We carried out a review of the data available to us about Regency Hall on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Regency Hall, you can give feedback on this service.
Regency Hall is a residential care home providing personal care for to up to 68 people. The service provides support to a range of people including some who are living with dementia. At the time of our inspection there were 46 people using the service. Care was provided across 2 floors which were organised around 3 communal lounges. The provider was not providing care on a third floor and kept this decision under review. There was a large garden for people to enjoy.
People’s experience of using this service and what we found
People were supported by kind and caring staff who understood risks to their health and wellbeing. There were enough staff to meet people’s needs and they were safely recruited and trained. Medicines were administered as prescribed and safely managed to reduce the risks associated with them. Staff adhered to infection prevention and control procedures in line with legislative requirements and recognised best practice guidelines. Safeguarding systems were effective and regularly reviewed and analysed.
There was a new registered manager in post since the last inspection, who was committed to continuous improvement of the service to make a difference in people's lives. Systems such as audits were well managed to ensure a culture of safety and continuous improvement. Community links were being strengthened to ensure people retained connections and interests.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 12 March 2020). There was a breach in regulation relating to medicines management. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was prompted by a review of the information we held about this service and prompted in part due to concerns received about a safeguarding incident. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe and well-led only.
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 Requires Improvement to Good based on the findings of this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Regency Hall on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
¿ The registered manager received support from the nominated individual to stay informed of government and best practice guidelines in relation to infection prevention and control.
¿The registered manager had completed supervision for all staff to provide support and ensure staff were adhering to infection prevention and control procedures .
¿ Additional Personal Protective Equipment (PPE) had been ordered, to ensure there were adequate supplies to manage infection control and outbreaks of coronavirus.
¿ People were receiving care in their bedrooms when necessary. Where people were not isolating and able to use the communal areas, the furniture had been arranged to ensure people maintained social distancing.
¿ Cleaning schedules and staffing levels within the home had been reviewed to reduce the risks associated with the infection and ensure there were enough staff to meet people’s needs.
¿ Testing was completed in the home weekly for staff and monthly for people using the service. People using the service had consented to testing.
¿ People’s temperatures were checked throughout the day to ensure early signs of illness could be identified.
Further information is in the detailed findings below.
Regency Hall is a residential care home for up to 68 older people. At the time of inspection they were supporting 50 people across three floors. There was a fully equipped fourth floor, the provider was planning to open this floor in the future. There was also a separate activities area at the top of the home which included a hairdressing salon. People had access to communal areas on each floor and there was an accessible garden.
People’s experience of using this service and what we found
Medicines were not always managed to reduce the risks associated with them to ensure people received them as prescribed. There were mostly enough staff deployed to meet people’s needs but at some points of the day this was not the case. This meant risks to people’s safety were not always managed and people were not always meaningfully engaged. The provider’s quality assurance systems did not always highlight the areas for improvement. We made a recommendation to the provider to consider how people's preferences for activities and interests could be met.
People had care plans which were detailed, personalised and included how risk should be managed. They were regularly reviewed and staff were aware of people’s changing needs. The systems in place to monitor people’s health and wellbeing were effective and led to good outcomes for people. People were supported to maintain good health and nutrition; including partnerships with other organisations when needed. Lessons were learnt from when mistakes happened.
People received caring and kind support from staff who respected their dignity and privacy. They were encouraged to be independent and staff understood their needs well. 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.
There was good communication with staff and people who lived at the home to ensure their feedback was followed up. Communication was adapted to be accessible for people when there was an assessed need. The registered manager and the nominated individual were approachable and there were meetings in place which encouraged people and staff to give their feedback. People and relatives knew how to raise a concern or make a complaint. The environment was adapted to meet people’s needs.
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 1 November 2018).
Why we inspected
The inspection was prompted in part due to concerns received about staffing levels and quality of care. A decision was made to bring our inspection forward and examine those risks.
We found no significant evidence during this inspection that people were at risk of harm from this concern. However, we did find found evidence that the provider needs to make improvement in medicines management and governance. Please see the safe and well led sections of this full report.
Enforcement
We have identified one breach in relation to medicines management at this inspection.
Please see the action we have told the provider to take at the end of this report.
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.
We inspected the service on 3 August 2018. The inspection was unannounced.
This was a follow up to the inspection carried out in January 2018 where we had concerns about the care of people. At this inspection visit we found the provider had made the improvements we found necessary to care for people safely and effectively.
