Hatfield Manor

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 is the first assessment for this newly registered service. This key question has been rated 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 at the service.

This service scored 54 (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; however, this was not embedded at the service.

We received mixed feedback about the culture of the service, with many staff sharing changes to management had negatively impacted them in their work. A member of staff told us, “Hatfield Manor is a safe place for residents to live, largely due to the dedication and professionalism of the staff. Concerns are currently raised with management, but follow-up or resolution is inconsistent.” Other members of staff told us, “I love it here. I think it’s a good home” and “I would have a relative here. No worries at all.”

The provider had a service user guide which was provided to people when they were admitted to the service. However, it was not clear how this was shared wider to fully ensure the stated objectives of the service were modelled in day-to-day practice.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. However, changes in management meant that the service had not benefitted from consistent leadership.

We received mixed feedback from staff regarding their experiences of management and leaders at the service. Whilst some expressed no concerns and would recommend the service to others, other staff expressed concerns and a feeling of disconnection.

The service did not have a registered manager in post. At the time of this assessment the position had been vacant since February 2025. The deputy manager was managing the service on a day-to-day basis, with input and support from senior staff from the provider organisation. Recruitment for a registered manager was in progress.

It was clear from the feedback we received and the findings of our assessment changes in management at the service had created instability and had negatively impacted the overall oversight of the service. The management team were confident that the appointment of a new registered manager would ensure that quality assurance processes would be strengthened and fully embedded into the service which, in turn, would ensure the service was running safely and action would be taken where needed to make improvements.

The provider had not fostered a consistent culture where people, relatives and staff feel they could speak up and that their voice would be heard.

We received mixed feedback from relatives. A relative told us, “Manager does walk round. I get asked for views. No concerns at all.” Another relative told us, “[Name of previous manager] was responsive. I don’t think that’s the case now. We need a really good manager here.”

Staff also shared differing feedback. A member of staff told us, “I know how to speak up. I see (interim) manager walking round. [They are] supportive and open to views.” Another member of staff told us, “I would report to [management team], however I have no confidence in [them] dealing with my concerns appropriately.”

Staff meetings, surveys and supervision had not consistently been completed. This limited the opportunities for staff to provide feedback on their experiences of working at the service. However, the provider had processes in place to support staff to speak up, alongside an up-to-date whistleblowing policy.

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

The provider employed a diverse workforce from varying backgrounds and cultures.

The provider had policies in place to support equality, diversity and inclusion.

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 in place had not always been effectively implemented to ensure robust oversight of risk and quality improvement. There had been a number of changes in management which had led to systems and processes being applied inconsistently. This meant we could not be assured oversight was effective and risks to people mitigated.

The service had a specific improvement and monitoring plan which had been implemented following internal audits by the provider identified improvements were required, and in response to a local authority review of the quality and safety of the service. This plan had been ongoing for 2 months prior to our visit. However, we found failings at this assessment that had either not been identified or had not been acted upon sufficiently to make the required improvements. During this assessment we found the provider to be in breach of 3 regulations.

Staff told us they knew their roles and what was expected of them. However, we received mixed feedback regarding the management processes with most staff not able to confirm any part where they felt able to contribute to driving improvements at the service.

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.

People told us they were supported to access other professionals, where needed, in relation to their health, safety and wellbeing.

Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing.There was a clear system in place to ensure partnership working.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

A learning culture had not fully embedded in the service. Some staff shared feedback that they did not feel involved or able to contribute to the delivery of the service, however many shared a desire to give feedback, share ideas and contribute to areas of development in which they could be involved.

Processes were failing to ensure learning happened when things went wrong. As described in other areas of this report, inconsistencies and changes in management had led to improvements not being made where needed. However, the management team responded positively to the assessment process and welcomed feedback to improve people’s outcomes and the quality of service provided.