Regency Hall

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained as requires improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed.

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 demonstrated a positive approach to safety, with an emphasis on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were documented electronically by staff. Leaders reviewed incidents and accidents and completed a checklist to ensure appropriate actions had been completed. Leaders used safety events to learn where things had gone wrong and where action had been taken, this was shared with staff to aid learning.

Staff we spoke with understood how to report and record any safety events should they occur.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider had systems in place to help protect people from the risk of abuse. Safeguarding concerns were investigated once identified, and appropriate action was taken, including making referrals to external professionals where required. The provider monitored and analysed safeguarding incidents to identify any emerging trends or patterns, supporting learning and improvement.

All staff had completed safeguarding training and were able to describe the actions they would take if they had concerns, including how to escalate issues. This helped ensure people were supported by staff who understood their responsibilities to keep them safe.

The provider did not consistently involve people in understanding or managing risks. Care plans did not always contain sufficient guidance to staff to support people effectively. For example, where a person required support with a stoma, their care plan lacked guidance to staff on how regularly this should be done, and how to complete this safely.

We found staff were not completing ABC (Antecedent–Behaviour–Consequence) forms consistently, which meant patterns of behaviour and potential triggers were not always clearly recorded. This limited the service’s ability to fully understand risks and develop strategies to keep people safe.

Care plans were not always accurate, and staff did not consistently follow the guidance in place. For example, a person’s care plan stated their clothes should be washed separately due to the risks associated with their emollient cream, yet laundry staff told us this was not happening. This showed people were not always supported in line with their assessed needs and risk management plans.

Despite the findings of this inspection, people and their relatives indicated they felt risk was well managed at the service.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Since the last inspection, the provider had made clear improvements to the safety and suitability of the environment. Areas previously identified as requiring attention had been addressed, including repairs, décor, and environmental risk management. During this inspection, the home was clean, well‑maintained, and free from hazards.

People told us they felt safe in their surroundings. Routine checks were completed consistently, and records showed that any issues were responded to promptly. We found no immediate concerns with the environment, and the home provided a safe and comfortable setting.

We observed staff were mostly deployed effectively. Staff and relatives told us there were occasions, particularly at night and during weekends, when they felt staffing levels were not always sufficient to meet people’s needs promptly. The provider had completed dependency assessments for each person, and staffing levels were planned in line with these assessments.

Staff received appropriate training relevant to their roles, and new staff told us they had a thorough induction, including opportunities to shadow experienced colleagues before working independently. This helped ensure staff had the skills and confidence to support people safely.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading. Personal Protective Equipment (PPE) was readily available to staff and observations were made of staffing wearing this appropriately.

People and their relatives told us the home was clean and hygienic. One relative told us, “It is clean and hygienic, the home is spotless”.

We found several concerns in relation to medicines that meant people were not always protected from avoidable harm. A stock discrepancy was identified during the inspection, and there were no regular stock checks in place to ensure medicines were accounted for and safely managed.

Protocols for ‘when required’ medicines did not contain sufficient detail to guide staff on when to offer or administer them, and instructions for variable‑dose medicines were unclear. This created a risk of inconsistent decision‑making and unsafe administration.

We also observed staff not following the correct guidance for administering liquid medicines, and a medicine was found accessible to people, creating a potential safety risk.

These issues showed that medicines systems were not always robust or consistently followed. The provider took immediate action to address the concerns, including reviewing protocols, reinforcing staff training, and implementing strengthened stock‑checking processes to ensure medicines were stored, administered, and recorded safely.