Headingley Nursing Home

Updated 21 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by an inspector and an Expert by Experience. An Expert by Experience is someone who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Headingley nursing home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Headingley nursing home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 20 June 2022 and ended on 13 July 2022. We visited the location on 29 June and 5 July 2022.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We reviewed information we had received about the service, such as details about incidents the provider must notify CQC about, for example incidents of abuse. We reviewed all other information sent to us from stakeholders such as the local authority and members of the public. We used all this information to plan our inspection.

During the inspection

We spoke with nine relatives about their experience of the care provided. We spoke with seven staff members including the manager. We looked at three people's care records and three medicine records. We looked at three staff files regarding recruitment. We also looked at quality monitoring records relating to the management of the service, such as audits and quality assurance reports.

Updated 21 September 2022

About the service

Headingley nursing home is a 'care home' which provides accommodation and personal care for up to 38 older people some of whom may be living with dementia. At the time of the inspection there were 35 people using the service.

People’s experience of using this service and what we found

There was a lack of oversight on safeguarding concerns. Not all safeguarding concerns were raised, and the safeguarding log lacked details. Care plans contained information for staff to manage risks to people's health and wellbeing, however, some records were vague. The provider had oversight of the maintenance of the service and was in the process of improving the home to keep people safe. Staffing levels were safe. There was enough staff employed to ensure people's needs were being met.

The management of the home was not robust. The acting manager did not demonstrate understanding of the roles and responsibility of a manager. The nominated individual was providing increased support during the interim period and there was ongoing recruitment for a new registered manager. The feedback about management was positive from staff, people who use the service and relatives. One relative said, "Yes, I see them, they are approachable, always say hello and have a little chat or a word. They know my name."

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 23 April 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe section of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Headingley nursing home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safeguarding at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.