Cera Castleham 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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

p>The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

People said they did not feel confident in the provider as they did not feel their well-being was a priority for the company. For example, people said, “It’s been hell” and “I’ve found it so stressful.” People listed the reasons for their frustration and unhappiness. These included the constant changes in management within the Cera Care Castleham Lodge team after an experienced manager left in early 2025.

One person described staff as being in “a constant muddle” when inexperienced managers changed the runs on the rotas. They questioned the suitability of interim managers who had only been in their role a short time and covered other sites. People described some of the managers as being “over their heads” and “trying to do the best they could.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity and openness. High quality leadership was not sustained through long term succession planning and development.

People and staff said most of the management team had worked with the best intentions but either did not have the time, knowledge or support to address the long standing concerns. For example, a manager said they had not been given a staff handbook when they started, and said they, “Didn’t know who to contact about anything.” They described being passed to different people within the organisation to try and resolve IT issues. The provider told us the scheme manager had received training on processes, systems, and escalation procedures.

Leaders were either not aware of or did not address quickly issues relating to culture that impacted on people’s care and support.

The October – December 2025 rota showed 2 managers providing oversight for the service as well as managing their own services. Different managers had also been providing oversight on different days.

People did not feel they could speak up and that their voice would be heard.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Quality assurance systems and processes failed to ensure new staff were appropriately supported. A new staff member said they had experienced a poor induction with conflicting advice and a lack of supervision.

The wellbeing of staff was not prioritised and we did not see a culture that recognised the importance of supporting staff well with a focus on equality, diversity and inclusion.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Quality assurance systems and processes to monitor and drive improvement in the quality of the service, including the quality of the experience for people using the service, were not effective. Systems and processes had not identified all of the issues we found on this assessment. During the assessment when we requested documents these were sometime difficult for staff to access.

Quality assurance systems and processes throughout 2025 failed to ensure managers were effectively reviewing care plans. Opportunities to drive improvements where people and staff had fed back about concerns were missed. There was not a clear and consistent management structure in place and this affected every element of service delivery.

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 local authority Quality Assurance and Improvement Team had been visiting the service to develop a quality improvement programme to work towards meeting regulatory standards and demonstrating best practice. However, the changes in managers had made it difficult to establish a consistent contact to move the service forward. There were times when the provider was not proactive in updating partners. For example, confirming a new manager had started working at the service.

Staff told us about how they worked with people to support them to access health care provision. People’s feedback, care records and the staff communication book confirmed this approach. A manager told us they were trying to build a better working relationship with the social landlord so they could be included in the panel assessing new tenants. Staff said they had noticed people being referred to their service were becoming more complex in their care needs. Staff were concerned some people had unrealistic expectations about what level of support could be provided.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The absence of robust governance processes and oversight resulted in the provider not addressing the service failings highlighted during this assessment. Consequently, the quality of service delivery had not been adequately monitored, potential risks to individuals were not consistently recognised, and opportunities for learning and continuous improvement were missed.