The Care Quality Commission
  • Mental Health
  • Independent mental health service

Windermere House Independent Hospital

Overall: Good read more about inspection ratings

Birkdale Way, Newbridge Road, Kingston-upon-Hull, Humberside, HU9 2BH (01482) 322022

Provided and run by:
Barchester Healthcare Homes Limited

All Inspections

During an assessment of Long stay or rehabilitation mental health wards for working age adults

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.

During an assessment of Long stay or rehabilitation mental health wards for working age adults

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.

During an assessment of Wards for older people with mental health problems

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.

During an assessment of Wards for older people with mental health problems

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.

During an assessment of the hospital overall

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.

17 to 19 April 2018

During a routine inspection

We rated Windermere House Independent Hospital as good because:

  • The hospital had made improvements following feedback from our previous inspection. The hospital environment was clean and well maintained. Staff exceeded the provider targets in key areas for mandatory training, supervision and appraisals. Hospital managers had introduced a robust process to effectively assess and manage the risks identified on the risk register.
  • The hospital had systems in place to protect patients from harm. Each unit had an up to date environmental risk register and risk management plans. Staff identified and managed risks appropriately. Risk assessments included monitoring of existing and potential physical health risks. Patients told us they felt safe.

  • Patients on both units had detailed, personalised care plans, which included information about physical health needs. Staff gathered information from carers to reflect a patient’s history and preferences, which contributed to their care plan. Patients felt involved in decisions about their care. Patients had positive behavioural support plans in place.
  • Carers and patients praised the care and treatment the service provided. Staff involved patients in decisions about their care where possible. They engaged with and supported carers where appropriate. Staff contacted carers with updates on patient progress and held regular carers meetings. The hospital was open to visitors throughout the day apart from during mealtimes.
  • The hospital had discharged nine patients since 1st January 2017. They considered discharge from admission and actively sought suitable placements that could best meet their patients’ needs. Patients visited all proposed placements and made the final decision about their future placement. All units experienced delays in discharging patients due to the lack of availability of suitable placements.
  • The organisation’s governance structure ensured effective communication from the hospital to board level and vice versa. There were effective systems in place to monitor performance, share good practice and manage risks. The hospital investigated serious incidents, fed back lessons learned to staff, and put in place any identified improvements to practice.

However:

  • Staff working on the rehabilitation units struggled to relate best practice to the care and treatment they provided. The hospital was not currently using any recognised rating scales to assess and record severity and outcomes. Not all staff had a clear understanding of the hospital’s transcription process for prescription charts, which had the potential to cause errors in administration.
  • Patients at the hospital had limited involvement from psychology and currently no access to a qualified occupational therapist. The opinion of the psychiatrist and nursing staff dominated individual patient reviews and these meetings lacked the perspective of other qualified disciplines.
  • On Kendal unit, staff did not have a clear understanding of the Mental Capacity Act and its basic principles. They did not distinguish between the Mental Health Act and the Mental Capacity Act and said they treat all patients the same, whether they were detained, informal or had deprivation of liberty safeguards authorisation. Capacity assessments varied in quality on the rehabilitation wards.
  • The hospital could not always guarantee a consultant psychiatrist could attend the service within 30 minutes in the event of an emergency.

09/11/2016

During an inspection looking at part of the service

We rated Windermere House Independent Hospital as requires improvement because:

  • Whilst a risk register document had been introduced following our last inspection, we found a no robust processes to effectively assess and manage the risks identified.
  • Staff recruitment and retention was of on going concern, with turnover in the last year of 54%.
  • When required to support direct patient care during what were due to be supernumerary hours, ward managers and charge nurses felt unable to complete their management responsibilities effectively.
  • Compliance with bi-monthly staff supervision was 62% and staff appraisal 68%. This fell below the provider’s target of 85%.
  • Overall compliance with mandatory and legislative training was 69%. This was below the provider’s target of 85%. For more than half of the modules staff were required to attend compliance was below 65%.
  • Whilst recruitment was underway, the range of mental health disciplines in the multi-disciplinary team at the time of the inspection was limited to nursing and psychiatry.

However,

  • Patients that were able to said they knew their key worker, care staff and the hospital manager, most felt staff cared, showed them respect and were polite. We saw genuine caring interactions between staff and patients.
  • The hospital had adopted a positive approach to risk management. Patients had risk assessments and robust risk management plans that were individualised and updated regularly.
  • Patients had comprehensive admission assessments and care plans showed assessments and reviews took place in a timely way following discussion with patients or people who knew the patient well.
  • An externally validated learning programme offering courses that build on the strengths and interests of an individual was available to patients.
  • Staff felt able to raise concerns without fear of victimisation, they knew about the organisations whistleblowing policy, and that they could contact external organisations.

