CQC report explained · a residential care home
What the CQC found at Valley Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2020
Rated Requires Improvement; inspectors found good infection control and caring support, but serious gaps in water safety, consent and medicines management.
This was a focused inspection on 27 August 2020. The inspector spoke with two people, eight staff members and received feedback from relatives and health and social care professionals. They reviewed care, medicines, recruitment and management records.
The home was not always safe. There was no water safety assessment for legionella, and medicines checks and temperature records were incomplete. The home was also still not meeting the rules about consent for CCTV and photographs.
There were positive findings too. Staffing was generally sufficient, infection control was very good, and people were supported with meals, activities and healthcare. However, management checks had not found or fixed all the problems.
The overall rating remained Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not assessed during this focused inspection, so their earlier ratings were used in the overall rating.
Infection control
Inspectors found strong infection prevention arrangements. The building had been divided into zones and separate areas had been created for people needing to isolate.
“Infection prevention and control was very good and the home had been adapted to facilitate safe management of infection should there be cases of Covid-19.” from the report
Staffing
Inspectors saw enough staff to meet people's needs, and staff responded promptly to call bells. Recruitment checks and staff support were mostly in place.
“We saw sufficient staff deployed to meet people's needs and as call bells sounded, staff responded promptly.” from the report
Dementia-friendly design
The home had features designed to help people living with dementia, including familiar signs and reminiscence areas.
“The service was well designed to support people living with dementia, toilet doors were all the same colour for familiarity and there were extensive reminiscence resources around the service.” from the report
Activities and wellbeing
Inspectors found that people were supported to keep their skills and take part in activities that helped them have fulfilling lives.
“People were supported to maintain their skills and lead fulfilling lives as far as they were able.” from the report
Water safety
seriousThere was no legionella risk assessment, no named person responsible for water safety and no evidence that the water system had been tested. This left people at risk of harm.
“There was no legionella risk assessment in place, no identified person and no plan to ensure that the correct outlet temperatures were taken and appropriate outlets flushed.” from the report
Consent
seriousConsent forms for CCTV and photographs were not always signed by someone with legal authority. The forms were broad rather than specific to each decision.
“When we inspected, 12 of 26 consents were not clear as to whether they were consents signed by someone with legal authority to do so or by a family member without authority.” from the report
Medicines records
needs fixingControlled drugs were not being formally audited and some checks were not recorded. Medicines room and fridge temperatures were also not recorded.
“Medicines were not always safely managed. We looked at the controlled drugs and found that they were not being audited.” from the report
Management checks
needs fixingThe provider's quality checks had not identified or dealt with the water safety and consent problems. This was a continuing weakness from the previous inspection.
“Management monitoring systems were not always effective. Regulatory requirements were not met in two areas and these had not been identified and addressed.” from the report
Family communication
minorRelatives gave mixed feedback about communication. Some said contact during the pandemic was limited and that they were not always kept informed.
“Feedback about communication and openness during the pandemic indicated that there could be some improvements in keeping people informed about issues happening in the service.” from the report
- 01What has been done to complete the water hygiene and legionella risk assessment, and who now checks the water system?
- 02How are controlled drugs audited and recorded now?
- 03How are medicines room and fridge temperatures recorded and checked?
- 04How do you make sure CCTV and photograph decisions are signed by someone with the correct legal authority?
- 05How will you keep families informed about incidents, health issues and important changes?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and their earlier ratings were carried forward. This explanation was written from the published report of 22 October 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2019
Rated Requires Improvement; inspectors found safe, kind and responsive care, but consent procedures and leadership needed improvement.
This was an unannounced, comprehensive inspection on 23 and 24 October 2018. Inspectors spoke with people living in the home, relatives, staff and health professionals. They also checked care plans, medicines records, staff rotas, training records, risk assessments and quality checks.
The home was rated Good for Safe, Caring and Responsive. Inspectors found enough staff, safe medicines arrangements, suitable recruitment checks, kind staff and personalised care. People were supported with food, drink, activities, health appointments and complaints.
The home was rated Requires Improvement for Effective and Well-led. The main problem was that the home had not properly checked people's capacity or recorded best-interest decisions about CCTV in communal areas. Some refresher training was overdue, and a health professional said the home did not always follow up recommendations.
The overall rating was Requires Improvement. The report says the home had improved since its previous Good rating in November 2015 because it had addressed earlier problems with reporting incidents, but it still breached the rules about consent.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks were completed before staff worked in the home.
“There were enough staff to meet people's needs and recruiting practices ensured that all appropriate checks had been completed.” from the report
Medicines
Medicines were stored and administered safely by trained staff. Records and checks were in place.
“There were suitable systems in place to ensure the safe storage and administration of medicines.” from the report
Kind and respectful care
Staff built positive relationships, knew people's preferences and supported dignity and independence.
“Staff were kind and caring and knew people well.” from the report
Personalised activities and care
Care plans and activities reflected individual needs and choices. People could choose whether to join activities and what they wanted to eat.
“Care plans and activities were personalised and focused on individual needs and preferences.” from the report
Incident reporting had improved
The home had addressed the problem found at the previous inspection about reporting incidents and had acted on safeguarding advice.
“One area requiring improvement was in the reporting of incidents, which the provider has since addressed.” from the report
CCTV consent and people's rights
seriousThe home could not show that people who lacked capacity had been properly assessed or that best-interest decisions had been made about CCTV in communal areas. This was a breach of the regulations.
“The provider had not acted in accordance with the requirements of the MCA and associated code of practice, in relation to obtaining people's consent to the use of CCTV in the home.” from the report
Overdue training
needs fixingRecords showed that refresher training for some staff was overdue. A health professional also said some staff had not attended planned infection control and pressure ulcer care training.
“The records indicated refresher training for some staff was overdue.” from the report
Following health advice
needs fixingA health professional said the home did not always complete or follow up recommendations, including advice about reviewing falls.
“They do not follow up the recommendations that I offer, I have to chase them continually, but the work is not completed.” from the report
Limited recent surveys
minorThere was no evidence of recent surveys of residents, relatives or staff at the time of inspection. This meant the home had less recorded feedback to guide improvements.
“There was no evidence of recent resident, relatives and staff quality assurance surveys available at the time of the inspection.” from the report
- 01What assessments and best-interest decisions have now been completed for people affected by CCTV in communal areas?
- 02How do you now record and review consent for CCTV, and can relatives see the relevant records where they have legal authority?
- 03Which staff had overdue refresher training after the inspection, and has all of it now been completed?
- 04How do you make sure recommendations from health professionals, including advice after falls, are completed and followed up?
- 05Have resident, relative and staff surveys now been carried out, and what changes resulted from the feedback?
This was an unannounced comprehensive inspection covering all five key questions, and the premises and care provided were both looked at. This explanation was written from the published report of 5 January 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Valley Lodge Care Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- October 2020Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 29 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
26 live-in carers within about an hour of Hampshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
“I cannot recommend Prisca highly enough, she is one in a million.”
“He stayed with her throughout the pandemic, refusing to visit his own family, who lived nearby, to reduce the risk of infection.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.