Castleman House

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 service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. Staff stated they were proud to work at Castleman House. They team told us they are committed to the people using the service and had seen an increased presence of the provider which ensured a positive culture and a sense of community at the heart of the service had been created.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. Leadership of the service had not always been consistent, and this had contributed to the shortfalls identified within this assessment. Staff were not always clear in their role and responsibilities in particular with medicines management. A health and social care professional told us changes within the staff team and absences of leaders had caused confusion and a lack of understanding of the medicines policy which contributed to shortfalls found in this assessment. However, during the assessment we found both the manager and provider to be committed and ambitious about the improvements the wished to make at Castleman House. The manager told us they were fully supported by the provider and had received a comprehensive induction.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff knew how to raise concerns and access support. There were clear procedures for regular team meetings. Staff consistently told us the manager had made improvements to the service and they felt able to discuss their concerns, views and ideas with them. Castleman House had policies and procedures in place to support staff in speaking up and raising concerns. This included up to date policies in relation to safeguarding and whistleblowing.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures incorporated all aspects of recruitment and staffing and included retention plans, equality, diversity, fairness and protected characteristics. Support and reasonable adjustments were made for staff as and when needed. Other resources were available to assist staff with their physical and mental health. This included an employee assistance programme, so that staff had the necessary access to services to thrive in their roles.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were inconsistent and not always operating effectively. Systems had not been embedded to monitor the quality and safety of the care provided. The impact of not having robust systems and processes in place has resulted in people not receiving medicines as prescribed and a lack of robust leadership at Castleman House. Staff told us the service had experienced many changes in leadership and practices, which had led to a period of instability and caused low staff morale. The provider expressed a commitment to ensuring staff development and wellbeing are prioritised. The home manager demonstrated a proactive approach to addressing concerns and offered assurances about how audits will be managed moving forward. We saw evidence this has been communicated to staff and saw the provider had taken an active role in supporting to make needed improvements.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. Castleman House had established links with a local nursery, the local church and a number of local voluntary groups. Feedback from people included, “There is always something going on here.” And, “My family attend and are able to join all the parties we have, someone’s son even dressed up as Father Christmas for everyone’s grandchildren.” Health and social care professionals shared their views of care staff and remarked, “They know residents well and are always gentle and polite in their approach”, “They are always helpful when clinicians are visiting. Staff know the residents well, or get someone who does so a more informed assessment can occur.” And, “We have a good working relationship with the team at Castleman House.”

The service 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 contribute to safe, effective practice and research. Staff told us they were grateful of the provider’s presence to support with review of care plans and how the service was run. Comments included, “Things had slipped on the paperwork side, care has always been brilliant, but we didn’t always find time or know what we should be documenting.” And, “Having the quality assurance team in the home has helped us put things right.” The provider demonstrated an understanding of how to make improvements happen. The provider was responsive to concerns raised by inspectors onsite. Following the assessment the provider encouraged reflection and collective problem-solving to address shortfalls at Castleman House.