Castletroy Residential Home

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• 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 the governance at the service. 

This service scored 36 (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 not always a culture of openness and honesty. Leaders and staff consistently told us that if people became distressed whilst they were being supported and did not respond to verbal reassurance, staff left and returned later. We reviewed people’s care notes and the incident logs completed by staff and leaders and saw staff had continued to support people with personal care and hoisting on multiple occasions when they were distressed and resisting this. There was a risk of a closed culture where staff and leaders were not consistently transparent.

The provider failed to act on information gathered as part of the quality monitoring carried out with stakeholders. We reviewed the findings of the Castletroy Quality Survey 2025, which had been undertaken in January 2025. We saw that staff had raised concerns about physical aggression from people, highlighting that it was not always possible to walk away and leave people until they were calmer. Staff identified they had not received appropriate training to support people with their behavioural needs and requested further training. At the time of inspection, no improvement had been made, and people and staff remained at risk of harm.

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 identified breaches of the legal regulations and concerns in the areas of safeguarding, safe care, person centred care and governance. Leaders had not independently identified and acted on these concerns prior to our assessment. Processes were not effectively implemented to help make sure the service was led in an effective manner by staff who were capable in their job roles. The provider could not be confident the processes they had in place for monitoring and improving the quality of the service were used effectively because they did not have appropriate checks in place. We identified multiple areas of concern during this assessment. These had not been identified by the management and leadership within the service.

However, we received positive feedback from relatives about the leadership of the service. People’s relatives and staff told us the registered manager was approachable and they felt listened to.

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

We could not be assured people and staff always had the freedom to speak up. Due to our findings that safeguarding concerns and incidents were not always reported by staff or identified by the provider, we could not be assured people, and their relatives would be informed of these promptly and would be given an apology where required. 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures were in place for workforce equality, diversity and inclusion to enable a more equitable and inclusive organisation. Staff told us they were treated fairly by the provider.

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.

The provider had failed to ensure governance processes were effective. The systems in place had not resulted in the service being maintained to a safe and appropriate standard. Areas for improvement were not identified, and improvements were not made when required.

There was poor governance and a lack of effective monitoring of the safety of the environment, safeguarding, care documentation, medicines, responding to concerns and ensuring people’s rights were always promoted.

Staff told us they were supported by the provider and systems were in place for the management and oversight of the service. Following our feedback from the assessment, the registered manager took immediate action to begin the improvements required to improve the safety and quality of the service. However, this assessment identified that systems of oversight were not being implemented effectively and there were multiple concerns within the service. These had not been identified or acted upon in a timely manner. Failure to maintain oversight of quality monitoring processes placed people at risk of receiving poor care.

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.

A local authority assessment of the service had taken place in March 2025 during which areas for improvement had been identified.The local authority had worked with the service to support improvements, however at the time of inspection we identified the provider had failed to maintain safe,appropriate standards of care and the service was in breach of regulations.

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

At the time of assessment, we found multiple areas of concern in the service that had either not been identified or addressed.

Processes were not implemented effectively to enable a consistently good service to be provided to people and improvements had not been made where required. Audits were not effective in identifying where improvements needed to be made and the service was not meeting the fundamental standards we expect from care services. Although the registered manager took action to make improvements in response to our feedback following this assessment, we cannot be assured these improvements will be sustained and embedded.