Lighthouse Professional Care Ltd was rated Requires Improvement overall following a focused July 2023 inspection, remaining in breach of Regulations 12, 17, and 19 due to unsafe recruitment practices, inadequate risk assessments, poor medicines management, and ineffective governance systems. Warning notices were served for governance and recruitment failures, though some improvements were noted in training, supervision, and staff documentation since the previous inspection.
Concerns (11)
criticalStaffing levels: “One staff member was found to be lone working without an up-to-date British criminal record check in place. No risk assessment was in place to support this potential risk.”
critical
Staff competency
: “Staff employment history had not been checked in line with current legislation or their own policy. Gaps in employment had not always been recognised and checked.”
criticalSafeguarding: “1 incident had to be notified to CQC retrospectively because the registered manager had not recognised it as potential abuse.”
criticalCare planning: “Risks to people lacked guidance in place to mitigate the risks. People's care plans contained little to no risk assessments in line with best practice, statutory guidance and legislation.”
criticalMedication management: “1 person's medicine records stated they had not been administered, whilst daily notes said staff had been there. This meant systems could not assure that people received their medicine as prescribed.”
criticalMedication management: “One person was at risk of choking or aspiration because they had been administered tablets whilst on a specialist soft diet. No instructions were in place.”
criticalGovernance: “Audits which had been completed identifying actions needed to be taken were incomplete. An audit in May and June 2023 had identified risk assessments had not been completed; by July 2023 this was still the case.”
criticalIncident learning: “We were informed about an incident which was a potential safeguarding...no records were shared with us despite requesting them.”
criticalLeadership: “Systems were not in place to ensure safeguarding and duty of candour had been followed fully. No suitable level of training had been completed by senior staff.”
moderateRecord keeping: “Information that should have been readily available was not accessible throughout the inspection. On the first day a comprehensive list of people receiving care was requested on 4 occasions.”
moderateConsent / capacity: “People's care plans did not always reflect what we were being told or demonstrate people's capacity had been considered in line with current legislation.”
Strengths
· Staff received regular training, competency checks and supervisions; training records now in place.
· Relatives reported feeling people were safe and well looked after by carers.
· Management invested time helping overseas staff acclimatise to living and working in the UK.
· Staff competency around medicine administration checked regularly by senior staff; new staff shadowed prior to administering medicines.
· People and relatives informed when staff were running late and received regular reviews of care.
Quality-Statement breakdown (13)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffRequires improvement
First inspection of this domiciliary care service identified breaches of Regulations 17, 19 and Registration Regulation 18 due to inaccurate records, incomplete recruitment checks, poor training documentation and unreported notifiable events. Despite governance shortfalls people and relatives reported very positive, caring and person-centred experiences with consistent staff.
Concerns (9)
criticalGovernance: “Not all records were accurate or up to date. We found some shortfalls in recruitment and training documentations. Not all monitoring systems were accurate and up to date”
criticalRecord keeping: “Not all accidents and incidents were recorded. One incident was reported in the handover book but had not been added to the log. The audit had not identified this omission.”
criticalStaff training: “Only one member of staff was up to date with the provider's required training. Some certificates in personnel records had incorrect dates on them.”
criticalIncident learning: “the accident and incident log showed events which should have been reported to CQC as a Notification. We were not assured that all safeguarding incidences were recorded or referred appropriately.”
criticalOther: “Only one member of staff had all the required recruitment checks in place to ensure safety. For example, appropriate work or character references and complete application forms”
moderateSafeguarding: “the details of this incident were not in the service safeguarding file, there were no actions or outcomes recorded. This meant the incident and any actions and outcomes were not effectively monitored”
moderateMedication management: “Only two out of four members of staff had received a medicines administration competency assessment within the last 12 months... audits had not been completed for September and October 2021.”
moderateConsent / capacity: “The registered manager did not give us assurances they fully understood the MCA, different legal representations or Deprivation of Liberty Safeguards procedures in the community.”
moderateSupervision / appraisal: “Staff had received induction, supervision and service spot checks but these were not efficiently recorded. Two staff members induction competency checks were not dated.”
Strengths
· Positive feedback from people and relatives about caring, kind and cheerful staff
· Consistency of carers with no missed or late calls reported
· Person-centred care plans including life history, routines and preferences
· Good communication with families and other health and social care agencies
· Compliant with the Accessible Information Standard (AIS)
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated