Hazelwood 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, and fair culture. We rated this key question Good. This meant the service was consistently managed and well-led. Leaders and the culture of the service promoted high-quality, person-centred care. The senior leadership team had action plans, strategies, policies, and procedures in place which maintained good governance, oversight, and effective overall management of the service. Leaders prided themselves on having a culturally diverse workforce as it better represented the patients they cared for, and the wider communities. The service had clear vision and values around the patient experience and the quality of care and support they offered and provided. The service provided various innovative initiatives for its staff to maximise their skill set and practice which enhanced the care, support, and treatment they were able to offer, and provide to patients and their families. The service had a culture of openness, honesty, and inclusion which encouraged and supported all staff to provide feedback, positive or negative. Where appropriate lessons had been learnt, and this maintained a consistent drive for improvement.

This service scored 82 (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 demonstrated a clear shared vision and culture based on openness, honesty, equality, diversity, and inclusion. Staff aligned with and promoted the organisation’s values in their everyday working roles. Leaders communicated the vision effectively to all staff, this ensured alignment with the service’s aims and ambitions.

The most recent staff survey in April 2025 showed high staff engagement at 81%. All staff said they cared about the future of the service, 83% said they were proud to work for the organisation, and would recommend it as a place to work, 97% said they were able to communicate openly with leaders, and 81% said they would happily recommend the service, and the care, and treatment provided to a friend, or family member.

Staff had opportunities to contribute to discussions regarding the service’s strategy, especially through changes and transformation, this made them feel valued and included. Staff knew how their roles and practice helped to maintain the delivery of high-quality care and treatment.

Leaders proactively addressed workforce inequalities and fostered a culture of inclusion, resulting in more equitable and person-centred care and treatment for all patients. They showed a strong understanding of, and consistently modelled values and behaviours that promoted equality, diversity, and human rights.

The provider’s strategy focused on delivering safe, effective, and compassionate high-quality care while promoting equality, and partnership working, always putting people at the centre of everything they did. The service ensured all staff received regular, and clear communication promoting the shared goals and direction of the organisation. Staff felt included and valued, which underpinned, and promoted a positive culture within the service.

Leaders had the skills, expertise, and knowledge to perform their roles effectively. They had defined roles, responsibilities, and were accountable which ensured each leader was aware of any issues or concerns, and service priorities.

Leaders had an in-depth understanding of the services they managed and consistently supported their teams to deliver high-quality, and effective person-centred care and treatment. They were visible, available, and approachable to patients, their families and staff. This behaviour modelled and promoted inclusivity which aligned with the organisation’s values.

Career development opportunities were available for all staff, with multiple examples of staff being encouraged, and supported to progress. Leaders valued their staff teams and proactively challenged and addressed any cultural issues that could impact care or have a negative impact on the wellbeing of staff.

A freedom to speak up (FTSU) policy and procedure was in place. Staff had access to the FTSU Guardian and service, the service had 5 freedom to speak up champions who were based on the wards. They told us they knew how to raise concerns and were encouraged and supported to do so.

Leaders promoted an open culture where concerns were listened to, acknowledged, investigated, and the necessary actions taken when required, with regular updates given to the person raising the concern, and outcomes shared. Staff received training on whistleblowing and were confident to raise concerns.

FTSU concerns were discussed in governance meetings, they were monitored and audited to identify any common themes, if a theme was identified an action plan was formulated to address the findings. Staff felt confident that concerns were taken seriously and led to positive change.

There had been no freedom to speak up concerns raised in the 3 months prior to our on-site assessment.

There was a strong commitment to EDI across the service. The organisation’s values were at the centre of how care was delivered and how staff were supported. Leaders had good oversight of the service and its culture, they ensured staff were treated fairly, with kindness, and respect. Any unfair treatment or differences in experience were identified and addressed, particularly for staff with protected characteristics or from marginalised groups. The service facilitated reasonable adjustments and flexible working arrangements that supported the individual needs of staff whenever possible.

The service participated in a successful sponsorship programme for overseas staff. The organisation’s International Resourcing Team assisted and supported overseas staff with the transition to the UK. The organisation’s Relocation Service supported overseas staff with travel to the UK, and the appropriate accommodation to ensure a reasonable commute to their place of work. Service leaders ensured that all overseas staff completed role-relevant training, and competencies prior to commencing work. They felt listened to, valued and were recognised by colleagues for their positive contributions, and roles within the service. One staff member told us “When I first started working here, I was new to the area, the managers, and the team were fantastic. They supported me so much and helped me to settle in."

