Valerie Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.At our last assessment we rated this key question Outstanding. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff at Valerie Manor demonstrated a consistent approach to learning from incidents and used this to improve the quality and safety of care. Systems were in place to review incidents, identify patterns and ensure appropriate follow‑up. An incidents dashboard was used by the manager to monitor trends and review actions taken, supporting oversight and learning across the team.

Incidents were recorded in clear detail and actions were completed as required. For example, when a person developed bruising around the eyelids, staff recognised the increased risk because the person was taking blood‑thinning medication. Another incident involved a person found on the floor following an unwitnessed fall. Staff responded promptly, undertook 24‑hour post‑falls observations, and monitored the person for pain or changes in condition. When the person appeared more confused than usual, staff used a urine dipstick to explore a possible urinary tract infection and ensured the situation was explained to the person. This demonstrated a learning approach where staff considered causes, responded proportionately and used clinical insight to identify potential health concerns.

The service encouraged open discussion about incidents, and staff were supported to understand what had happened and what could be improved. The manager maintained oversight of incident actions and used this information to guide team learning. This supported a culture where staff felt able to escalate concerns and work collaboratively to reduce risks and prevent reoccurrence.

Safety and continuity of care was a priority in people’s care. This happened through a collaborative, joined-up approach to safety that involved them along with staff and other partners in their care.

Assessments of need and risk assessments were completed during the initial assessment of care to ensure safe, effective support. Care plans captured people's health conditions and medical needs. These provided the staff with the guidance they needed to seek additional professional health support and when to make appropriate referrals to partners

Staff made sure there was continuity of care, including when people moved between different services. Records showed clear planning for health appointments and transitions, including support for people’s specific and complex needs.

People told us that staff made them feel safe living at the home, while relatives told us they felt assured that their loved ones were cared for and protected. One relative said, “Yes, she seems comfortable and contented.”

People were protected from the risk of abuse because staff understood their safeguarding responsibilities and acted to keep people safe. Staff had the training and knowledge to ensure they could recognise when people may be unsafe and to identify potential signs of abuse.

People were safeguarded as staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). People were protected when issues around capacity had been identified. Mental capacity assessments had been conducted and recorded to determine whether they had capacity to make specific decisions about their care. Deprivation of Liberty Safeguards (DoLS) applications were completed appropriately and in people’s best interests with minimal restrictions. Where people had a DoLS in place, conditions to their authorisations were being met.

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people had been identified, assessed and managed with people’s involvement. These assessments had the information staff needed to manage these risks safely. For example, some people had been identified as requiring ongoing monitoring and support with pressure area care. There were detailed risk assessments that provided guidance which staff followed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment permitted people to be able to move around freely, and communal areas were being used. The registered manager told us that redevelopment and upgrading of the environment was ongoing, for example, access to a new lounge and bar space had been completed, while changes to the laundry facility had been upgraded.

Risks associated with the safety of the environment and equipment were identified and managed appropriately. Regular checks to ensure fire safety had been undertaken and people had personal emergency evacuation plans which informed staff of how to support people to evacuate the building in the event of an emergency.

Staffing levels were not consistently ensuring that people received timely care.

Feedback from people and staff was negative about staffing levels, and how staff were deployed to cover care tasks. Leaders, care staff and people told us that the needs of people at the service had gradually increased over the years, a change that meant people required a greater level of staff support. Many staff felt that staffing levels, and deployment, had not been adjusted accordingly to reflect these needs. One staff member said, “Our residents changed over time and the dependency went up. Staff did their utmost to keep the support going for the residents. Its more nursing now than residential; we do have clients that need a lot of support.” Another staff member said, “When you have the doubles - then one is running round answering the buzzers.”

People told us they felt there were insufficient staff and told us that they observed staff consistently rushing. One person said, “‘No. They are invariably short of staff, they’re always rushing.” Another person commented, “They’re in and out like yo-yos. You’re given what you’ve asked for and they’re out the door. Everybody does their best, but they’re so busy.” Another person said, “Sometimes it’s too long to wait if you need the loo. It’s a long, long time to wait. It’s not the staff’s fault, they’re rushed.” One person commented about night provision and said, “No, absolutely not. They’ve got people here who need two carers to help them. At night there’s only two on, so if someone wants something, they’re stuffed. There’s no one to answer their buzzer and that’s dangerous.”

We raised these with the provider. Following the inspection, the manger told us that they had, “undertaken an immediate review of staffing levels and deployment. We are actively progressing recruitment to strengthen the team and have adjusted rotas to better reflect dependency levels within the home and balanced skill mix.”

New staff completed a full induction and probationary period. Training had been identified and provided to staff according to the needs of the people living at the home. Staff were consistently recruited through an effective recruitment process that ensured they were safe to work with people. Appropriate checks had been completed prior to staff starting work which included checks through the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection.

The service had effective systems and processes in place to prevent and control infections, ensuring people lived in a clean, safe, and comfortable environment. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Infection control measures were effective. One person said, “They keep the rooms clean and in here. If you complain that something hasn’t been cleaned, they get on it.” Another person said, “The cleaner is the best member of staff. She’s very good.”

The environment was clean and hygienic, and personal protective equipment (PPE) was readily available. Staff understood the importance of good infection control practices, had received appropriate training, and were observed following guidance on hand hygiene and safe food handling. Processes were in place to support effect and safe laundering of people’s clothing and items.

Medicines were managed safely.

The provider ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. People’s medicines were managed, administered and stored safely. One person said, about staffs approach to medicines, “They’re conscientious about that.” Staff had received training in medicines and practice competency checks in administration were completed regularly.

Medication Administration Records (MAR) showed that people received their medicines as prescribed, and these records were completed accurately. PRN protocols were in place for medicines which were prescribed on a ‘when required’ basis. Regular audits were carried out to ensure there was enough stock and that storage was appropriate.