Valley Lodge Care Home

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 as requires improvement. At this assessment, the rating has remained the same.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and staffing. Improvements were not consistently found at this assessment, and the provider remained in breach of the legal regulation relating to safe care and treatment.

This service scored 59 (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 consistently demonstrate a proactive and positive safety culture underpinned by openness and transparency. Concerns were not always consistently listened to, investigated or reported, and opportunities to identify and embed learning were not always fully realised.

However, the provider had strengthened systems to support learning from incidents. Staff described the use of reflective practice and structured debriefs, including discussions about contributing factors and preventative actions. These approaches were reinforced through team meetings and safety huddles.

Governance records showed improved analysis of incident trends and the implementation of mitigation strategies, such as increased night-time observations, enhanced falls management and the introduction of monitoring equipment. Relatives reported noticeable improvements, including more frequent checks and the use of alert systems to support timely responses.

These improvements were recent and required further time to become fully embedded in practice. Further work is required to ensure consistent practice across all shifts and to embed improvements in reporting, escalation and communication.

The provider did not always work effectively with people and healthcare partners to establish and maintain safe systems of care. Monitoring of safety and continuity of care, particularly during transitions between services, was not always consistent.

Although staff demonstrated a clear understanding of escalation processes, weaknesses in incident management systems reduced the effectiveness of oversight. In particular, delays in sharing safeguarding concerns with the local authority, limited opportunities for timely multi-disciplinary review. This meant that risks were not always considered collectively with partner agencies, reducing the effectiveness of wider professional input in identifying patterns, addressing root causes, and implementing preventative measures.

As a result, improvements to people’s care were not always coordinated or sustained, which impacted people’s experiences and increased the risk of repeated incidents. The use of both electronic and paper-based systems to manage follow-up actions further increased the risk of communication gaps, particularly during busy periods or staff handovers.

Despite these concerns, staff described responding to incidents promptly and appropriately. Actions included contacting emergency services when required, seeking clinical advice, and recording incidents in a timely manner. Relatives’ feedback supported this, indicating that people’s immediate needs were addressed effectively. This provided reassurance about the management of urgent situations.

The provider did not always work effectively with people and partners to understand what safety meant to individuals or how best to achieve it. Systems did not always ensure timely sharing of concerns or consistently protect people from risks including avoidable harm or neglect.

Safeguarding records identified a sustained period of concern, with multiple referrals relating to unwitnessed falls, delays in reporting, pressure care, continence management and a failure to apply prescribed treatments. While actions were taken in response, the subsequent referrals indicated improvements. Particularly in relation to the provider’s reporting processes, were not consistently embedded or sustained. In addition, variation in staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards highlighted the need for continued training and strengthened managerial oversight.

At the time of the assessment, Valley Lodge remained under review with the local authority safeguarding team. The provider had engaged constructively with this process and was taking action to address identified concerns and drive improvement. Despite the issues identified, staff demonstrated an appropriate understanding of safeguarding responsibilities and described how they would escalate concerns to external agencies where required. Relatives reported they felt their family members were safe.

The provider did not consistently work effectively with people to identify and manage risks. Care was not always delivered in a way that fully supported people’s safety, wellbeing, and ability to maintain independence or continue activities that were important to them.

Relatives described variable communication and involvement following incidents, particularly after falls. While some felt informed and engaged, others reported delays in being notified, which limited their ability to contribute to decisions about their family member’s ongoing care and risk management. This inconsistency indicated that involvement in managing risk was not embedded across the service.

Despite this, staff described a more proactive approach to monitoring and responding to risk, particularly following incidents or an individual’s deterioration. This included increasing observations, reviewing care needs, and updating care plans to reflect changing levels of risk. Relatives also described the use of monitoring equipment and staff encouraging the safe use of mobility aids. These examples demonstrated a more responsive approach to risk management; however, this was not yet consistently experienced by all people using the service.

The provider effectively identified and managed environmental risks and ensured that facilities and equipment supported safe care.

Relatives reported clear improvements over time and expressed confidence in the current standards of the environment. Feedback consistently indicated that the service was clean, tidy and well maintained, with any issues addressed promptly.

Staff described completing routine environmental checks and following clear processes to report and resolve maintenance concerns. Governance audits confirmed that there were no significant environmental risks at the time of the assessment. This meant there was effective oversight and systems to maintain a safe, clean and comfortable environment for people living at the service.

The provider ensured there were sufficient numbers of appropriately skilled and supported staff to deliver safe care.

Some relatives described periods where staffing appeared stretched, which at times had a negative impact on their experience of care. For example, one relative reflected staff had “seemed rushed at first,” indicating that workforce pressures had affected the timeliness and responsiveness of support.

Since the provider engaged in quality improvement support, there was evidence from both staff and relatives that staffing arrangements had stabilised and were more effectively managed. Staff reported that there were sufficient numbers to meet people’s needs and that additional cover was arranged when required. This was corroborated by relatives, who described prompt responses to call bells and a consistent staff presence, providing reassurance that people received timely support.

Systems for recruitment, training and staff deployment were well established and supported safe care delivery. Workforce oversight data demonstrated improved staff retention and high levels of training compliance over time, which contributed to greater continuity of care and enabled staff to be deployed effectively to meet people’s individual needs.

At our last assessment, we found some aspects of the cleaning of the home needed attention. Relatives and staff consistently described the service as clean and hygienic, with prompt action taken to address any concerns. Staff demonstrated a clear understanding of infection prevention and control practices, including the use of PPE and routine hygiene procedures.

Systems were in place to monitor and manage infection risks, supported by regular audits and effective oversight. Staff understood how to escalate concerns, and there was evidence that issues would be shared promptly with relevant external agencies when required. This provided assurance that infection risks were effectively identified, managed and controlled.

The provider ensured that medicines were managed safely and in line with people’s needs, preferences and capacity, with individuals involved in decisions where appropriate.

Previous safeguarding concerns relating to prescribing communication indicated that medicines systems had not always operated effectively. This highlighted the need for continued vigilance, robust monitoring, and assurance that staff competency is consistently maintained. While governance records now demonstrate structured oversight, including regular audits and monitoring processes, further time is needed to ensure these improvements are fully embedded and sustained in line with regulatory requirements.

Staff demonstrated confidence in managing medicines and reported receiving appropriate training to support safe administration and accurate recording. Relatives also expressed reassurance, noting that medicines were administered regularly and that they were kept informed, reflecting improved transparency in practice.