The Vale Residential 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 Good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. There was an extremely poor and a closed culture within the service. A closed culture is a harmful environment within a care service that increases the risk of human rights breaches, abuse, and neglect for people receiving care. We found that staff fractions had caused a negative culture which relatives were aware of.

Some staff behaviour was poor, and this had impacted the service. Relatives told us they were aware of issues between staff, that staff would not work with other staff, and that some staff would not converse with other staff. Staff shared with us that some staff would not speak with other staff, which caused a negative atmosphere. There was also disconnect between staff who worked days and staff who worked nights. A staff member told us, “Apparently the night staff don’t clean. Nothing is said to them,” and “Nights could do more.” Agency staff working at the service told us they felt it was not their place to raise concerns, meaning there was a high risk of issues not being raised in a timely way.

Some staff had discussed the poor culture within their supervisions, however action to resolve this had not been effective in addressing this. Despite interactions with the registered manager and senior manager, the poor culture had continued over a significant period of time and impacted on people’s safety.

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

We found that leaders had not responded to the poor culture within the staff team. Leaders were aware of rifts within the staff team but had been unable to address them positively. Although we received some positive feedback about the registered manager, staff did not feel well supported by senior managers. Staff told us, “We don’t see senior management much, they don’t put a pinny on when they go in the kitchen, they look down their nose at you.” Relatives told us they did not always feel leaders were responsive when they raised concerns. A relative told us, “I’ve raised things, they’re not always dealt with. We find it tricky to get responses.”

Relatives raised that they did not feel that the environment was meaningful or engaging for people living with dementia. This had not been identified and acted on my leaders. A relative told us, “[Loved one] is bored There’s a lack of fidget toys and fiddle cushions.” We identified one person in their room where the radio was playing extremely loudly and causing them visible distress. Staff had not regularly checked on this person or identified they were in distress.

People did not feel they could speak up and that their voice would be heard. Although most staff we spoke with told us that the culture was positive, and they knew how to speak up, we found this has not been the case. Significant incidents of concern had been alleged over a prolonged period of time and staff had not come forward at the time of the concern. Some staff we spoke with told us they were not confident to come forward, despite having concerns.

There was not a positive, open, open culture where staff shared concerns. Staff feared that if they shared concerns, their job would no longer be secure. Some staff and relatives told us senior management were not approachable, comments included, “Some managers talk to you but one doesn’t,” and “I’ve raised things, they’re not always dealt with. We find it tricky to get responses [from management.]”

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.

Staff had completed training in equality and diversity; however we found that staff did not feel they could be open and honest. Staff had not come forward when they had concerns about people, due to fear of retribution. There had not been an inclusive culture within the service, as the staff team were fractured. A relative told us, “Theres’s always been a rift between the two shifts.” A relative shared with us their concern about the lack of support staff received. They told us, “They are complex people, I’m not sure the staff get support from senior management.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Although the registered manager, and senior managers had completed checks and audits, these had not been effective in identifying, and improving the quality of the service.

A medication audit was completed in October 2025, but this failed to identify the concerns raised with medicines within this inspection for example the lack of guidance for staff to follow for “as needed” medications. This audit did not highlight that staff lacked understanding about risks to people for example, when one person was at risk of choking, and had been given large tablets to swallow or about the poor staff knowledge of medications for epilepsy.

An infection prevention audit completed in September 2025 raised no areas of concern. However, when we inspected the service we found several areas to be highly odorous. When we brought these to the attention of senior managers, they organised for the flooring to be replaced, however this had not occurred without our intervention.

Checks and audits had failed to identify that risks to people had not been mitigated. Care plans did not always contain the information needed to inform staff how best to support people. Staff we spoke with told us they were ‘key workers’ for some people, however they could not name who the people were. One staff member told us “I key work for tor 2 people- But I can’t remember who they are.” This was despite staff being specifically responsible for knowing and advocating for these people. There was a lack of oversight and checks of care plans and guidance for staff.

The poor culture at the service had significant impact on people, relatives and staff. The registered manager and the senior managers were aware of fractions in the staff team, but action taken to address this had not been effective.

We asked senior leaders to share any oversight or audits completed by the provider, but we did not receive any. There was a lack of learning and sharing information across the providers services.

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.

Staff we spoke with told us they were unaware they needed to document seizures people experienced. We found that not all seizures had been documented, this meant that this information could not be shared with healthcare professionals to provide joined up care. Staff had not shared safeguarding concerns at the time concerns occurred and in some instances year had passed without these being raised, meaning that leaders could not share key information with stakeholders including the local authority safeguarding team.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The provider failed to ensure that opportunities for learning were identified and used to enhance people’s care. For example, one person’s care plan stated that they ‘really bad seizures’ in January 2025, however, despite this when we inspected in October 2025 their care plan was still not sufficiently detailed about how staff should respond if this person had a seizure. Their care plan detailed that staff should call 999 if the person experienced a seizure lasting longer than 5 minutes, however the person had been prescribed rescue medicine, to be administered in the event of a seizure lasting more than 5 minutes.