Quality Account
2014 / 2015
2
Quality Account 2014/ 2015
Contents
Pages
Part 1
Part 2
Part 3
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A statement on quality from the Chief Executive Officer
Lighthouse Healthcare services
Priorities for Improvement 2015/16
Quality of services provided on behalf of the NHS
Review of quality performance 2014/15
3
4
9
15
18
We are specialists in providing bespoke solutions for people with complex and multiple needs
3
Quality Account 2014/ 2015
Part One
Statement on Quality from Julian Ball, Lighthouse Healthcare’s
Chief Executive Officer
Lighthouse Healthcare Group is dedicated to supporting people with very complex needs to return
to their communities as soon as possible.
Our agenda for improvement and change reflects the Transforming Care agenda. We welcome and
respect the greater national and NHS focus on the voice, choices and rights of the person in
modelling their own care and support.
We continue to invest in better and more training for staff, more suitable, bespoke and adapted
environments that better reflect every-day living (e.g. single person apartments, small group
apartments and a reduction in traditional ward environments).
Our teams are committed to improving reporting, more effectively evidencing the great outcomes
we achieve for people and ensuring best practice and best value for our NHS partners with whom we
are privileged to work with.
We have a strong ethos of open, honest reporting that strengthens the trust between us and our
many stakeholders. We firmly believe in analysing our data, learning from it and implementing
change around that learning to influence improved outcomes for the people we support.
Our robust clinical governance and quality assurance structures remain the foundation of our
accountability to the people we support, evidenced through our regulators. Our annual surveys
across stakeholders measure progress and inform future planning from the micro to the macro.
In a world demanding change of perspectives, greater efficiency, better outcomes and lower costs
we continue to deliver services with a focus on the detailed nuances of bespoke support for people
who need very personal care, kindness and understanding of their particular needs.
The information we provide in the quality accounts is a true reflection of our work but will never be
the whole story. The personal accounts and stories of lived experience we hear only add to support
the data and are the true reason we are here.
Julian Ball, Chief Executive Officer
We are specialists in providing bespoke solutions for people with complex and multiple needs
4
Quality Account 2014/ 2015
Lighthouse Healthcare Services
Lighthouse offers a range of specialist services to people with learning disabilities, autism, mental
health problems and personality disorders across the East and West Midlands and Wales. We offer a
pathway of integrated care through our individually tailored hospital placements in our six hospitals
and our five bespoke move-on care services, providing person centered enablement and support,
with a commitment to minimised stays in services.
All our services are specifically designed to provide small group or single person environments,
replicating an ordinary living setting. These allow for the development of daily living skills aimed at a
move towards more independent living.
Our services offer person-centred and care planned, outcomes focused interventions to support
recovery to better health and greater independence. We facilitate engagement in the community
and the opportunity to develop new lifestyle choices to improve self-esteem and confidence.
Our ethos is built upon a shared belief that the person is central to everything we do and we ensure
we are responsive to service users’ changing needs, reviewing and revising plans to meet these
needs. We value positive risk taking opportunities within a context of robust risk assessment and
management to ensure those we support are kept safe.
Each of our services are staffed by an experienced team of professional managers, support workers,
and nurses. Each service has a team of clinical psychiatrists, psychologists and assistants,
occupational therapists, social worker, speech and language therapists and advocacy.
Our services are well-led by caring, professional and experienced staff and as a small organisation,
our senior management team is always close to the patients and service users, staff teams and
service managers, so our care is developed in direct response to people’s needs We measure the
effectiveness of our interventions using a range of validated tools and by listening to and acting on
feedback from the people we support, their carers and case managers and commissioners. We are
committed to the continuous improvement of service delivery and providing services which meet
changing demand.
We are specialists in providing bespoke solutions for people with complex and multiple needs
5
Quality Account 2014/ 2015
We are specialists in providing bespoke solutions for people with complex and multiple needs
6
Quality Account 2014/ 2015
Bradley Woodlands, Bradley Road, Bradley, Grimsby, Lincolnshire
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
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Purpose built low secure unit for people with learning disabilities
and complex needs
Bespoke Pathway Step Down Service
Gender specific apartment based accommodation
Bradley Apartments, Bradley Road, Bradley, Grimsby, Lincolnshire


Community based registered care service for men and women with
a learning disability, autism and/or challenging behaviour
Structured rehabilitation programme in place to help individuals
develop new skills, promote independence and social integration
Chesterfield House, 411 Newark Road, North Hykeham, Lincolnshire


