Regency Hall

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 requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance.

This service scored 46 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Whilst the provider had a range of policies and procedures in place to support the delivery of safe and effective care, these were not always followed. For example, the provider’s mental capacity policy highlighted the importance of adhering to the MCA (2005), yet care records showed the principles had not been followed. This placed people at risk of receiving inconsistent, or poor-quality care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Not everyone spoken with felt leaders acted to address concerns. Feedback included, “Leaders do not respond always in reality.” And “They say they will do things but don’t.” And “[Leaders have not always] done things, they said they were going to do.”

However, most people, relatives and staff spoke positively about the registered manager, describing them as visible and approachable. The provider had implemented a structured senior leadership team which provided support to the registered manager in carrying out their role, this included regular leadership meetings. The registered manager understood their regulatory responsibilities.

Whilst systems were in place to speak up, people did not always feel that their voice would be heard. This was because people were not always confident action would be taken by leaders. However, relevant policies were in place to support staff in speaking up about unsafe care. This included a whistleblowing policy. Staff confirmed they knew how to whistle blow.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Relevant policies were in place to support equality, diversity and human rights. We received no concerns that staff had experienced discrimination.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes to oversee risk and quality were not effective. Checks and audits carried out had not identified some of the issues we picked up during our inspection. For example, a recent medicine audit noted that protocols were in place to support the administration of ‘as required’ medicines, but during our inspection we found these were not in place. Similarly, a medicine audit noted fire risk assessments were in place for the use of emollient creams, but during our inspection we found these were not in place. Some of the audits did not robustly review key risk areas, such as care plan audits which only checked if care plans had been reviewed and not whether the contents were accurate and sufficient. Other checks were not fully completed, and therefore did not provide a comprehensive or accurate overview of the area reviewed. This included a manager review of accidents and incidents. This placed people at risk of harm.

Whilst the provider understood their duty to collaborate and work in partnership, they did not always share information and learning with partners effectively or collaborate for improvement. We received feedback that information was not always shared promptly, or to an adequate standard when requested by partner agencies. We found that whilst action was taken to address some concerns raised by stakeholders, action was reactive rather than proactive and only taken following intervention from partner agencies.

However, other feedback was that the provider had positive working relationships with relevant stakeholders and records showed referrals were suitably made and advice sought as appropriate. People and relatives confirmed they were satisfied with how the service worked in partnership with their support networks.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. Audits and checks completed by leaders did not always generate clear actions plans where risk, or quality concerns were identified. This meant there was no assurance that issues were being prioritised and addressed in a timely manner. This placed people at risk of unsafe care. Furthermore, provider had no overall service improvement action plan in place informed by their own quality assurance checks. Actions to improve the service had already been identified through feedback from the local authority, and feedback we had shared on-site during our inspection. This demonstrated reactive action, rather than proactive action.