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

There was sufficient staff to support patients, and staff had the required skills, and training to support patients in their care. All staff had received an induction before working in the hospital and they had received suitable training and supervision. Patients risk assessments were up to date and staff knew where to find current information about patients and supported them in accordance with care plans and risk management plans. Staff followed systems and processes to prescribe and administer medicines safely. Staff understood how to protect patients from abuse, had received appropriate training and worked well with other agencies to do so.

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.

We spoke with 2 patients and 1 parent/ carer. Patients and parents/carers told us they could raise concerns with the hospital director and staff directly and these were dealt with quickly. We reviewed patient feedback forms gathered by the service for the 3 months preceding our on-site visit. We found that patients reported they felt safe and supported at the service. Patients told us that staff debriefed with them after any incidents they were involved in.

Staff understood how to raise concerns and report incidents. They demonstrated knowledge of accessing the service’s incident reporting systems, knowing what to report and how to report it. Staff said they were encouraged to report incidents and raise concerns. All staff described a positive, safe working environment with the freedom to speak up, emphasising an open and transparent culture. Staff told us incidents were discussed in handover, supervision and staff meetings. Team meeting minutes showed that staff discussed learning from incidents and actions required to improve patient care.

There were processes for dealing with complaints, accidents, incidents, and other adverse events. These were effectively implemented. There were systems to learn from things that went wrong. For the 6 months prior to our assessment there had been 2 complaints and 4 compliments about the service. The staff were encouraged to report all incidents. For the month prior to our onsite visit there had been a total of 69 incidents reported. Incidents were reviewed at each multidisciplinary team meeting. Learning from incidents were shared directly with staff through email bulletins and team meetings. Managers reviewed and analysed incidents at clinical governance meetings to understand themes and trends, how to reduce these and implemented actions.

Patients were involved in the development of their care plans and risk assessments. They were invited to multi-disciplinary team meetings to discuss their care and chose to attend some of these meetings. The meetings included discussions about goal setting and how to support people to move forward in their treatment.

Leaders told us that they assessed referrals into the service to ensure the care and support available was suitable for the patients. Staff told us that their opinions were valued and that they were able to share their views about patient care and risks. They gave examples of collaborative working to keep people safe.

We received concerns from partners prior to our assessment which we followed up during are visit. Our assessment provided assurance that systems, pathways and transitions were safe.

Processes that we observed were effectively managing the safety of patients at the hospital. These included handovers and regular multi-disciplinary meetings. Systems that we looked at also ensured a good use of information which was accessible to staff to enable them to deliver safe care, for example feedback from the review of incidents.

Patients we spoke with told us they understood why they were in hospital, they were given information on admission to orient them to the hospital, were told about treatments and had their rights under the Mental Health Act explained to them. All patients we spoke with said they felt safe, and they could speak to staff if they ever felt threatened.

The provider had a clear policy on the Mental Capacity Act, which staff could describe and knew how to access. Staff knew where to get accurate advice on the Mental Capacity Act. Staff knew how to make a safeguarding referral and who to speak with if they had concerns. At the time of the assessment, 100% of staff had completed mandatory safeguarding training. During the assessment we spoke with staff members, including managers, nurses and healthcare assistants. Staff were able to describe examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Leaders told us they had taken steps to reduce the risk of closed cultures developing, including inviting external agencies for visits, and encouraging patients to speak out about any concerns.

We observed staff utilising de-escalation techniques to good effect on more than one occasion during our onsite assessment. We observed patients being supported by staff who understood how to protect people from harm. We saw posters displayed giving details of the safeguarding lead as well as information about how to contact the Independent Mental Health Advocate. Care records we reviewed showed that patients had been given information about their rights under the Mental Health Act upon admission to hospital and on a regular basis afterwards.

Safeguarding policies were in place and up to date and staff had received safeguarding training at a level appropriate to the needs of those using the service. Minutes from governance meetings contained evidence that managers had considered safeguarding concerns, and any actions required. As part of the assessment, we reviewed the hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, Local Authority referral date and any learning outcomes.

All patients we spoke with confirmed they were involved in their risk assessments. Patients told us they understood their observation levels and why their observation levels may increase or decrease, depending on their risk.

