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 assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant the 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 was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider’s vision was not consistently reflected in practice. Weaknesses were identified in areas such as engagement with people, escalation of skin integrity risks and communication with external professionals. Relatives described communication as reactive rather than proactive, indicating that information was not always shared in a timely way. This limited the provider’s ability to promote consistent working practices or a shared understanding of care delivery.

Following the identification of concerns, the provider demonstrated greater openness to learning and improvement. Staff described increased opportunities to reflect on incidents and risks through team discussions and structured meetings. While progress had been made, consistency in embedding a transparent and learning-focused culture across all roles and shifts was still developing.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Relatives and staff described uncertainty around leadership visibility and communication. Some relatives were unclear about who held key leadership roles and reported that updates about changes were not routinely shared. Safeguarding activity and whistleblowing concerns also highlighted gaps in oversight and supervision, indicating that risks were not always identified or addressed at an early stage.

As concerns were escalated, leadership capacity began to strengthen, including the introduction of a new manager to lead the service and provide clearer direction. Governance records showed that action had been taken to improve oversight, increase management presence, and review care planning and escalation processes. Staff feedback reflected this progress, with some reporting improved access to support and clearer guidance from leaders.

People and staff did not always feel they could speak up and that their voice would be heard.

Records showed that staff concerns were not always acted upon promptly, with some issues escalating externally before appropriate action was taken. Recurring themes, including delays, incomplete documentation and unmet care needs, indicated that systems were not consistently effective in enabling staff to raise concerns or contribute to risk management.

Once concerns became more visible, the provider showed greater openness to listening and learning from feedback. Whistleblowing concerns were taken seriously and used to inform wider governance reviews. Staff demonstrated increased awareness of escalation processes, and some described feeling more confident in raising concerns. Despite this progress, further work was required to ensure systems consistently supported early escalation and resolution.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Feedback indicated that aspects of workforce culture were not always experienced as fair or inclusive. This suggested that equality and professional standards were not yet fully embedded, with the potential to affect staff confidence and consistency in care delivery.

The provider had taken steps to support a diverse workforce, including access to training and development opportunities. Staff feedback reflected a mixed experience, with some reporting they felt supported in their roles. While progress had been made, further work is needed to ensure a consistently inclusive culture, underpinned by clear communication and equitable practices across the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Previous governance arrangements had not been effective in identifying and mitigating risks at an early stage. Concerns were often identified after incidents had occurred or through external escalation, rather than through internal monitoring systems. Repeated issues demonstrated that oversight had relied on reactive processes rather than consistent and embedded governance.

At the time of inspection, governance systems had been reviewed and strengthened. Improvements included enhanced oversight, more structured audits and better use of information from frontline staff. Where risks were identified, action was taken to manage immediate concerns, particularly in areas such as nutrition, hydration, pressure care and environmental safety.

The provider demonstrated increased awareness of previous shortcomings and had acted to prioritise risk reduction. However, sustained improvement was dependent on maintaining consistent oversight and ensuring governance processes remained proactive and effective over time.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Partnership working had initially been affected by communication breakdowns, with concerns raised about delays in information sharing and limited joint working. This impacted the early identification and management of risk.

Following this, the provider took steps to improve collaboration with external professionals. This included engaging more effectively with healthcare partners to review care, access equipment and update documentation.

Relatives reported more positive experiences of partnership working over time, particularly in relation to end-of-life care, where coordinated support was evident. Although relationships had improved, maintaining trust required ongoing, clear and consistent communication.

The provider 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. They did not always actively contribute to safe, effective practice and research.

Opportunities for learning and improvement were not always identified early, with changes often introduced in response to incidents or external involvement rather than through proactive governance processes.

When concerns were raised, the provider responded constructively. External feedback was used to inform improvements, actions were completed, and learning was applied more broadly to strengthen governance systems, leadership oversight and escalation processes. Staff and relatives recognised improvements in care and monitoring.

The service showed increased willingness to learn and develop. While progress had been made, further work was required to ensure learning was consistently embedded and that improvements were sustained across all areas of the service.