All inspections: Valley Lodge Care Home

Date of inspection – 23 and 26 March 2026.

Valley Lodge is a residential location providing support and accommodation to older people who may be living with dementia.

At this assessment, there were shortcomings in safety, governance and consistency of care. Systems were not effective in identifying or managing risks early, with concerns often only recognised after harm to people had occurred or when external agencies became involved. This contributed to repeated safeguarding issues, delays in incident reporting, inconsistent communication with relatives, and variable care quality. Leadership and governance arrangements did not provide effective oversight, and early warning systems were not sufficiently robust. As a result, concerns escalated to whistleblowing and external intervention, leading to a breakdown in trust and reduced staff confidence to speak up.

The provider remained in breach of legal regulations relating to safe care and treatment and good governance. Learning from incidents was not consistently embedded. Safeguarding records highlighted concerns across multiple areas, including falls, pressure care, continence management and environmental standards. Staff understanding and application of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was inconsistent. Relatives also reported they were not always involved following incidents, limiting openness and shared decision-making.

While staff were able to assess and respond to risk, governance systems did not consistently demonstrate proactive identification, effective management or regular review. Ongoing issues with falls, skin integrity and record keeping indicated that preventative approaches were still developing. Although relatives consistently described staff as kind and responsive, personalised care, independence, choice and involvement were not always clearly evidenced, and communication with families was often reactive rather than proactive.

The service had previously experienced periods of management instability, and the local authority had been working alongside the provider to support improvement. Following the introduction of external oversight and quality improvement support, the provider took meaningful action. Improvements were made in areas such as medicines management, infection control, recruitment, training and staffing stability. Governance and supervision arrangements had also begun to strengthen, and leaders demonstrated a more open and responsive approach to feedback.

Staff and relatives reported visible improvements and increased reassurance. However, these changes are recent and not yet fully embedded in everyday practice. Further work is required to ensure improvements are sustained, that risks are consistently identified and managed early, and people experience safe, person-centred care with clear communication and involvement.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Date of Assessment: 12 March to 27 March 2025. The service is a residential service providing support to older people living with dementia.

At the previous inspection the service was in breach of 6 regulations relating to safeguarding, safe care and treatment, consent, person-centred care, governance and notifications. At our last inspection, the location was rated requires improvement, at this inspection our judgement remains the same.

At this inspection we found whilst the issues previously identified at the last inspection relating to safe care and treatment, person-centred care and governance had been met. We found new issues, which meant the service continued to be in breach of these 3 regulations. The provider had not ensured all aspects of medicines records were either complete or provided enough guidance for staff. We noted some aspects of the cleaning of the home needed attention. The provider did not always ensure people were central to all decisions and information was not always accessible to people. Although people’s records were accurate, they were incomplete.

At this inspection we found sufficient improvements had been made in relation to safeguarding, consent and notifications and the service was no longer in breach of these 3 regulations. People said they felt safe, and staff reported incidents and potential safeguarding concerns. Staff ensured the required applications were made where people were subject to any restrictions. Staff understood the application of the Mental Capacity Act (2005) in relation to their role. People’s consent forms were signed by those who were authorised to do so. Staff had submitted notifications of significant events to CQC.

People were not always provided with enough social stimulation. We saw not all staff responded quickly to people’s needs at times, whilst other staff did. We saw that although a lot of work had taken place to improve the culture of the service, further work was required.

The provider had processes to ensure people received continuity of care when they moved between services. People were consulted where possible about how they wanted risks to be managed. People’s care was provided by sufficient numbers of trained staff who had been recruited safely.

People’s care needs were assessed using evidence-based tools and their care was reviewed regularly. People were referred to external health professionals when needed.

People were treated with kindness and compassion by staff, who treated them as individuals.

The provider sought people’s views, and their feedback was used to improve the service. People were supported by staff to plan for life changes.

The provider had made changes to the management structure since the last inspection and leaders had been making the required improvements but needed further time. The provider had processes in place to enable staff to speak out if required.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Date of assessment: 23 April to 24 May 2024.

At this assessment we found breaches of regulation relating to safeguarding, safe care and treatment, consent, person-centred care, governance and notifications. There was not always a strong understanding of safeguarding or how to take appropriate action. Risks to people were not always assessed and mitigated. Staff did not always receive training appropriate and relevant to their role. Medicines were not always managed safely. Consent to care and treatment was not always sought in line with legislation. There was not a person-centred or empowering culture at the home. The provider failed to establish and operate robust quality assurance processes to monitor and improve quality and safety. The registered manager was responsive when concerns were raised and began to take action to address shortfalls identified during the assessment.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

Valley Lodge Care Home is a residential care home providing personal and nursing care to 26 people at the time of the inspection. The service can support up to 47 people.

