CQC report explained · a residential care home
What the CQC found at Regency Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that recruitment checks, risk assessments, medicines management and infection control were safe. They also found enough staff to meet people's needs.
- Effective?
- Good
- This area was not inspected during this visit. Its rating was carried forward from the last inspection.
- Caring?
- Good
- This area was not inspected during this visit. Its rating was carried forward from the last inspection.
- Responsive?
- Good
- This area was not inspected during this visit. Its rating was carried forward from the last inspection.
- Well-led?
- Good
- Inspectors found stronger audits and management systems, visible managers and a positive, open culture. People, relatives, staff and professionals spoke positively about the leadership.
What inspectors found, February 2022
Regency Retirement Home was rated Good; inspectors found safe care and stronger management after earlier recruitment problems.
This was an unannounced, focused inspection on 27 January 2022. One inspector spoke with people using the service, staff and managers. They reviewed care, medicines, recruitment and management records, and gathered views from relatives and visiting professionals.
The home had improved since the last inspection. Staff recruitment checks were now completed before people started work. Risks, medicines and infection control were managed safely. People and relatives said they felt safe and were positive about the care.
Inspectors rated Safe and Well-led as Good. The overall rating also became Good, partly because the ratings for the other areas were carried forward from the previous inspection. The earlier breach about staff recruitment had been resolved.
Safer recruitment
The home had fixed the recruitment problem found at the previous inspection. Required checks and interview records were in place before new staff started.
“Staff were now recruited safely. All required checks were made before new staff began working at the home.” from the report
Managing risks
Risks such as falls, eating and drinking, skin care and legionella were assessed, acted on and reviewed.
“Risks to people were assessed and managed safely. Risk assessments clearly guided staff to care for people in a safe way.” from the report
Medicines
Medicines were received, stored, given and disposed of safely. Staff had training and regular checks of their competence.
“Staff completed appropriate medication training and had their competency assessed prior to administering, and routinely thereafter.” from the report
Stronger oversight
Managers had strengthened audits and checked staff practice. The report says shortfalls found through audits were acted on promptly.
“Audits were now in place to monitor all aspects of the service and ensure people received safe care.” from the report
Manager registration was still pending
minorThe registered manager was due to retire. Two managers were preparing to become joint registered managers, but the report says their registration application had not yet been submitted.
“They told us they still planned on submitting their application to become registered.” from the report
Lessons-learned records were still developing
minorManagers reviewed accidents and used them to make changes, but inspectors noted that documentation of lessons learned was still being improved.
“The managers told us they continued to improve their documentation of lessons learned.” from the report
- 01What is the current progress of the two managers' applications to become registered managers?
- 02How do you check that recruitment checks are completed before every new staff member starts?
- 03How are accidents and incidents reviewed, and where are the lessons learned recorded?
- 04How do your audits identify and resolve any shortfalls in care or safety?
- 05What are the current ratings and most recent inspection findings for Effective, Caring and Responsive?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 15 February 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.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found kind, personalised care, but recruitment checks, legionella risk checks and quality monitoring needed improvement.
This was a planned first inspection after a change of ownership. Inspectors visited on 26 April 2021, spoke with people, relatives, staff, managers and professionals, observed care, and checked care, medicine, recruitment and management records.
People were treated with kindness, dignity and respect. The ratings for Effective, Caring and Responsive were Good. Inspectors found that people's care needs, choices, health needs, activities and communication needs were generally well supported.
The Safe and Well-led ratings were Requires Improvement. Some staff recruitment checks were missing, including references from previous social care employers. Legionella risks had not been fully assessed, and audits had not identified these problems. The provider started taking action during and after the inspection.
The overall rating means the home was not consistently meeting the standard expected. CQC identified a breach of Regulation 19 about fit and proper persons employed. It planned to monitor progress and return for another inspection.
Kind and respectful care
Inspectors found that staff treated people with kindness, dignity and respect. People were involved in choices about their care.
“People were supported to have maximum choice and control of their lives” from the report
Personalised support
Care plans recorded people's likes, dislikes, needs and wishes. Staff supported people to remain as independent as possible.
“People received person-centred care according to their individual needs and wishes.” from the report
Good health support
Staff worked with relatives and health professionals to meet people's needs. Healthcare recommendations were clearly recorded and followed.
“People's healthcare needs were met by staff who worked in partnership with relative's and healthcare professionals” from the report
Activities and relationships
People were supported to take part in activities and maintain relationships during the pandemic. The home adapted activities when usual arrangements were not possible.
“People were supported to engage in interests and activities within their home and in the local community.” from the report
Safe medicines management
Staff had medicines training, records were up to date, and medicines were stored safely. Audits checked medicine stocks and removed unused or out-of-date medicines.
“Medicine Administration Record (MAR) charts were accurate and kept up to date.” from the report
Incomplete recruitment checks
seriousSome required checks were not completed before staff were employed. This included references from previous social care employers and records supporting employment decisions.
“The required pre-employment checks had not always been undertaken.” from the report
Legionella risk assessment
needs fixingSome steps had been taken to reduce the risk from legionella bacteria, but the required full risk assessment was not in place.
“A legionella bacteria risk assessment had not been completed as required by the provider's policy” from the report
Gaps in quality checks
needs fixingAudits did not check recruitment practice or legionella risk management. Managers therefore did not identify these problems before the inspection.
“Audits were not in place to check that service followed the provider's policies in relation to recruitment practices and the management of legionella bacteria risks.” from the report
- 01Have all staff recruitment checks and previous social care employment references now been completed and audited?
- 02Has the required legionella risk assessment been completed, and who reviews the controls and water temperature records?
- 03How do you now check that recruitment and legionella policies are being followed?
- 04What progress has been made with the managers' applications to become registered managers?
- 05What changes were made after CQC's action and what were the findings of any later re-inspection?
This was the first comprehensive inspection after a change of ownership and covered all five key questions, including infection prevention and control under Safe; the previous Good rating was under the former provider and was published on 7 April 2018. This explanation was written from the published report of 5 June 2021 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 Retirement Home
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2019
Registered with the Care Quality Commission on 1 November 2019.
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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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.