Updated 5 August 2025
Cera Castleham Lodge is a domiciliary care agency. It provides personal care to people living in their own homes in an extra care scheme. Not everyone using the service received a regulated activity; CQC only inspects the service being received by people provided with 'personal care' such as help with tasks related to personal hygiene and eating.
We carried out this assessment as we had received some information of concern. At the time of this assessment, 16 people were receiving personal care from the service. We completed an onsite visit over 2 days. We assessed all quality statements under the 5 key questions: Safe, Effective, Caring, Responsive and Well-led. We found 6 breaches of the legal regulations in relation to safeguarding, safe care and treatment, person-centred care, complaints, staffing, and governance. At this assessment, the overall rating was requires improvement.
The absence of robust governance processes and oversight resulted in the provider not previously addressing the service failings which our assessment highlighted. There were ineffective quality assurance processes in place to ensure managers had the skills and appropriate level of support to turn around a service struggling with multiple quality issues.
People described some staff “as over their heads” and “trying to do the best they could ”while being under “intolerable pressure.” There had been a lack of consistent managerial oversight in the last 12 months, although a new manager started in January 2026 which was hoped would stabilise the service.
Governance processes failed to address concerns raised by care staff regarding poor oversight and management of rotas which resulted in “call cramming”, missed visits and delayed visits to people. Since the provider had taken over the service, staff retention had been an issue both at care staff and manager level. This put significant pressure on the remaining care staff who felt responsible for the well-being and safety of people using the service without appropriate managerial support.
Risk assessments and care plans were not routinely reviewed with people. Not everyone had a care plan produced by the current provider.Improvements were also needed in safeguarding and the oversight of medicine concerns. Some aspects of involving people in making decisions also needed improvement to protect people’s legal rights.
Staff were mainly up to date with their training. However, staff supervisions had not been a regular occurrence. Staff said they had not always felt listened to when they raised concerns, and the complaints system lacked a robust approach to ensuring people’s concerns were recorded and addressed.
Despite the above, there was a core team of care staff who were committed to maintaining a service for people and therefore stayed out of loyalty. New care staff had been recruited and were being inducted to the service during our assessment.
We met a member of the management team who was committed to improving and supporting the staff and people at the service. However, we noted this role was in addition to other responsibilities for other services too, including ones where there were similar problems to resolve.
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