- Independent mental health service
Windermere House Independent Hospital
Assessment report published 29 August 2025
Contents
Ratings - Long stay or rehabilitation mental health wards for working age adults
Our view of the service
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.
People's experience of this service
We spoke with 1 patient and 5 carers. Our opportunities to speak with people using the service were limited because people were not well enough to speak with us. Throughout the inspection we observed that people felt safe and supported. Feedback from patients was wholly positive. This was also reflected within our observations of clinical practice.
We spoke with carers who had relatives across both wards. For this inspection we utilised an expert by experience to gain feedback from patients’ carers on the care that they were receiving. An expert by experience is a person who has used services or has relatives who have used mental health services. The feedback we received was positive. Carers told us that staff were very friendly and helpful, and staff communicated with them well. Carers told us that the service kept them informed of patients’ care including any changes.
We were told that staff take patients’ interests into account when competing care plans and ensured patients felt safe. Carers told us that it was a safe environment with plenty of activity options such as a pool table and garden space. Carers noted that there was good quality food and dietary requirements are taken into consideration.
The service completed regular community meetings, patient and carer surveys and also had voluntary patient representatives for each ward to ensure patient voices felt heard.
As part of our inspection, we used the Short Observational Framework for Inspection (SOFI). SOFI is a tool used by our inspectors to capture the experiences of people who use services who may not be able to express this for themselves. The observations do not replace talking to people who use services but can help an inspector get a clearer picture. This helped us to identify that there was a strong culture of care and compassion towards patients.