Castle Lodge Independent Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

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

Good: This meant people were safe and protected from avoidable harm.

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service kept a clear record of all accidents, injuries and incidents, and these were monitored using a multi-disciplinary approach. In addition, a monthly report was created by the hospital director to monitor trends and themes of incidents, where a trend was developing, such as patients with a falls risk, there were discussions regarding changes to medication, fall diaries implemented, up to date care plans and continued monitoring of these.

All staff we spoke with were clear about what incidents they needed to report and how to report them. The level of incident reporting indicated that they were open and transparent. Staff understood the duty of candour and gave patients and families a full explanation if and when things went wrong. The hospital had recorded 11 incidents which met the duty of candour threshold during the past 12 months. We saw evidence of the letters written to patients and their relatives or carers.

There was evidence that changes had been made because of incidents and feedback from complaints. The service created monthly lessons learnt bulletins. In June 2025 the bulletin was regarding food labelling by the kitchen team, where there were known allergies to patients, following an incident.

Staff attended de-briefs following incidents, lessons learnt and sharing good practice was embedded within all meetings from daily handovers, stand up meetings to team meetings and individual supervisions.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service had a clear referral and admission process. All referrals were screened using admission criteria and following pre-admission assessment and planning. The service prepared a preadmission bundle for families and carers and provided the relevant dates for relatives for multi-disciplinary meetings. A relative told us their family member was admitted from the local hospital and said they, “went over everything with us before they got here. We have full involvement in care plans.”

We received feedback from external partners who were very positive about how well the team at Castle Lodge worked with patients, their families, and system partners to ensure effective admission to the service and told us, “They consistently keep everyone updated, listen to different perspectives, and include advocacy in their approach.” We were also given some positive examples where contact was made with previous services to gain an understanding of the person’s care such as “…not altering a person’s medications from a previous service until they could gain a better understanding of why this medication was in place. Another example relating to safe systems of care involved an admission from a general hospital setting, requiring them to provide more detail around incidents involving the persons family that had occurred there, so that Castle Lodge could ensure a safe transition.”

The service planned for discharge during regular ward rounds and invited appropriate people to pre-discharge planning meetings. External partners fed back “Castle Lodge is proactive in discharge planning and ensures continuity of care for patients.”

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

All staff were trained in safeguarding adults and children, and staff were 97% compliant at the time of our assessment. All staff we spoke with could give examples of how to identify risks and protect patients from harm, they knew when to escalate concerns and how to make a safeguarding referral. Staff members told us they had good access and knowledge of safeguarding and external sources. They knew who the speak up champion was and told us there was a clear escalation process.

Between 01 Nov 2024 to 23 Nov 2025, the service had logged 105 concerns on a safeguarding consideration report log. The service logged if a member of the safeguarding team was contacted for advice, how the incident was handled and the actions taken. During the same period, 10 safeguarding of vulnerable adult alerts were made.

The service had a positive risk-taking culture and a focus on the least restrictive approach. Restraint was only ever used as a last resort. Records showed the service had recorded 855 incidents July – September 2025, which had required intervention. An average of 87% of the interventions utilised de-escalation techniques and most restrictive interventions were to support patients with their personal care needs. The service admitted 2 patients in September, which had increased the number of incidents within the service. In September, 50% of all incidents were related to one patient. There were no incidents of prone or supine restraint, and all restrictive interventions were reviewed for all patients in multi-disciplinary team meetings and analysed monthly through reporting and governance. Staff told us they completed an accredited course on restraint training and compliance was 100%.

The service had reported 8 uses of rapid tranquilisation in September 2025. Records showed minimal use of rapid tranquilisation and indicated the 8 uses in September were for one patient, newly admitted to the service. We also reviewed records which indicated the use was decreasing throughout the month.

The service did not seclude or segregate patients.

Mental Capacity Act

Staff received training in Mental Capacity Act and the Deprivation of Liberty Safeguards.

Staff we spoke with had a good understanding of consent including the Mental Capacity Act. Patients were supported to communicate and make decisions to enable the service to deliver person-centred care and treatment in line with people's best interests. This included the use of a recognised pain tool to enable staff to monitor pain when patients could not verbalise.

We saw evidence in care records that people's needs were met in line with current guidance and by undertaking capacity assessments and best interest decisions when appropriate. Multi-disciplinary team discussions involved the patient and patient's family in decision making and planning care and treatment.

The hospital had good governance in place regarding patients who required restrictive or safety interventions, such as the use of bed sensors, assistance with personal care, wheelchair or bath belts and covert medication. A multi-disciplinary team conducted regular reviews of the use of these interventions which involved carers, families and advocates, where appropriate. We saw evidence of effective use of and record keeping in relation to the Mental Capacity Act and best interest decision making.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction program. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 6 care records and found that all patients had up to date risk assessments in place, including falls care plans were appropriate to manage risk. The service invested in the Royal Society for the Prevention of Accidents (RoSPA) training to learn about falls and how to prevent them, to educate and inspire others. Evidence-based risk assessments were reviewed every 3 months and involved the patients, relatives and advocates, if the patient lacked capacity.

