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.

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 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 at the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders were focused on driving improvement and fostering a culture of learning. Organisational quality systems were in place to support ongoing development and enhance the standard of care delivered. Staff and leaders demonstrated a positive culture and shared a strong commitment to providing good‑quality, person‑centred care.

The provider now had inclusive leaders who understood the context in which care and support were delivered and demonstrated the values and culture of the organisation. Leaders had the skills, knowledge, experience and credibility needed to lead effectively, and they did so with integrity, openness and honesty.

Staff, people and relatives told us the service had improved since the registered manager had been appointed. A staff member told us, “Managers lead by example, I feel like I can talk to them. They’re like a normal person”, reflecting the approachable and supportive leadership style.

Leaders at all levels were visible within the home. During the inspection, we observed senior leaders supporting staff during mealtimes to enhance people’s dining experience. This demonstrated a hands‑on, compassionate approach to leadership.

The provider promoted a positive and open culture where people and staff felt able to speak up and raise concerns. Staff told us they felt listened to and were confident that any issues they reported would be taken seriously and acted upon. They described an environment where leaders were approachable, supportive and encouraged open communication.

Staff were aware of the organisation’s whistleblowing procedures and understood how to escalate concerns both internally and externally if needed. Several staff told us they felt empowered to speak up, and that leaders created a culture where concerns were welcomed rather than discouraged.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance systems were not always effective in identifying risks, monitoring practice or ensuring actions set out in the provider’s own improvement plans were fully implemented. For example, shortfalls identified during this inspection relating to care plans and medicines demonstrated the providers quality assurance processes were not always effective.

There was no effective system in place to monitor or analyse call‑bell response times. The electronic monitoring system was not fully operational, and no alternative arrangements had been implemented to provide oversight. As a result, we could not be assured that appropriate measures were in place to ensure people’s needs were responded to promptly.

Overall, governance arrangements lacked the robustness needed to ensure risks were identified, actions were completed, and improvements were sustained, which limited the provider’s ability to ensure safe and consistent care.

The provider recognised their responsibility to work collaboratively with partner agencies. However, they did not always share information or learning effectively and timely. We received feedback that information requested by external professionals was not always provided promptly or to the required standard. This limited the provider’s ability to work in partnership to support people’s care and drive improvements across the service.

The provider was keen to drive improvements within the service and had begun introducing new systems and processes to strengthen the quality of care. However, these changes were not yet fully embedded, and we found that several shortfalls identified at the previous inspection had not been fully addressed. This meant learning had not consistently translated into sustained improvement.

Despite this, leaders demonstrated a clear commitment to ongoing development and were invested in improving the service. The provider was dedicated to striving for better outcomes and was making use of wider organisational resources, including support from the quality and compliance team, to help strengthen practice and embed learning.

While the foundations for improvement were being established, further work was needed to ensure new systems became fully effective and that learning led to consistent, measurable and sustained improvements in people’s care.