Lighthouse

We did not rate Lighthouse at this inspection as it was a focused inspection of the safe key question. We carried out this inspection after receiving information of concern about how the service was managing a mixed gender environment and the assessment and management of risks associated with individual clients supported by Lighthouse.

We inspected Lighthouse on two dates: 24 September 2019 and 8 October 2019.

After the initial visit we issued a letter of intent to the service on 27 September 2019. We did this under Section 31 of the Health and Social Care Act 2008 to notify the provider of the serious concerns that had been identified during the inspection. The letter of intent detailed that we would take enforcement action if the provider did not take immediate action to address concerns raised. We then returned to check the actions had taken place.

By the end of this inspection the provider had taken most of the steps needed to ensure the risks posed by mixed gender care had been mitigated. However, some further work was needed including the completion of environmental risk assessments. At the inspection on 24 September 2019, we found the service was not safe. Staff were not assessing and managing the risk posed by the service being mixed gender. Staff were not doing all that was possible to mitigate the risk. On the ground floor, there were three males who passed two female’s bedrooms to access the toilet, bath or shower. There had been an incident where a male and a female client had spent time in each other’s bedrooms. However, by the time we revisited the service on the 8 October 2019 clients had moved bedrooms and there was a female only corridor, with two female’s bedrooms on it and another female was moving to this corridor during the inspection. The service confirmed that the further two females had moved to the female only corridor by 10 October 2019. The female only corridor had a different keycode which only females and staff had the access code. All female clients had a documented risk assessment considering their potential risks of staying in a mixed gender environment and how these could be mitigated. However, environmental risk assessments needed further work to ensure they clarified how staff should promote the client's safety throughout the whole building and mitigate potential risks.

The provider still had further work to complete to ensure client risks were appropriately assessed and managed. At the inspection on 24 September 2019, we found records did not reflect the risks posed by clients to themselves and others, including historic risks and staff were not provided with information on how to mitigate the risks. The documentation had changed since the last inspection and was more suitable for services caring for older people. When we returned on 8 October 2019, one client's risks had been carefully considered and this person was on one to one observation. In addition staff working at night as waking nights had increased from two to three to allow for the increased observations, eight out of 14 of these shifts included male members of staff. Mitigation was in place for the shifts when there was three female members of staff, including the use of personal safety alarms and carrying a mobile phone with them to summon assistance if required. However, further work was needed to ensure all clients had comprehensive risk assessments in place.

However, the environment was clean and well maintained. Clients we spoke with, told us they were happy in the service and felt safe there.

Staff had a good understanding in safeguarding and had received training. Incidents were reported, and actions taken were shared with staff via team meetings.

There were still requirement notices from the previous inspection, that will be followed up at a later date.

The provider has made progress since the previous inspection and we recommend the service be removed from special measures.

We rated the Lighthouse as requires improvement because:

• The service had not assessed and mitigated environmental risk to clients. Following the change in medicine administration the manager had stopped clients progressing with the self administration process. Support plans, risk assessments and risk management plans were not reviewed following incidents.

• Staff did not follow the Mental Capacity Act. Client records were not complete, current and contemporaneous. Group therapy activities in relation to addiction and lifestyle were not taking place as marketed. Lighthouse did not consider blood borne viruses of clients and staff did not have training in this area.
• Although the governance procedures and oversight had progressed, there were areas that the manager did not have oversight of. There was no risk register in place. Staff were not receiving supervision in line with the providers policy. Clients were not involved in the running and development of the service.

However:

• We observed, and clients told us, that staff at all levels were respectful approachable and responsive to the clients’ needs. Clients were involved in the local community. Residents meetings took place and change happened following these meetings.
• Lighthouse was accessible for people with mobility needs and had a variety of rooms and facilities to pursue activities or have access to a quiet environment, dependant on client preference. Clients spoke positively about the new chef; saying that they provided tasty and varied food. Clients knew how to complain, information was displayed, and the manager was following the complaints policy.

We are placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We rated Lighthouse as inadequate because:

• Managers had not ensured that the building that accommodated the clients was safe. Staff did not risk assess the environment in relation to risks to clients, especially in relation to managing a mixed sex environment. Staff had not identified repairs that required to be made to the building to keep clients safe.
• Staff did not follow basic procedures to protect clients from risk. The service did not have a system for checking clients as they entered or left the building. This meant that, if there was a fire, staff would have no way of knowing who was still in the building. Managers had not ensured that staff had all the training required for their role, in relation to drug misuse, overdose awareness and how to administer emergency medicine. Records did not contain the completed documentation to keep clients safe. In the records we reviewed we found staff had not completed fully, physical identity forms and health action plans. This meant staff would not have the necessary information to share if a client went missing or to meet their healthcare needs. They did not have any risk management plans in the records we reviewed.
• The governance arrangements for the service were not effective. The service could not be assured that the oversight was in place to provide high quality services and keep clients safe. Lighthouse did not have a system to identify the number of staff required for each shift. There was no way of knowing if the service was under or over staffed. There was no system to monitor the compliance with health and safety checks of the environment. Policies did not comply with legislation and there was no system to review the policies and ensure they were relevant to the client group. There were policies from three different services in use. The provision of the therapy in relation to addictive behaviours was not being provided as marketed in the services literature and information to commissioners and clients.
• The registered manager was not following policies in relation to Duty of Candour, complaints and CCTV. The risk register did not capture current risks to the service in relation to governance and how staff would mitigate risks.
• Lighthouse breached Regulations 12 Safe care and treatment and 17 Good Governance of the Health and Social Care Act 2008, we have issued warning notices for these breaches. Lighthouse also breached Regulation 18 Staffing of the Health and Social Care Act 2018, we will issue a requirement notice in relation to this.

However:

• Feedback from clients, carers and care coordinators was positive. Clients were supported and encouraged to participate in activities within the local community.
• Staff received a comprehensive induction, regular supervision and annual appraisal.
• Staff worked in a person-centred way. They demonstrated an understanding of equality and diversity issues and working with clients belonging to vulnerable groups. Staff had developed a therapeutic programme tailored to the needs of clients with a dual diagnosis of substance misuse and mental health needs.