Regency Nursing Home

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

This was the first assessment of this newly registered service. This assessment considered the following quality statement: Governance, management and sustainability. Improvements were needed to systems and processes to ensure effective oversight and to identify areas requiring improvement. Clearer records were needed to demonstrate effective systems of governance and improvement. The registered manager and provider were open to feedback and demonstrated a willingness to develop and improve the service. The service was registered in October 2023 and systems and processes were still being developed and embedded. This assessment did not include sufficient quality statements to provide a rating for the service under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 11 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The service was registered in October 2023. The registered manager spoke of the ongoing work required to develop and embed improvements at the service. This included expanding the senior team and developing systems and processes. Staff and most external professionals were positive about the registered manager who they felt was approachable, supportive and competent. One staff member told us, “You can talk to (registered manager).” The registered manager presented as open to suggestions for areas of improvement and ensured prompt action was taken wherever possible, which we saw had occurred on the second day we visited. Observation and discussion with the registered manager showed they knew the people living at the service well and understood how to access external clinical and social support when required.

Governance processes were not yet effective in ensuring quality and safety issues are identified and resolved in a timely way. The Registered manager shared their audit plan but confirmed this had not been completed, for example monthly medication audits were planned but none had been completed since registration. It was not always easy to identify the latest information in people’s care plans. Information in some sections differed from others where updates had not been reflected throughout the record. This could lead to confusion for staff and result in inconsistent or inappropriate care to people. Following the visit, the provider informed us they had appointed a clinical lead and director of care who would have oversight of care plans. Risks to people were not always managed or mitigated effectively. For example, whilst mattresses were checked, these were not set appropriately for people’s weight. When people had fallen, the incidents had not been reviewed in line with the provider’s policy. There was no system in place to review accidents and incidents to identify patterns or trends and to drive improvement. The service was supporting people living with Dementia. We noted a lack of suitable signs or evidence of action taken to make the service safe and dementia friendly, for example the menu and activities information was written and not pictorial. At the time of this visit, the provider had not carried out an audit of the environment to consider adaptions to enhance the environment for people living with Dementia and to promote independence. The lack of effective systems to assess, monitor and improve the quality and safety of the service placed people at risk of potential harm. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the site visits we received further information from the provider which stated they were planning to move to a digital auditing system.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.