Staff confirmed that they involved patients in their risk assessments. They ensured that all safety equipment was in good working order and that staff were complying with handover requirements including security checks. Staff also ensured the environment was clean and safe and any damage to items or the building were reported to the maintenance teams. Staff were also responsible for the ligature audit. Staff told us that they had received training in restraint and restraint was only used as a last resort. Staff were able to discuss patients’ individual preferences and how to de-escalate patients to avoid the need for physical restraint.

We reviewed care records for both patients. Staff completed risk assessments for patients, these were updated frequently and mostly updated when risk changed, for example following an incident. Risk assessments were comprehensive and contained details on how to manage identified risks. Risk information relevant to each patient was clear and consistent which ensured staff were up to date, this included detailed discussions at handovers and multi-disciplinary meetings.

The patients were generally happy with the environment, the hospital was in a good state of repair and any maintenance issues were dealt with swiftly. Patients had personalised their bedroom and they had been allowed to personalise the environment in communal areas. For example, the walls had been painted with murals. Patients did not raise any concerns in relation to the safety of the environment.

Managers had oversight of the environment and could escalate issues as appropriate within the organisation. Managers and staff spoken to did not raise any issues regarding the environment.

We reviewed care records for both patients. Staff completed risk assessments for patients, these were updated frequently and mostly updated when risk changed, for example following an incident. Risk assessments were comprehensive and contained details on how to manage identified risks. Risk information relevant to each patient was clear and consistent which ensured staff were up to date, this included detailed discussions at handovers and multi-disciplinary meetings.

During the assessment we reviewed both environmental and ligature risk assessments. These were well written. Staff knew about any potential ligature anchor points and mitigated the risks to keep the patients safe. Staff had completed fire risk assessments for the building. Electrical and gas safety checks were in place. Staff had easy access to personal alarms and patients had easy access to nurse call systems. Staff always carried personal alarms on them.

Patients we spoke to told us that staff knew them well. Staff supported patients to access leave in the community and attended various local activities including go karting and visiting local restaurants. Patients told us this had improved in the month before our inspection, and activities were being planned in advance and with their input on where they wanted to go.

Staff told us that staffing levels were good, they felt they always had time to provide one to one support and enough staff to support patient’s leave. Staff also told us that the staff team was supportive and that they received debriefs following incidents. Bank and agency staff were nearly always regular staff, and we checked staff records for those on the rota and all had completed an induction and observation competency checks.

We saw that staff did engage with the patients; we saw them encouraging them to join them in activities. All staff could describe the patients and their needs, likes and dislikes.

Staff told us, and rotas showed, that staffing levels were at an expected and safe level. They told us that where gaps might appear, because of sickness for example, they were easily filled. Staff said that there was always at least one qualified nurse on duty but there were two on most shifts. Staff said that the skill mix of their teams was helpful, there were enough skilled staff to respond to incidents and they attended quickly where needed. If agency staff were needed, they were familiar with the hospital and how to support the patients. Robust vetting procedures ensured they had the right background and skills to work.

The patients did not raise any significant concerns in relation to the cleanliness of the hospital or about infection prevention and control measures. One patient did mention that there had been some mould in their bedroom area but on inspection of the bedroom this had been cleaned and removed.

Managers had oversight of the environment and could escalate issues as appropriate. Managers and staff spoken to did not generally raise any issues regarding the environment.

We observed staff washing their hands as per guidance at appropriate times such as before dispensing medicines and serving food.

We saw that cleaning rotas were complete and up to date, and the environment was clean.

Patients understood their medicines and most felt involved in medicines reviews through multi-disciplinary team meetings. We reviewed patients’ records and found that they were involved when making decisions about their treatment. We saw records of patients who had capacity to consent to treatment and this was documented clearly.

Staff reviewed patient’s medicines regularly as part of multidisciplinary meetings and provided specific advice to patients about their prescribed medicines and their effects. The local pharmacy that supplied the medicines also carried out audits. Staff carried out work to ensure that medicines continued to be administered in line with best practice and trust guidance.

We reviewed the clinic room and found appropriate checks of clinic equipment were carried out on a regular basis, including medicines storage, fridges and emergency equipment and medicines.

There were effective processes in place to ensure that medicines were administered safely. Staff had undertaken the necessary training to ensure they were competent to carry out these processes.