Windward House

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

Well-led – 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 inspection in 2019, when the service was owned by a different provider, we rated this key question requires improvement. At this inspection the rating has remained as requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance and management of the service. The leadership of the service had been changed, and the new management was present only for an interim period and new practice had not had time to be embedded. Previous leaders and the culture they created had not always supported the delivery of high-quality, person-centred care. The new management of the service was actively seeking to change the culture of the staff team.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider had a vision, strategy and desired culture, however this was not present in the service’s staff team. There had not been adequate opportunities previously for staff to pass on their experiences to service leaders. We saw examples where staff did not work together and where staff had not changed their practice despite management directions to do so. For example, required daily checks of pressure mattresses. These issues had been identified and were being worked with by the leaders in the service and at provider level in the organisation.

Not all of the previous leaders that had led the service, had understood the context in which the provider delivered care, treatment and support. They had not always embodied the culture and values of their workforce and organisation. These leaders had not always had the skills, knowledge, experience and credibility to lead effectively, or they had not aways done so with integrity, openness and honesty.

The service now had interim leadership, put in place by the provider to move the quality of the service forward. These new leaders understood the context in which the service delivered care, treatment and support. These leaders were also visible within the service and lead by example to their staff team, demonstrating inclusive behaviours. However, these leaders were temporary and will have to be replaced with effective permanent managers in the service in the future.

The service was now fostering a positive culture where people their relatives and staff could speak up and their voice would be heard.

Staff were beginning to receive supervision, and meetings with residents and staff were taking place. Complaints were now being appropriately investigated to address the concerns raised. People, relatives and staff were increasingly confident that if they raised concerns to the service these would be effectively addressed by leaders of the service.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked at this service.

The provider had policies and procedures that directed employees towards a fair staff culture by improving equality and equity for people who work for them. However, staff told us that there were separated groups within the staff team and that at times staff did not work well together. We were told of racism taking place from white staff towards staff from an ethnic minority background. Though leaders were aware of the issues and were attempting to alleviate them, they had not yet been able to conclusively overcome such issues within the staff team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service had not had effective accountability and good governance before October 2024. From October 2024 the provider’s audit oversight of the service identified there were issues in the service that were not being addressed, and information being provided to the provider was not complete. Audits had been completed by the service before October 2024, but these had not been comprehensive and accurate. Since October 2024 the provider had been identifying the issues in the service, what needed to be improved, and making improvements. Oversight and Governance were now taking place, but further issues continued to be identified up to and during our assessment. We were confident that oversight of the service was now properly in place, but it will take some time to address the multiple issues in the quality of the service and embed the improved processes in the oversight and management of the service.

The providers’ Directors were actively involved in addressing the issues within the service and had visited early in December 2024 to meet with the service’s staff team.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service had previously not always understood their duty to collaborate and work in partnership with other stakeholders. There had sometimes been a lack of trust between health professionals and the service’s staff because of previous poor experiences. The new management at the service were aware that this trust needed to be built so that co working was effective. We saw effective relationship building taking place between staff and external professionals and joint working between them had already improved.

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had only recently begun to be aware of issues in the service and there were considerable changes that were planned to be made, but had not yet been fully actioned. While we did identify shortfalls during this assessment, the provider’s representatives were responsive to our findings and were acting urgently on key areas of improvement that they had identified. For example, completion of required training as directed by the provider, had improved quickly following changes to management at the service. From a low level of compliance a few months before our assessment, compliance had risen to 71% completed for all of the staff team when our assessment took place.