Windermere House Independent Hospital

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 as good. At this assessment the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders and the culture they created promoted high-quality, person-centred care. There were strong links between partners such as social services and specialist professionals. Leaders had the skills, knowledge, and experience to perform their roles to a high standard. They had a good understanding and oversight of the service, the needs of patients, families and staff.. Staff told us they were approachable, supportive, and always visible. Governance systems within the service were effective in identifying areas for improvement and actions were taken to address them.

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.

We spoke to staff who had clear understanding of the purpose of Coniston ward. Staff all maintained the goal of reaching successful discharges for their patients and spoke passionately about this. Staff’s shared vision of ensuring high quality care was evident throughout our observations and within interviews.

Monthly bulletins were circulated to the team and we observed posters with news and updates within both staff and patient area’s. Staff told us handovers were good and that information sharing from management was strong. Leaders told us they ensured all staff understood the shared direction by gathering feedback through team meetings, staff awards, supervision and appraisals. Staff told us the diversity of the team had a positive impact on the ward and patient care. A staff member told us “I am really proud of the way we support our patients. We look after them really well. They live here like they are in their own home, its so positive”.

We spoke with staff who told us that “The hospital directors door is always open and I'll point my staff to her door too. We also see the regional manager often too. So we learn from her experience about the other Barchester hospitals. There is a channel that all the staff know to raise concerns. We also have a speak up champion”.

Leaders told us that they have opportunities to meet with other hospitals to learn from any incidents or share good practice. Leaders demonstrated a clear understanding of the patient group and the needs of Coniston ward. Leaders were looking to work with both staff and patients to make further improvements and developments to the ward environment. Leaders were passionate about upskilling staff and ensuring the staff team felt valued within their roles. We observed senior leadership presence throughout the inspection. Staff corroborated that there is always a leadership presence available and that leaders were approachable, compassionate and helpful. The hospital director had been in post for 12 years and was proud of the hospital and staff. There was clear leadership at both local and senior level. Leaders were up to date with best practice and guidance and ensured that knowledge was shared across the whole team through a range of meetings and learning sessions.

Staff knew how to raise concerns and told us they felt confident to do so. They said leaders were supportive and approachable, and they felt reassured that managers dealt with issues appropriately and efficiently. Managers regularly shared learning with staff during meetings, handovers and lessons learnt sessions. Incidents and investigations were managed well and the outcomes shared with the board of commissioners and regulators where appropriate. The ward adhered to duty of candour where appropriate.

Staff were aware of the whistleblowing policy and procedure in place. Staff had access to a freedom to speak up guardian and staff we spoke with knew how to contact them/who they were. There were posters on the ward which detailed how to make a complaint. Staff were able to raise concerns through a variety of feedback methods.

Staff told us that managers were supportive of cultural diversity and felt assured that any incidents of abuse would be thoroughly investigated. Staff we spoke to had not felt there was any culture of bullying or abuse. As part of our inspection, we reviewed staff meeting minutes which reflected feedback from staff and leaders. Staff told us that Coniston ward was a good place to work and had worked there many years. Staff we spoke to told us that managers were supportive of them in enabling flexible working where necessary. Staff had the appropriate training in equality and diversity and at the time of inspection, staff training compliance was at 100%. The ward also jointly celebrated with Kendal ward around Silver Pride to support both LGBTQ staff and patients.

During this inspection we observed both morning meetings and handovers and reviewed MDT discussion notes. It was evidenced that multi-disciplinary team meetings were structured, goal orientated and involved both patient and carer views. There were structured team meetings led by the hospital director or senior nurse which shared information with staff. Monthly lessons learned bulletins were shared with staff, which outlined issues, the lessons learned and the subsequent action taken. Leaders then monitored actions had been taken during regional director visits and monthly reports.

There were audits in place to monitor risk assessments, such as ligature risk assessments, infection control audit and nursing file audits to ensure paperwork and documentation was correct. We reviewed 5 care records which evidenced regular checks were carried out to ensure care plans, nursing notes, nutrition, hydration and physical health checks were completed. We spoke to staff who advised they would work across both units depending on clinical need. Kendal ward required more personal care for patients and staff from Coniston were available to assist Kendal ward when needed. Staff understood how to escalate the need for more staff to leaders.

Staff told us they knew how to access the ward risk register and how to raise potential risks within the environment. Risk registers were reviewed monthly or when a new risk had been identified. Leaders at senior level would review this on a monthly basis and kept records of these reviews. There were personal emergency evacuation plans in place for each patient. We reviewed 14 records of these and all were individualised, including what potential equipment may be required for evacuation.

Staff had access to the equipment and information technology needed to do their work such as IT equipment. Most care records were paper notes. The hospital was undergoing work to improve internet speed, which had been raised as an issue and at the time of inspection this work was being undertaken. Managers had access to information to support them with their management role such as liaison between other Barchester hospital sites. This included information on the performance of the service, staffing and patient care.

Directorate leaders engaged with external stakeholders such as the integrated care board, probation services and commissioners. The hospital met regularly with Healthwatch and engaged with the Care Quality Commission prior to this inspection. The ward had strong working relationships with adult social care, safeguarding and the hospitals independent mental health advocate.

Both patients and carers were viewed as partners and carers were invited to give feedback in different ways, such as at meetings, in writing or via email. Carers are positive about feeling included in their relatives care and treatment from admission to discharge. One carer we spoke to had expressed that they’d have been happy for their relative to remain on Kendal ward as they felt their relative was safe. Partnership record notes showed regular contact with other health professionals, including physiotherapy, psychology and physical health practitioners such as district nurses.

There were clear policies around learning and staff development in place. There was a specific policy around learning and development for staff and this underwent Quality Assurance Monitoring by leaders. At the time of inspection, staff mandatory training was at an overall percentage of 96.94%. The service provides a Development Directory for staff which provides clear understanding of the opportunities available and choices staff have to develop. Staff told us that they were encouraged to learn and develop in their roles. Staff told us that they had opportunities to attend multi-disciplinary meetings and register interest in specific area’s of learning.

Staff and patients received debriefs following incidents. Staff met regularly to discuss incidents during handover/ team meetings. There was evidence that staff and leaders complied with duty of candour when reporting incidents and lessons learned.

The ward is aligned with the Safe Wards initiative. This had been well received by both staff and patients. Patients had suggested that staff had the same initiatives for wellbeing and helped implement staff ‘hug in a box’. The ward also held community meetings where new ideas could be shared and ‘you said, we did’ feedback bulletins.