The Lighthouse

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. The service was no longer in breach of regulations.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

The service reported 22 incidents between January and August 2026, with 12 of these being medicine errors. The service had a medicines incident log that included details of medicine errors, outcomes of the error and any action taken to prevent it re-occurring. Leaders raised any medicines errors with staff in supervision and team meetings and provided additional medicines administration training to staff if required.

Staff reported incidents using a form on an online portal which was sent to leaders for review. Leaders completed an investigation of all incidents and provided feedback to staff in supervision and team meetings. Leaders identified any themes and trends which were then discussed in team meetings.

Staff were aware of the duty of candour and gave examples of times when they had explained and apologised to people after something had gone wrong.

Staff were able to give examples of changes made as a result of incidents, including adding a question about any current wounds to the admission assessment after someone had to be taken to hospital after being admitted with a soft tissue infection. 

The service worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. They ensured continuity of care, including when people move between different services.

The service’s referral and admission processes ensured that all essential information was received to determine if someone’s needs could safely be met. An admissions co-ordinator collected the initial information for anyone referring themselves to the service and this was passed on to leaders to make sure they met the inclusion criteria. The medical team then reviewed the referral information and requested a G.P. health summary be provided.

On admission staff completed an admission assessment, physical observations and completed withdrawal scales with the person before they were seen by one of the prescribers within 24 hours.

At the time of the inspection the service were not requiring a recent blood test to review before commencing prescribing. This is in contradiction to best practice guidance for detoxification prescribing to ensure people with liver damage are not prescribed any medicines that will further impact liver health. This was raised with the service during the inspection and leaders updated the policy and process to ensure that people received a blood test before prescribing started.

The service had a discharge policy in place which included guidance on early exit from treatment and post discharge support.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

The service had a safeguarding policy in place and a designated safeguarding lead to advise staff on any concerns. Staff were trained in safeguarding with 100% of staff having received up to date level 2 safeguarding vulnerable adults, and safeguarding children training.

Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. 

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The service had not made any safeguarding referrals to the local authority in the six months before inspection, but staff kept a log of safeguarding concerns that they had identified and taken action on, including contacting the local authority to confirm someone’s child had an allocated social worker.

Mental Capacity Act

All staff had received training in the Mental Capacity Act and had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

If someone arrived at the service unable to consent to treatment due to the influence of drugs or alcohol staff would wait with the person until they were able to consent.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people well. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 5 care records. Staff completed a risk assessment with people on admission, and these were updated when required. 

Risk assessments were thorough and included risk management plans. Staff involved people in completing risk assessments which included substance use, physical and mental health, relationships and social needs.

Staff displayed people’s risk levels in the staff office so that all staff were aware of current risks. People were allocated as high risk for the first 72 hours after admission so that staff could monitor them closely and get to know their needs and risks. Staff had allocated a bedroom on the ground floor, close to the staff office, for people whose physical and mental health needs required increased monitoring and support.

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 service had environmental risk assessments in place for each area of the service which included ligature risks. Staff had completed risk assessments for hazardous substances, legionella, kitchen equipment and fire risks.

The service complied with mixed-sex accommodation guidance with some bedrooms having en-suite bathrooms and the others having gender specific shared bathrooms. 

People using the service had hand-held alarms allocated to them so they could call staff if they needed assistance. 

The service did not have a clinic room big enough to conduct examinations so any physical health observations took place in bedrooms or in the corridor outside the clinic room. Medicines administration took place in the corridor, and staff put a portable screen up to protect people’s privacy and dignity while these took place. However, this did not provide any sound privacy for people. 

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service was fully staffed and did not have any vacancies. Staffing included a consultant psychiatrist, a non-medical prescriber, counsellors, recovery workers and managers. Leaders calculated the number of staff needed based on the number of people using the service, treatment activities and skill mix, and staffing levels could be adjusted when needed.

The service reported sickness absence at 1% which met the service target of less than 4% sickness. Turnover was 16% which related to 2 members of staff leaving and 3 joining the service. 

Leaders ensured that staff had received and were up to date with appropriate mandatory training. The service had 24 mandatory training courses which all staff had completed in the last year. These included safe administration of medicines, safeguarding adults and children, first aid and clinical observations training. 

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was visibly clean in all areas and was comfortably furnished. The service employed 2 housekeeping staff who completed daily cleaning of the service.

Staff adhered to infection control principles, including handwashing.

Staff were trained in food hygiene and food allergies. 

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management including dispensing, administration and medicines reconciliation, and did it in line with national guidance. Staff received annual training in medicines administration and refresher training was delivered by the non-medical prescriber if required throughout the year.

The service had policies and procedures in place for detoxification from alcohol, opiates, ketamine, cocaine and benzodiazepines. Staff completed daily observations and withdrawal scales for people undergoing detoxification to ensure they were receiving the correct dosage.

Staff completed daily, weekly and quarterly audits of medicines. These picked up any administration or recording errors which were fed back to staff in supervision and team meetings. The pharmacy also visited quarterly to complete audits.

The service had naloxone in stock which is used to temporarily reverse the life-threatening effects in the case of an opioid overdose.