Community based registered care service for men and women with
learning disability and complex needs
Forms a key part of our specialist learning disability services
pathway in Lincolnshire
Field House, Chesterfield Road, Alfreton, Derbyshire



Locked rehabilitation service for men with learning disabilities and
mental health problems
Management of longer term conditions both mental and physical
Assisted access environment
We are specialists in providing bespoke solutions for people with complex and multiple needs
7
Quality Account 2014/ 2015
Healthlinc House, Cliff Road, Welton, Lincolnshire


Gender specific apartment based locked rehabilitation for people
with learning disabilities and complex needs
Set in own private grounds of almost four acres in the heart of the
community
Healthlinc Apartments, Cliff Road, Welton, Lincolnshire


Community based registered care service adults with learning
disability, autism and/or complex conditions such as mental health
problems, challenging behaviour and personality disorder
Forms a key part of our specialist learning disability services
pathway in Lincolnshire

The Cottage, 31 Norbeck Lane, Welton, Lincolnshire


Registered care service adults with learning disability, autism and/or
complex conditions such as mental health problems, challenging
behaviour and personality disorder
Aim of the service to prepare individuals for living more independently
through a programme of activities within the service and the local
community
The Woodhouse, Lockwood Road, Cheadle, Staffordshire


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Pathway of services for people with learning disabilities, complex needs
and mental health problems
Low secure and locked rehabilitation accommodation over eight
distinctive units
Small, specialist units for people with Autism
The Woodlands, 20 Woodland Avenue, Wolstanton, Newcastle- under-Lyme


Community based specialist residential service for adult men with
learning disability and complex conditions such as personality disorder,
mental health problems and forensic issues
Forms a key part of our specialist learning disability pathway of services
in Staffordshire
We are specialists in providing bespoke solutions for people with complex and multiple needs
8
Quality Account 2014/ 2015
Ballington House, Ballington Gardens, Leek, Staffordshire


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Mental health rehabilitation hospital for females over 18 years old
Apartment based living
Replicates domestic living environment that enables people to
experience having their own front door and be responsible for
maintaining their own living space
Phoenix House, Little Henfaes Drive, Welshpool, Powys


