Castle Lodge Independent Hospital

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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

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 outstanding.

Outstanding: This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved high-quality, person-centred care.

At our last assessment, we rated well-led as good. At this assessment, the rating has changed to outstanding. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team and put people at the heart of the service. Staff felt respected, supported and valued. Staff were highly motivated and proud of the service. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe, person centred, compassionate and effective care. There were consistently high levels of constructive engagement with staff, people who use services and external partners. Staff collected and analysed data about outcomes and performance. They used this to continually identify improvements for the benefit of people who use the service.

We have not awarded this service a score for Well-led.

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

We scored the service as 4. The evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Staff, patients, families and external partners we spoke with said the service was consistently well-led. Leaders and managers engaged with staff, people who use services, relatives and other stakeholders. The service promoted clear, person-centred vision and values that included respect, integrity, empowerment and responsibility. The service had a positive culture that was person-centred, open, inclusive and empowering.

All staff we spoke with were motivated and proud to work at the service.

Staff understood the service’s vision, values, and strategic goals and implemented these in their day-to-day work. Staff had the opportunity to contribute to discussions about the service, especially where the service was changing or making improvements. In the most recent staff survey, 100% of 29 respondents rated agree or strongly agree to questions regarding wellbeing, culture and values within the workplace and the organisation. Culture and values were some of the top themes discussed in a positive manner.

The service had very good governance processes and systems in place. Managers and leaders of the service used these to regularly assess performance, training and supervision of staff, to monitor incidents and complaints, to analyse any themes and trends and learn lessons from these. The processes and systems ensured a positive, open and transparent culture which enabled delivery of high-quality care, treatment and support for patients and provided an inclusive and supportive working environment for staff.

In addition to this the hospital manager showed us how the service was gathering evidence to demonstrate how they could meet the core commitments of the Culture of Care Standards which aims to transform mental health inpatient services by promoting inclusivity, dignity and person-centered care for all patients.

We scored the service as 4. The evidence showed an exceptional standard. The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Managers led by example and were positive role models for staff. Staff were positive about the leadership of the service, staff spoke about positive and effective handovers, de-briefs and support following incidents or difficult shifts, regular and effective supervision sessions, access to training and development. Staff told us they had “great support from managers and regional director”.

Leaders, managers and staff had a well-developed understanding of equality, diversity and human rights, and they prioritised safe, high-quality, compassionate care. This was reflective in the feedback we received from patients, relatives, staff and external partners. We asked relatives if they were confident about the treatment and care provided and we were told “Very confident. I can now go to bed without constantly worrying as I know they are safe here and being very well cared for” and “It's a good place. They keep me informed, I know they are safe with the staff.”

In the most recent staff survey an average of 99% of 29 respondents rated agree or strongly agree to questions regarding leadership, communication, management, support and engagement. The themes that were discussed in a positive manner as part of the survey were work environment, team, support, management, wellbeing and job satisfaction.

Managers and leaders genuinely welcomed feedback, fed back, learned lessons and involved people in reviews of concerns, accidents, incidents and adverse events to prevent similar incidents in the future. Managers had a high level of constructive engagement with people both internally and externally to the service. External partners fed back “The team is highly proactive in collaborating with external services, including case management teams, social workers, care coordinators, and Section 117 case managers. They maintain frequent communication to keep all partners updated and ensure seamless care.”

Leaders and managers were visible in the service and approachable for patients and staff and led by example. Staff felt respected, valued and supported. Leadership development opportunities were available, including opportunities for staff to complete training to improve outcomes for people who use the service.

We scored the service as 4. The evidence showed an exceptional standard. The service was exceptional at fostering a positive culture where people knew they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The provider had an active survey for friends and families to complete. We reviewed 6 responses received in September 2025 and saw both patients and relatives scored 96% of questions 8-10 on a rating scale of 0-10. Managers and staff had access to this feedback from patients, carers and staff and used it to make improvements.

Staff knew how to raise concerns and told us they felt confident to do so without fear of reprisals. Staff were able to raise concerns through a variety of feedback methods. Leaders were supportive and approachable, and dealt with issues appropriately and efficiently. Where issues could not be resolved immediately, action plans were in place and reviewed through governance meetings.

Staff were aware of the whistleblowing policy and procedure was in place. Staff had access to a freedom to speak up guardian and staff we spoke with knew how to contact them and who they were. The hospital also had a member of staff acting as a Speak up Champion. The induction checklist for new starters indicated that staff completed a Speak Up webinar as part of their induction. There were posters on the ward which detailed how to make a complaint.

The freedom to speak up process was well embedded within the hospital. We saw evidence that showed it was discussed in team meetings and accessible to staff via an innovative app on their phones which made the guardian accessible to all staff, easy to use when they needed it and enabled staff to speak up timely. Checks and audits were in place, such as a hospital managers daily walk around the hospital which included speaking with the team and escalating any concerns.

The provider had conducted a staff survey in January 2025 and the ‘Your Voice Results’ showed 29 respondents 100% agreed with the questions regarding communication and the opportunity to ‘Speak Up’.

