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

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 inspection, this key question was rated requires improvement, at this inspection our judgement remains the same. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider and registered manager have since the last inspection, made considerable improvements and we found the majority of the issues identified at the last inspection have been addressed.

However, we did identify a new issue in relation to record keeping. Therefore, there is a continuing breach of governance.

The provider had met the previous breach from the last inspection in relation to required notifications.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a clear shared vision and strategy, and staff understood the provider’s values. However, further work was required to fully embed the ongoing changes being made to the working culture of the home.

The provider’s trainer and the registered manager both told us how there had been a focus on improving the working culture since the last inspection and building a greater understanding and appreciation of different staff's backgrounds and experiences across the team.

Staff had attended various training sessions focused on equality and diversity and values and their impact upon the delivery of people's care. Staff told us they felt as a result they were now working better as a team.

The provider and the registered manager felt although there had been improvements, there was still further work to do to ensure staff in all roles worked together as a whole team. Our observations and records confirmed further work was required, to ensure all staff were fully focused on people's needs and ensuring the consistent delivery of care in order to promote good outcomes for people.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Relatives we spoke with felt the service was well managed, which was reflected in the last relatives survey. Staff spoken with during the inspection felt managers were accessible and supportive and this was reflected in the staff survey. The provider visited the home weekly and spoke with people and staff. The registered manager was still running 2 locations but told us about the plans to shortly recruit a new registered manager solely for the home. Since the last inspection changes had taken place within the management team and a second deputy manager had been recruited. There were opportunities for staff development and a member of the management team was completing their level 5 diploma in leadership.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had access to the provider’s whistleblowing policy which was displayed. The registered manager had an open-door policy, and staff were encouraged to speak out if required. Staff spoken with during the inspection told us they felt listened to and their feedback was acted upon. We saw evidence that where concerns had been raised, these had been investigated and any required actions taken.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider’s trainer told us how staff training groups were now organised around staff's personal level of experience and training needs. This had enabled some staff to become more confident and to gain more from their face-to-face training.

The service had not ensured regulatory requirements were fully met in relation to all aspects of record keeping. Processes for medicines did not identify all of our findings and oversight of the service failed to ensure care was provided to people that was person-centred.

We saw that although people’s records reviewed were accurate, they were incomplete in relation to areas such as people’s pressure care, and food and fluid intake. There were significant gaps in people’s records as staff had not ticked off the ‘care’ tasks on the provider’s electronic records system once they had provided the care required.

There were also gaps as staff still documented some of the care provided on paper records. Therefore, although staff told us people's care had been provided and there was no indication people were dehydrated, malnourished or not being re-positioned where required. There was a lack of written evidence to demonstrate when people’s care had been provided. The registered manager was fully aware of this issue with the records and continued to take actions to address this with the staff team. Their actions will take further time to complete and to become fully effective.

However, the provider had recently introduced a new electronic audit system which was being embedded. This has enabled the registered manager to use the monthly audit schedule in order to assess various aspects of the service. When the registered manager and staff identified areas which required attention, these were delegated to staff to action.

The registered manager was already fully aware of the other issues we have identified at this inspection and actions to address them were underway but had not yet been fully completed.

The provider had taken action since the last inspection and ensured the required water safety checks had been completed.

The provider and registered manager have made sufficient improvements since the last inspection in relation to notifications and the service is no longer in breach of this regulation. The registered manager had ensured CQC was notified of significant events.

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

The service 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.

Although learning and improvements had taken place. For example, the provider’s new audit system provided more effective oversight of the service as a whole and enabled the tracking of progress against the remaining improvements required. Staff were encouraged to take the lead on areas of practice in their champion roles. Staff valued the opportunity to access regular face to face training, which was interactive. The registered manager was linked in with various forums to enable them to learn and support improvement.

The provider’s systems to ensure ongoing monitoring of the service and to drive further improvement, had not identified the new issues which we saw at this inspection, which meant despite the learning that had taken place in response to our last report. The provider continued to be in breach of 3 regulations. The provider had not yet demonstrated continuous improvement and innovation were sufficiently embed within the service.