Avondale Castlemount 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.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a strong culture at the service which put mental wellbeing at the heart of every interaction, but in creative and personalised ways that handled the topic in a safe and approachable manner. The manager explained to us, “Our big goal for this year is a values lead approach and trauma informed care. This will be focus on using reflection, for example how a person handled a complex incident, what worked well, how did trauma affect them, and what can we replicate”. They were designing a manual to help staff with how to support and explore individual trauma and life experience in a sensitive and open way.

People felt safe and included living at the service, were actively involved as equals in their own care and treated with respect at all times. They spoke to us positively and described trusting and positive relationships with staff members. People’s human rights were well understood and re-enforced through the systems in place at the service, which sought consent and involvement in all elements of people’s care.

The provider had 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 did so with integrity, openness and honesty.

Leaders embodied the values behind Right Support, Right Care, Right Culture and led by example and with compassion. We received positive feedback about the impact they had on the service, and that they were accessible and open to challenge whilst advocating for people. People, relatives and staff all spoke of positive relationships with the management team.

One relative told us, “I have a good relationship with manager. If I have concerns, I feel able and supported to raise these. I can’t fault the care and have no reason for concern”. Another relative added, “We recently had challenges with my relative’s care at another service. The manager was unbelievably supportive throughout and was giving me regular updates and liaising with services to advocate for (person name)”.

A new deputy manager had recently started, and one staff member stated, “The new deputy manager has made a really positive impact and has such knowledge and commitment. They have gone above and beyond and is very supportive.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt actively involved in their service, and that there were multiple opportunities to share their voice or any concerns. There was a whistleblowing policy in place which staff were knowledgeable about and felt confident that however they chose to share their feedback, they would be listened to.

One staff member explained, “I have supervisions, but if I ever need anything I can speak to the manager or deputy at any time. I could also speak to the nominated individual, to the local authority or to CQC”. Another staff member explained, “The responsiveness of management is really great. Any feedback is acted on quickly.”

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. Staff universally felt safe, empowered and trusted working at Castlemount Lodge. Their own personal circumstances were respected, and management made adjustments where needed to promote people’s wellbeing so they felt included and invested in. All staff had undertaken equality and diversity training, and this was reflected in the interactions we saw and were told about, which were based on respect at all times. Some staff members discussed how they required adjustments to their job roles due to their wellbeing, communication needs or other circumstances and these were responded to with compassion.

One staff member told us, “I have a good work life balance and I've got amazing colleagues. They have been very supportive here of my personal needs. Another staff member added, “My work life balance is good. I really appreciate the flexibility with things. They are really good at making sure we're taking leave. Whenever I pop into the office, they always check on how I am”.

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

There were strong governance processes in place which were largely robust and effective, with regular audits at all levels of the service focused on safety, and the wellbeing and outcomes of people. Areas of risk were actively identified, responded to and mitigations put in place to protect people. There were robust business continuity arrangements in place including plans to cover emergency situations such as the loss of an important utility, staffing shortages or damage to the property. There were clear management structures in place where everybody knew their own roles, and regular meetings to set a clear strategic direction for the service.

In a minority of cases, further improvements were needed to governance systems to identify issues found during the inspection. However, responsive and immediate action was taken where concerns were raised by the inspection team.

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.

There were clear and embedded relationships with partner organisations which were based on trust and collaboration. For each person, there were detailed care plans setting out at what point the service may need to seek involvement from other health and care stakeholders in response to a persons’ physical or mental health needs. We received positive feedback from stakeholders about the relationships they had built with the service to provide collaborative and joined up support to people. One stakeholder explained, “I have consistently found the staff to be approachable, person‑centred and knowledgeable about the adults in their care. They appear to know individuals well and have a good holistic approach to their care and support needs”. Another told us, “They always keep in contact with us and will raise any concerns they have for those we support immediately. I have attended meetings where staff from Castlemount also attend, and I have noted how passionate they are about each person and ensuring the best care and outcome is achieved”.

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.

There was a positive learning culture at the service, where opportunities for quality improvement were actively sought out. The management team attended local partnership groups with other services, as well as local groups specifically for mental health providers which they explained helped them share and exchange best practice to continually improve people’s outcomes. The manager told us, “It’s important to take learning from other services run by our provider, so I visit these often. Learning culture is really important and I want to let staff thrive and show off good practice”.

There was a structure of using incidents and feedback from people’s care reviews to inform ongoing quality improvement, with these first being discussed at a management meeting and then at a key worker meeting, where individual “focuses” would be designed to help people around specific challenges. These had recently taken place to support people with challenges around their emotions, substance misuse and managing personal relationships. These focused pieces of worked were regularly reviewed to ensure they were effective in helping people achieve the things that were meaningful to them.

Staff, people, relatives and visitors also had an opportunity to submit “Strengths and Strains” using an online portal highlighting areas they thought were working well or could be improved, with a clear system to analyse these and shape ongoing care around people’s live feedback.