Windermere 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

The overall rating for this key question is good, however, there had been an issue with the previous managements understanding of their regulatory responsibilities which had now been rectified. During the assessment the newly appointed manager was open and transparent about safeguarding investigations and outcomes. Most quality assurance systems highlighted areas of improvement. Shortfalls were identified, addressed and monitored. Staff championed areas of the service and monitored and provided advice to their colleagues, any areas of concerns were fed-back to the manager. Managers and staff created a culture to support the delivery of high-quality care. Staff told us they felt supported by the management team. There was a capable and compassionate management team who promoted an open culture to deliver good quality care for people in partnership with external professionals. People and external health and social care professionals told us they felt the service was managed well. The provider sought views of people, their relatives and staff who provided feedback about the service through online reviews, quality survey questionnaires and meetings. Feedback was listened to and addressed. Staff were enabled to speak up; the management team provided advice and reassurance. If staff felt unable to speak up within the service, they had access to a whistle-blowing line. Staff equality and diversity was respected.

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 manager worked with staff to instil a positive and inclusive culture. The management team held staff meetings to enhance communication and to share and embed the provider’s vision. The manager’s open-door policy was extended to staff as well as people and their relatives. Staff felt supported in their roles, they received regular supervision with their line manager. Staff spoke highly of the support they received form the management team and told us they could give suggestions and ideas. There were meetings amongst teams and departments, as well as full staff meetings. Staff told us how the discussions were relevant and addressed areas highlighted for improvement. For example, staff discussed safeguarding, and this included consideration of self-neglect as a potential safeguarding concern. Staff operated an open approach to learning from incidents. Staff, people, their relatives and other stakeholders were encouraged to give feedback formally and informally.

The recently appointed manager was supported by a team of senior staff in the service. A senior manager regularly visited the service to support the staff and management. A staff member said, “The manager has a great vision for the home, has identified issues and risks and is working on it”. During the assessment the manager spoke of the need to improve the quality of records to ensure they could evidence decisions people made on occasion at odds to medical advice. They told us, “I have asked all staff to read through the care plans to ensure these are accurate and reflective of current support needs. I explained they know people’s routines and preferences best and that is valuable information that we need to add to the care plans”. A health professional who regularly visits the service spoke of their observations in relation to staff. They said, “The nursing team are regular and well-trained. It is my understanding that the staff regularly attend teaching and learning development opportunities. The team worked proactively with us when the new management started, to provide consistent, safe clinical care”. The management team recognised staff’s strengths and delegated responsibility accordingly, this was in relation to staff qualification, skills and interests which made sure people received effective care.

Staff told us they would be comfortable to speak up and gave examples when they have. Staff were able to speak with their line managers and were encouraged to speak directly with the manager whenever they wished. A staff member told us, “If I was worried about anything, I would report to the manager, if nothing happened there is the whistleblowing policy on the wall with email address, phone number and everything. There is an area manager too. Outside of Silverlake I can go to CQC.” Systems and processes were in place to ensure everyone had the freedom to speak up. The service had an open culture and there was a visible whistle-blowing policy should staff wish to refer to it.

The management team ensured staff were treated with respect and were included. The workforce at the service was diverse and staff had a range of backgrounds, skills and experiences. The management team was supportive of oversees workers to work towards achieving their nursing qualifications and other social care qualifications. Staff were supported to adapt to life in the UK by the management team and other staff members. A senior staff member told us, “I've been growing with the company I started as an overseas student and carried out several roles. I'm working with the new provider and I feel the residents and staff here are a real team.” Staff were treated fairly and without discrimination. The services equality, diversity and inclusion policy was being followed by staff and management.

The current manager understood their role and responsibilities. The manager was open about safeguarding investigations and outcomes.. Senior management from the provider’s head office conducted audits and devised actions plans based on their findings. Most audits were effective; however, they had not always identified shortfalls in the implementation of reporting processes under the previous management . The manager told us they were revisiting team understanding to avoid similar concerns arising. Other quality assurance processes were in place and were effective in identifying shortfalls. These included audits which covered all aspects of the service, such as, medicines, care records, infection prevention and control and kitchen safety. The management team were present in the service. They ensured staff were kept up to date by attending meetings, handovers and supervision which were relevant to their roles. Staff spoke highly of the management team and how they supported development and learning, a staff member said, “We have supervisions after our training, they check we have completed our training and watch to see if we do it properly.”

People accessed services, not only for health and social care but socially and to enhance their well-being. One person told us how they regularly visited the shops, “I go to town, there is transport available”. People were engaged, we saw visiting professionals providing therapeutic activity. Peoples wishes were respected if they wanted to spend time in their bedrooms. The service supported some people with complex health conditions who required one to one staff support. Staff spoke knowledgeably about people and how they had collaborated with partners and relatives to ensure people received joined-up care. The management team was working to develop good working relationships with health and social care professionals and spoke of the links they had with health professionals which meant people and the service received timely and appropriate support. Visiting health professionals provided positive feedback about the staff and management team and their willingness to engage. They spoke of engagement and joint training sessions, “We are in regular contact with the home throughout the week to urgently address any concerns raised outside the scheduled weekly visit and have introduced joint teaching/ training sessions on a quarterly basis.” Involvement from health and social care professionals was contained in people’s care records so staff could access and follow advice. Staff handovers and meetings provided an up to date picture of how people were responding to professional input and the required changes to their support.

Staff and management addressed improvement actions as needed. Actions from incidents, safeguarding and audits were shared to embed a culture of learning and being open. Staff were supported to develop their skills and encouraged to contribute to improvement ideas. For example, a senior staff member told us how they were developing a visual aid for staff which included photographs to support learning in moving and handling and supporting people with transfers. Staff and managers welcomed and proactively learned from professionals; we saw records relating to joint training sessions designed to continually strengthen understanding and links with community health services.