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Purpose built mental health rehabilitation hospital
Gender specific service for males over 18 years old
Promotes independence and integration into the community
through the use of the recovery approach
We are specialists in providing bespoke solutions for people with complex and multiple needs
9
Quality Account 2014/ 2015
Part Two
Priorities for Improvement 2015/16
During 2015/16 Lighthouse Healthcare will continue to build on the quality improvement measures
already in place within the organisation, with a particular focus on the following areas. These will be
monitored through the business planning cycle led by the Executive Team and will be reported on
within next year’s Quality Account.
 Continue to provide an evolving staff
training programme focusing on specialised
service and service user specific, training
which responds to changing needs
 Continue to develop effective staff
recruitment and retention systems for all
professional groups supporting our patients
and service users
 Supporting our nurses around the
revalidation process and our Support
Workers to meet the Care Standards.
Developing a
skilled,
professional
and passionate
workforce
 Continue to develop and improve our
services and staff teams in line with
external regulatory frameworks such as the
new CQC Fundamental Standards of Care,
the Care Act and Code of Practice
 Develop internal quality reviewing systems
and take part in national peer review
initiatives
Continuing to
provide high
quality
treatment in
high quality
environments
Service
User
Meeting and
exceeding
regulatory &
quality
frameworks
 Continued review of service provision
and expansion of pathways of services
to reflect people’s needs and the
changing sector
 Ongoing development of bespoke
solutions for people with highly complex
needs
 Cementing Lighthouse’s niche place in
the learning disability sector
Clinical
effectiveness –
outcomes and
pathways
 Demonstrate effective outcomes for
our patients and service users through
Life Star, HONOS and HCR 20 data.
 Implement the PRISM system for
incident management to record and
analyse incidents within services.
 Effective and timely discharge
planning to continue to minimise
lengths of stays in hospitals.
We are specialists in providing bespoke solutions for people with complex and multiple needs
10
Quality Account 2014/ 2015
Statements Relating to Quality of Services Provided
2014/15 has been a particularly important and challenging year for Lighthouse Healthcare in
the learning disability sector.
Enhancing our Learning Disability Pathway
Lighthouse Healthcare has responded proactively to the changing focus of learning disability services
nationally. We remain committed to playing an integral part in transforming the care for people with
learning disabilities and / or autism.
In response to this we have reduced our learning disability hospital beds by 33% and developed
specialist community based services. These services now provide a robust step down pathway that
provides a route for developing independence and integration within the community. These services
are also a viable alternative to hospital admission to ensure care is provided in the least restrictive
setting possible.
Our three new specialist community based services; Healthlinc Apartments and The Cottage, which
now complete our pathway of specialist learning disability care in Lincolnshire. Bradley Apartments
in Grimsby compliments our Low Secure Unit in Grimsby by offering a robust step down from secure
care in to the community.
Learning Disability Provision
2013/14
Learning Disability Provision
2014/15
hospitals
25%
hospitals
40%
75%
community
services
60%
community
services
We are continuing to review and develop our hospital provision and to design and develop locally
focused community based services by working alongside commissioners and service users to ensure
that people with learning disabilities receive the right care in the right place at the right time.
We have been able to provide specific bespoke solutions for a number of people with complex needs
and challenging behaviours which have allowed them to step down out of secure and hospital care,
to settings in which they are able to lead more independent and less restricted lives where they are
engaged more fully in their community.
We are specialists in providing bespoke solutions for people with complex and multiple needs
Quality Account 2014/ 2015
Length of Stay within our Learning Disability Hospitals
This year we have continued to
focus on reducing the lengths of stay
for individuals in our hospital
services. Through effective
discharge planning and positive
engagement with Care and
Treatment Review teams we have
successfully discharged 89 service
users from hospital this year.
Length of Stay in our Learning Disability
Hospitals*
5.00
Number of Years
11
4.00
3.00
2.00
1.00
11.12
12.13
13.14
14.15
*data relates to Bradley Woodlands, Field House,
Healthlinc House and The Woodhouse services
only
Calendar Years
Discharge Destination and Moves in the Lighthouse Pathway
Compare to average length of stay
Our continued focus on timely and planned discharge has meant that we have been successful in
discharged 60 people into the community this year. Many of these individuals
have
been in hospital
BLAH BLAH
BLAH
or secure settings, detained under the Mental Health Act for many years and have now had the
opportunity to step down into a less restrictive environment within a community setting to lead
fuller and more independent lives.
Discharge Destinations 2014/15
Supported Living
Home
5%
13%
Residential Service
25%
Low Secure Hospital
Unknown
14%
1%
1%
Deceased
18%
Hospital
Medium Secure Service
12%
11%
Internal Moves (Stepping Up
and Down)
We are specialists in providing bespoke solutions for people with complex and multiple needs
12
Quality Account 2014/ 2015
The addition of our three new community
based services, has allowed us to expand
our step down community provision and
we now have pathways into the community
in all our key locations.
Internal/ External Moves
15%
External Moves
Internal Moves
85%
Almost all of our discharged service
users have been successful in
progressing in their treatment by
stepping down. Some, whose needs
have increased, have been
supported to receive the care they
require within hospitals or secure
services both within Lighthouse and
also external services.
15% of the people discharged from our
hospitals have moved on to Lighthouse
pathway community based services which
allows them to continue to receive the
specialist care they require in locations
they are familiar with.
Internal Move Destinations within
Lighthouse
8%
Step Down
Internal Move
92%
Step Up
Internal Move
We are specialists in providing bespoke solutions for people with complex and multiple needs
13
Quality Account 2014/ 2015
