- Care home
Regency Hall
We served a warning notice on Regency Hall on 18 May 2026 for failing to meet the regulations relating to safe care and treatment and good governance.
Assessment report published 16 September 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
Overall people felt safe living at Regency Hall and knew how to report concerns about safety. They told us staff supported them to experience a smooth transition into the service. People and relatives confirmed they were involved in their care planning, and reviews of their care, but sometimes their requests to add information were not always listened to. Some people and relatives shared examples of times they felt staff had not been responsive to people’s needs. This included not having access to a call bell, which was also observed on-site. Some relatives felt staff were not always easy to locate, and they sometimes had to ask for tasks to be completed. However, most people and relatives felt staff knew people well. Some people and relatives felt improvements could be made to ensure accessibility for everybody, such as ensuring aids and equipment were in place as needed. People told us there were a lack of activities and stimulation and told us they would like more to do. However, people were supported to maintain relationships important to them. Not everyone felt they were involved in the running of the service and reported a lack of opportunities such as surveys or meetings to share their views. People were not always clear how their feedback was used to make changes. People told us they were supported by kind and patient staff. One relative told us, “[Person] is made to feel like the special one.” We observed warm interactions between people and staff, and people were comfortable in the presence of staff. People told us they felt supported to see relevant healthcare professionals as required.