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

At the time of our inspection there was no Registered Manager in post as the previous manager had recently left the service. A new manager had been appointed and was due to start once all relevant vetting checks were complete. Other senior leaders in the organisation were supporting the service and new clinical lead roles had been appointed to. They had recognised where improvements had been required and put appropriate actions and support in place. The staff team reported a positive change in the culture at the service in the last month before our assessment. They reported that a new leadership team had been appointed and this had given more present leadership at the hospital and support for more junior staff. The new staff had experience in working with patients in a range of settings and had brought new skills and experience to the hospital. The service had a stable management structure in place. Governance and auditing processes were embedded, and performance and feedback indicated that these processes were effective.

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.

Staff and managers acknowledged that there had been some recent changes at the service including a new manager and the introduction of some new senior roles at the hospital to support the manager. Staff feedback was that they now felt well supported to carry out their roles and that the morale in the service was good. There had been no incidents of bullying and harassment. Staff told us they felt supported by their managers, and they said they were present and approachable.

We saw that the service gathered information that was useful for them to review and improve the service. An example of this was incidents that occurred. We saw evidence that data in relation incidents was gathered and where necessary appropriate action was taken to improve practice. This was also shared with staff via team meetings and in supervision. All staff received an induction appropriate for their role within the organisation, as well as ongoing training that was monitored.

Staff felt respected, supported and valued. Staff told us they had felt well supported when incidents occurred. Staff told us the executive team visited the hospital occasionally and that senior leaders visited the hospital regularly. No member of staff raised concerns in relation to bullying or racism during the assessment.

Staff were effectively managed and supported by managers. Supervision levels were high at almost 100%. Training compliance was also above 90%. Managers followed policies and procedures, for example ensuring that staff were inducted prior to working at the hospital. Leaders ensured that the environment was safe and patients reported feeling safe at the hospital. The staff survey results were mostly positive. However, some staff fed back that not enough staff attended team meetings, that in the past managers have not been approachable, and that there had been some favouritism within the team from managers. At the time of our inspection the previous Registered Manager had left the service, and a new manager had been appointed but was not yet in post. Other senior leaders in the organisation were supporting the service and new clinical lead roles had been appointed to. Staff gave positive feedback about the new roles and senior team in the interim before the new Registered Manager started. Managers told us they could access training specific to their roles and that there was induction training in place for new managers.

Staff told us that they felt the culture at the hospital was positive. Managers knew how to address any concerns raised by staff and there was a good working relationship between members of the multi-disciplinary team.

There was a whistle blowing policy in place and managers confirmed they attended staff meetings. They examined staff surveys and incidents for any intelligence of trends which would identify inappropriate behaviour. Managers were able to give us examples of when concerns about staff behaviour had been addressed and appropriately investigated.

Leaders valued, understood and respected different cultures across the workforce. The service enabled open communication with staff. Staff could seek guidance through team meetings and one to one supervision. Staff said that workforce morale was good at the time of the inspection.

There were policies and procedures in place focused on equality and diversity. This meant staff had guidance if needed. Staff had training in equality and diversity.

Managers had efficient and comprehensive governance arrangements in place and had relevant information at hand to ensure the service was performing well. Managers attended regular clinical governance meetings and there was sufficient oversight from senior leaders within the organisation.

Managers monitored incidents during clinical governance meetings and identified themes and trends which helped them to understand and reduce risk. They had oversight of governance issues for example, clinical notes, multidisciplinary team and service user meetings, learning and development, physical health, safe staffing and risk. They used dashboards routinely to monitor performance targets.

Patients told us family members and external teams were involved in their care and treatment when they had consented to this.

The provider was open and transparent with external stakeholders such as community mental health teams and commissioners. The provider had put processes in place including, pre-discharge meetings and multi-disciplinary team meetings to ensure all relevant partners were invited to be involved in patient care.

We could see from reviewing patient records that partners including commissioners and carers were consulted about issues regarding the care of the patient.

There were systems in operation to ensure that patients had regular physical health checks, and these were recorded within the patients’ records, and we could see they attended local surgeries when and if required.

Managers told us they were committed to continuous improvement at the hospital. They had recently held a nurses development day to ensure staff working in the hospital were involved in decisions about the service and worked together as a team.

Reflective practice sessions were held with staff, and debrief sessions were held when needed. Learning was shared with the staff team at regular handover and other multidisciplinary team meetings. Managers encouraged staff to reflect on what could be changed, and to problem-solve as a team. Leaders encouraged staff to speak up with ideas for improvement and innovation. Staff told us there was a sense of trust between leaders and staff.