1-3 December 2015

During a routine inspection

We rated Windermere House Independent Hospital as requires improvement because:

  • managers had no key performance indicators to enable them to oversee the hospital’s performance
  • the hospital did not analyse reported risks to patients and staff effectively to enable them to learn lessons from incidents of harm or risk of harm
  • Barchester policies had not been updated or re-written to ensure compliance with the Mental Health Act Code of Practice
  • visits by the external pharmacist were not frequent enough to identify and correct any concerns about medication practice
  • the provider did not undertake their own medicines management audits, nor investigation of discrepancies
  • the hospital did not have effective systems to measure, control and improve the quality of services based on an overall vision for the service
  • the hospital premises were not fit for the purpose of long-term recovery and rehabilitation
  • the hospital had no clear arrangements for discharge planning so patients stayed longer than necessary
  • the different staff disciplines did not work together effectively, and relationships and communication between them was poor
  • staff did not review patients’ care plans effectively or involve patients in the process appropriately
  • staff had worked regular extra hours for over a year and uncertainty about the future of the hospital was causing anxiety

However,

  • staff were genuine and caring, engaging with patients in a respectful manner
  • feedback from carers about the treatment of patients and support for themselves was entirely positive
  • the hospital had adopted a positive approach to risk management for its current patient population
  • staff supported patients to make decisions, when they lacked capacity to do so decisions were made in their best interests
  • the head chef worked closely with the patients, ward staff and dietician to ensure that specific
  • there was a positive commitment to the training and development of staff in the hospital
  • personnel files were uniform with staff records including documented evidence of supervision, appraisal and training.

2 December 2013

During a routine inspection

We used a number of different methods to help us to understand the experiences of the people who used the service. This was because some people had complex needs, which meant they were unable to tell us their views and experiences.

We spoke with sixteen patients who were able to communicate with us. They told us they were happy with the service and their views were sought by staff. They also knew how to make a complaint, if they had one.

We saw the complaints procedure was available to people who used and visited the service. Staff told us how they would support people to raise concerns if they could not do so themselves.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Patients who were able to speak with us told us they were involved in decisions about their support and treatment. They commented 'Staff are great, they do look after me.' 'I like the food here, and can ask for snacks when I fancy a biscuit.' and 'Yes, they do ask me what I need and explain things to me when I say I want to go and watch the football match.' Relatives and people who used the service told us that they were always involved in decision making.

People who used the service were provided with a balanced and varied diet. Health professionals provided guidance and treatment when required.

People were happy with the care they received and told us they saw a range of health professionals for advice and treatment.

We found that staff helped to make sure health and social care was well coordinated and provided by a range of professionals.

We found the numbers of staff provided was based on individual need and regularly reviewed to ensure there was adequate support available to meet the needs of the people who used the service.

We found there were sufficient numbers of staff on duty to support people's needs. Staff had access to training and supervision and told us they were well supported. Comments included, 'We have loads of training.' and 'We have a good team that is happy and upbeat.' A visiting health professional told us staff had been skilled in supporting people and always contacted them when required.

We found people were able to express their views about the service via daily activities of living, surveys and meetings. Audits and checks were completed to monitor quality and where further action was required, this was put in place in order to improve services.

We found that people's personal records and other records relevant to the management of the service were accurate and fit for purpose.

11, 12 September 2012

During a routine inspection

We used a number of different methods to help us understand the experiences of people using the service, because some of the people had complex needs, which meant they were unable to tell us their views and experiences. We spoke with two relatives and they told us they thought the service provided very good care and support. They commented, 'This place is brilliant, it outshines the lot of them' and 'The staff show interest and commitment and there is a lot of one to one care.'

Patients who were able to speak with us told us they were involved in decisions about their support and treatment. They commented, 'We have a meeting every week with the doctor' and 'I go and see the doctor when I am poorly.'

We spoke with several patients who were able to communicate with us and they said they felt 'safe' within the hospital.

Patients told us they liked their bedroom and said the environment was comfortable. One patient told us, 'I love my room ' look at my paintings' and 'Yes I like my room and there is nothing else I need in it.'

We saw that positive relationships were developed and patients spoke highly of the staff. We spoke with two relatives and they said, 'The staff are approachable and explain what's happening and we are able to take my son out and staff come with us as he is detained.'

Patients and relatives told us their views were sought by the hospital and they also knew how to make a complaint if they had one.

5 July 2011

During an inspection in response to concerns

Patients told us that they could make choices and that they were involved in decisions about their care, 'I am working towards getting my own place'. They also said that they could go to bed and get up when they chose to.

Patients told us that they were able to take part in activities, the food was of a good standard and that staff were supportive and helpful. Some comments included, 'They are nice', 'I like them here', 'I have painted lots of pictures' and 'I like the food'.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.