The service had a registered manager who supported staff and ensured the service was run in the best interests of the people who lived at Regency Hall.
People were kept safe through the use of effective care planning and risk assessment and management. There was sufficient trained staff who were given clear directions on how to care for people and their performance was reviewed and managed.
The service was clean and fresh and there were processes in place to keep the service infection free.
Medicine was stored and administered as prescribed. Accurate records were kept.
People were now consulted on how they wanted their care delivered. Care plans were now inclusive and were up to date and reflected people’s needs and wishes. There were communication systems in place to ensure all staff were aware of the current needs and welfare of people.
Staff ensured they had the person’s consent to care for them and when people were unable to give consent appropriate actions were taken. Staff had knowledge on how to safeguard people and what to do should they have concerns.
People’s dignity and independence was promoted as staff delivered care in a person centred and caring manner. Staff were kind and caring in their interactions with people.
Complaints were investigated and responded to in a timely manner. The service received many compliments.
The provider ensured there was a system in place to inform CQC of incidents. Records were up to date and were stored in a confidential manner.
There was a quality assurance process in place that covered all aspects of the service. Accidents and incidents were recorded and reviewed to reduce the chance of a re-occurrence.
Regency Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Regency accommodates up to 68 people in one building. On the day first day of our inspection there were 19 people and 16 on the second day living in the service, with one person was in hospital.
Regency Hall has not been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion.
This was the first inspection of the service since they registered with the Commission in October 2016.
The service is required to have a registered manager. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service did not have a registered manager. The provider did not ensure the service was managed effectively and in the best interests of people.
The provider did not have systems in place to manage the service and to ensure people’s safety. There were no systems in place to establish the number of staff or how they were deployed to keep people safe and meet their needs.
There was no process in place to ensure the control of infection. The home was visibly dirty in places and there were no process or schedule in place to keep the home clean. Care staff had to perform these duties as well as prepare meals. There was a part time chef which meant staff also had to cook meals for people taking them away from providing the care.
Risk was not effectively assessed or updated to ensure they had a reliable care plan to follow. Some accidents and incidents were recorded, but not reviewed to ensure the cause of accidents was recognised and where appropriate acted on to prevent other accidents happening again. People were left alone during breakfast without means of communication or calling for assistance.
No new staff had been recruited since the service was registered with the Commission. There was no system in place to ensure agency staff were given enough information about people to ensure their safety and welfare.
Medicine was stored and administered as prescribed although medicines due for return were not stored appropriately.
People were not consulted on how they wanted their care delivered. Daily information on people’s care was not analysed and if appropriate added to their care plan. There was no assessment process in place to re-admit people who had been in hospital. There were no communication systems in place to ensure all staff were aware of the current needs and welfare of people.
Staff were not supported or supervised appropriately to ensure their developments needs were discussed or met. There were no systems to recognise and put best practice in place. Menus were not planned in advance taking account of people needs wants and wishes.
There were no systems in place to recognise signs that the service may no longer be able to meet people’s needs. Staff had concerns about their ability to meet some people’s needs. The training provided to staff had been completed when the service was registered in September 2016 and not updated since then.
The MCA act was followed and where appropriate the local authority had been involved in determining people’s ability to make decisions about their care. Staff had some knowledge on how to safeguard people.
People’s dignity was not always promoted as people were not offered baths or showers as they wanted them. People were not involved in the planning or delivery of their care. Staff were kind in their interactions with people.
Care was not person centred and reviews were not completed in a timely manner. People were not supported to pursue their hobbies and interests. Complaints particularly regarding the cleanliness of Regency Hall and laundry services were not effectively responded to.
The provider did not ensure there was a system in place to inform CQC of incidents. Therefore there were incidents we were not informed about. Record keeping was poor and ineffective. Some records such as rotas were not dated and paperwork was not stored in a manner which offered easy access and they were not stored in a confidential manner.
There was no quality assurance process in place. This meant audits of service provision were not completed, therefore there was no way the provider could show the service was recognising and meeting people’s needs and wishes. It also meant there was no process to learn from mistakes to ensure they were not repeated.
Staff were without direction and management and only responded to immediate needs of people.
We identified the provider was in breach of six of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see the action we have taken at the end of this report.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.
Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.
The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.
If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.
For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.
You can see what action we told the provider to take at the back of the full version of the report.