The Light House

Updated 10 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience contacted people's relatives by telephone to request their feedback.

Service and service type

The Light House is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Light House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service and 3 relatives. We spoke with 5 members of staff including the registered manager and regional manager. We undertook observations of people receiving care to help us understand their experiences. We reviewed a range of records. This included 2 people's care records and 4 people's medicines records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service and quality assurance were reviewed including accident and incident records and management audits. We sought feedback from professionals who work with the service.

Updated 10 June 2023

About the service

The Light House is a residential service providing personal care for up to 9 people with mental health support needs. The service consists of an adapted building, which includes individual bedrooms, communal spaces and an accessible outdoor space. At the time of our inspection there were 6 people using the service.

People's experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support:

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff supported people with their medicines in a way that promoted their independence. People had a choice about their living environment and were able to personalise their rooms. The service gave people care and support in a safe, clean and well-maintained environment.

Right Care:

The service did not always have plans and guidance in place for staff to support people with their individual risks. We received mixed feedback as to whether people always felt safe within the service. Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it. The service had enough appropriately skilled staff to meet people's needs and keep them safe. People told us they had good relationships with permanent staff. However, we received mixed feedback about support provided by agency staff.

Right Culture:

Systems were in place to monitor the quality of the service to people. However, quality assurance systems were not always effective at resolving issues within the service promptly. The service enabled people to work with staff to develop the service. Staff ensured risks of a closed culture were minimised so that people received support based on transparency, respect and inclusivity.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published November 2021) and there was a breach of Regulation 18 (Registration) Regulations 2009. At this inspection we found the service was no longer in breach of Regulation 18 (Registration), however we identified a breach of Regulation 12 (safe care and treatment). This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We carried out an unannounced inspection of this service on 21 and 24 September 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to ensure notifications were submitted to CQC as required.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Light House on our website at www.cqc.org.uk.

Enforcement

We have identified a breach of Regulation 12 (Safe care and treatment) at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.