Headingley Nursing Home

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.

Headingley Nursing Home is a converted Victorian villa located within the Headingley area of Leeds. The home was previously known as Grove Court Nursing Home, however changed its name in December 2019, following a change in ownership. The home is registered to provide personal and nursing care for up to 38 people across three floors. At the time of inspection 37 people were living at the home.

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

People told us they felt safe living at Headingley Nursing Home and were supported by kind staff who knew how to support them. Enough staff were deployed to support people safely. Staff were knowledgeable about how to identify and report safeguarding concerns. Accidents, incidents and falls had been documented and reviewed to look for trends and help prevent a reoccurrence. We found the home to be clean, with effective cleaning and infection control processes in place. Overall, medicines were being managed safely.

We have made a recommendation about medicines management, specifically around information relating to ‘as required’ medicines and ensuring administration times on medicines records are correct.

The current manager had commenced a new training matrix, as they were unable to evidence the previous matrix was accurate, due to a lack of certification. As a result, a number of staff needed to recomplete specific sessions. This work was underway, with staff commenting on the recent improvements in training and support. 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. People’s healthcare needs were being met. Referrals had been made in a timely manner to professionals when any issues had been noted or concerns raised. Equipment was in place to support people to stay well. People were happy with the food provided, with choices available at each mealtime, along with snacks in between. People’s food and fluid intake was documented, however this process required strengthening.

We have made a recommendation about how food and fluid consumption is recorded.

Care files contained information about the people who lived at the home and how they wished to be supported and cared for. The home was in the process of updating care documentation, to ensure enough detail was included to support personalised care. Observations showed staff knew people well and provided care and support in line with people’s wishes. Peoples’ social and recreational needs were met through an activities programme, facilitated by an activity co-ordinator and staff members. The manager had identified further work was required, to encourage more people to engage, particularly in group-based activities. People’s views around this had been sought.

The home used a range of systems and processes to monitor the quality and effectiveness of the service provided. Actions had been identified and added to the home’s improvement plan, which was regularly reviewed. Staff spoke positively about the current management team, who were reported to be open, honest and approachable.

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 the service under the previous provider was good (published January 2018).

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels, medicines management, pressure care, dietary management, cleanliness and personalised care. A decision was made for us to inspect and examine those risks.

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 coronavirus and other infection outbreaks effectively.

We found no evidence during this inspection that people were at risk of harm from these concerns. However, we have recommended the provider make some improvements. Please see the safe and effective sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Grove Court Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.