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.

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.

We had not intended speaking with people during this follow up visit, but during a tour of Kendal unit, one person spoken with told us they were happy with the new floor in their bedroom.

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”.

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.