CQC report explained · a residential care home
What the CQC found at The Light House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Rated Requires Improvement; missing risk plans led to a Regulation 12 breach, although medicines and infection control were sound.
This was an unannounced focused inspection on 24 April 2023. Inspectors spoke with people, relatives, staff and professionals. They observed care and checked care records, medicines records, recruitment files, incidents and quality checks.
The home was rated Requires Improvement for Safe and Well-led. Some people's risk assessments and support plans were not up to date or detailed enough. This included missing guidance for seizures and falls, and missing updates after an increase in behavioural incidents.
The home had enough staff during the inspection, but relied regularly on agency staff and feedback about this was mixed. Medicines were safely managed, the home was clean, and staff understood safeguarding and consent.
The home had improved since the previous inspection and was no longer in breach of the earlier Regulation 18 requirement about notifications. However, it has been rated Requires Improvement at the last two consecutive inspections. The CQC will request an action plan and monitor progress.
Medicines
Medicines were administered, recorded and stored safely. Records had no gaps, and staff had training and competency checks.
“People received their medicines from staff who administered, recorded and stored their medicines safely.” from the report
Positive relationships
Inspectors saw positive interactions between people and staff. People spoke positively about permanent staff and the atmosphere in the home.
“There was a friendly atmosphere within the service. We observed positive interactions between people and staff.” from the report
Choice and consent
People were supported to make choices and staff sought consent before providing support. The report also says people's rights to make decisions were protected.
“People's rights to make their own decisions were protected.” from the report
Incomplete risk plans
seriousSome people did not have adequate risk assessments or current guidance for staff. This created an increased risk that people could be harmed, although inspectors found no evidence that anyone had been harmed.
“Where a person experienced seizures we found there was no written guidance or risk assessment in place for staff to know how to support the person in the event of a seizure.” from the report
Quality checks did not act quickly enough
needs fixingAudits identified some improvements, but they did not ensure that risk assessments and support plans were updated promptly. Lessons from incidents were also not always recorded clearly.
“However, governance systems were not fully effective in ensuring all issues were identified and addressed in a timely way.” from the report
Agency staff and consistency
needs fixingStaffing levels were sufficient during the inspection, but agency staff were used regularly. Feedback about agency staff and consistency was mixed.
“A relative told us they felt staffing needed to be more consistent to meet their relative's needs.” from the report
Incomplete meeting records
minorRecords of staff meetings were not kept consistently. Staff who missed meetings might therefore not receive important updates.
“We found records of staff meetings were not being consistently maintained which meant if staff missed meetings they may not remain up to date.” from the report
- 01Have all risk assessments and support plans now been updated for seizures, falls and changing behavioural needs?
- 02What checks make sure staff follow the latest risk guidance, including agency staff?
- 03How are you making agency staffing more consistent for people who need familiar support?
- 04How are lessons from accidents and incidents recorded and shared with all staff?
- 05What new audit system is being introduced, and how will you show that identified problems are fixed promptly?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 10 June 2023 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, November 2021
Highbridge Court was rated Requires Improvement; inspectors found kind, personalised care but shortfalls in medicines, infection control, staffing and management.
Inspectors visited on 21 and 24 September 2021. The first visit was unannounced and the second was announced. They spoke with five people, five staff and two relatives, and checked care, medicine and management records.
The home was rated Good for effective, caring and responsive care. People were supported with their health, food, independence, choices and activities. Staff were described as kind and caring, and people said they felt listened to.
The home was rated Requires Improvement for safe and well-led care. Inspectors found incomplete medicines records, gaps in some medicine protocols, unsafe infection control practices and low permanent staffing. Required notifications about several incidents had not always been sent to the CQC, and audits had not found some of these problems.
The overall rating fell from Good at the previous inspection to Requires Improvement. The provider had an improvement plan, and the CQC said it would request an action plan, monitor progress and return under its reinspection programme.
Kind and respectful staff
People spoke positively about staff, who were observed speaking respectfully and supporting people's dignity and privacy.
“People were supported by staff who were kind, caring and committed.” from the report
Personalised support
Care plans reflected people's histories, preferences, goals and aspirations. People were supported to make choices and develop their independence.
“Care plans showed people's goals and aspirations.” from the report
Health and independence
The home supported people with healthcare, healthier food choices, cooking, shopping and attending appointments.
“People were supported to develop their skills and independence around food and drink.” from the report
People had a voice
People were involved in meetings about how the home operated and could choose activities, trips and how they spent their time.
“Meetings give people a voice.” from the report
Medicines records and checks
seriousMedicine administration records were not always complete. Variable doses were not always recorded, and the home's own medicine records did not always receive a second check.
“Medicine Administration Records (MAR) were not always fully completed.” from the report
Infection control
needs fixingStaff did not always wear face masks as required. Some bins were unsuitable, and the laundry process did not keep dirty and clean laundry flowing safely.
“Laundry systems were not ensuring a safe flow of dirty and clean laundry in line with current guidance.” from the report
Low permanent staffing
seriousStaffing numbers were kept at the provider's stated safe level, but this depended heavily on agency staff. Inspectors found a potential risk because few permanent staff were trained to administer medicines.
“There was a potential risk to people due to the minimal amount of permanent staff trained in medicine administration.” from the report
Incidents not reported
seriousSeveral police incidents, safeguarding concerns and one serious injury had not been notified to the CQC as required.
“Notifications were not always submitted as required.” from the report
Audits missed problems
needs fixingAlthough audits were carried out, they had not identified some of the medicines, infection control and notification issues found during the inspection.
“Audits had not identified some of the issues found at this inspection such as the submission of notifications and medicine shortfalls.” from the report
- 01What has changed in the medicines records, including recording variable doses and checking the home's own medicine administration records?
- 02How many permanent staff are now trained to administer medicines, and how often is agency staff used?
- 03What has been done to ensure staff wear face masks correctly and that dirty and clean laundry follow separate safe routes?
- 04Which incidents were not reported to the CQC, and what checks now make sure all required notifications are sent?
- 05What evidence can you show that the improvement plan and management audits have fixed the problems identified in this inspection?
This inspection looked at the whole service, including care and premises, and rated all five CQC questions; inspectors spoke with five people, five staff and two relatives and reviewed care, medicines, recruitment, infection control and management records. This explanation was written from the published report of 9 November 2021 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 The Light House
7 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvement
- May 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2014
Registered with the Care Quality Commission on 2 December 2014.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
76 live-in carers within about two hours of Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
“She was not phased by anything, she was adaptable, kind & gave us complete confidence to go away & not worry about a thing!”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.