CQC report explained · a residential care home
What the CQC found at Lighthouse
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found improved risk management, safety checks, infection control, safeguarding, staffing and medicines systems.
- Effective?
- Good
- People's outcomes were described as consistently good. Staff had training and support, care plans were reviewed, and people were supported with recovery, healthcare and decision-making.
- Caring?
- Good
- This question was not inspected during this focused visit.
- Responsive?
- Requires improvement
- This question was not inspected during this focused visit.
- Well-led?
- Good
- Inspectors found effective governance, regular audits, positive communication and a supportive culture.
What inspectors found, May 2022
Rated Good; inspectors found safe, effective and well-led care, with clear improvements since the previous inspection.
This was an unannounced focused inspection on 13 and 14 April 2022. Inspectors spoke with five people, eight staff and one visiting professional. They observed care and checked care, medicine and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found people felt safe, medicines were generally managed safely, staff were trained, risks were assessed and management systems were working.
The previous rating was Requires Improvement, with breaches of regulations. The provider had completed an action plan, and inspectors found the earlier breaches had been addressed. They also found improvements to the recovery approach and the building, including a major refurbishment.
This report did not inspect Caring or Responsive. Their previous ratings were used when calculating the overall rating.
Improved safety systems
The home had introduced regular premises safety checks and clearer risk assessments. Accidents and incidents were reviewed so lessons could be learned.
“A system of regular safety checks connected to the premises were now in place and audited monthly.” from the report
Supportive staff
People and staff were positive about staffing levels and support. Staff had training, induction, supervision and appraisals.
“People were positive about the staff and the staffing levels.” from the report
Recovery and refurbishment
A new recovery tool and regular workshops were in place. People had been consulted about a substantial refurbishment of the home.
“A very impressive refurbishment had taken place throughout the home and the people living there had been consulted about the changes made.” from the report
Strong management oversight
Inspectors found governance systems, provider audits and action plans that addressed shortfalls. People and staff described the culture as positive and supportive.
“Effective governance systems were in place and actions plans were regularly completed to respond to any identified shortfalls.” from the report
One medicine competency check was overdue
minorOne staff member's medicine competency assessment was out of date at the inspection. The registered manager acted promptly to correct this.
“One staff members competency was out of date.” from the report
- 01How do you make sure every staff member's medicine competency assessment stays in date?
- 02How is the new recovery model helping residents make progress, and how is that progress reviewed?
- 03How often are premises safety checks and provider audits completed, and what happens when they identify a problem?
- 04What support and training will staff working with my relative receive?
- 05How will you involve my relative in care planning and the running of the home?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 25 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2020
Rated Requires Improvement; inspectors found caring staff but serious gaps in infection control, safety checks, training and oversight.
This was a planned focused inspection carried out over 16, 17 and 18 September 2020. Two inspectors and an expert by experience spoke with staff and relatives, reviewed records and checked the home’s infection control arrangements.
The home was not always safe. Staff were not wearing face masks when inspectors arrived, urgent electrical work had been delayed and some staff had not completed fire drills. The home was clean, medicines were generally managed safely and staffing levels were judged sufficient during the inspection.
Care was kind and people said they felt safe and supported. However, staff did not have enough training in mental health and recovery work, and quality checks had missed important problems. The overall rating stayed at Requires Improvement, as did Safe, Effective and Well-led.
Kind and respectful staff
People told inspectors they were happy with the support and felt safe. Staff knew people well and supported them in a caring way.
“People told us that they were happy with the support they received, and the staff were caring.” from the report
Medicines usually managed safely
Medicine records were maintained and staff were trained and assessed as competent. The clinic room temperature was a remaining concern because it sometimes went above 25°C.
“Medicines administration records were appropriately maintained by staff and checks were conducted to ensure continued safe administration.” from the report
Enough staff during inspection
Inspectors found staffing levels were enough to meet people’s needs and support activities and health appointments. One staff member raised a concern about night staffing, which the manager agreed to discuss.
“Sufficient staff were available to meet people's needs promptly throughout our inspection and to enable people to follow their chosen activities and support with health appointments.” from the report
Healthcare support
People’s healthcare needs were met in a timely way. Staff helped people access healthcare and followed professional advice.
“People's healthcare needs were met in a timely way.” from the report
Infection control
seriousStaff were not wearing the required protective equipment when inspectors arrived. The provider’s COVID-19 policy did not contain enough detail or follow Public Health England guidance.
“The service did not protect people from the spread of infection.” from the report
Electrical and fire safety
seriousNineteen potentially dangerous electrical issues were still outstanding from a January 2020 report. Fire drills were inconsistent, so some staff had not practised what to do in an emergency.
“The report highlighted 19 electrical issues, that were of a risk rating C2, which means potentially dangerous with urgent remedial action required.” from the report
Staff training
seriousStaff had not been given mental health awareness training or the recovery worker training described on the provider’s website. The induction did not fully cover the care certificate.
“The provision of the regulated activity had not received the appropriate support and training necessary to enable staff to carry out the duties they are employed to perform.” from the report
Weak quality oversight
seriousAudits had not found the problems with safety, training, recovery planning and mental capacity records. The provider supplied only two recent audits, with the latest completed in February 2020.
“Governance systems had failed to protect people from the possibility of harm and been ineffective in identifying shortfalls in quality.” from the report
Recovery progress not clearly tracked
needs fixingThe home provided two daily recovery workshops and one-to-one sessions, but it did not have a clear recovery model or a reliable way to show people’s progress.
“We found there was no clear framework or registered manager oversight monitoring people's progress around their recovery.” from the report
- 01Have all 19 electrical issues from the January 2020 report now been repaired, and can you show us the completed safety checks?
- 02What infection control policy and face mask arrangements are now in place?
- 03How often do staff complete fire drills, and have all current staff taken part in one?
- 04What mental health and recovery worker training have staff completed since this inspection?
- 05How do you record and review each person’s recovery progress and identify whether risks are increasing or reducing?
This was a focused inspection planned because of the previous rating, mainly covering Safe and Well-led, with checks of infection prevention and some aspects of Effective; no separate ratings were given for Caring or Responsive. This explanation was written from the published report of 16 October 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lighthouse
4 rated inspections over 3 years: the service has improved, from Inadequate to Good.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2020Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2019Inspected but not ratedSafe: Inspected but not rated
- July 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2019InadequateSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- December 2016Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- May 2015
Registered with the Care Quality Commission on 27 May 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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