The Vale Residential 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 Good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to, people’s safe care and treatment, safeguarding people from abuse and staffing.

This service scored 31 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Incidents relating to seizures had not been appropriately documented. When people had seizures, staff were unaware that these should be logged as incidents, so that analysis could be completed and information relating to seizures could be shared with healthcare professionals. This meant there was no way of these being effectively monitored by specialist teams to ensure they were being managed safely.

A relative told us that one person had been given a tablet medication, when they were prescribed liquid medication due to a significant choking risk. This was raised with the registered manager, who ensured that the medication was changed to liquid, however this was not logged as an incident on the providers electronic system. The provider could therefore not be assured that all incidents were logged and could not be assured that appropriate action had been taken to address or mitigate any concerns. We asked one staff member if learning was shared following accidents and they told us, “Not really,” and that “Sometimes information only gets shared with some staff.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Although some aspects of people’s care had been managed well, we found that a full review of people’s needs had not taken place. Key guidance relating to seizure management and choking risks was not in place. Where people were placed at higher risk of internal bleeding and staff would need to contact emergency services following a fall or injury, we saw examples of people’s care plans where this was not mentioned at all. This meant that guidance was not always up to date and accurate in reflecting people’s needs, and we could not be assured people would be treated consistently or safely.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. Although all staff had completed training in safeguarding people, and some staff told us they were confident to raise concerns, we found this had not been happening for a significant period of time. When staff had concerns about people being subject to abuse, they had not always raised these in a timely way to management, or to the local authority safeguarding team to ensure action was taken to protect people from harm. Not all staff we spoke with were confident to raise safeguarding concerns. One staff member told us they were uncomfortable with the way some staff spoke with a person and would often tell them to sit in an abrupt manner. This staff member had not shared their concerns with management. Another staff member could explain what safeguarding was but could not tell us who or where they could raise concerns (for example to the local authority safeguarding team). This placed people at risk of avoidable harm.

The provider had a safeguarding folder where they logged all safeguarding concerns. However, this was not up to date and did not contain any information relating to 2025. This included any concerns raised, what action had been taken to address the concern, and any learning and sharing information with staff.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people’s health were not always managed safely. Some people had epilepsy, and experienced seizures. Care plans and risk assessments in place were not sufficiently detailed to inform staff how best to support people. For example, one person’s care plan did not detail what kind of seizures the person experienced, and another person’s care plan had not been updated to reflect that they had been prescribed rescue medicines. Staff we spoke with were not clear on who experienced seizures, and what action staff should take if someone was to experience a seizure. A senior carer told us that that they were not aware that seizures should be captured as incidents, and therefore the provider could not be assured that when people experienced seizures they were documented. The provider could not be assured that this information could be shared with other professionals to provide joined up care to people.

Other risks to people were also not well managed. For example, one person was at high risk of choking, and cared for in bed. Their relative found a needle cover on their top, which if the person had accidently ingested would have been a serious choking risk. On another occasion staff told a relative they supported their loved one to take a large antibiotic with ‘lots of water’ the person was at risk of choking and could only manage small sips of water at any time.

People who were cared for in bed, and needed support to reposition frequently to reduce the risk of developing a pressure related injury had not always received this. One person was required to be re-positioned every 4 hours, however in 1 week in September, there were 12 instances where the person was not re-positioned within this time frame, on one instance there was an 8 hour gap in between re-positioning. This meant that the provider could not be assured that people’s skin was being cared for safely, exposing people to a significant risk of their skin breaking down leaving them in extreme discomfort and at increased likelihood of other risks such as infections.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The provider did not always detect and control potential risks in the care environment. There were areas of the service where radiators did not have guards in place to reduce the scalding risk if someone were to fall or lean against them for a period of time. There was no risk assessment in place to consider this risk and any mitigation that could be put in place. We also noted some commodes were in a poor state, rusted and not cleaned causing a malodour within one person’s room.

Although some areas of the environment were physically safe, we were not always assured they were psychologically safe for people who had dementia and at high risk of being confused or distressed. Some people shared rooms in situations which were not dignified, for example one person lacked capacity to make decisions for themselves. Despite this, another person had been moved into their room. Other people shared rooms with just a curtain separating them, giving a complete lack of privacy or dignity.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. Staff, people and their loved ones told us there was not always enough staff to support them. We observed periods of time where there were clearly not enough staff to support people. For example, on the second day of our inspection there was an incident, which took one staff member away from supporting people. There were no ancillary staff to support the cook during mealtimes, and therefore a carer undertook this role. This left less care staff to support people with their personal care for example in the mornings.

Although staff had received training in supporting people with dementia, we found that staff did not always support people in a positive way. During our inspection, we observed two staff members put their finger to their lips gesturing for them to be quiet in response to one person trying to communicate. We asked the registered manager if this was a response they would expect from staff, and they confirmed it was not. We checked the person’s care plan and found this was not a suggested care approach. By making this gesture, staff were not respecting that this person had every right communicate and should not be silenced. At other times during our inspection, we observed people interact with staff without response, for example, one person told a staff member they didn’t feel well, and the staff member did not respond to the person. Some of the language used to described people we heard was inappropriate such as a person being addressed as a “good girl”, or people being talked about as if they were not there.

Although the registered manager had completed supervisions with staff, these had not always been successful in creating a positive culture within the service. Supervisions had not been successful in providing a safe space for staff to raise any concerns.

Staff had been recruited following safe recruitment processes. Before staff started working, the registered manager ensured that all pre-employment checks were completed, including obtaining references, checking work history and ensuring each staff member had a clear disclosure and baring service (DBS) check. The DBS helps employers make safer recruitment decisions.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. There was a strong smell of urine throughout the home. In some people’s bedrooms the smell or urine was particularly strong. Some relatives also raised concerns with us about the service smelling of urine. We raised this with the registered manager and senior manager, who then sought to have soiled carpets replaced, and told us they would put an improvement plan in place.

Some parts of the service were tired making cleaning and preventing the spread of infection difficult. Staff told us there were not enough cleaning staff, and that the service “Could be cleaner.” Another staff member told us, “The cleaning is always rubbish,” and “Very short staff all the time. Waiting for new staff, mainly for housekeeping.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The provider did not always make sure that medicines management was safe. Some people were prescribed ‘as and when’ medicines to be administered in the event of a seizure. We found that not everyone had protocols in place to inform staff how and when to administer the medication. We found that these medicines were stored together loose, meaning that in the event of a seizure, it would be difficult for staff to identify an individual’s medication quickly and easily.

Other ‘as and when’ medication did not have protocols in place to inform staff when to administer it. For example, one person was administered medicine for distress. There was no protocol to inform staff when this should be administered, and other methods to try before administering the medicine. When this medicine had been administered there was no records to say why it had been given, and if it was effective.

One person’s care plan stated they were at risk of choking. However, their medicine administration record (MAR) stated there was no choking risk. This information was incorrect. Most of the person’s medication was dispersible. However, the person had become unwell, and been prescribed antibiotics. These were not dispersible and large capsules, the relative told us, “[Staff] put the tablet in her mouth and walked away. It’s dangerous, she could have choked.”

A relative told us that they found “A large tablet” in their loved one’s mouth. They told us, “This is the first time in 8 years I don’t feel confident” and “We have been coming in earlier, and staying later”