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The Lighthouse Requires improvement


Inspection carried out on 2 March to 3 March 2021

During a routine inspection

We have not previously rated this service. We rated it as requires improvement because:

  • Young people did not receive care and treatment in a manner that safeguarded them from potential abuse. Positive behaviour support plans were not based on functional assessments. Positive behaviour support plans contained strategies which included the use of punishments which were not in keeping with the therapeutic ethos.
  • Disclosure and barring service checks were not always conducted robustly. Staff had started employment without having the appropriate checks in place which ensured they could work with children as well as adults.
  • Restraint was not safe. Staff involved in restraint had not always undertaken the providers restraint training. This meant staff could potentially use different methods of restraint which could result in the young people being physically harmed.
  • Children and young people requiring assistance did not have a way to alert staff if they needed assistance quickly. Whilst hand held equipment was available in the unit to enable communication in an emergency, this was rarely being made available to the young people.
  • There was no target for staff supervision. This meant that there was not a measurable target for the service to work towards.
  • Staff did not use child friendly approaches with children and young people to engage them in decisions about their individual care and treatment. This meant children and young people felt uninvolved.
  • There were gaps in the governance processes that did not identify there were issues with disclosure and barring service checks and restraint training for staff.


  • Infection prevention control measures had improved following prompting by the Care Quality Commission. Staff were now wearing masks and following national guidance.
  • Staffing at night had improved since the last inspection. Registered nurses were employed to work at night. This meant that children and young people had access to registered nurses at all times.
  • The service sought to ensure that children and young people had access to the appropriate therapies and treatment. Alternative therapies were sourced and funded by the service where necessary.
  • Community meetings were held regularly. Children and young people were asked of their opinions and changes were made based on their feedback.
  • The service had sought input from external bodies such as the Restraint Reduction Network, Safewards and was working towards Quality Network for Inpatient Child and Adolescent Mental Health Services accreditation.

Inspection carried out on 5 May 2020

During an inspection looking at part of the service

This was a focused inspection on elements of the safe and well-led key questions only. Therefore, we did not rate the service. The service has not previously been inspected. We found the following:

  • There were no qualified nurses working at night. This meant that young people with complex needs might not have access to the professional support needed. There were no qualified nurses working in the hospital at night. This meant that children did not have immediate access to a qualified nurse.
  • Staff restrained children and young people using training models that were not consistent. This meant there was a risk of restraint not being done safely. The provider acknowledged that all staff should be trained to use the same techniques and has taken steps to address this.
  • Staff had not received the appropriate level of training to fulfil their roles. Staff lacked training in the Mental Capacity Act and Gillick competency and so did not always consider consent appropriately. Safeguarding children training was not completed to the required level of competence. There were plans for this training to be completed by the end of May 2020.
  • Our findings from the other key questions demonstrated that governance processes were in their infancy. Policies required improvements. There were plans to fully review policies and procedures and implement robust governance.
  • There had been a failure to notify CQC of safeguarding concerns and police contacts.


  • The service managed patient safety incidents well. Staff assessed and managed risks to children, young people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff understood how to protect children and young people from abuse and the service worked well with other agencies to do so.
  • The service had enough support staff, who knew the children and young people well. Staff had easy access to clinical information, and it was easy for them to maintain high quality clinical records.
  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff felt respected, supported and valued.