Castor Lodge Care Home

On this page

• 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.

This is the first assessment for this registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

Leaders told us that risks to people were analysed in the monthly clinical governance meetings. However, it was not clear that records were updated following these meetings due to the conflicting information in care plans and risk assessments. Audits were completed regularly by leaders but failed to identify gaps we found during our assessment.

People and staff had some anxiety regarding changes in management, but everyone was clear they had a senior member of staff to speak to if they had any concerns.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

People and staff had some anxieties with the management changes but reported a positive culture. One person told us “The atmosphere is good”. Staff meeting minutes referred to ways of improving staff culture and promoting teamwork. Staff told us senior management offered them reassurance and support.

The provider had 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.

There was a new manager in post, who was aware of issues and priorities within the service, and with support from a senior leadership team, they were working towards improvements and changes to systems and processes. This included new systems to enhance oversight and analysis.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People told us they could speak up and would be listened to. One person told us “I speak my mind”. One relative told us that the previous management team did not communicate well but that communication had improved. Staff said they felt comfortable speaking up and were aware of the whistleblowing process. A staff member told us “Area and regional [managers] are approachable and knowledgeable. All know how to guide [staff]”.

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.

The home manager told us “We have a diverse staff team here, nice to see people from different backgrounds and cultures come together”.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Some systems and processes required further development, for example the auditing of care plans. Leaders were already aware of this, and there were several planned changes and improvements which had not yet been implemented or embedded at the time of our assessment.

Audits were completed monthly by leaders but failed to identify gaps we found during our assessment. For example, where sufficient Mental Capacity Act assessments were not in place and where risk assessments contained conflicting and out of date information that meant risks were not mitigated.

Leaders told us that risks were analysed in the monthly clinical governance meetings. However, it was not clear that care plans and risk assessments were updated following these meetings due to the conflicting information in care plans.

However, leaders and staff we spoke to were clear about their roles and responsibilities and were aware of the governance systems that needed to be in place.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Relatives told us they were informed of appointments and referrals made and they knew which services were supporting their family member.

Professionals confirmed the service worked with them to develop and improve care.

There had been some safeguarding concerns and issues relatingto caring for people at risk of choking. There were also previous concerns that following incidents the service had not referred to the safeguarding team for further investigation when required. There had been improvement with their reporting and the provider had taken on board guidance from the local authority and arranged additional training.

Whilst the senior management team had reacted to these issues and started to take action to improve the service, this was following concerns being raised by external professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

We carried out an inspection at another of the provider’s care homes during November 2024. During that inspection we found similar themes and issues which did not demonstrate the provider undertook prompt reviews of their other service locations to ensure effective action was taken and lessons were learnt.

However, there was a comprehensive home action plan in place and the provider was completing regular quality assurance visits and reports.