Regent House 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider was aware there were areas of the service which needed to improve. Plans had been shared with CQC regarding the direction of the service . These plans were currently being shared with staff, people, and their relatives.

Areas of good practice were highlighted as well as areas where the provider were aiming to improve. The registered manager told us about the new processes he planned to implement. The provider told us they were working on new ways to get up to date feedback about the service. Although changes were being made, these were not yet fully embedded and reflected in staff practices and the culture of the service.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager told us they implemented a practice of staff referring to people as room numbers because there was a problem with confidentiality with staff talking about people in front of others. The registered manager did not fully consider, this was not person centred and other options such as supporting staff to refrain from talking about people in shared areas were not explored. However, following our assessment, steps have been taken to stop this practice whilst maintaining confidentiality.

Some people with learning disabilities were being supported in the service, however not all of the relevant specific training had been delivered to staff. This has been a statutory requirement for providers since 2022.

The registered manager was not always open and transparent during the assessment. For example, they told us that supervisions and appraisals were on the system and were used to promote a positive culture in the service. Some staff said that they did not have formal supervisions, contradicting what the registered manager told us. Information was later given to us by the registered manager that should have been highlighted earlier in the assessment.

However, staff told us they were well supported by the team leaders and nursing staff. One staff member told us, “The team leader has been brilliant!”

Staff did not always feel they could speak up and that their voice would be heard. Some staff told us they didn’t feel able to voice their concerns openly. There were insufficient processes in place to support staff to speak up. This included staff having regular, confidential meetings such as supervisions. This is an area the service is working to improve to ensure supervisions are conducted more regularly and implementing new surveys for staff, people and relatives. Whilst staff gave mixed views about their ability to speak up, they were confident they would speak up in the event of people’s safeguarding and general welfare. People and relatives all fed back positively they could speak up and be heard.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they had a good understanding of equality diversity and human rights. They told us they respected one another to promote a good work culture and were accepting of differences.

There were systems and processes in place to support workforce equality, diversity, and inclusion. This started during the provider’s recruitment process, where there were systems in place to enable staff and support their protected characteristics.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. There were various systems and processes in place to support the management of the service. These included weekly reports to the nominated individual about various aspects of care delivery and service management. However, we found that these systems and processes were not always operated with the emphasis on how person centred care was being delivered. Following the assessment, the provider has reviewed their auditing process and practice to include a wider governance framework.

These audits had not found the issues we identified, some issues we raised the provider had not identified such as the concerns regarding people being referred to as room numbers rather than their names. Staff and managers were using this practice both verbally and in documents. For example, audits from the registered manager referred to people in this way and this was not identified as poor practice. However, when staff and managers spoke directly to people, their names were being used and conversations were respectful.

Accurate and completed records were not always kept which negatively impacted on the providers ability to maintain and demonstrate effective oversight of the service. For example, supervisions and appraisals were not being recorded on the system and the provider could not be assured that these supportive practices were taking place.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. People told us they received input from other healthcare professionals where required. People and relatives told us local groups associated with the church visited the service as well as local school children that visited on a weekly basis. Other professionals visited the service such as hairdressers and chiropodists to help people to maintain their appearances. Staff told us they worked in partnership with other professionals to try to meet people’s needs as well as learn and improve aspects of the service. There were also systems and processes in place to enable partnership working for example referrals were made between services.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider told us that they will be reviewing the systems and processes for the management of the service and identified issues and updates required to the current processes. For example, the provider and registered manager identified and booked additional training for staff to understand how to better support people with a learning disability.

The service had a service improvement plan and an action plan with systems and processes to address certain issues. However, these action plans did not always address the shortfalls we found at this assessment. The provider and registered manager told us that changes would be implemented immediately however, these changes to affect improvement will need to be embedded over a period of time for these changes to take effect.