The care home is an adapted and extended property which has recently been zoned to provide two main accommodation areas, each with access to an outside space. There are also two separate isolation areas.

People’s experience of using this service and what we found

People were not always safe. We found there were improvements needed to water hygiene risk management.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive ways possible, or in their best interests; the policies and systems in the service did not support this practice. This was a continued area of concern from the last inspection.

We made a recommendation about medicines as we were concerned at how they were being managed.

Risks associated with people and the environment were thoroughly assessed and there were extensive security measures including key pad entry systems and extensive CCTV coverage.

Staff were safely recruited and most people’s feedback told us there were sufficient staff deployed.

Infection prevention and control was very good and the home had been adapted to facilitate safe management of infection should there be cases of Covid-19.

Staff had a working knowledge of the MCA and ensured people were offered choices.

Assessments are care plans were completed and care plans were displayed on the e-care system so staff could refresh themselves each time they undertook a care task.

Staff had received both formal and informal supervision, particularly during the pandemic. There had also been counselling provided should staff wish to participate.

Face to face staff training had been temporarily suspended during the pandemic. Alternatives such as workbooks and online learning had replaced some courses to ensure staff maintained their knowledge.

Most relatives were happy with the dietary and fluid support provided however we had one specific concern that a family member had lost significant weight and this had not been properly dealt with.

Healthcare professionals were available as required. Additional safety measures such as using full PPE were in place to facilitate their access to the service.

The service was well designed and had specific areas designed for reminiscence to enhance the lives of people living with dementia.

People were supported to live fulfilling lives.

The provider was aware of their responsibilities under the duty of candour. Relatives felt that communication could be improved.

The nominated individual was very supportive to the registered manager and there was a management team in place who oversaw particular areas of the service. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Care staff told us that support from the management team was good and they were approachable.

We received mixed feedback from health and social care professionals about how engaged the provider was with them.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 5 January 2019). The service remains rated requires improvement.

At our last inspection, the provider was in breach of Regulation 11 of the Health and Social Care Act, Regulated Activities Regulations 2014, need for consent. At this inspection we found, although some improvements had been made, there were almost half of the inspected consent documents either not signed by someone with legal authority to do so or not signed. Not enough improvement had been made or sustained and the provider was still in breach of regulations. We found that the provider was also in breach of Regulation 12 of the Health and Social Care Act, Regulated Activities Regulations 2014, safe care and treatment.

Why we inspected

We carried out an unannounced, comprehensive inspection of this service on 23 October 2018. A breach of legal requirements was found. We undertook this focused inspection to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Valley Lodge on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to Regulation 12, safe care and treatment as the provider did not have a suitable water hygiene risk assessment, and a continuing breach of Regulation 11, the need for consent. This related to consents obtained for use of CCTV and photographs.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The inspection took place on 23 and 24 October 2018 and was unannounced. At our last inspection in November 2015 the service was rated as good overall. One area requiring improvement was in the reporting of incidents, which the provider has since addressed.

As a result of this inspection we have made one requirement. This is where we have identified a statutory breach of regulations. The breach in regulation requires the provider to make sure the service complies with legislation designed to protect people’s rights, in this case the requirements of the Mental Capacity Act 2005.

Valley Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides accommodation and personal care and support to a maximum of 47 older people, including those who are living with dementia, in one adapted building. There were 31 people using the service at the time of our inspection.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; however, the policies and systems in the service had not always supported this practice and legislation designed to protect people’s rights had not been followed.

There was a friendly atmosphere in the home and staff supported people in a kind and caring way that took account of their individual needs and preferences.

There were systems and processes in place to protect people from harm. Staff were trained in how to recognise and respond to abuse and understood their responsibility to report any concerns. Risks to people were individually assessed and action taken to minimise the likelihood of harm.

There were suitable systems in place to ensure the safe storage and administration of medicines. Medicines were administered by staff who had received appropriate training.

Safe recruitment practices were followed and appropriate checks had been undertaken, which made sure only suitable staff were employed to care for people in the home. There were sufficient numbers of experienced staff to meet people’s needs.

Staff received an induction and on-going training to support them to meet the needs of people using the service.

People received regular and on-going health checks and support to attend appointments. They were supported to eat and drink enough to meet their needs and to make informed choices about what they ate.

The service was responsive to people’s needs and staff listened to what they said. Staff were prompt to raise issues about people’s health and people were referred to health professionals when needed. People could be confident that any concerns or complaints they raised would be dealt with.

The provider and registered manager were promoting an open, empowering and inclusive culture within the service. There were a range of systems in place to assess and monitor the quality and safety of the service.

This inspection was unannounced and took place on 23 November 2015. It was carried out by two inspectors. A further visit by two inspectors took place on 25 November 2015 to complete the inspection.

The previous inspection took place in February 2014 when we found the service complied with all essential standards of quality and care we reviewed.

