Castleholme Lodge

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 service. This key question has been rated outstanding.

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

This service scored 89 (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 hada very clearshared vision,strategyand 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.

The provider’s vision for the service was kindness, integrity, teamwork and excellence.(KITE).

The registered manager and management team provided high-quality leadership which resulted in the provision of good quality care and quality of life for people. This had been achieved by staff dedication, investment in the environment, opportunities for staff career progression, enhanced care planning, and governance. The management team listened to and responded to feedback which enabled the service to continually adapt and improve, and feedback from people, their relatives and staff reinforced this.

The management team recognised people accessing care often had increasingly complex physical, and dementia related needs, additional to their enduring mental health needs, which required good partnership working with external professionals which was evidenced in people’s care records.

Staff spoke of a positive culture with open communication and were encouraged to share ideas to improve the service for the people who use it. One staff member told us, “I love my job. The [registered manager] really listens to my ideas and always tries to support me”

The provider 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.

The registered manager and management team were highly skilled and experienced and delivered the organisation visions and values along with the development of staff through training and career progression.

Staff felt there was visible management presence throughout the service and consistently reflected upon how they led by example by working alongside staff. Throughout the inspection it was very clear how passionate the management team was about the service as a whole, and about the high level of care and support offered to people. They spoke knowledgably about people and understood their needs and wishes well.

Feedback from people, staff and relatives was overwhelmingly positive about the management team. A member of staff told us, “I enjoy working here because of the management”.

This supported a positive culture in which staff and people using the service felt respected, included and empowered.

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

Staff told us they felt listened to and comfortable speaking up if they had concerns or suggestions and described the management team as approachable. A whistleblowing policy was in place and accessible to staff, providing clear guidance on how concerns could be raised safely, which included contacting the providers freedom to speak up guardian.

Regular meetings were held for staff, people and their relatives where they we offered the opportunity to raise concerns and be heard. This demonstrated an open and transparent culture and supported continuous improvements across the service.

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 provider had created an inclusive working environment where staff were individually recognised and there was no evidence of discrimination identified during the inspection.

The registered manager told us reasonable workplace adjustments would always be considered in response to staff needs and gave an example where they offered adjustments to a staff member after being made aware of their personal circumstances.

Staff spoke positively about the support they received and felt they were treated well. One staff member said, “The managers always say we can talk to them if we need to”.

Staff had undertaken training in relation to equality and diversity and their knowledge and understanding of people’s individual diverse needs were evident when they spoke about the people they supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider demonstrated an exceptional commitment to continuous improvement through a highly effective and well-embedded quality assurance framework. Comprehensive audits, robust spot checks, and detailed reviews of care records were carried out consistently and used proactively by the registered manager to identify opportunities for learning, drive innovation, and embed best practice across the service. Findings were acted upon promptly and effectively, resulting in measurable improvements to people’s safety, health, wellbeing, and overall experience of care. This culture of excellence and continuous learning ensured the service remained highly responsive to people's changing needs, consistently delivering outstanding, person-centred care and achieving positive outcomes for those it supported.

The service demonstrated a strong commitment to meaningful involvement by developing and implementing the ‘My Voice in the Governance Meeting Resident Participation Prep’ initiative. This innovative approach empowered people to actively participate in monthly governance meetings in a way which they told us felt accessible, supportive, and free from intimidation. As a result, people were able to contribute their views, share ideas, and provide feedback on the running of the service. This not only strengthened their sense of inclusion and influence over service development but also enhanced their confidence and independence.

Feedback from external stakeholders about the provider was positive, reflecting confidence in the management and leadership of the service

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.

The management team had fostered exceptionally strong partnerships within the local community, demonstrating a proactive and innovative approach to improving care outcomes. This included collaborating with a local healthcare provider to develop bespoke training programmes in falls prevention and catheter care, ensuring staff were equipped with specialist knowledge and skills. They also worked closely with a local hospice to co-produce end-of-life care training tailored specifically to the needs of people experiencing mental health conditions. The training explored the similarities between end-of-life symptoms and mental health presentations, enabling staff to provide more responsive and person-centred care. This innovative programme was subsequently embedded across the service and made available to all staff, supporting consistent, high-quality practice.

People's care and support plans clearly demonstrated referrals to relevant healthcare professionals were made promptly and proactively whenever needs changed or specialist expertise was required. This ensured people received timely, coordinated support and their individual health needs were consistently met through effective multi-disciplinary working.

The management, nursing and wider staff teams worked exceptionally well in partnership with local healthcare services and external agencies to promote positive health and wellbeing outcomes for people. Strong relationships enabled referrals to be made swiftly when people's needs changed, ensuring access to the most appropriate support and interventions. Professional guidance and best practice recommendations were consistently followed and embedded into care delivery, helping to ensure people received safe, effective and person-centred care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had systems in place to support continuous learning and service improvement. Audits were carried out to help review practice and identify opportunities to enhance people’s experiences and outcomes. The management team was proactive in responding to identified issues and implementing improvements.

Effective systems were in place to learn from accidents, incidents, safeguarding, concerns, complaints and situations where things had not gone as planned, and any learning was shared with staff. This approach supported a culture of reflective learning and continuous improvement.