Patients, staff and relatives could meet with members of the provider’s senior leadership team and commissioners to give feedback.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Equality and diversity were actively promoted and work undertaken to identify the causes of any workforce inequality and action taken to address these. Staff felt they are treated equitably. The staff team consisted of wellbeing champions to support the team through raising awareness of wellbeing activities and initiatives, promoting healthy lifestyles and positive mental health.

Staff were supported with reasonable adjustments or flexible working arrangements to support them to carry out their role and to account for personal circumstances, where relevant. The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group. This was evidenced within staff survey ‘Your Voice Results,’ from January 2025, 29 respondents 100% agreed with the questions regarding wellbeing, culture and values.

Staff had the appropriate training in equality and diversity and at the time of inspection, staff training compliance was at 100%.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Any incidents were reported, investigated and lessons learnt to assist with the reduction of restrictive interventions. Patients’ background, history, likes and dislikes were integral to enable staff to support patients with respect, dignity and compassion and with an emphasis on patient choice.

Risks within the environment were assessed, the clinic rooms well maintained and audits in place, however the provider needed to ensure that the risk assessment considered all risks in the garden areas and checks of the emergency grab bag to ensure items were easily accessible.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Managers provided staff with appropriate induction, training, regular supervision and appraisal of their work performance.

Staff implemented recommendations from reviews of incidents, use of restrictive practice, complaints and safeguarding alerts at the service level.

Staff undertook or participated in local clinical audits including auditing medication, paperwork, adherence to the Mental Health and Mental Capacity Acts, a monthly quality audit, health and safety and mattress quality audits. The audits provided assurance and all actions were discussed in staff meetings so that the results could be acted on as required.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients and other teams would be invited, as part of a multidisciplinary team, to reviews.

Staff maintained and had access to the risk register, and all staff could escalate concerns and add them to the risk register and to the central action plan, which was reviewed from ward to board level.

The service had a business continuity plan plan for emergencies, for example, adverse weather or a flu outbreak, this was comprehensive and up to date.

The service used systems to collect data that were not over-burdensome for frontline staff. All information was entered into a quality dashboard by the hospital director which supported them with their management role. This included information on the performance of the service, staffing and patient care, which was available in an accessible format, timely, accurate and identified areas for improvement, themes and trends.

Staff had access to the equipment and information technology needed to do their work. The hospital used a paper-based system for all patient care which was organised, audited, and well managed however, the provider had plans to implement a digital patient record system to further improve the quality of care. 100% of staff completed data protection training which included confidentiality of patient records. Patient records were kept in a locked office and within a lockable cabinet. Detention papers were kept by the mental health act administrator securely.

Staff made notifications to external bodies as needed such as commissioners, the local authority safeguarding team, care quality commission and health and safety executive.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders such as commissioners who had recently attended a carers’ meeting to provide an update on what their role is.

The hospital had strong working relationships with adult social care, safeguarding and an independent mental health advocate. We received feedback from the advocate which confirmed this and they told us “I am able to visit Castle Lodge on a weekly basis to visit my advocacy partners. This is always facilitated by the staff. I receive invites for important meetings regarding my advocacy partners.”

The hospital had developed strong relationships with other external voluntary services relevant to the patient group and ensured families and carers had information to support them in their role. Patients and carers had been supported to attend the Alzheimer’s Society wellness café in the local area and the hospital supported attendance at a national training course for carers of people who are living with dementia, delivered by the same provider.

The service had a strong person-centred culture and viewed patients and their relatives as partners in decisions about care and treatment. Carers were invited to give feedback in diverse ways, such as at meetings, in writing or via email. Carers were included in their relative’s care and treatment from admission to discharge. Patients, staff, carers and relatives could meet with members of the provider’s senior leadership team and commissioners to give feedback. The regional director conducted monthly quality assurance visits, and posters were visible informing patients and visitors of the next visit.

We saw evidence that staff maintained regular contact with and worked collaboratively with a range of other health professionals, including speech and language therapy, art psychotherapy, mental health teams and physical health practitioners such as district nurses.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The hospital aligned with the Safewards model and had successfully implemented the 10 interventions (the objective of the model is to reduce conflict and containment within mental health services). The ward held community meetings where innovative ideas could be shared and ‘you said, we did’ feedback was provided via a poster.

Staff had opportunities to participate in learning and development and make suggestions for innovations taking place in the service. This included making improvements to the environment and health promotion activities within the service. Staff used quality improvement methods and knew how to apply them through regular audits by both staff and leaders and by creating action plans to address issues identified.

The hospital had piloted a new reception meeting in the first week of admission covering an agenda including getting to know you/me, setting expectations and gathering historical information. The hospital manager told us this had been carried out for the last 3 admissions to the service, it was going well and received positive feedback.

Staff also participated in national audits and surveys relevant to the service and learned from them through sharing between Barchester hospitals. The service had been awarded the RoSPA Healthcare Sector fall prevention award 6 times since 2019. The service had also been nominated for several awards as part of the organisations Barchester Care Awards and the deputy ward manager had won registered nurse of the year award in 2025. The service had also been recognised and spotlighted as a Barchester beacon service in May 2025 as a service highlighting best practice.