Valley Lodge is a care home without nursing which can provide care support and accommodation for up to 30 people. At the time of our visit 24 people were living there, most of whom were living with dementia.

The service had recently extended to provide accommodation for up to 47 people. The owner had applied to CQC to vary their registration in this respect and following our visit this was agreed.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People said they felt safe and said they received a consistently good standard of care and support. Staff had a good understanding of how to protect people from avoidable harm such as from potential abuse. Some incidents of potential abuse should have been reported to Hampshire County Council under local safeguarding protocols and to CQC, but had not been. Risks to people’s health or wellbeing was assessed and actions were taken to minimise them. Staff recruitment processes were robust and staff were employed in sufficient numbers to meet peoples’ needs. Where staff assisted people with their medicines this was managed consistently and safely.

There was appropriate training and support to ensure staff could effectively meet people’s needs and preferences. People were always asked to give consent to their care and support. Staff ensured they acted in people’s best interest when they lacked capacity to consent to aspects of their care and support, although the assessment of this could at times be made clearer for some specific decisions. People’s health care needs were discussed with them and staff liaised effectively with health care professionals on people’s behalf.

Staff had developed trusting relationships with people who used the service and they cared about their wellbeing. Staff were kind and caring. They responded quickly to people’s distress. Staff communicated effectively using their knowledge about people’s background and interests to engage people’s interest.

The building had recently undergone substantial building works to accommodate an additional 17 people. Whilst this was being completed, everyone’s bedrooms and bathroom facilities, where possible, were also upgraded. Fixtures and fittings installed throughout the building had been carefully considered to assist people to remain as independent as possible.

People’s care needs were assessed and their preferences recorded and understood by staff. People’s plans of care provided staff with further relevant and up to date information to help them to support people appropriately. There were some activities provided, which were flexible to suit people’s wishes and preferences. There was a robust complaints procedure and changes had been made to improve the service as a result of comments made.

The service had a positive culture Managers and senior staff were available for guidance and support. Quality assurance arrangements were robust.

There were 21 people using the service at the time of this inspection. The manager told us that all had been assessed as having some degree of dementia. We spoke with seven people who use the service, two visitors, four staff, the manager and deputy manager, a hairdresser and a chiropodist. We looked at the care and support records of five people who used the service and observed the care and support provided in communal areas.

We found that the service assessed, planned and delivered care for people with dementia in a considered and responsive way. They cooperated effectively with other providers to ensure that the safety and welfare of people was protected when their health care needs changed or when they moved between different services. The service was well led and continually assessed the quality of the care provided.

We observed that staff promoted an inclusive and supportive environment. A person living in the home told us 'The care staff always make time to talk to me. There was something I was worried about; the staff told me they are here to help'. Another person said 'The main thing is I feel safe here; they have taken away the worry from me'. A visitor remarked 'This is a lovely home and the staff have so much patience and respect for the residents'.

During this inspection we spoke with four people who used the service, with four staff and with the manager. People were happy with the service provided and we saw that staff interacted well with people in their care and talked positively about their work.

People were, as far as they were able to do so, involved in making decisions about their care and support.

People's needs were continually assessed and care was delivered in line with their care plans. There were policies and procedures in place to ensure that the safety and suitability of the premises was maintained, these were understood and followed by staff.

Staff were well supported by management and were provided with appropriate training to help them understand and meet the needs of the people who use the service.

There was an effective system in place to deal appropriately with comments and complaints made by people, or persons acting on their behalf. People living at the home had been given information about procedures to make comments and complaints and staff were trained to listen and act appropriately.

People told us they are happy living at the home. They receive the care and support thy need in a way they prefer because staff listen to their wishes and involve them in care planning processes. They told us there was always sufficient staff available to provide then with the care and support the need. They commented that the home arranges for them to see health care professionals such as General Practitioners (GP's) and Community Nurses when they need to.

People confirmed that they are able to influence the running of the home in a variety of methods that include formal meetings with staff, general discussions and care plan reviews.

They told us they enjoy the meals provided at the home. There was always sufficient food a drink available to meet their requirements.

People told us the home is always clean and tidy. The home is kept warm at all times and provides a homely environment for them to live in.

People told us that if they have any problems or concerns they can talk to staff about it and the problem will always be resolved. Relatives of people using the service also told us that any concerns raised with the home would be resolved promptly.

Valley Lodge Care Home

All Inspections

During an assessment under our new approach

During an assessment under our new approach

During an assessment under our new approach

27 August 2020

During an inspection looking at part of the service

23 October 2018

During a routine inspection

23 and 25 November 2015

During a routine inspection

5 February 2014

During a themed inspection looking at Dementia Services

11 January 2013

During a routine inspection

4 January 2012

During a routine inspection