We found

• The clinic room was dirty and the floors were not clean.
• Single use medicine pots were being washed by hand which was not infection control. These were lying dirty in the sink. This was despite the infection control training being at 93%. 
• The drug fridge was open with the key in the lock. This was rectified immediately.
• Mandatory training figures were lower than expected. 

However

• The ward complied with same sex accommodation guidance. Staff knew the incident reporting process.Pressure ulcer risk assessments were completed on admission. Debriefs for staff occurred after incidents and learning was fed back to them via meetings or supervision.
• The hospital director had sufficient authority to increase staffing numbers should they be required to deliver enhanced nursing care.

We used a number of different methods to help us understand the experiences of people who used the service, because some of the people had complex needs, which meant they were unable to tell us their views and experiences. We spoke with several people who used the service who were able to verbally communicate with us and one relative and they told us they thought the service provided a good standard of care and support.

We spoke with several people who used the service and they told us they could make choices about going out and taking part in activities. Comments included, "I have been baking today", "I like to go for walks and to the shops" and "They (the staff) are very nice and kind."

We spoke with one relative who told us their concerns had been listened to and action taken to address them. They commented, "The management and staff are wonderful and they have sorted all of the concerns I had" and "My husband is doing well and seems settled" and "We have just had a carers meeting and everyone is extremely happy with the care and support offered."

We looked at various written documentation that included the care files of people who used the service, the environment and staff records. We saw that these had improved since our last visit.

We were able to chat to patients during the course of our visit. No concerns were raised by patients about their experience of living at Castle Lodge. One detained patient said that they were happy with their care.

When talking to patients about how they were involved in decisions about their care they told us; “we can have drinks and snacks when we want”, “I can choose to do what I want” and “we get up and go to bed when we want”.

People told us that staff were helpful. Some comments included, “staff help us, but sometimes we have to wait a long time” and “the staff are good to us and help us lots”.

We rated Castle Lodge Independent Hospital as good because:

• The stages of the admission process were available to referrers, patients and their relatives and staff were involved in a pre-assessment to ensure the hospital could meet the needs of the patient. Following a twelve week assessment period that included two formal review meetings, treatment plans were agreed which showed targets for progression in recovery.
• Assessments completed after admission were comprehensive, timely and informed care planning. Care plans were personalised, recovery focussed and used patients’ chosen name. Care plans records were relevant to individually identified needs and showed evidence of regular review.
• Staff engaged with patients in a respectful manner and offered reassurance and support to patients who were showing signs of distress. Patients told us they felt safe at the hospital, that staff were always nearby and treated them well. Carers’ spoke of their loved ones being happy and that the care they saw was good.
• Staff were clear about the need to safeguard vulnerable adults in their care and saw safeguarding as everyone’s responsibility. We found positive communication between the hospital and the local safeguarding authority.
• Staff knew their responsibility to be open and explain to patients if something went wrong. The carers we spoke with were confident the patients and themselves would be contacted if anything untoward happened. We saw the duty of candour policy followed at the hospital.
• Staff received regular clinical and managerial supervision that they reported as being both challenging and supportive. The staff compliance rate for supervision was 100%.
• The staff we spoke to were committed to their work and wanted to deliver patient care that was the best it could be. Staff spoke of being supported by the hospital manager and the senior managers in the organisation who they knew.
• Staff received regular training and appraisal that supported their development. Against provider target of 85%, the hospital showed staff training compliance of 95% and compliance with appraisal was 89%.
• Staff felt able to raise concerns without fear of victimisation, they knew about the organisations whistleblowing policy, and that they could contact external organisations to report concerns.

However,

• We found issues with safe systems in the management of medicines that were not identified in the hospital’s regular medicines audits. Not all staff involved in administrating medication worked to hospital protocols, there were discrepancies in medicine stock levels and medicines were not all disposed in a timely way. Whilst agreed following capacity assessments and best interest meetings, the administration of covert medication did not always follow consultation with a pharmacist, nor was it regularly reviewed in multidisciplinary team meetings.
• Barchester consultant psychiatrists that provided on-call cover for the hospital when the locally based consultant was on leave may not be able to attend in the event of a psychiatric emergency within 30 minutes. The Royal College of Psychiatrists accreditation standards for inpatient older adults mental health November 2014, state that an identified duty doctor should be available to attend within 30 minutes in the event of a psychiatric emergency.
• Whilst wide enough for a wheelchair to pass through, the door into the garden from the female lounge was not wide enough for a patient to propel herself with their hands on the wheels of the chair.
• The hospital had no dedicated space for therapeutic activity. Activities took place in communal lounges, dining areas and the garden.