Patients were supported to engage in activities that mattered to them, and the risks managed positively. We spoke with 8 members of staff, including the hospital director, who all told us they communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties.

We spoke with 3 patients and reviewed written feedback from 2 patients which indicated they felt safe on the wards. Patients did speak to us about high noise levels recently but that this was being managed as well as possible by staff. Patients were involved in monthly community meetings where they were asked individually about whether they felt safe and we observed staffing levels to be good.

Patients were assessed and reviewed by specialist teams such as occupational therapists and speech and language therapists, when appropriate. Allergy information was contained within patients’ risk assessments and all staff we spoke with were aware of this.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

A ward tour and check of the environment and equipment was undertaken during our onsite activity. Regular risk assessments were undertaken of the environment and hospital managers completed a daily walk around the environment and fed back concerns into a daily managers meeting. Senior management also conducted monthly hospital checks and reviews. Safety issues were identified and addressed as part of these processes. We identified some ligature risks and blind spots in the gardens. We raised this with the service and were informed that this risk was mitigated by staff presence however, managers assured us they would consider any additional risk factors and mitigations.

The hospital complied with guidance on eliminating mixed sex accommodation by having separate wards for male and female patients. Bedrooms had ensuites and there were bathroom facilities on both wards.

Staff had easy access to alarms, and patients had easy access to nurse call systems.

Our check of the environment included a check of the clinic room environment and emergency bag. We found that the medication fridge plug required labelling to ensure this was not accidentally switched off, and the service rectified this immediately. The emergency grab bag was missing an eye torch and filled with multiples of the same item which could make it difficult to find items in an emergency. Managers replaced the eye torch and said they would review the bag to ensure the correct number of items were present.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The hospital used a system which allowed managers and staff to review the skill mix, number of nurses, and vacancies for each shift. The service did not have any vacancies at the time of inspection. The service recruited both bank nurses and support workers to cover for staff sickness, leave, training and increased staffing levels. The service was currently recruiting 3 additional bank support workers at the time of the inspection.

The rota system ensured safe staffing in terms of the nurse to support worker ratio. During the day, the service required 1.5 nurses to be on shift. The minimum number of support workers was 4, but this was entirely dependent on patient needs and observation levels, for example at the time of inspection there were 2 additional support workers on shift due to patient’s needs.

Patients all had regular 1-to-1 time with their allocated nurse, and this was evidenced within care records. There were no instances of staff cancelling escorted leave or ward activities due to staffing levels.

The average sickness rate over the last 12 months was 1.9%. There were comprehensive induction policies and checklists in place for all staff. The service had a digital HR system to upload employment checks and Disclosure and Barring Service certificates which had to be in place before staff could start working within the service.

At the time of inspection, staff mandatory training was at an overall compliance of 96%. All staff training was above 86%. Training was appropriate for the service, including Basic Life Support, trauma-informed care and the Oliver McGowan training in learning disability and autism.

We spoke with the responsible clinician who informed us that they could attend the ward if there was a mental health emergency and the service could access the local crisis and home treatment team for support. For physical health concerns or emergencies, nurses were appropriately trained and would contact emergency care services.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The wards were well maintained, tidy and clean. The wards had recently undergone redecoration of the communal areas and further improvements were due to be made to patients’ bedrooms. We inspected the clinic room and found it to be well maintained and clean, with all equipment cleaned. Staff completed fridge and room temperature checks in line with policy.

Managers completed regular audits of cleaning records for the environment and clinic rooms to ensure they had been completed correctly. Infection prevention and control was part of the mandatory training requirements for staff. At the time of our inspection, this was at 97%. Staff also completed mandatory training on the Control of Substances Hazardous to Health (COSHH) and at the time of our inspection, this was 92%.

Castle Lodge had a lead member of staff for infection, prevention and control. Staff had a good awareness of infection, prevention and control guidelines and principle and we observed staff adhering to policy.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff stored medicines records safely and completed regular audits of medicines stock to identify any shortages or medicines that had expired. There were processes in place which staff followed to check medicines orders on arrival. Staff worked alongside the local pharmacy to ensure patients’ medication was prescribed and ordered effectively. Patients with covert medication plans in place were created in line with national guidance.

External partners also told us that when visiting Castle Lodge, they had observed “clinical curiosity in understanding patient distress and a strong ethical approach, prioritising non-pharmacological interventions over psychotropic medication wherever possible.”

We reviewed 15 medication charts which were in-line with best practice and staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. However, we identified and fed back to the service that International Dysphagia Diet Standardisation Initiative (IDDSI) levels needed to be clear to ensure the correct thickness of food and fluid for people with swallowing difficulties.