Castle Lodge Independent Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment, we rated this key question good. At this assessment, the rating has remained good.

Good: This meant people’s needs were met through good organisation and delivery.

At our last assessment we rated responsive as good. At this assessment the rating has remained good. Staff managed admissions well. Patients did not have to stay in hospital when they were well enough to leave. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity and relatives were positive about the facilities. Staff supported patients with activities inside and outside the service, undertaking assessments and providing equipment were required. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication needs, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 4. The evidence showed an exceptional standard. The service was exceptional at making sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans and positive behaviour support plans were detailed and written collaboratively with patients, included the patient’s personal history, preferences and dislikes. Staff involved people and their family, external partners and advocates in their care and support plans, so that they felt consulted, empowered, listened to and valued. Staff we spoke to told us “Castle Lodge does person centred care well, proactive care responding to needs”.

We spoke with 3 patients and 3 family members and reviewed feedback from 4 relatives and 2 patients as part of the ‘Barchester Tell All’ survey. People told us that staff had an excellent understanding of patients’ needs, social and cultural diversity, values and beliefs that could influence decisions on how they want to receive care, treatment and support. Staff knew how to meet these preferences and were dynamic as a multi-disciplinary team to make any necessary changes that would benefit the patient. One family told us about personal touches that the service makes such as that their loved one had always been a keen cyclist,the service supported this interest and bought them a cycling top.

External partners told us that the service is focused on providing person-centred care and support and achieves exceptional results for patients. Feedback we received stated that “The way they interact with patients and the respect shown during ward rounds and CPA reviews is exemplary. Staff consistently speak about patients with dignity and compassion, demonstrating a deep understanding of each individual without needing to rely on reports.”

During our SOFI observations the support provided was person centred and compassionate. Staff demonstrated that they understood patient’s individual needs and responded to these in line with care plans and positive behaviour support plans, for example, during mealtimes staff were aware of patient preferences and any dietary needs. One patient had always been used to having cash on them, so the service printed some pretend money and found this decreased the patients distress and provided a good distraction and talking point. We observed a good response to a patient incident, including consulting with external services and contacting the family to make them aware and kept them updated.

We scored the service as 4. The evidence showed an exceptional standard. The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Arrangements for social activities met people’s individual needs, were goal specific, integrated family and carers into the process and was meaningful to patients to enable them to live as full a life as possible. The service played a key role in the local community and was actively involved in building further links and contacting other community resources and support networks. For example, the service had built relationships with the voluntary sector and was using resources to assist individuals with communication. The service went the extra mile to find out what people had done in the past, hobbies, work, interests and where possible incorporated activities or tasks relevant to their interests.

Staff supported patients to maintain contact with families and friends, they accommodated visits and phone calls for carers and family members. The service was actively involved with John's campaign and promoted an open visiting culture to reduce anxiety and enable them to be with a person with a dementia, when they may be stressed, anxious, upset or lonely.

Patients and families were integrated into the service and carers told us they felt involved throughout their relative’s admission. Two relatives told us their loved one had been in a few different services, but that Castle Lodge was the best. They said, “The care is brilliant, they are 100% safe, and we want them to stay here really”.

External partners fed back “The team has a strong understanding of the diverse health and care needs within our local community. They are based locally and have excellent knowledge of community services and pathways. They work closely with other community providers and have access to step-down provision, which supports smooth transitions and improves patient pathways from hospital into long-term residential or nursing care. Castle Lodge is well known among local NHS providers and is often a first choice for longer-term admissions.”

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

During our inspection, we noted that Care Quality Commission posters with ratings were displayed. Staff made notifications to external bodies as needed. Information governance systems included confidentiality of patient records. The service complied with the Accessible Information Standard. Staff audited records to ensure there were no gaps in record keeping, Mental Health Act documentation or Deprivation of Liberty Safeguards paperwork.

We observed several information posters and leaflets within the hospital. This included information about the service, welcome booklets for patients and relatives, how to raise complaints, how to give feedback, information regarding physical health, mental health, support networks in the community and advocacy details. Feedback from surveys and community meetings was displayed and shared. The hospital could provide various forms of information, including larger print, easy read and different languages if required.

The hospital aligned with the Safewards model (to reduce conflict and containment within mental health services) and as part of this produced ‘Getting to know us’ easy read booklets displayed on the wards. This provided information about the staff for patients, relatives and visitors to the wards.

Care records showed that regular contact with other professionals involved in patients care was documented so communication was maintained throughout the patient's admission. We reviewed 3 feedback forms from hospital managers who were all happy regarding the information received prior to the meetings, they were welcomed to the service and did not think anything could be improved. Comments received were “It is always a pleasure to attend at Castle Lodge and appreciate the warm but professional reception/welcome from the team” and “As always, efficient and very supportive staff.”

