Hayes Park Nursing Home

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 rated inspection (published 8 March 2022) we rated this key question Good. At this inspection the rating has changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance.

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.

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.

The provider has a strategy, vision and values that underpinned the service provided. This was shared with staff and was consistently measured by the provider’s systems and processes that assessed, monitored and reviewed quality and safety. Improvements were ongoing in developing the staff’s understanding about the provider’s culture and expectations of staff.

A staff member described the provider’s vision and values and said, “The providers vision and values are about maintaining safety for people and providing good care, food and a safe environment."

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.

The management team were supporting the staff team to further develop, embed and sustain a positive staff culture. The provider had identified improvements were required, and a series of staff team-building meetings had been delivered with additional meetings planned. Staff confirmed this was making a positive difference. The management team acknowledged improving staff culture was not an easy fix and showed a continued commitment to make further improvements.

The registered manager was an experienced manager and a qualified nurse. They were found to be open, honest and transparent during the inspection. Where shortfalls were identified during the inspection, the registered manager was responsive and showed a commitment in making required improvements.

External agencies and us, identified the registered manager needed additional onsite management support to enable them to fulfil their responsibilities. Following the inspection, the regional manager confirmed this had been agreed and action was being taken to recruit a deputy manager. This will be a valued and added support to the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were overall positive about working for the provider and how well the registered manager supported them. Whilst some staff told us they felt valued and listened to, others did not. However, staff confirmed they were encouraged and enabled to speak up if they had any concerns. Staff meeting records confirmed this.

Staff confirmed they had access to the provider’s whistleblowing policy (this is a procedure for employees to report suspected wrongdoing or illegal acts within an organisation in a protective and confidential manner).

A staff member said, “Whistleblowing is a concern about a colleague's practice, that needs to be reported to the manager. I have no concerns about safety, and I've only seen good care being provided."

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had policies and procedures that protected staff’s human rights and working conditions. This included a Flexible Working policy. Staff could also opt out of the working directorate, enabling them to work additional hours if they wished and this was monitored by the management team to ensure staff wellbeing. The staff rota considered staff’s shift and work pattern preferences.

A staff member said, “I’m supported to work around my family commitments."

The provider’s systems, processes and procedures that included responsibilities, roles, and accountability were not fully effective. The provider’s monitoring procedures had not identified all the shortfalls identified during this inspection.

For example, the provider’s internal audits and checks had failed to identify and or take effective and timely action, to make improvements required to the shortfalls identified in the environment and infection prevention and control, as described in the key question Safe of this report. This shows a lack of effective and responsive governance procedures and compromised people’s safety, dignity and respect.

Care plans lacked detail to support staff in providing person centred care based on people’s individual routines, preferences and what was important to them. There was a lack of detail for staff in understanding people’s mental and psychological care needs. Leadership, direction and oversight of care staff found shortfalls as described in the key question Caring and Responsive of this report. Whilst staff had received training in dementia care, our observations showed improvements were required in staff’s awareness and understanding to ensure people received consistent care with empathy. This had not been identified through the provider’s monitoring systems.

Additionally, the provider’s oversight and leadership procedures had failed to recognise the shortfalls and improvements required. This demonstrated oversight and leadership monitoring procedures needed strengthening to become fully effective.

We were aware the local authority had completed a health and safety audit in January 2025 where numerous actions were required for the service to become fully compliant. A further health and safety audit visit completed in May 2025, found overall improvements, however, it also identified outstanding actions. Whilst we were assured the provider was working towards completing these improvements, we were concerned about the length of time it was taking.

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.

Feedback from external professionals was positive about partnership and collaboration. External professionals confirmed referrals for assessment and guidance were appropriate and made in a timely manner. They also confirmed recommendations were followed. An external professional said, “I would describe partnership working as very good. There is good communication links with staff and management.”

The registered manager had developed links with the local community. For example, a local school visited the service in April 2025 as part of their charity work. Photographs of the children’s visit were displayed confirming what we were told.

The registered manager told us how they wanted to improve community opportunities for people and were exploring community trips.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The registered manager and provider kept up to date with best practice guidance, learning and improvement by attending external forums such as opportunities hosted by the local authority and East Midlands Care, a local long term care sector support organisation. They additionally received news and alerts from CQC and NHS.

The provider had a number of other locations within their provider group across the country and shared any learning and best practice and ways of working.