Leaders promoted religious and cultural themed days to celebrate the diversity of its workforce. Staff celebrated their cultures with colleagues and patients through music, and activities. They would prepare, cook, and share cultural meals. Themed days were also used as an education, and gave an insight into the staff members culture, and what was important to them.

The service was part of the wider organisational Race, equality and Cultural heritage network (REACH). Reach provided a safe place and offered support for REACH colleagues to raise any concerns regarding discrimination they may have experienced within the workplace on the grounds of their race, ethnicity, or culture.

Employment procedures ensured prompt, fair and equal treatment of all applicants in accordance with the Equality Act 2010, and the trust’s EDI Policy. The organisation actively promoted Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ+) employment opportunities, and promoted an organisational LGBTQ+ network support hub. Core HR policies stated a commitment to not discriminating against employees on the grounds of sexual orientation This ensured the workforce was diverse and reflective of the people using and visiting the service.

Leaders fostered a culture of inclusion and promoted a zero-tolerance stance regarding bullying and harassment. They also endeavoured to make sure that all staff, including those who may be less heard, had input in shaping services. EDI was clearly embedded in the organisation’s values, policies and strategic priorities.

The service had clear governance and management processes that worked well and supported safe, high-quality, and sustainable care. Staff understood their roles and responsibilities within the service and were held accountable by leaders where appropriate.

Morning, and team meetings consistently covered key topics such as incidents and risk, complaints, safeguarding, patient admissions, discharges, and care quality. Staff learned from audits and reviews and acted on outcomes, and any recommendations made, this demonstrated a culture of ongoing learning, improvement, and service development.

Staff collaborated and communicated well with colleagues and external partners to meet the needs of the patients they cared for. The service’s risk register was current, accessible, regularly reviewed, updated with staff escalating concerns promptly. Emergency response plans were in place, for example, in the event of infection outbreaks or other service disruptions.

IT systems were reliable and supported staff to complete their clinical work, while information governance processes ensured that patient information was managed securely and confidentially.

Leaders accessed timely and accurate performance data, which maintained effective oversight of the service. Leaders submitted required notifications promptly to external bodies, for example, CQC in accordance with regulation, and legal obligation.

Leaders implemented recognised quality frameworks and supported innovation through effective and proportionate risk management practices. This ensured that governance structures remained resilient, flexible, and sustainable.

Staff and leaders were open, transparent, and effectively engaged with external stakeholders, and partners in care. They collaborated with commissioners, and other relevant organisations to support and maintain service delivery and integrated care.

Leaders shared learning across local, and national networks and used partnerships to support, and drive improvement within the service. For example, collaborative working with IMPACT the provider collaborative across the Midlands region. IMPACT actively promoted the positive transformation of services, through co-production between services, patients, families, and carers. This approach was designed to ensure people’s needs were met more effectively, and service variation minimised to ensure better and more consistent outcomes for patients.

Leaders valued feedback from partners and communities and used this information to shape services and identify innovative ideas, and practice to improve and promote better outcomes for people.

The organisation fostered a culture of continuous learning and improvement. Staff and leaders understood how to drive and implement change and effectively applied quality improvement methods and projects to enhance care, support, and service delivery. For example, Expert by Experience and Carer Engagement which had created a new and robust approach that involved and valued the input of experts by experience, carers, and families in service development.

The organisation learned from patients and their families which led to meaningful service changes. For example, the service had implemented changes to actively seek out and include the views of families and carers views in the care and safety planning processes.

The service participated in relevant national audits and clinical benchmarking schemes. For example, membership in the Quality Network for Forensic Mental Health Services (QNFMHS). The Quality Network for Forensic Mental Health Services utilised a multi-disciplinary approach to quality improvement in medium and low secure mental health services.

This promoted the sharing of best practice, innovation, and ideas by listening to and being led by frontline staff and patients at different services across the region. Areas for improvement were identified through a culture of openness and enquiry. The approach was one of engagement rather than inspection and aimed to deliver quality improvement through a supportive network and peer-review process.

The service was recognised by the Royal College of Psychiatrists and accredited with the Quality Network for Inpatient Learning Disability (QNLD). The accreditation is awarded in recognition of best practice, high quality care, and innovative strategies focused on reducing the risks of relapse and reducing the patient’s length of stay in secure care.

Staff engaged in research and embedded evidence-based practice into care delivery. Strong external links supported innovation. Leaders maintained open and clear communication with staff and promoted a culture of trust, and involvement where ideas for change were encouraged, welcomed, and acted upon.