The service conducted surveys for patients and relatives. In the most recent survey conducted in September and October 2025 and the question ‘How well do you feel involved, listened to and kept informed about the person you support's treatment and care’ scored 93 out of 100.

Staff bulletins and newsletters were regularly produced and shared, and we observed posters with news and updates within both staff and patient areas. Staff told us handovers were good and that information sharing from management through various meetings such as local governance, daily and monthly staff meetings was delivered effectively and gave staff clear direction.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients and their families knew how to complain or raise concerns. Patients were given the opportunity to provide feedback through a range of different ways such as mutual aid meetings, community meetings, verbally to staff or through an independent advocate. Patients and their relatives were also invited to their ward rounds and able to express their wishes and needs and provide feedback.

Staff we spoke with knew how to handle complaints appropriately.

The service recorded 24 concerns and complaints between 12 September 2024 to 17 September 2025. The service had upheld 22 of these concerns and complaints and 2 were not upheld. No complaints had been referred to the Ombudsman in the last 12 months. All complaints were responded to within 10 days and the majority within 2-3 days of the complaint being raised.

The provider fully investigated all complaints and provided feedback and outcomes. If the provider identified any themes and trends this would be escalated, the service acted on the findings, lessons learnt discussed in meetings and bulletins issued and we saw evidence that this was followed through.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of patients with mobility issues were met and made reasonable adjustments for patients, if required, and had access walking aids, shower chairs and assisted bath.

The service assessed patients to ensure the most appropriate and relevant equipment and adjustments were made for individuals. Examples such as use of wheelchairs to improve support, mobility and meaningful activity; seeking appropriate headwear to reduce risk of head injury from transfers and falls and purchasing swimwear and devices to support a patient to attend a local swimming pool.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency, and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff planned for patients’ discharge, including good liaison with commissioners, community health services and GPs.

Discharge from the service was never delayed for other than clinical reasons, and the service did not report any current delayed discharges.

We scored the service as 4. The evidence showed an exceptional standard. Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

The 4 patients we spoke with felt they were treated fairly and equally and the 3 relatives we spoke with confirmed that they were actively involved with planning care for their relative. Staff made every effort to ensure reasonable adjustments were in place to support equity in experience and outcomes.

Staff made every effort to understand and address any barriers to the care and support of patients. For example, the hospital worked with external partners to educate and train staff in effective communication for patients with aphasia. The provider showed us examples of how this had led to a reduction in incidents and improved therapeutic relationships. The hospital also engaged patients in meaningful activities within the hospital and in the community ensuring reasonable adjustments were in place.

The provider had different modes of feedback in place and tailored the care, support and treatment in response to this feedback. The service also conducted regular patient and carer surveys. The most recent survey was being conducted at the time of our assessment, and we reviewed 6 returns in September 2025. The feedback received was highly positive about the staff and the care they received at the hospital. The service created action plans to make improvements based on this feedback and the management team used this feedback to discuss, action and embed strategies to produce better outcomes for patients.

The hospital had recently completed a survey for a study to understand how mental health wards work with and support family carers during a person with dementia’s admission to a mental health ward. The goal of the study was to provide evidence-based strategies for wards to involve and support carers to improve patients’ outcomes.

The hospital was working towards meeting the core commitments of the Culture of Care Standards which as an initiative embeds a culture of collaborative and patient-centered decision making and practices to improve experiences and outcomes for patients.

Staff were 100% compliant in mandatory equality and diversity training which was refreshed annually. All staff we spoke with were alert to inequality; they gave examples of when they had faced barriers in getting patients with dementia equal access to physical health services and had advocated on their behalf.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage, including an allocated freedom to speak up guardian. The service had links with local support and social groups to support patients with dementia and recognised members of the LGBT+ community.

We scored the service as 3. The evidence showed a good standard. People were supported in planning for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The 6 care records we reviewed showed personalised care plans to account for the patient’s needs, wishes and feelings, and both the patient’s and relatives voice was evident throughout. A discharge plan was evident in 5 of the 6 care records, it was clearly documented what support would be needed to achieve this and staff ensured all relevant healthcare professionals and other relevant bodies were involved. Where appropriate, patients had their wishes documented and paperwork in place regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPRs) decisions.

Care for people who were nearing the end of their life was managed and communicated in a sensitive and dignified way. The hospital had a member of staff as a palliative care champion, to promote and enhance palliative care practice to ensure high quality care for patients.