Windermere House Independent Hospital

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• 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.

The service had a clear vision and values which centered on delivering high-quality, person-centered care with a focus on dignity, choice, and independence. The service strive to create a supportive and fulfilling environment where residents feel respected, valued, and empowered. Their values include compassion, excellence, commitment, ownership, and effective communication. We saw that Staff shared this vision by ensuring high quality care, which was evident throughout our observations and within our discussions with the team.

Staff maintained the goal of reaching successful discharges for their patients and spoke passionately about this.

Leaders ensured all staff understood the provider's 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.

The service had inclusive leaders at all levels who understood the context in which they deliver 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 did so with integrity, openness and honesty.

We observed senior leadership presence within the service throughout the inspection. Staff told us that that there is always a leadership presence available and that leaders were approachable, compassionate and helpful. 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.

We spoke with staff who told us that “The hospital director’s 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 met with colleagues from other hospitals to learn from any incidents or share good practice. Leaders demonstrated a clear understanding of the patient group and their needs. Leaders were passionate about up-skilling staff and ensuring the staff team felt valued within their roles.

Staff knew how to raise concerns and told us they felt confident to do so without fear of reprisals. Leaders were supportive and approachable, and dealt with issues appropriately and efficiently. Where issues could not be resolved immediately, action plans were in place and reviewed through governance meetings.

Staff were aware of the whistleblowing policy and procedure was in place. Staff had access to a freedom to speak up guardian and staff we spoke with knew how to contact them and 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.

The trust valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff we spoke with told us they were able to apply to work flexibly around family and caring commitments. There were flexible working agreements to account for personal circumstances such as health issues.Managers put reasonable adjustments in place for staff members to help them carry out their role.The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.This was evidenced within staff surveys and in what staff told us.

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 Coniston ward around Silver Pride to support both LGBTQ staff and patients.

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 strong oversight and governance. Managers were aware of any risk issues and these were addressed quickly and effectively. This included issues such as slow internet speeds raised by staff, updating of the environment which patients raised, all which were documented and acted upon through managers oversight and governance meetings.

During this inspection we observed both morning meetings and handovers and reviewed notes of multidisciplinary team discussions. It was evidenced that multidisciplinary 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.

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

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. We saw that action plans were put in place following audits to ensure action was taken to address any shortfalls identified and the action plans included clear allocation of responsibility for each action and realistic timescales for compliance.

Staff were able to escalate any perceived risks to leaders and knew how to access the ward risk register. Risk registers were reviewed monthly by senior leaders or when a new risk had been identified.

Staff had access to the equipment and information technology needed to do their work. Most care records were paper notes. The hospital’s internet speed was in the process of being improved at the time of our inspection.

The service had a business continuity plan for dealing with emergency situations such as adverse weather conditions, flu outbreaks, loss of IT and fires. There were personal emergency evacuation plans in place for each patient. Information governance systems included confidentiality of patient records and staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

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 in decisions about care and treatment. Carers were invited to give feedback in different ways, such as at meetings, in writing or via email. Carers were included in their relative’s care and treatment from admission to discharge.

We saw evidence that staff maintained 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.

There was a development directory for staff which provided clear understanding of the opportunities available and choices staff had to develop. Staff were encouraged to learn and develop in their roles.

The ward was 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.

Staff had opportunities to participate in research and make suggestions for innovations taking place in the service. This included making improvements to the environment and health promotion activities within the service. Staff used quality improvement methods and knew how to apply them through regular audits by both staff and leaders and by creating action plans to address issues identified. Staff also participated in national audits and surveys relevant to the service and learned from them through lesson sharing between Barchester hospitals. The ward participated in the Safe Wards and Star Wards accreditation schemes, patients also were responsive to the accreditation's and were actively involved in reaching targets.