The Light House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At our last inspection the provider was in breach of the legal regulations in relation to risk management. At this assessment improvements had been made, and the provider was no longer in breach of regulations.

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.

There was a proactive and positive culture of safety based on openness and honesty. Lessons were learnt to continually identify and embed good practice. There were processes in place to record and learn from accidents and incidents.

Staff understood how to report incidents and told us learning was shared through handovers, team meetings and supervision. One staff member told us, “Yes we 100% learn.”

The registered manager gave examples of how they shared learning from incidents with staff and how organisational learning was shared.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff followed processes to assess risks and needs when people moved into the service. Care plans were updated with professional advice, including from mental health teams, occupational therapists and GPs. People had hospital passports and personalised information ready for emergency admissions. The registered manager completed compatibility assessments to ensure the mix of people living together remained safe and supportive.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe. One person told us, “Yes definitely, I have a key to my door.” Another person commented, “Very much so.” Most relatives told us people were safe, 1 relative told us, “I have no safety concerns.” One relative raised some concerns about safety and wellbeing; the registered manager was aware and taking steps to address these.

Staff understood how to recognise and report abuse. They described the actions they would take and felt confident to escalate concerns through management, whistleblowing routes or external agencies. Safeguarding was discussed in team meetings and information was visibly displayed in the service. A recent medication incident had been reported appropriately, with clear actions, notifications to relevant professionals and written apology to the person affected.

The registered manager was aware of their responsibility to ensure appropriate applications were completed where required to authorise a person being deprived of their liberty.

The service worked well with people to understand and manage risks. They provided care to meet people’s needs that was safe and supportive.

People were involved in decisions about managing their own risks. Staff used individualised risk assessments that considered triggers, early signs, and agreed control measures.

Care plans showed how people were helped to take positive risks, such as going on holidays, accessing the community or developing independence. Staff described how they balanced safety with people’s choices, and how they revisited plans when risks changed.

People had plans in place to support them if they had a deterioration in their mental health. These identified how each person presented themselves when they were well and what was important to them to continue to keep well. They identified when a person was showing signs of becoming unwell and the signs they were in crisis.

A visiting professional told us, “The dealings I have had with them since [name of registered manager] took over has been good, particularly their communication and management with a person who has a significant risk history.”

One relative commented, “They have strategies for the residents, ways of de-escalating situations.”

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was safe and well maintained. There were a range of health and safety checks in place, these included checks on equipment, water, fire, gas and electric. A recent external fire risk assessments had been completed with actions identified, the registered manager confirmed they were working with the providers estates team to complete the work required.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Staffing levels met people’s needs, and rotas were planned in advance. Staff told us there were enough staff to provide safe care, with flexibility to cover sickness or vacancies. People and their relatives told us there were enough staff and they were consistent. One relative told us, “There are always staff available.”

There were effective systems in place to support staff recruitment.

The provider had an induction and staff training programme. One staff member told us, “I had an amazing induction, all staff were available to help. It was easy to find the information I needed, I shadowed, did in house training and online. It was really good, I requested more training for areas I was unsure of to get a better knowledge.”

Training covered mandatory topics and additional modules relevant to people’s needs, including mental health, specific health needs and positive behaviour support. Senior staff had been enrolled on a ‘Lead to succeed’ course, 1 staff described this as, “Amazing” training. Staff spoke positively about their support and supervision.

One person had been involved in training staff around a specific subject; this had involved the person talking about their past to the staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Infection prevention and control measures were effective. The home was visibly clean and staff followed cleaning schedules. Personal protective equipment (PPE) was available and used appropriately. Staff completed infection prevention and control (IPC) training and leaders carried out checks to ensure standards were maintained. People confirmed staff supported them to maintain a clean environment. One relative told us, “It is a clean and tidy home.” An IPC audit had recently been completed with full compliance.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People confirmed they received medicines when needed and they were happy with staff support.

Medicines were managed safely. Staff followed procedures for ordering, administering, storing and disposing of medicines. Medicines administration records were completed accurately, and stock checks were undertaken weekly. Where a medication error occurred, staff took action, sought clinical advice and recorded the incident. The registered manager told us following an increase in medicines errors the provider completed a service audit. They confirmed actions had been taken to learn lessons and improve practice, this had reduced the amount of medicines errors.

People who could manage their own medicines had assessments in place and appropriate storage.

Protocols for ‘when required’ (PRN) medicines were in place, some required further detail and the registered manager was addressing this. Storage area temperatures were monitored, and allergies were clearly recorded.