Regency Hall

Date of assessment: 28 April to 12 May 2026. The service is a residential care home providing support to adults, some of whom live with dementia and/or a physical disability. The service is registered to support up to 68 people. At the time of our inspection, 28 people were living at the service.

​Theproviderwas previously in breach of legal regulation in relation to safe care and treatment and good governance. Improvements were not found at this assessment, and theproviderremained in breach of these regulations.​

The provider did not consistently involve people in understanding or managing risks, and this limited people’s ability to make informed decisions about their care. We identified several concerns in relation to medicines management, meaning people were not always protected from avoidable harm. Although people’s care plans were reviewed regularly, these reviews did not always identify the shortfalls we found during the inspection. Stakeholders also told us information was not always shared with them in a timely or effective manner, which impacted partnership working. The provider did not always ensure people had equitable access to the care, support and equipment they required.

Governance systems were not consistently effective in identifying risks, monitoring practice or ensuring that actions from the provider’s own improvement plans were fully implemented. This demonstrated a lack of robust oversight to ensure care was delivered safely and in line with assessed needs.

Despite these concerns, the provider was keen to drive improvements and had begun introducing new systems and processes to strengthen the quality of care. However, these changes were not yet fully embedded, and further work was required to ensure improvements were sustained and translated into consistent, safe practice across the service.

The provider had systems in place to help protect people from the risk of abuse and to identify and control potential risks within the care environment. Infection prevention measures were effectively assessed and managed. People were supported in ways that recognised their individuality and reflected a person‑centred approach.

Leaders demonstrated the skills, knowledge and credibility needed to guide the service effectively. They promoted a positive and open culture where people and staff felt confident to speak up and raise concerns, contributing to a supportive and transparent environment.

Date of Assessment: 4 August to 14 August 2025. The service is a residential care home providing support to adults, some of whom live with dementia and/or a physical disability. The service is registered to support up to 68 people. At the time of our inspection, 45 people were living at the service.

This assessment was carried out in response to information of concern received.

The provider was in breach of 3 legal regulations relating to consent to care, safe care and treatment and good governance at the service.

Lessons were not learned when things went wrong because oversight and monitoring of safeguarding, accidents, incidents and falls was not effective. People’s care plans and risk assessments were not always in place for people’s identified risks, such as diabetes, and did not always provide sufficient guidance for staff to support people safely. This included when people communicated signs of distress. Medicines prescribed on an ‘as required’ basis to manage pain, or behaviour, lacked protocols to support their safe administration. Not all areas within the home were clean or maintained to a high standard, and some practice observed was not in line with best infection, prevention and control (IPC) guidance. Staff had not received specialist training in relation to some of the needs of people using the service. Staffing levels were in line with the assessed needs for the service, however staff were not always deployed effectively. Systems were in place to support a smooth admission process.

Governance systems were not effective. Actions were not identified or proactively taken where concerns about risk or quality were identified. Whilst the provider had good working relationships with a range of stakeholders, we received feedback that information sharing could be improved. People, relatives and staff spoke positively about the registered manager, however, did not always feel feedback was listened to and acted upon. Policies and procedures were in place to support service delivery but not always followed.

The provider did not follow the principles of the Mental Capacity Act (2005), as mental capacity assessments were not in place for all specific decisions. Care plans lacked guidance for staff on monitoring the deterioration of health conditions. However, people were referred to relevant healthcare professionals appropriately and supported to manage their health and well-being independently as appropriate. Nationally recognised tools were used to inform people’s care and support.

Whilst staff demonstrated an understanding of people’s diverse needs, these were not always sufficiently reflected within people’s care plans. End of life care plans lacked person-centred details on how people wished to be cared for at the end of their lives. The provider worked well to identify when the support provided by the service was no longer appropriate, or meeting a person’s needs. This included the identification and support to move people onto more independent settings. The provider supported workforce wellbeing.

We have asked the provider for an action plan in response to the concerns found at this assessment.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.