The Hamptons

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

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 requires improvement. At this assessment the rating has remained requires improvement.

This meant the service management and governance was inconsistent.

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes. We identified gaps in various documentation that we reviewed, along with inconsistencies with how certain information was recorded and located.

However, staff felt supported within their roles and gave positive feedback about working for the service. Managers were passionate about the service and were keen to continue to make improvements.

The service was in breach of regulations for governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff spoke positively about working for the organisation and felt that the values were reflected in the care and treatment that the staff team provided to patients.

The service had an award scheme called “step up and stand out” where other staff or patients could nominate a staff member who they felt had gone above and beyond their role or who had made a significant contribution to the people the support. The nominating party would be asked to describe this contribution in relation to one of the organisation’s values. The unit had a display in the downstairs corridor for winners of the awards.

The service had a relatively new management team that were still being embedded within the hospital. The service had appointed a new hospital manager in July 2024 who was the CQC Registered Manager, along with being the controlled drugs accountable officer. The hospital manager was receiving support and guidance from senior managers within the organisation. They described that there was always someone in the organisation who could provide them with advice when needed.

A new ward manager had started in post 4 weeks prior to the assessment and was still in their induction phase within the service. This post had been covered by other members of the management team pending an appropriate person being appointed.

The hospital manager noted that the management team for the unit had been inconsistent over the last 2 years and believed that a stable management team would significantly benefit the patients, staff and unit overall.

It was not always clear that managers had appropriate oversight and awareness of issues identified in the service, or that necessary actions were taken and monitored appropriately. We observed examples where issues that had been identified by the service’s governance processes were still occurring which did not indicate that the actions to address and manage these issues were robust enough.

The hospital manager had implemented a leadership team away day on 12 February 2025 to discuss key challenges that the service was facing and to consider how the effectiveness of the leadership team could be enhanced. Managers had requested feedback from staff on the leadership as part of this process. The leadership team considered the challenges in the service and as a team identified solutions and actions that could be taken to address these challenges; along with key milestones and timescales associated with these improvements. The hospital manager was adapting this into a service improvement plan.

Managers spoke passionately about the service, patients and staff. Managers were keen to continue to make improvements within the service and had positive attitudes to tackling any issues or areas of improvement.

The provider had implemented a manager’s office on the unit by converting a small meeting room. This enabled managers to have a space where they could be more present, accessible and visible on the unit.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service had undertaken various surveys to gather feedback from patients including around patient experience as well as activities and therapies.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Action plans were created based on the findings of the surveys.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. Senior leaders from the organisation attended the site for a meeting with staff every 6 months.

Managers explained how staff would be supported within the workplace and that staff were able to apply to work flexibly, for example flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers advised that reasonable adjustments could be put in place for staff members to help them carry out their role, based on their individual needs.

Staff received training in equality, diversity and inclusion as part of the mandatory training. Managers noted that some additional workshops for staff around culture, equality and respect were being planned by the organisation’s human resources team.

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes. We identified gaps in various documentation that we reviewed, along with inconsistencies with how certain information was recorded and located.

We requested a copy of the provider’s observation policy following the on-site assessment. The provider sent their observation and engagement policy for The Hamptons. The policy’s last review date was 06 September 2019 and it indicated that the next review was due by the 25 May 2022. This made the policy significantly past its review date and it was not clear that the provider had reviewed this or considered if the policy still met the organisation’s expectations and requirements for observation and engagement within the service.

We reviewed a sample of 4 patients observation records. Whilst there were no apparent gaps in recording, the records often contained limited descriptions and did not generally consider patient mood, mental state or presentation. For example, we noted multiple entries across the forms where the only description recorded within the overview of observation section was just one or two words, such as “smoking” or "watching TV”. The observation forms prompted staff to consider and document factors such as mood, mental state and presentation. It was not clear if the observation forms were checked or reviewed once completed, to assess if these met the standards expected of the service.

We requested copies of handover documentation for the two weeks prior to the initial day of assessment. On review of this documentation, we noted gaps in the documentation submitted. There was no indication that these gaps had been identified or escalated within the service to ensure that the handovers had taken place as appropriate, or that the service had the required allocation of staff for those days where there were gaps.

The service had not undertaken regular risk assessments of the care environment within their identified time scales. The service had undertaken a ligature risk assessment on 25 February 2025 which was still being written up and required sign off through the provider’s governance processes. The previous ligature risk assessment had been completed in November 2023 and indicated it was due for review in November 2024. The provider sent CQC the new ligature audit dated 11 March 2025 following the on-site assessment, although this did not indicate clear timescales as to when actions identified should or would be completed, or how this would be monitored.

We reviewed 10 patient prescription charts of which only 3 had all medicines signed for by staff. Some only had one or two missing but there were examples which had several missing including important medicines such as mood stabilisers and antipsychotics. We reviewed an external audit of the clinic which had been undertaken in December 2024 that had raised issues around staff not signing when administering medication. The audit recorded actions which were to be taken by the provider to address this including an email being sent to all nursing staff and discussions to be held in supervision and the nurse meetings. As this was identified as an issue during the on-site assessment, we were not assured that the actions had appropriately and robustly addressed this issue.

There was a clear framework of what must be discussed in team meetings to ensure that essential information, such as learning from incidents, was shared and discussed.

The provider had policies to guide staff in the day-to-day operation of the service. There was a standard agenda to ensure consistency, and meetings served a clear purpose.

Managers had ensured the wards were staffed to safe levels and that patients were safe and treated kindly.

Managers described how the service was engaging with external stakeholders and partners. Managers recognised the importance of these relationships and ensuring that they were being kept informed and involved.

Staff invited family members and external professionals to meetings where appropriate so they could discuss any issues and receive any updates about the patient's care and treatment.

The hospital manager was developing a service improvement plan following a leadership team away day in February 2025.

The organisation had a quality assurance manager, and the hospital manager had requested for them to undertake a quality assurance visit in the near future. This was to help advise on and target areas where the service could make improvements.

The unit was not participating in any accreditation schemes at the time of the assessment. Managers noted that this was a future ambition for them.