Baldock Manor

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people's needs.

At our last assessment we rated this key question good. At this assessment, the rating has remained. This meant people's needs were met through good organisation and delivery.

This service scored 75 (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 made sure people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs.

Staff regularly met with patients to understand their views on care and treatment. We saw examples of these discussions in one-to-one meetings, care plans and multi-disciplinary meetings. Staff monitored patients’ conditions and discussed any changes at daily handover meetings.

Community meeting minutes demonstrated that patients were offered the opportunity to give feedback about all aspects of ward operations, such as food, activities, the environment, facilities and resources available to them. Where feedback was negative, appropriate actions were raised to try to resolve these issues.

We observed a compassionate response from staff towards a patient who was grieving the anniversary of a loved one’s death.

Staff encouraged patients to work alongside them to develop their activity and therapy timetable so that activities and therapeutic interventions were relevant and met their needs.

The service understood the diverse health and care needs of people, so care was joined-up, flexible and supported choice and continuity.

When appropriate, staff ensured that patients had access to external opportunities to support their recovery, for example support to access accommodation and a recovery college where a range of educational courses and resources were available. Some patients had been able to obtain qualifications and university degrees.

Staff supported patients to maintain contact with their families and carers. Where this was appropriate, families and carers could visit people on the ward and there were rooms that were suitable for family and carer visits. If patients needed it, they were offered encouragement to phone families and carers so that they could stay connected.

Staff supported patients to access their chosen place of worship within the community, where this was appropriate.

The service provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Team managers had access to information to support them in their management responsibilities. This included information on the performance of the service, staffing and patient care. This information was presented and discussed in clinical governance meetings.

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress. Staff made notifications to external bodies as needed.

The service provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Information governance systems included confidentiality of patient records.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights and how to complain to the provider and other regulatory bodies. The information provided was in a form accessible to the patient group.

The service made it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. Staff involved them in decisions about their care and told them what had changed as a result.

Patients knew how to complain or raise concerns. There were clear instructions around the ward for people to follow. When patients complained or raised concerns, they received feedback.

Staff knew how to protect patients who raised concerns or complaints of discrimination and harassment. Staff knew how to handle complaints appropriately.

Staff received feedback on the outcome of investigations of complaints and acted on the findings. Patients were supported by the advocate at the service to make improvements for example the advocate worked with patients to ensure a welcome booklet was devised and put in place for patients on admission. The advocate also supported patients in reducing restrictions related to their care, with the support of staff. For example, they helped patients request changes to their care and treatment during ward review meetings and restrictive practice meetings.

The service had advertised for the role of a family ambassador the aim being to have more input from relatives of people using the service.

The service received many compliments between 2024 and July 2025. Compliments referenced many staff who they felt were kind, caring and supportive.

Between June 2024 and June 2025, the service had a total of 24 complaints. Four of these were upheld, 4 were partially upheld, 1 complaint was retracted, and the remaining were either not upheld or had mixed outcomes. Themes of complaints that were upheld involved safeguarding concerns, a data protection breach and a delay to discharge. Managers ensured each complaint was investigated and outcomes were shared with patients and relatives.

The service did not have any complaints that were referred to the Ombudsman in last 12 months.

The service made sure that everyone could access the care, support and treatment they needed when they needed it.

Occupational therapy staff assessed patients’ mobility needs to ensure they had the right equipment available to support them, Staff also accessed physiotherapy if patients needed this.

The service had a range of mobility aids including ramps, walking frames, wheelchairs, walking sticks, toilet and shower chairs, stair lifts and lifts for patients whose mobility was limited.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff planned for patients’ discharge, including good liaison with care coordinators. Staff ensured patients had access to post-discharge care, for example, S117 aftercare, community mental health services and crisis services.

Between October 2023 and July 2025, the service had 20 delayed discharges. Thirteen of these patients had been discharged at the time of our inspection. Seven current patients had delays to their discharges at the time of our inspection and had been admitted between 2023 and 2024. Delays were due to finding appropriate placements or people had no fixed abode. The service monitored this and worked with commissioners and community teams to ensure discharge was facilitated as soon as possible. Patients’ length of stay varied between 28 days and 243 days.

The service actively sought out and listened to information about people who were most likely to experience inequality in experience or outcomes. Staff tailored the care, support and treatment in response to this.

The service admitted patients from diverse religious and cultural backgrounds. Staff asked patients about their religious and cultural needs when they were admitted to the ward.

Staff made sure patients could access information on treatment, local services, their rights and how to complain. For example, one patient was able to provide feedback that the service did not have a prayer room, and the service had created a multifaith room as a result.

At the time of inspection, 92% of staff had completed training in equality and diversity. Eighty four percent of staff had completed The Oliver McGowan Mandatory Training on Learning Disability and Autism.

The service supported people to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff created personalised care plans to account for the patient’s needs, wishes and feelings. Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.

Staff supported patients to develop skills to enable them to be prepared, confident and independent for the future. This included budgeting skills, community skills; including utilising public transport, cooking skills, routine building and home environment visits.

Staff supported patients to make decisions about their care and treatment and their future, for example with home visits, or visits to potential placements that they may be discharged to. Patients who were able to work towards discharge had clear plans to enable this. These plans were being developed alongside patients, families, and carers. It was possible to see the work that was being done by the staff to try to support people in their journeys.