Regency Park

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This the first assessment for this newly registered service. This key question has been rated requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider was in breach of legal regulations 12 relating to people’s safe care and treatment including the management of medicines.
 

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider promoted a proactive and positive culture of safety, based on openness and honesty. Staff were encouraged to raise concerns about safety, and incidents were investigated and reported appropriately. Learning from incidents was used to identify opportunities for improvement and embed good practice.
Action plans were developed where areas for improvement had been identified through the provider's quality assurance processes.
Accidents and incidents were investigated, and outcomes were shared with staff to promote learning and reduce the risk of recurrence.
Lessons learned were documented following incidents and shared with staff to support continual improvement in the quality and safety of care provided.
 

The service had effective communication systems in place, with internal support available through the organisation, including access to a Positive Behaviour Support (PBS) service. Staff liaised appropriately with GPs and pharmacies when required. Referrals were submitted in a timely manner. Pre-assessments were completed prior to individuals moving into the service, and compatibility with existing residents was considered as part of this process. One professional shared with us when the person they were supporting was moving into the service numerous visits were undertaken allowing staff from previous placements to attend, this allowed for information to be shared.
Easy-read and accessible service user guides were available to support people using the service.
 

There were effective systems in place to safeguard people from abuse, including clear safeguarding, Mental Capacity Act (MCA), and Deprivation of Liberty Safeguards (DoLS) policies and procedures. Incidents requiring reporting were submitted to the relevant authorities as required. Staff had completed safeguarding training and were able to confidently explain the actions they would take if they had concerns about a person's safety or wellbeing.
One staff member explained that they kept key safeguarding contact numbers on their lanyard, ensuring they were readily accessible if needed. Statutory notifications were submitted as required. A DoLS tracker was in place to monitor applications and authorisations, helping to ensure people's legal rights were protected.
 

The provider did not always ensure risks were managed effectively. Whilst risks were clearly documented within care plans and risk assessments, not all staff were able to describe the actions they would take when rescue medication was required. Staff advised that they would need to access the electronic care management system for guidance. This presented a risk that support may not be provided promptly in an emergency situation. Staff did not consistently demonstrate sufficient knowledge to ensure safe and timely support in relation to rescue medication.
Staff supported people with positive risk-taking opportunities to promote their independence and develop life skills. This included encouraging and supporting people to prepare their own meals, complete their own laundry, and undertake tasks important to them.
Behavioural tools were utilised to ensure incidents of distress were clearly recorded to allow for analysis and to recognise any triggers which would enable lessons to be learnt.
 

The provider did not always identify and manage potential risks within the care environment. We identified one person whose bed was positioned directly against a radiator without a protective cover. Although the provider advised the radiator could not exceed a safe temperature, there was no evidence of temperature monitoring or checks to support this assurance.

The environment reflected people’s sensory needs, and individuals had access to their own private space. Bedrooms were secured using biometric access systems, ensuring they were only accessible to people living at the service and authorised staff. Access out of the rooms was not restricted.
 

The provider did not always ensure there were sufficient staff available to support people to access community activities. We reviewed daily activity records, which evidenced occasions where people were unable to participate in planned activities due to staffing levels.
Staff told us there were always enough staff on duty to meet people's needs safely. However, due to shortages of additional staff required to support community access, people were not always able to participate in activities outside the service as planned, despite this being part of their daily routines and preferences.
Relatives spoken with were generally satisfied with staffing levels. However, one relative shared, “I would say there's enough staff although on occasion on a Sunday there may not be enough. I do appreciate it's a weekend. The staffing levels on a weekend can be a bit lower. I understand that they have their own families.”
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Cleaning schedules were in place and were actively followed. IPC audits were completed and no concerns were identified.

The provider did not make sure that medicines and treatments were safe and met people’s needs.
We found inaccuracies on the electronic medicines administration record (eMAR), including incorrect directions recorded for one medicine. It was identified that when the eMAR was created, the provider had not followed their own procedure to ensure the information had been checked by a second person. This meant systems and documentation to support safe medicines management were not always effective, which increased risks to people.

Medicines were stored securely. However, a medicine that a person required immediate access to was sometimes kept in the medication room rather than with the person, which was not in line with their care plan.

We also found medicines were not routinely recorded as signed in and out when the person left and returned to the home, as required by the provider's procedure.

We identified one medicine where the dispensing label had faded and was difficult to read. We also found the titration of one medicine had not been completed in line with prescribers’ instructions. Although the provider's investigation concluded no harm had occurred, record-keeping issues meant it was not always clear what dose had been administered.

People had person-centred guidance available for the administration of 'when required' (PRN) medicines. However, we found an outdated PRN protocol which included a medicine that was no longer prescribed, creating a risk staff could refer to inaccurate information. We shared this with the registered manager who took action and updated the PRN protocol.

We identified that not all staff had completed medicines training at a frequency deemed necessary by the provider.

The provider completed regular medicines audits. However, these audits had not identified the concerns we found during the inspection, indicating governance and oversight arrangements were not always effective in identifying and addressing risks relating to medicines management.