Valley Lodge Care Home

At this assessment, there were shortcomings in safety, governance and consistency of care. Systems were not effective in identifying or managing risks early, with concerns often only recognised after harm to people had occurred or when external agencies became involved. This contributed to repeated safeguarding issues, delays in incident reporting, inconsistent communication with relatives, and variable care quality. Leadership and governance arrangements did not provide effective oversight, and early warning systems were not sufficiently robust. As a result, concerns escalated to whistleblowing and external intervention, leading to a breakdown in trust and reduced staff confidence to speak up.

The provider remained in breach of legal regulations relating to safe care and treatment and good governance. Learning from incidents was not consistently embedded. Safeguarding records highlighted concerns across multiple areas, including falls, pressure care, continence management and environmental standards. Staff understanding and application of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was inconsistent. Relatives also reported they were not always involved following incidents, limiting openness and shared decision-making.

While staff were able to assess and respond to risk, governance systems did not consistently demonstrate proactive identification, effective management or regular review. Ongoing issues with falls, skin integrity and record keeping indicated that preventative approaches were still developing. Although relatives consistently described staff as kind and responsive, personalised care, independence, choice and involvement were not always clearly evidenced, and communication with families was often reactive rather than proactive.

The service had previously experienced periods of management instability, and the local authority had been working alongside the provider to support improvement. Following the introduction of external oversight and quality improvement support, the provider took meaningful action. Improvements were made in areas such as medicines management, infection control, recruitment, training and staffing stability. Governance and supervision arrangements had also begun to strengthen, and leaders demonstrated a more open and responsive approach to feedback.

Staff and relatives reported visible improvements and increased reassurance. However, these changes are recent and not yet fully embedded in everyday practice. Further work is required to ensure improvements are sustained, that risks are consistently identified and managed early, and people experience safe, person-centred care with clear communication and involvement.

We have asked the provider for an action plan in response to the concerns found at this assessment.