Regency Park

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
This is the first assessment for this newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a clear Statement of Purpose and Service User Guide, which helped ensure staff, people using the service, and their representatives understood the aims, values, and expectations of the service. Staff were able to describe the service's values when speaking with CQC.

Staff attended regular team meetings where information was shared and key issues were discussed, helping to promote a consistent approach to care and support.

There was a structured induction process in place to ensure staff received the training required to meet people's needs safely before providing support. Following an initial week of training, new staff were given the opportunity to visit the service before commencing shadow shifts. This enabled people living at the service to become familiar with new staff before support was provided.

All staff completed mandatory training during their induction. However, it was not always clear how frequently refresher training should be completed, and training renewal periods were not consistently applied across all training courses.
 

The provider had leaders who understood the service, the people they supported, and the environment in which care was delivered. Leaders promoted the values of the organisation and demonstrated a commitment to providing safe, person-centred care.

There had recently been a temporary change within the management team while the registered manager was providing support to another service. Despite this, staff spoke positively about the leadership team and said they felt well supported. One staff member shared, “The [manager] said I could change my shift pattern to half a day if I wanted but at the minute, I am enjoying 3 days in and 4 days off.”

The provider-maintained oversight of the service through regular visits and audits. This helped to monitor the quality of care provided and ensure people received safe, caring, and effective support.

The service and Registered Manager had also received external recognition and awards for the work they had undertaken, reflecting their commitment to achieving positive outcomes for people and continually developing the service.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of the whistle blowing policy and described how they would use it if they needed to.

One staff member shared they had raised a concern and was happy with the response from the manager. Another staff member we spoke with shared, “they [managers] are very supportive; I could go to them if I needed to.” A relative shared “I know the Manager. She is approachable and listens to me. If I had complaint I would go to her. I feel confident she would deal with it.”
 

The provider promoted an inclusive and supportive working culture and recognised the value of a diverse workforce.
Staff told us they felt supported by managers and were able to seek guidance when needed.

Staff described a positive culture within the service and understood their roles and responsibilities. They told us managers were approachable and supported them to carry out their duties effectively. This helped create an environment where staff felt valued and able to contribute to the delivery of high-quality care.
 

The provider did not always have effective systems of governance and oversight in place. Responsibilities, roles, and systems of accountability were not always clear, and the provider did not consistently act on the best available information regarding risk, performance, and outcomes.

There were inconsistencies in training requirements, and the service was not always operating in line with its own policies and procedures. For example, the physical intervention policy stated that Positive Behaviour Support (PBS) training should be refreshed annually; however, the training matrix indicated this training was completed every two years.

Medication audits had not identified the concerns found during the assessment, indicating that auditing processes were not always effective in identifying and addressing areas of risk.

Care plan reviews had been completed; however, some information remained out of date and had not been updated to accurately reflect people's current needs and circumstances. This meant governance systems had not always been effective in ensuring records remained accurate and up to date.

The registered manager was dedicated to supporting the people and demonstrated she was passionate about the support they provided. When concerns where highlighted during the assessment they responded appropriately and either took immediate action to address them or identified them as actions within the services ongoing development plan.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service worked well with other professionals and agencies to help ensure people received the support they needed. Information was shared appropriately and in a timely way to support consistent care. Staff worked closely with health and social care professionals to help achieve positive outcomes for people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff received service specific training to meet the individual needs of people living in the home, supporting consistent and informed care.

When spoken with about any improvements to the service one relative shared, “There is no room for improvements, its good as it stands, I think [person] is very happy there.”