Hatfield Lodge

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 assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.The service was in breach of legal regulation in relation to governance of the service.

This service scored 25 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The provider had a statement of purpose in place stating they aim for privacy, dignity, independence, choice and fulfilment. Staff were unable to describe the culture of the service, its aims or the philosophy of care.

The provider’s culture policy stated, ‘Managers and senior leaders are responsible for setting the tone and upholding our values’. There was no evidence to demonstrate the registered manager had kept the culture of the service under review and acted to make sure staff worked in line with the provider’s aims.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Staff had completed a survey, comments included, ‘Need to treat staff with more respect and stop making staff walk on eggshells. Better communication other than the computer. All the staff do care for residents, but management makes you feel bad when you sit down and interact.’ Staff also did not feel the registered manager was approachable and there were not enough staff to do the things they wanted with people. The provider had not acted to understand these concerns and how improvements could be made.

Staff meeting minutes showed staff including senior care staff had raised concerns about staffing levels. The registered manager had told senior care staff it was their responsibility to lead shifts and manage time, there had been no further support from the registered manager with these concerns.

There were processes in place to recruit staff safely, but these had not always been followed. Some application forms had gaps in the employment history, and these had not been followed up as required. Disclosure and Barring (DBS) checks had been completed, when a conviction was highlighted on the DBS, it was not clear what was discussed with the staff member. The registered manager had not completed a risk assessment about employing a person who had a criminal conviction.

Staff had received an induction, when they had started working at the service. However, some staff had received their induction on one day. There was a risk staff would start to support people without understanding their needs.

People did not always feel they could speak up and that their voice would be heard. There were processes in place for staff and people to speak up, however, these had not been effective in making changes to people’s experience of living at the service.

People and relatives had raised concerns, these had not always been acted on fully or led to change. Staff had raised concerns about staffing, but this had been acted on. People had been asked for suggestions about meals, a person had stated they did not like pasta. On the day of our onsite inspection, 2 of the meal choices were pasta and we observed the person being given that as their meal.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was not an open and inclusive culture at the service. The registered manager did not promote an inclusive workforce during team meetings. The meeting minutes showed the registered manager had blamed the staff for not managing their time and senior care staff not leading the shift, when they raised concerns about the workload and staffing levels. During a care staff meeting they praised a member of staff and expressed they would like other staff to be like them. This approach did not support equality in the workforce.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The processes in place had not been effective in monitoring and improving the quality of the service and identifying risk. There had been regular audits completed by staff which had identified shortfalls, but these had not been acted on. For example, the housekeeping staff had completed infection control audits, the audit dated January 2025 identified damaged flooring and furniture among the concerns. In the May 2025 audit the concerns remained the same and other shortfalls had been identified.

When audits had promoted an action plan to be put in place, there were no dates for completion or who was responsible for making the improvements. There was no evidence the action plans had been reviewed to assess if improvements had been made.

Some audits, such as care plan audits, were unclear as they had been printed off the electronic system and had coloured dots against the elements of the care plan or risk assessment. Most of the care plans had been written and reviewed by the registered or deputy manager. There was no evidence to show the content of the care plan had been checked as being person centred or accurate by the provider. The audits had not identified the shortfalls found at this inspection.

The registered manager had not submitted notifications of safeguarding incidents or Deprivation of Liberty Safeguards (DoLS) authorisations as required. The day following our onsite inspection 11 DoLS authorisation notifications were received dating back to February 2024, and we identified 4 incidents in May 2025 which CQC had not been informed about.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. The service did not work with local community groups supporting people with dementia. People had not attended events outside of the service which might have benefited their wellbeing.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. The management team did not support a learning culture within the service. The registered manager did not act to make improvements to the service when concerns were raised.