inspection.
Improved staffing
Inspectors found staff were effectively deployed and responded to people's needs promptly. Staffing had increased since the previous inspection.
“We observed staff respond to people's needs in a timely way.” from the report
Person-centred care
Inspectors observed care that was individualised and respectful. Staff were knowledgeable about the people they supported.
“We observed that care provided was person-centred and individualised.” from the report
Strong quality checks
The home had detailed monitoring systems and used lessons learned to make improvements.
“Quality monitoring systems were in place that were robust and detailed.” from the report
Open communication
People and relatives said the management team was approachable and kept them informed. Staff also described better communication and support.
“Staff said communication had greatly improved with the new manager, they were also approachable, listened and they made them feel part of a team.” from the report
Minor medicines issues
minorInspectors found some minor medicines problems. The managers' monitoring system had already identified them and action was being taken.
“Some minor issues were identified. However, these had already been picked up by the managers quality monitoring system and were being addressed.” from the report
Occasional waits for help
minorSome people said they sometimes had to wait for assistance. Inspectors did not see this during the visit and found people's needs were met promptly.
“However, some people said at times they had to wait for assistance.” from the report
Manager registration pending
minorThere was no registered manager in post during the inspection. A new manager had been appointed and was applying to register.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What were the minor medicines issues found by your monitoring system, and have they now been fully resolved?
- 02What infection-control issues were identified, and what action was taken?
- 03How do you monitor whether people are waiting too long for assistance?
- 04Has the new manager's application to register been completed and accepted?
- 05Which ratings were carried forward from the previous inspection rather than reassessed during this visit?
This was a focused follow-up inspection of Safe and Well-led; ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 1 September 2023 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, February 2023
Rated Requires Improvement; inspectors found unsafe medicine and infection control practices, too few effectively deployed staff, and weak leadership.
This was an unannounced focused inspection. Inspectors visited on 28 November 2022 and reviewed information up to 14 December 2022. They spoke with people living in the home, relatives and staff, and checked care, medicine, staffing and management records.
The home was not always safe. Inspectors found dirty or damaged equipment and areas, inconsistent use of protective equipment, medicine recording errors and uncertainty about whether medicines had been given as prescribed. Staff were not always available or able to respond quickly, and people said they often waited for help.
The home was also not well-led. Care was described as task-focused rather than personal, and some people's basic needs, choices, warmth and personal presentation were not properly supported. The overall rating remains Requires Improvement, as it was at the previous inspection and for the last three consecutive inspections.
Safeguarding awareness
Most people said staff made them feel safe. Staff understood how to recognise and report safeguarding concerns.
“Most people we spoke with told us staff made them feel safe.” from the report
Learning from incidents
The manager reviewed accidents and incidents, and the report says risks were generally identified and managed.
“Accidents and incidents were reviewed and monitored by the registered manager to ensure lessons were learnt.” from the report
Recruitment checks
The staff recruitment records inspected showed that pre-employment checks had been completed before staff started work.
“The files we saw showed pre-employment checks had been obtained prior to staff commencing employment.” from the report
Healthcare involvement
The home sought advice from healthcare professionals when people's needs changed.
“The provider engaged with healthcare professionals. We found that advice was sought when people's needs changed.” from the report
Staffing and response times
seriousInspectors could not be sure that enough suitably skilled staff were deployed. People sometimes waited for assistance, and staff were often reliant on agency workers.
“The provider had failed to ensure sufficient numbers of suitably competent, skilled and experienced staff were deployed” from the report
Medicines
seriousMedicine records contained many errors, and some topical medicines were not given or recorded as prescribed. Inspectors could not always tell whether medicines had been given safely.
“We found many errors with recording and although most appeared to be missed signatures, we found some medicines that records did not tally.” from the report
Cleanliness and infection control
seriousInspectors found dirty or damaged equipment and areas that could not be cleaned effectively. Staff did not always follow protective equipment procedures, and some soap and sanitiser dispensers were empty.
“On the day of our site visit we found areas of the service were dirty and not well maintained so could not be effectively cleaned.” from the report
Person-centred care
seriousCare was often task-focused. Inspectors saw people left cold or in dirty clothes, and found that choices, personal care and requests for help were not always respected.
“People did not always receive care and support that was person centred.” from the report
Weak management checks
seriousThe home's monitoring systems had not identified important problems. Staff said they lacked support and felt their concerns were not acted on.
“The systems in place to monitor and improve the quality of the service were not effective.” from the report
- 01How many permanent care staff are now in place, and how do you make sure enough staff are available on every shift, especially at night?
- 02What checks now confirm that medicines, including creams and other topical medicines, are given and recorded as prescribed?
- 03What has been changed to keep equipment, bathrooms, bedrooms and kitchenette areas clean and in good repair?
- 04How do staff record and respond to requests for baths, showers, toilet support and help from call bells?
- 05How are you checking that people are kept warm, dressed appropriately and supported according to their personal choices?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 22 February 2023 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 Park Care Home
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- September 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2019
Registered with the Care Quality Commission on 10 January 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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