Baldock 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

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 remained. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 had a shared vision, strategy and culture that is based on transparency, equity, equality, human rights, diversity and inclusion. Staff focused on engagement and meeting the needs of people and communities.

Staff knew and understood the provider’s vision, five core values and how they were applied in the work of their team. The values of professionalism, honesty, openness, competence and kindness were promoted from recruitment through to the induction and continued throughout staffs’ employment. Managers ensured the values were reinforced through reflective practice sessions, team meetings and supervision.

We observed the service’s vision and values posters were displayed throughout the hospital.

The service promoted equality, diversity and inclusion. Managers recently hosted a culture of collaboration week where the diversity of cultures amongst the staff and patients was celebrated at the service. An awards ceremony was held, and staff were able to be nominated by their peers under the core values.

Managers embedded equality, diversity and inclusion in practice by ensuring these principles were visible, easily accessed and regularly discussed.

Staff had the opportunity to contribute to discussions about the strategy for their service, including when the service was changing. Available forums included reflective practice sessions, staff meetings, nurse forums, access to freedom to speak up guardian, clinical governance meetings and staff surveys. Managers ensured co-production was central to the strategy. For example, the service employed experts by experience, were recruiting carer ambassadors and engaged with carers, family and staff.

The service 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. They had the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

The hospital’s leadership team was well established, with a registered manager and clinical services manager who worked well together.

Leaders were knowledgeable about issues and priorities for the services they managed. They held regular meetings where information about the service was shared. Patients we spoke with told us they could speak with senior staff when needed. Staff we spoke with said leaders were visible in the service, were approachable and worked well with them. Carers we spoke with felt able to talk to staff or managers when needed. Staff reported a friendly, open and supportive culture between colleagues and the leadership team.

Senior managers engaged with staff on how to improve the service. Staff told us managers gave them opportunities to make suggestions on how to improve the service.

Staff were able to enhance their development and skills through further training and courses. Staff we spoke with said the provider offered good opportunities for training and development. Some leaders previously worked for the provider in other roles before progressing to their current positions.

The service created a positive culture where people felt that they could speak up and that their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients took part in restrictive practice meetings, recruitment interviews and clinical governance meetings, giving them opportunities to share their views and opinions.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. For example, feedback from patients ‘you said we did’, surveys, patient forums and community meetings.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback.

The service had a freedom to speak up guardian who produced a monthly report on freedom to speak up issues and themes. This was shared in the clinical governance meeting for oversight of the issues raised and to ensure actions were taken. Minutes were reviewed from October 2024 to June 2025. Issues were raised by staff in October and November surrounding role responsibilities, allocation of tasks and the culture on one ward. Senior staff engaged with and encouraged staff to raise these concerns and took action to address these concerns. There had been no further freedom to speak up concerns raised since November 2024. The freedom to speak up guardian continued to support staff to be able to raise concerns and attended team meetings regularly to reinforce this.

The service 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 service had policies in relation to equality and diversity, and staff and leaders had completed face to face and online equality and diversity training.

Staff and leaders gave examples of how equality and diversity were actively promoted within the service.

The service employed a diverse team of staff from international backgrounds. Managers said the service did not discriminate against staff from minority groups. Staff did not raise any concerns about discrimination and all the staff we spoke with said they were treated fairly and had good opportunities for personal and professional development.

The service participated in the confident disability scheme to ensure the service was inclusive and accessible, were offering opportunities, challenging stigma and supporting disabled colleagues. They also signed up to the mindful employer scheme to ensure they supported the mental health and wellbeing of staff and provided supportive recruitment practices.

Staff had access to an online app that provided online counselling and well-being resources.

The service had an employee of the month award programme to recognise and reward staff.

The service ensured it provided sexual harassment training for staff.

The service held staff teamwork breakfasts where senior managers shared breakfast with staff from the day and night shifts and sought their views on teamworking.

Staff participated in reflective practice where they discussed how equality and diversity impacted care delivery and considered how inclusive practices could be improved.

The service provided a multi faith room on each ward to ensure religious and spiritual practices could be met. They also ensured cultural and dietary needs were met by providing halal, kosher or vegetarian meals.

Employment practices promoted equality of opportunity. Managers used screening tools based on best practice, to ensure decisions were free from bias and mindful of protected characteristics including religion, age, sex, ethnicity and disability.

The service ensured staff experiencing the menopause had relevant support. This included cognitive behavioural therapy specifically for managing menopausal symptoms.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level. This ensured that essential information, such as learning from incidents and complaints, was shared and discussed. For example, all leaders produced clinical governance reports each month for the clinical governance meeting where themes and trends were reviewed covering standard agenda items including safety, quality, training and education, responsiveness, the experience of patients and carers and lessons learned from incidents.

Although we found some issues relating to medicine management, managers had policies and practices in place for staff to follow and took immediate action to address the issues to prevent re-occurrence. Managers ensured immediate learning was shared to address the issues we found during the inspection.

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts at the service level. For example, during the inspection we could see that lessons learned were discussed and shared with all staff following recent self-harm incidents.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results appropriately.

Staff understood the arrangements for working with other teams, both internal and external, to meet the needs of the patients.

Managers maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. The service held a risk register specific to each ward where there were up to 20 current risks. Risks related to safety, quality, responsiveness and well led. The risk register included a score for the severity of each risk, actions being taken to address the risk (including immediate mitigation) and timescales for completing those actions.

The service had plans for emergencies, for example, business continuity plans including adverse weather or a flu outbreak.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service understood it’s duty to collaborate and work in partnership, so its services worked seamlessly for people. they shared information and learning with partners and collaborated for improvement.

The service worked well with other agencies including commissioning bed managers, health and social care professionals, the police and the local authority safeguarding team. For example, the safeguarding lead held regular meetings with the local safeguarding team and the police.

The service had developed a good relationship with an NHS trust that commissioned the service through a block-booking arrangement and worked alongside them to provide evidence-based training on suicide prevention.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. For example, patients provided feedback at the clinical governance meeting and feedback was sought from staff at breakfast meetings.

The service focused on continuous learning, innovation and improvement across their organisation and the local system. they encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was a focus on continuous learning, innovation and improvement across the organisation. The service had a positive and robust approach to improvement and learning from incidents and all staff we spoke to were able to give us good examples of where lessons had been learnt and changes made after incidents.

We saw evidence of positive collaborative working between occupational therapy and psychology staff, where patients had a therapies treatment programme to provide a collective pathway of care and treatment to support patient’s recovery.

The service ensured trauma informed practice was embedded by providing trauma informed training to all staff and commenced a trauma informed committee where the 6 principles of trauma informed care were focused on in practice. This was to ensure trauma informed care was understood by staff, how trauma impacted patients and how to support patients to feel safe.

The service was conducting 2 research projects on the effects of social media on the recovery in a psychiatric intensive care ward and physical exercise and psychiatric symptoms.

The service was registering to be accredited with the quality network for older adults in mental health and the quality network for psychiatric intensive care units.