Cera Castleham Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This service was previously unrated. At this first assessment the rating was requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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 38 (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 have a proactive culture, and lessons were not learnt to continually identify and embed good practice.

Lessons had not been learnt from the turnover of staff and managers. 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 and staff said the management cover arrangements had been piecemeal over a period of months and resulted in poor communication and inconsistent leadership. For example, different managers from other sites or roles covering on different days each week.

They described managers as seeming out of their depth and overwhelmed by the issues within the service with poor support. For example, a senior manager acknowledged in the service’s records the last manager had been poorly inducted.

The provider did not work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not make sure there was continuity of care.

People and staff said there was poor communication within the service. Staff shared concerns how they had not been told about the arrival of a new person needing care support. This meant the person had a missed care visit as staff did not know they needed care support. When the person became unwell, care staff had no care records to refer to when the ambulance service was called. They said this impacted on the safety of people and harmed their own professional reputation.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People said they felt safe with the regular staff group but at times felt unsafe due to missed visits, delayed visits, or a lack of consistency with changing agency staff. Care staff understood their responsibility to raise safeguarding issues, but records showed these were sometimes raised within the staff communication book and it was unclear whether managers were aware of staff concerns. Staff safeguarding training was up to date.

Staff shared concerns with us about a person who was at risk of potential abuse. We saw the person’s care plan did not effectively address risks associated with abuse. It recognised the risk of abuse but gave no guidance to care staff to help them keep the person safe or raise concerns.

Staff shared a concern relating to safeguarding concerns for another person. They told us how they had contacted external agencies and raised a safeguarding referral. However, they had not notified the CQC of this incident and a previous one, which is a legal duty.

The provider did not routinely work well with people to understand and manage risks.

While staff generally felt they had sufficient information to support people safely, risk assessments were not completed for all known risks. This meant staff did not always have the necessary guidance to deliver safe and appropriate care. For example, the management of the risks associated with specific health conditions. The goal in one person’s care plan was ‘To manage my [health condition] so that I don’t go back into hospital’. However, there was no information available to staff about how they would identify the person was becoming unwell, which impacted on the effectiveness of staff monitoring. This placed the person at potential risk of harm as staff did not have information on how to safely support management of their health condition.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were aware of the fire procedures and explained how their doors were connected to the fire safety system. Care plans also detailed the potential fire hazards from the use of emollient creams.

Care plans reminded staff of potential environmental risks to people’s safety. For example, when people required equipment to help them move, staff were reminded to ensure the environment was uncluttered to help create a clear path around people’s homes. Care plans also recorded when people wore glasses to ensure staff checked they were wearing them and they were clean.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People told us they were saddened by the loss of experienced staff since the service had been taken over by the provider. They said in their view this was due to poor management, a lack of support and lessons not being learnt by the provider. Staff confirmed there had been a consistent turnover of staff and managers since the provider had taken over the management of the service. People said the staffing changes had impacted on their view of the effectiveness of the service to provide safe reliable care.

People said the changes of care staff took a toll on their well-being and their confidence in the running of the service. They raised concerns that inconsistent management support further threatened the stability of the staff group.The provider had made the decision to book regular agency staff to provide a short-term solution while permanent staff were recruited with the aim to stabilise the service.

Permanent care staff were up to date with their training, which was mainly on-line, although they told us more face-to-face training was planned to encourage discussion and group learning. A new staff member said they had experienced a poor induction with conflicting advice and a lack of supervision. Agency staff reported a poor induction from Cera Care Operations Limited with no oversight and a reliance on permanent staff to verbally share their knowledge.

Care staff said there was a lack of regular and effective supervision or competency checks. Staff said they had recently received a supervision, but it had been rushed and brief and said it felt more like a tick box exercise. They said they did not receive regular one to one time with a manager to discuss their areas for development or to receive recognition of their good practice.

Permanent care staff organised shadowing opportunities or answered queries from agency staff. Agency staff worked block hours, for example for 2 weeks but did not always stay longer as some came from outside of the county. Due to changing managers and a lack of consistency of one manager on site, care staff were often left to resolve issues linked to people receiving a service and shift queries.

At the end of our assessment, we were told new care staff had been recruited and were completing their induction, with a new manager starting in January 2026. Senior managers felt these 2 factors would help stabilise the service and agency staff would no longer be needed after Christmas 2025.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were happy with staff practice. Records showed the staff group were up to date in their infection and control training, which staff confirmed. They were provided with the necessary equipment to maintain good infection control measures. Care plans reminded staff to wear appropriate personal protective equipment when assisting people with their incontinence to help minimise the risk of cross infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People generally managed their own medicines and had no concerns. However, entries in the staff communication book showed staff raising concerns about the ordering and management of some people’s medicines. For example, staff queried whether a person on an ‘as required’ strong pain relief medication at night should be reviewed as they were frequently requesting the medicine. There was no record whether this had been arranged or escalated to the management team.

Records showed staff queried on several occasions whether another person was safe to manage their own medicines as they were concerned the person was at risk of overdosing on pain relief. One staff member suggested hiding it out of the person’s reach as a safety measure.

There was no mention of assessing the person’s capacity to manage their own medicines. Instead, there were further examples in the staff communication book of the person being at risk.

Care staff were trying to resolve problems amongst themselves because of poor management oversight, but this potentially put people at continued risk of harm.

The provider confirmed concerns had been escalated to external professionals.