CQC report explained · a residential care home
What the CQC found at Regents Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, care, consent and management.
This was an unannounced inspection carried out over four visits. Inspectors spoke with people, relatives, staff and health professionals. They also observed care and reviewed care plans, medicine records, staff files and management audits.
The overall rating was Inadequate. Safe, Effective and Well-led were rated Inadequate. Caring and Responsive were rated Requires Improvement. Inspectors found people were at risk from weak safeguarding, poor risk management, unsafe medicines practices, gaps in staff training and poor oversight.
Care records were not always accurate or up to date. Staff did not always seek consent, support people's communication needs or provide person-centred care. The home had not made enough improvement since the previous inspection, when it was rated Requires Improvement and legal breaches were found.
Visitors allowed
People could receive visitors without restrictions during the inspection.
“People were able to receive visitors without restrictions in line with best practice guidance.” from the report
Some community activities
An activities coordinator supported some people to go into the community and attend local activities.
“We did observe the activities coordinator supporting individual people out into the community and to attend activities in the local community.” from the report
Activities inside the home
People had some activities within the home, including a visit from an exercise coach.
“People were supported with activities inside the home, for example an external exercise coach had visited” from the report
People at risk of abuse
seriousPotential abuse incidents, including unexplained bruising and allegations of staff sleeping on night shifts, were not properly investigated or reported. Inspectors said this left people at risk of ongoing abuse.
“We found several incidents of potential abuse had not been reviewed, investigated and, where appropriate, reported to external agencies.” from the report
Poor risk management
seriousImportant health risks were not covered by detailed care plans, and accidents and incidents were not recorded and reviewed consistently. Fire doors were also routinely propped open.
“Systems had not been established to assess, monitor, and mitigate risks to the health, safety and the welfare of people using the service.” from the report
Unsafe medicines practice
seriousSome staff giving medicines had not received the required training. Medicine records were not always completed promptly and medication errors were not properly reviewed.
“We found evidence of medication administration errors by staff had not been effectively reviewed by the registered manager and were not reported to safeguarding.” from the report
Consent not reliably obtained
seriousStaff did not always ask for consent before providing care. People's capacity and best-interest decisions were not consistently assessed or recorded.
“People's consent was not routinely sought by staff before carrying out care.” from the report
Care not always personalised
needs fixingPeople were not always supported in line with their preferences, and some spent long periods alone. Communication needs and accessible information were not properly recorded or provided.
“People spent long periods alone, without engagement.” from the report
Weak management oversight
seriousAudits were not regular or thorough and did not lead to effective action. Staff lacked regular supervision, and the provider did not have a reliable system for learning from problems.
“Robust quality assurance processes were not in place to support the care provision.” from the report
- 01What immediate changes have been made to investigate and report possible abuse, unexplained injuries and allegations of staff sleeping on night shifts?
- 02How do you now check that every person has current risk assessments and care plans for conditions such as epilepsy, catheter care, weight loss and distress?
- 03Which staff are currently trained and assessed as competent to administer medicines, and how are medicine errors reviewed?
- 04How do you make sure staff seek consent and follow Mental Capacity Act requirements for every person's care?
- 05What evidence can you show of completed audits, staff supervision and action taken in response to complaints and incidents?
The inspection began as a follow-up to earlier breaches but was widened to a comprehensive inspection after concerns about people's changing needs; all five key questions were assessed. This explanation was written from the published report of 25 January 2024 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, January 2023
Rated Requires Improvement; inspectors found kind, effective care, but safety records and management checks were not reliable enough.
This was an unannounced inspection on 16 and 17 November 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staffing, recruitment and quality records.
People and relatives generally said people felt safe, supported and treated well. Medicines were managed safely, staff understood people's needs, and people received support with food, activities, healthcare and end of life care.
The inspectors found gaps in infection control, recruitment checks, risk records and care plan reviews. They also found that management checks had not identified important safety problems, including unrestricted windows and unsafe storage of flammable chemicals. The home acted promptly on some issues during the inspection, and inspectors said they had not found people had come to harm.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement, while Effective, Caring and Responsive remained Good. The home breached Regulation 17 on good governance.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff working at people's pace, respecting privacy and supporting individual choices.
“We saw staff were friendly and supportive; they knew people well and what was important to them.” from the report
Medicines managed safely
People received medicines at the right time. The home followed safe processes for receiving, storing, giving and disposing of medicines.
“People received their medicines when they should and in a safe way.” from the report
Good support with health
Staff worked with healthcare professionals and recognised changes in people's health. People were supported to attend health appointments.
“They also said that staff recognised small changes in a person's health and would contact them promptly for advice.” from the report
Personalised daily life
People were supported to follow their interests, maintain relationships and spend their days in ways that suited them.
“People were supported to do activities which were important and meaningful to them.” from the report
Management checks missed safety risks
seriousThe provider's checks did not identify several problems found by inspectors, including window safety and unsafe chemical storage. This was a breach of Regulation 17.
“Systems were not comprehensive to identify, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Infection control gaps
needs fixingWaste rooms were not always clean and organised, some cleaning items and continence aids were stored there, and some staff wore masks below their noses. Unlabelled toiletries were also found in communal bathrooms.
“We were not assured staff were using PPE effectively.” from the report
Incomplete risk and care records
needs fixingIndividual risk records were not always comprehensive or up to date. Relatives were not always involved in formal care plan reviews after admission.
“People's individual risks had been assessed and staff had consistent knowledge of how to mitigate this; however, records were not comprehensive, or always up to date.” from the report
Recruitment records
needs fixingSome staff files did not contain all required information, such as a previous employer reference or full work history. The provider took prompt action after this was raised.
“Recruitment files did not hold all of the required information” from the report
Mixed mealtime support
minorInspectors saw one person being helped to eat by a standing staff member who did not engage with them. Other staff provided more supportive and engaging help.
“We saw mealtime experience for people who required assistance to eat their meal was mixed.” from the report
- 01What has been done to make sure windows, chemical storage and other environmental risks are checked regularly?
- 02How are infection control practices, including mask use and storage of waste and continence items, now monitored?
- 03How do you check that every new staff member's references, work history and other recruitment information are complete before they work alone?
- 04How are care plans and risk assessments kept up to date when a person's needs change?
- 05How are relatives now involved in formal care plan reviews after admission?
This was an unannounced inspection covering all five CQC questions, prompted in part by concerns about infection control and staffing; the previous inspection had rated all areas Good. This explanation was written from the published report of 12 January 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.
Every inspection of Regents Court Care Home
6 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- January 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2023Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Goodstayed GoodSafe: GoodWell-led: Good
- June 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019
Registered with the Care Quality Commission on 7 August 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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Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
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