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CQC report explained · a residential care home

What the CQC found at Regency Manor Care Home

Goodpublished 10 August 2023, 3 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
There were enough staff, safe recruitment checks and suitable infection control arrangements. Risk assessments were in place but were not always detailed enough, and some records for medicines given when needed lacked full administration times.
Effective?
Good
People received appropriate assessments, training-supported care, food and healthcare. Inspectors found that consent and best-interest processes followed the Mental Capacity Act.
Caring?
Good
People and relatives described staff as kind, attentive and respectful. Staff offered choices, supported independence and respected people's privacy, equality and faith.
Responsive?
Good
People had access to activities, outings, communication support and personalised social opportunities. Care plans were not always detailed or person-centred, although staff knew people well and a full review had started.
Well-led?
Good
People, relatives, staff and professionals spoke positively about the home's leadership and culture. Management audits had not always identified shortfalls, and the provider was asked to strengthen governance and use feedback more effectively.
The latest report, explained

What inspectors found, August 2023

Rated Good; inspectors found kind, safe care, but care plans and some medicines records were not always complete.

Inspectors visited unannounced on 18 and 19 July 2023. Two inspectors, a pharmacist and an Expert by Experience spoke with 12 people, 7 relatives, 16 staff and 3 health and social care professionals. They also reviewed care, medicine, recruitment and management records.

The overall rating was Good, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. People said they were happy and felt safe. Inspectors found enough staff, kind care, good access to healthcare, a wide range of activities and good communication with families and professionals.

There were some weaknesses. Risk assessments and care plans were not always detailed or personal enough. Some records for medicines given when needed did not include full administration times. Audits had not always found these problems, so the provider was asked to strengthen its management checks. Immediate action was started during the inspection.

The last rating was Good, published on 3 January 2020 under the previous provider. This inspection was needed because the service had re-registered under a new legal entity. The report says the Good rating remained appropriate.

What inspectors praised
  • Enough staff

    Inspectors found enough staff to meet people's needs. Recruitment checks, induction and training supported staff to work safely.

    “There were enough staff on duty. People and their relatives told us staff were available when they needed them.” from the report
  • Kind and respectful care

    People and relatives described staff as kind and caring. Staff offered choices, protected privacy and supported independence.

    “People and their relatives told us staff were kind and caring.” from the report
  • Activities and inclusion

    The home offered group and one-to-one activities, entertainers, outings and support for hobbies. Inspectors saw people enjoying activities and socialising.

    “People had access to a wide range of activities which included group activities, one to one sessions, outside entertainers, and weekly outings in the minibus.” from the report
  • Healthcare support

    People were supported to access healthcare when needed. Professionals said communication was open and concerns were referred on promptly.

    “People were supported to receive health care services when they needed them.” from the report
  • Food and choice

    People had enough to eat and drink, with choices, alternatives and lighter meals. Dietary needs and risks were recorded.

    “People had enough to eat and drink. People were given a choice of meals and there were alternatives and lighter meals available for them.” from the report
What inspectors were concerned about
  • Care plans not always personal enough

    needs fixing

    Some risk assessments and care plans did not give enough detail or reflect the person's individual needs and preferences. A full review had started during the inspection.

    “People had risk assessments in place for their care and support needs. However, they were not always detailed enough to ensure they were robust.” from the report
  • Medicines records

    needs fixing

    For some medicines given when needed, staff had not recorded the full administration times. Immediate action was taken to address this.

    “There were some occasions when staff were not recording full details of times of administration of these medicines.” from the report
  • Management checks

    needs fixing

    The home's audits had not always identified the care planning and medicines recording problems. The provider was asked to strengthen its governance systems and use feedback more effectively.

    “Quality assurance systems in place to monitor and improve the standard of the service were not always robust.” from the report
Questions to ask them, based on this report
  1. 01How far has the promised full review of risk assessments and care plans progressed?
  2. 02How will you make sure my relative's care plan reflects their individual needs, preferences and changes in condition?
  3. 03What checks now make sure medicines given when needed have complete administration records?
  4. 04How will management audits identify care planning and medicines recording problems more reliably?
  5. 05How is feedback from people and relatives being used to make improvements?

This was an unannounced inspection covering all five key questions, including infection prevention and control under Safe; it was prompted by re-registration under a new legal entity. This explanation was written from the published report of 10 August 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.

The story over the years

Every inspection of Regency Manor Care Home

3 rated inspections over 6 years: the service has slipped, from Outstanding to Good.

  1. August 2023Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Regency Manor Care Home →

  2. January 2020Gooddown from Outstanding
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
  3. February 2017Outstanding
    Safe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
  4. May 2022

    Registered with the Care Quality Commission on 27 May 2022.

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.

Next steps

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