Valley Lodge Care 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

We assessed 4 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was requires improvement. We identified breaches of regulation relating to governance and failure to notify of significant events. Of the 6 breaches found at this assessment, 1 is a continued breach from the past 2 inspections and 2 were continued breaches from the last inspection. There was a lack of effective governance systems in place to ensure people received safe, effective and good quality care. The provider was responsive to concerns and took action when they were raised, but we were not assured many of the shortfalls would have been identified or addressed independently.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a culture of blame throughout the home. When we raised concerns, the provider often looked to identify who was to blame, instead of seeing an opportunity for support and learning or considering the wider culture.

The provider had not identified that the culture in the home was not person-centred, inclusive or empowering. They had not identified multiple areas of concerning institutional practice or that observations, records and conversations with staff indicated care often provided in line with staff needs, instead of people’s needs and preferences.

We received mixed feedback from staff about management. Some staff told us they felt supported, but others did not. One staff member said, “I think [registered manager] is fair. If a resident is struggling with personal care she will offer to help” and another said, “The managers are approachable”.

The registered manager managed 2 homes and was only based at the service for 2.5 days a week. When the registered manager delegated tasks, they did not first ensure staff had the appropriate skills or knowledge and did not maintain effective oversight or checks. Although the registered manager told us they felt supported by the provider, we could not be assured they had the appropriate support mechanisms or governance systems in place to fulfil their role effectively. The provider had plans to recruit another deputy manager, and after our site visits told us they were looking to introduce a new role into the management structure. The management team were responsive to feedback, took action during the assessment when we raised concerns and shared a service improvement plan with us.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they understood their roles and responsibilities. However, we the shortfalls identified during this assessment meant we could not be assured of this. Staff told us they could contact the registered manager by phone on the days she was not in the service, but 2 staff members told us they felt the home should have a manager who was based at the home full time.

There was a lack of robust systems and processes to ensure compliance with the regulations. Audits were not always completed, and when they were, they were not always effective and had not identified issues found during our assessment. The provider had identified some areas for improvement, such as care plans and mental capacity assessments. However, these were areas that had also been picked up at our last 2 inspections. We could not be assured records were accurate or complete. For example, the registered manager made 3 entries in a person’s care record at midnight, 6am and 8am stating the person had been supported to reposition. However, records showed the person was not in the service as they were in hospital. Notifications of significant events were not always submitted to CQC as required in line with regulations.

We received mixed feedback from people and relatives, most of whom told us there was good communication with management. However, this was not consistent and most felt there needed to be more activities.

Staff were open and responsive to feedback during the assessment and communicated well with the inspection team.

We received mixed feedback from partners. Some professionals felt the provider was responsive but shared that communication could be better.

We saw evidence of the service engaging with and seeking support from health and social care professionals when needed. However, this was not always consistent.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.