Regency Care Home

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 Inadequate. At this assessment the rating has changed to 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 regulations in relation to safe care and treatment and staffing.

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 service promoted a proactive and positive culture of safety based on openness, learning, and improvement. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff said they felt comfortable raising issues with management and told us that incidents were discussed at team meetings. Team meeting notes showed communication of learning from incidents, including those at the provider’s other services.

A duty of candour policy and an accident and incident policy were in place and accessible to staff. Incident forms were completed and analysed for themes, which included falls analysis.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced safe care, with effective systems for managing risks and transitions. Referrals to partners were made in a timely way.

Systems were in place to provide information to healthcare partners in the event of an emergency admission to hospital. Care plans were reviewed if people’s needs changed following discharge from hospital. Care records included information from hospitals to support these reviews.

People were protected from abuse, neglect, and discrimination. Staff had completed safeguarding training and safeguarding policies were in place.

People felt safe. A person said, “I feel very safe, and at night. They always check. I can hear my door open because I am a light sleeper. They are always checking me in my room [in the day].” Another person said, “It’s a safe place and I get on with everybody.” A relative told us about a safeguarding issue which they felt had been handled well by the service.

Staff understood their safeguarding responsibilities. They were able to describe the signs of abuse and could explain the actions they would take if they suspected abuse.

Safeguarding records were in place which included referrals to the local authority and notifications to the CQC.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). A DoLS policy was in place and applications had been made and monitored by the service.

The provider worked with people to understand and manage risks.

People were happy that their risks were well managed. A person said, “I’ve had sores on my feet, so they use these boots. I get hoisted and I’m quite happy and feel safe.” A relative said, “They seem to handle [my family member] well as she’s quite frail and take notice of what she says.”

Risk assessments and support plans were in place to manage risks. Staff completed training regarding the management of risks including moving and handling and food safety.

Documentation was completed when people showed distress and these events were analysed to minimise the risk of reoccurrence. Support plans were in place but could be further developed to include more specific information on supporting people when in distress. Support plans were updated following incidents of distress.

Staff told us they used detailed risk assessments, support plans and handovers to help them understand each person’s needs. They described how they assessed and managed risks relating to skin care and nutrition. Staff said they always involved people as much as possible in decisions about their care.

Systems were in place to ensure equipment and the premises were monitored as required, however they were not effective. We identified concerns with the environment including poorly functioning doors, doors that would not be effective in the event of a fire, an unsafe walking aid and unsecured items in accessible areas which presented a risk to people. The provider took action to address these issues when they were brought to their attention, however, some of these actions could not be immediately completed and we will continue to monitor their completion.

The environment was not fully adapted to meet the needs of the people living there. Limited adaptations had been made to support people living with dementia, with no directional signage to support people to move around the home independently and not all bedrooms and bathrooms were clearly identified.

Health and safety policies were in place and staff completed health and safety training and fire safety training; however, fire safety training and fire drills had not taken place at the frequency referred to in the provider’s policy. Risk assessments and support plans contained guidance for staff on how to minimise environmental risks.

The provider had not made sure there were enough qualified, skilled and experienced staff.

We observed that the lounge was not supervised at all times. The provider’s call bell audit showed some delayed response to call bells and also referred to a staff member needing to be present in the lounge because of people potentially becoming distressed.

Care staff told us that they needed more staff and that staffing levels were usually lower than we observed on the assessment visit. Staff also commented that it was difficult to supervise the lounge with existing staffing levels as a number of people using the service required the support of two staff. Staffing rotas showed that care staff numbers were not consistent. A dependency tool was used which the provider relied upon to determine safe staffing levels and the most recent version showed that care staffing hours available were more than the required levels stated in the tool.

On the first day of our assessment, domestic staffing levels were low and a care staff member had been asked to supplement them, however, cleaning standards were observed to be poor. A staff member told us that appropriate staffing levels would be two cleaning staff and one laundry staff member in addition. Our observation of cleaning standards and feedback received regarding laundry supported that. Forward staff rotas showed some improvement in staffing, though not at weekends, and it was clear that annual leave had affected staffing numbers at the time of our assessment. The provider commented that they would be reviewing staffing levels and recruiting additional staff to increase capacity in this area.

Staff told us that they felt supported and received induction, training, supervision and appraisal. Records supported this, though the range of training was not wide and did not include specific training on managing distress, end of life care, falls prevention, skin care, first aid and mandatory training on Learning Disability and Autism. Fire safety training and fire drills did not take place at the stated frequency in the provider’s policy for all staff.

People and their relatives felt that there were enough staff to meet their needs. A person said, “I’d say there was enough as I’m not left for long.” A relative said, “There always seems to be people around.” A professional commented, ‘When I visit there always seems to be enough staff visible on shift.”

Staff recruitment processes were followed to ensure all the required checks for when staff worked in care had been completed. This included obtaining references of previous work experiences, checking the reasons for any gaps in employment history, obtaining a Disclosure and Barring Service (DBS) check. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Risks of infection were not managed and controlled. Suitable equipment was not always in place to enable effective infection prevention and control (IPC). Cleaning schedules were not fully completed and were not comprehensive, and the service’s IPC audit was not sufficiently detailed or effective to identify and address the concerns we saw during our inspection.

This included stained bedclothes, PPE not stored correctly, clinical waste not appropriately managed, stained carpets, unclean commode chairs, unclean bathrooms and toilets, clean linen being stored incorrectly, incorrect mop management, laundry concerns including the management of soiled laundry. The provider took action to address these issues when they were brought to their attention. They also put in additional checks to minimise the risk of reoccurrence.

The environment did not smell clean in all areas. A person said, “The home is clean but some days it smells. Horrendous. This wing smells.”

A person commented, “Everything is kept clean enough and I get my bed changed once a week, unless I’ve had an accident.” Another person said, “The cleaners are very good.”

People told us that staff used PPE when providing support. A person said, “They use their aprons and gloves [when providing care].”

A range of IPC policies were in place. Staff had completed IPC training.

Medicines were managed safely and effectively. Staff received training and their competency was assessed. Medicines policies were in place.

People were satisfied with medicines management at the service. A person said, “They give me my medicines on time. The night staff give me them at the right time.” Another person said, “I have painkillers and such and she always waits with me.” We observed medicines being administered safely.

Medicines audits were completed; medicines errors were investigated and lessons learned shared with staff.

Protocols were in place for ‘as required’ medicines. One protocol required further detail and the provider immediately put this in place when brought to their attention.

Creams were stored in bedrooms, but temperatures were not being monitored to ensure that they were being stored in line with recommended temperatures. Creams were moved into the medication room where temperatures were monitored following the assessment visit.