Windermere House Independent Hospital

Updated 29 August 2025

We inspected this service on the 10th and 11th of June 2025. This service was registered by the CQC on 15th of February 2011. We last inspected Windermere House Independent Hospital in 2018 and the service was rated Good. Windermere House is run by Barchester Healthcare Homes Limited and is a 30-bedded independent hospital that provides care under the Mental Health Act for males across 2 separate wards; Kendal ward for older adults and Coniston ward, a long stay and rehabilitation for working age adults. The hospital provides needs-led services for people with functional or organic diagnoses who are detained under the Mental Health Act, or on an informal basis.

The service has a registered manager who is experienced and been in post for 12 years who is also the controlled drugs accountable officer. The service provides regulated activities under assessment or medical treatment for persons detained under the Mental Health Act and treatment of disease, disorder and injury.

As part of this inspection we visited both wards over two days. We rated this service as good. The service provided a safe, purpose-built environment with skilled staff that delivered a range of therapeutic interventions in line with peoples individual needs. Care records were detailed and showed that staff involved patients and their carer's in decisions around care and treatment. At our last inspection the service was rated good.

There was enough staff to keep people safe and ensure therapeutic activities were consistent. There was clear governance and oversight in place and the wider multi-disciplinary team were integrated into patients care and discharge planning. Policies and procedures were in place ensuring transitions and discharges were safe and effective. There was minimal use of restraint within the service.

Updated 28 January 2025

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

All staff within the services had received training in the Mental Health Act at the time of our inspection. Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrator was, and the service was in the process of developing staff to provide further cover around this role. The service had relevant policies and procedures that reflected the most recent guidance and staff had access to this information.

Patients had access to information about independent mental health advocacy (IMHA) and at the time of inspection, all patients had an advocate in place who visited at least once per week. As part of this inspection, we spoke with the service's designated IMHA who told us that access to patients and meetings had been good on both wards. There were no issues accessing multi-disciplinary meetings and they always started on time and as planned. The advocate told us that staff were friendly and that referrals for advocacy and support were made in a timely manner.

We saw evidence that staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done so within patients' care records. We also saw evidence in patients' care records that staff ensured they had access to Section 17 leave (permission for patients to leave hospital) where this had been agreed by their doctor. Staff requested an opinion from a second opinion appointed doctor when necessary.

Mental Health Act documentation was stored safely and securely so that it was available to all staff who required access to it. Leaders completed regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act

Staff made best interests' decisions for patients who lacked capacity and documented them in the patient's care record, taking into account their wishes, feelings, culture and history. Care records indicated staff took practical steps to enable patients to make their own decisions, including easy read documents.

The service had arrangements to monitor adherence to the Mental Capacity Act through auditing by the Mental Health Act administrator and the service manager acted on any learning that resulted from it.

Updated 28 January 2025

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

All staff within the services had received training in the Mental Health Act at the time of our inspection. Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrator was, and the service was in the process of developing staff to provide further cover around this role. The service had relevant policies and procedures that reflected the most recent guidance and staff had access to this information.

Patients had access to information about independent mental health advocacy (IMHA) and at the time of inspection, all patients had an advocate in place who visited at least once per week. As part of this inspection, we spoke with the service's designated IMHA who told us that access to patients and meetings had been good on both wards. There were no issues accessing multi-disciplinary meetings and they always started on time and as planned. The advocate told us that staff were friendly and that referrals for advocacy and support were made in a timely manner.

We saw evidence that staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done so within patients' care records. We also saw evidence in patients' care records that staff ensured they had access to Section 17 leave (permission for patients to leave hospital) where this had been agreed by their doctor. Staff requested an opinion from a second opinion appointed doctor when necessary.

Mental Health Act documentation was stored safely and securely so that it was available to all staff who required access to it. Leaders completed regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act

Staff made best interests' decisions for patients who lacked capacity and documented them in the patient's care record, taking into account their wishes, feelings, culture and history. Care records indicated staff took practical steps to enable patients to make their own decisions, including easy read documents.

The service had arrangements to monitor adherence to the Mental Capacity Act through auditing by the Mental Health Act administrator and the service manager acted on any learning that resulted from it.