The Lighthouse

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The service had set out its values of respect and dignity, individualised care, honesty and integrity, compassion and understanding, safety and wellbeing, personal responsibility and independence, working together, and learning and improving, and a mission statement of how staff put these values into practice. 

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles and had a good understanding of the services they managed. Leaders had good oversight of the risks and performance of the service through regular audits and reviews of feedback.

Leaders were visible in the service and approachable for staff and people using the service. Staff felt supported by leaders and were confident they could raise any concerns.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

People using the service had opportunities to give feedback in a number of ways including weekly community meetings, feedback surveys or directly to staff. 

Leaders created a monthly report and an action plan in response to people’s feedback. Leaders had taken action when people had made suggestions for improvement, including changing some beds and increasing food options. 

Staff felt comfortable to give feedback or raise any concerns, and action was taken to address any concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had policies in place for equality and human rights and dignity and respect which set out the expectations and responsibilities of staff and people using the service. Staff had all received up to date equality and diversity training. 

Staff we spoke with did not raise any concerns about being treated fairly and equitably and had equal access to training and development opportunities.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders had good oversight of governance and risk within the service. There was a robust programme of audit to identify, record, monitor and take action on risks and concerns.

Clinical governance and management meetings had a clear framework and agenda to ensure that essential information including learning from incidents, complaints, and audits were discussed and shared with staff.

The service had a risk register in place which accurately reflected the relevant risks to the service. 

The service had plans in place for emergencies including business and major incident contingency plans.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service had good working relationships with other services. These included people’s G.P surgeries and local drug and alcohol teams, the local authority safeguarding team, housing providers and local recovery programme.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service had an improvement plan in place with actions that had arisen from audits, previous inspection report, and quality improvement initiatives. These included new protocols, audits and training in medicines, the creation of patient information leaflets explaining the medicines used, and the purchase of monitoring equipment for people with diabetes.