CQC report explained · a residential care home
What the CQC found at Regency Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were enough staff and medicines, safeguarding, risk management and infection control had improved. However, application forms, employment histories and references were not always checked robustly, so CQC recommended a review of recruitment.
- Effective?
- Good
- Staff had the training and support they needed. People's nutritional needs and healthcare needs were met, and the home worked within the principles of the Mental Capacity Act.
- Caring?
- Good
- People were treated with kindness, compassion, dignity and respect. Families were involved in care planning and people were supported to express their views.
- Responsive?
- Requires improvement
- Care was generally personalised and activities were offered, but one care plan had not been updated after a change in needs. One person did not have an end-of-life plan, so their wishes were unknown.
- Well-led?
- Requires improvement
- Leadership had improved and new quality checks were in place, supported by an external consultant. These systems still needed to become established, and some records were not legible or consistently completed.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found significant progress since the previous Inadequate rating, but recruitment records, end-of-life planning and leadership systems still needed work, and the home left Special Measures.
This was an unannounced follow-up inspection after the home had previously been rated Inadequate and placed in Special Measures. Inspectors visited on 25 January 2023 and reviewed information and records through 3 February 2023. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home had improved in several important areas. Inspectors found enough staff, safer medicines management, better risk management, good infection control and staff training. People were treated kindly and with respect. People received personalised care, had access to healthcare and enjoyed their food.
Some work was still needed. Recruitment records were not always accurate or complete. One person's care plan had not been updated after their needs changed, and one person did not have an end-of-life plan. Some records were hard to read or incomplete. The overall rating was Requires Improvement. Safe, Responsive and Well-led were Requires Improvement, while Effective and Caring were Good.
Enough staff
Inspectors found enough staff to meet people's needs and keep them safe. Staffing levels were reviewed using a dependency tool.
“There were enough staff deployed to meet people's needs and keep them safe.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people gently while protecting their privacy and dignity.
“People were treated with kindness and compassion by staff and their privacy and dignity was maintained.” from the report
Safer medicines
Medicines were stored securely and medicine records were generally well completed. Two missing protocols for medicines given when needed were addressed during the inspection.
“Medicines administration records (MARs) were well completed with explanations recorded for any omissions.” from the report
Recruitment records
needs fixingChecks were carried out before staff started, but application forms, employment histories and references were not always accurate or fully verified. CQC recommended that the provider review this process.
“Further improvements were required to ensure the accuracy of application forms, employment history and verification of references.” from the report
End-of-life wishes
needs fixingPeople were not consistently supported to record their preferences for end-of-life care. One person who had been unwell had no plan, so their wishes were unknown.
“People were not consistently supported to make decisions about their preferences for end of life care.” from the report
Care plan updates
needs fixingMost care plans had improved, but one person's plan had not been updated after their needs changed. The manager took action during the inspection.
“One person's care plans had been updated to reflect the changes but another person's care plan had not.” from the report
Record keeping
minorSome handwritten daily records could not be read easily, and records of people's belongings were inconsistent. Further work was needed to make all care records reliable.
“Further work was required to ensure all care records met this standard.” from the report
- 01How are you checking that application forms, employment histories and references are accurate for every new staff member?
- 02How will you make sure every person's care plan is updated promptly when their needs change?
- 03How do you record and review each person's wishes about end-of-life care?
- 04What checks are now in place to make sure daily records are legible and belongings are recorded consistently?
- 05How are you maintaining the improvements identified by the manager, provider and external consultant?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control, after the previous Inadequate rating and breaches. This explanation was written from the published report of 24 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2022
Regency Court was rated Inadequate and remains in special measures; inspectors found serious risks involving safety, staffing, medicines, personalised care and leadership.
This was an unannounced follow-up inspection. Inspectors visited on 20 July and 8 August 2022, with inspection activity ending on 12 August. They observed care, spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
Inspectors found people were at risk of harm. Risks were not properly assessed or managed, medicines were not always stored or recorded safely, and there were not always enough staff. Safeguarding incidents, accidents and injuries were not consistently investigated or referred.
Care was not always personalised, dignified or respectful. Care plans were out of date, activities were limited, and some people spent long periods without interaction. Leadership and quality checks had not identified or fixed repeated problems.
The overall rating was Inadequate. Safe, responsive and well-led were rated Inadequate. Effective and caring were rated Requires Improvement. The home remained in special measures after also being rated Inadequate at the previous inspection.
Improved staff training
Inspectors found that staff training and support had improved. Training was up to date, new staff completed an induction and staff had received supervision.
“Staff received the training and support they required to carry out their roles.” from the report
Access to healthcare
Care records showed people were supported by health professionals, including GPs, district nurses and an optician.
“Staff supported people to access the healthcare support they needed.” from the report
Family contact
People were supported to keep in touch with family and friends. Relatives were happy with the visiting arrangements.
“People were supported to keep in touch with family and friends.” from the report
Mental capacity practice
The home had improved its work under the Mental Capacity Act. A tracker showed applications and authorisations for Deprivation of Liberty Safeguards.
“The service was working within the principles of the MCA.” from the report
People were at risk of harm
seriousSafeguarding incidents were not always recognised or acted on. Inspectors also saw an assault between people when no staff were present, and one person left the home without staff knowing and suffered a serious injury.
“People were not protected from the risk of abuse as control measures were not implemented consistently.” from the report
Unsafe risk and medicines management
seriousRisks such as weight loss, pressure damage, falls and unsafe moving and handling were not managed reliably. Medicines were not always stored safely and records did not always show that creams or patches had been used correctly.
“Systems were either not in place or robust enough to demonstrate medicines were managed safely.” from the report
Not enough staff
seriousCommunal areas were sometimes left without staff, and staffing levels did not fully reflect people's needs or the layout of the home. This left people at risk and without a reliable way to summon help.
“There were not enough staff deployed at all times to meet people's needs.” from the report
Care plans were not accurate
seriousCare plans did not fully record people's needs, including skin damage and continence needs. Staff did not always follow the plans, including instructions about footwear.
“People's care plans did not reflect their needs and were not accurate or up to date.” from the report
Limited activities and interaction
needs fixingThere was no planned activity programme or activity co-ordinator. Some people spent long periods without stimulation, including a person whose plan said they needed one-to-one activities.
“People were not receiving personalised care.” from the report
Poor oversight and dignity
seriousThe provider's audits did not identify or correct repeated problems. Inspectors also saw people not being offered choices and found that dignity and respect were not consistently maintained.
“We found systems to assess, monitor and improve the service were not sufficiently robust.” from the report
- 01What specific changes have been made to ensure there are enough staff in communal areas at all times?
- 02How are falls, unexplained injuries, safeguarding incidents and other accidents now recorded, investigated and reviewed?
- 03How are medicines, prescribed creams, food supplements and medicine patches now stored and recorded?
- 04How have care plans been updated to reflect each person's current risks, continence needs, skin condition and preferences?
- 05What regular activities are now available, including one-to-one activities for people at risk of isolation?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, after the previous Inadequate rating and required improvements. This explanation was written from the published report of 22 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Regency Court
9 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- November 2021InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- August 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementstayed Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £980 to £1,250 a week. 87 can care for a couple. 12 years' experience on average.
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