Cera Castleham Lodge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding, person centred care, staffing, complaints and governance.

This service scored 33 (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 did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Staff raised concerns how people were being assessed for extra care housing. They had noticed people were being referred to the service with increasingly complex care needs. They were concerned people saw the setting as more like a care home which raised their level of expectation on staff availability to assist them for a range of tasks. Staff said they thought the provider should have a role on the panel when people were assessed to move to the scheme.The provider clarified how once notified of a new resident at the extra care housing scheme, they carried out their own assessment to ensure their care team had the skills to meet the person’s individual needs. They stated additional training was arranged, where appropriate.

When we asked who had been assessed by the provider to receive support with personal care, staff were not able to produce a list of people, and we were given different numbers of people receiving a service. This showed a lack of management oversight to ensure staff numbers met people’s care needs.The provider told us staff had received training in how to access a list of people receiving support with personal care.

Records showed there was acknowledgement by the management team care staff were also assisting people who were not receiving a service from Cera Castleham Lodge but lived in the complex. The staff communication book confirmed this to be the case.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Where care plans had been completed, they showed people had contributed to them as they contained personalised information. However, people and staff said care plans were not being effectively monitored and reviewed. This potentially put people at risk as it meant deteriorating conditions or increasing concerns were not being addressed and guidance updated.

A person using the service said no-one from Cera Castleham Lodge had reviewed their care plan with them in 2025, so they had requested a review with the local authority instead. This meant the service had not ensured their care plan still met their care needs.

The provider did not work well across teams and services to support people.

Governance processes failed to address concerns raised by care staff regarding poor oversight and management of rotas which resulted in not enough time between visits, missed visits and delayed visits to people.

Permanent care staff said this put undue pressure on them as they worked without breaks to compensate for rota errors. This could lead to delays in medicines being given, which we saw from entries in the staff communication book. However, there were practices for staff to follow, such as a medicine policy and recognised tools which promoted best guidance in how to assess risks to people’s health.The provider told us robust governance arrangements were in place, and it was leadership instability rather than a lack of governance systems

Staff told us they were constantly asked by different managers about their availability. However, there were still errors in the rotas despite staff providing repeated information on their previous working shifts. Care staff commented new managers were “overwhelmed.” Rotas for 1 week in December 2025 showed poor management oversight when one agency staff member worked 15 hour shifts 3 days in a row, which could lead to the staff member making mistakes from becoming overly tired.

Agency staff did not always have access to a working device which contained care planning information. One agency staff member told us they worked 4 days without a care device and were not offered paper care plans as an alternative. This potentially put people at risk of harm.

Another staff member reported there was no IT support re technical issues with care devices, and on one occasion it took 4 days to provide agency staff access to a working care device. They told us this meant some care interventions had subsequently not been logged.

The provider did not always plan and deliver people’s care and treatment with them. They did not always follow legislation and current evidence-based good practice and standards.

People’s care plans detailed their health conditions, which varied in detail. For example, a person who had a health condition which meant according to their care plan they needed to be encouraged to drink. There was no recommendation as to what amount of fluid would be effective. Staff were directed to monitor for infection but not given the information as to what it might look like for the individual.

Staff told us no risk assessments were available on the handheld care device. However, the provider told us staff could access risk assessments through handheld devices and had received training in this area.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Care plans were not routinely monitored. A staff member said it was hard to know what to prioritise as they were always ‘firefighting’ due to staffing issues and overseeing agency staff cover. They said this meant they had not reviewed care plans. This meant the review timings described in the service user guidewere not being put into practice.

On the second day of our assessment, an interim manager had started to review care plans with people. People said this had been a positive experience.

The provider did not always protect people’s rights around consent linked to their care and treatment.

People said staff asked for their consent before they carried out personal care tasks and we saw staff checking if they could enter people’s flats. The staff training matrix showed staff were up to date with relevant mental capacity act training.

However, we saw examples where people’s rights were not protected. For example, a person’s relative was contacted to review their care when the person using the service was assessed as having capacity.

We were shown the consent form for Artificial Intelligence– Assisted Care Planning. It made no reference to best interest decisions or the Mental Capacity Act. There was also a witness section with no reference to whether the person held a lasting power of attorney for care and welfare or finances for the person receiving the service.