“Bradley Woodlands Low Secure Service have succeeded where other care homes,
social services and hospitals have given up and pushed him onto someone else.
They have challenged my sons behaviour in a fair manner with earned incentives
which, he has lost on occasions but then earned back. He feels safe, supported and
listened too, he still has a long way to go but for the first time in his life I feel we
are on the right path. His physical health as well as is mental health has greatly
improved and I know my son has learned a lot about his challenges and how to
deal with them”
Mother of Service User at Bradley Woodlands
“What can I say about Ballington House....words cannot begin to express my
gratitude and sincere thanks to the wonderful staff at this hospital, not only did
they provide an excellent service for my daughter who not only had mental
health issues but autism and a mild learning difficulty, they also provided an
excellent service to me as a carer in the darkest of times. I really cannot
recommend this hospital enough.”
Mother of Service User at Ballington House
We are specialists in providing bespoke solutions for people with complex and multiple needs
Quality Account 2014/ 2015
Meaningful Activity Hours
During 2014/15 we have continued to offer meaningful outcomes focused activity programmes for
at least 30 hours per week, seven days a week.
This has meant that our service users can access care planned, individually tailored programmes to
enhance their independent living skills and community engagement.
Meaningful Activity Hours 2014/ 15
Hours
14
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
Accepted Hours
Offered Hours
We consistently offer 30 hours of meaningful activity each week for all service users, however as
their needs and moods change weekly they may choose not to participate in all activities offered.
We aim to give them as much choice as possible and a wide range of activities to enhance
motivation and engagement.
We are specialists in providing bespoke solutions for people with complex and multiple needs
15
Quality Account 2014/ 2015
Performance against KPI’s and CQUINS
Lighthouse Healthcare works with commissioners from NHS England (secure services), Clinical
Commissioning Groups and Local Authorities (locked rehabilitation hospital services and community
based registered care services) and the Welsh Health Board, delivering care and treatment in line
with NHS contracts and agreed national standards.
NHS England CQUIN Framework
The CQUIN payment framework enables commissioners to reward excellence, by linking a
proportion of healthcare providers' income to the achievement of local quality improvement goals.
Lighthouse secure services have been successful in achieving 100% of their CQUIN standards during
2014/15.
Commissioning for Quality and Innovation (CQUIN)
CQUINS
Low Secure
Services (BW &
WH- Hawksmoor)
Q1
100%
Q2
100%
Lighthouse Acheivements
Q3
100%
Q4
Not assessed yet
CQC & HIW Inspections
Lighthouse Healthcare is required to register all services with Care Quality Commission (CQC) in
England and with the Health Inspectorate Wales (HIW) in Wales. 2014 / 15 has seen four CQC
inspections take place within Lighthouse Healthcare, two of which have been undertaken using the
new Fundamental Standards for Care. We are working hard to address areas where standards have
not been met, liaising closely with CQC.
Service
Ballington House
Chesterfield House
Bradley Apartments
Bradley Woodlands
CQC Inspection date
January 2015
March 2015
March 2015
May 2014
Outcome
All Standards met *
Overall Rating GOOD **
Overall Rating REQUIRES IMPROVEMENT **
3 out of 4 Standards met *
* Service assessed under previous standards
** Service assessed under new standards
Service
Phoenix House
HIW Inspection date
January 2015
Outcome
Awaiting outcome
We are specialists in providing bespoke solutions for people with complex and multiple needs
16
Quality Account 2014/ 2015
Engagement with Our Stakeholders
Our Service Users
Each year we conduct a survey for all of our service users. During March 2014 we asked all service
users to participate in our annual survey and asked a range of questions around the following topics
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
General Health
Food & Healthy Eating
Activities
Staff & Clinicians
Living Environment
Friends & Family
Plans for the Future
The survey was carried out in both online and paper formats with Easy Read versions available for
both. Out of 130 service users, 84 that took part in the survey which equated to a 65% response
rate. The full results of the survey can be found on our website by clicking here
A snap shot of the results are:
Percentage of service users involved in planning
their activity programme
Don't know
1%
Didn't answer
question
15%
No
28%
Yes
56%
How often service users participate in planning the
food they eat
Daily
Weekly
Monthly
15%
Never
Didn't answer question
16%
18%
44%
7%
We are specialists in providing bespoke solutions for people with complex and multiple needs
17
Quality Account 2014/ 2015
Where do Service Users hope to live when they leave
the service
Don’t know
4%
Didn't answer
question
29%
Don’t want to
leave where
you live now In a care home
8%
7%
Back
with
your
family
13%
In your own
flat
19%
In a shared flat
with friends
20%
Appointment of Key Relationships Manager
As the health and social care sector and in particular the learning disability market, continues to
evolve, proactively engaging with our key stakeholders is essential. As such during 2014/15
Lighthouse Healthcare appointed a Key Relationships Manager to work in partnership with the
people purchasing and referring to our services, to ensure that our services continue to respond to
patients and service users’ needs and national priorities. More importantly this role enables the
needs of specific individuals, who are ready to move into the community or whose very complex
needs mean they continue to require specialist inpatient treatment, to be discussed to enable
Lighthouse to design and develop bespoke placement solutions.
We are specialists in providing bespoke solutions for people with complex and multiple needs
18
Quality Account 2014/ 2015
Part Three
Review of Quality Performance
Lighthouse Healthcare has robust structures in place to ensure the continual improvement of quality
across the organisation.
Board of
Directors
Executive
Team
Information
Governance
Health &
Safety
Senior
Clinicians
Quality &
Policies Audit
Group
Quality & Compliance Framework
Services
-
Clinical Governance
Health & Safety
Regulation
Commissioning Contract Audit
Review
- Care & Treatment Review
Clinical Governance Framework
Each service has a quarterly Clinical Governance Meeting attended by the Quality and Compliance
Manager, the Unit manager, members of the Multi-disciplinary team and service staff. This meeting
feeds into the quarterly corporate Clinical Governance Meeting of the Executive which is chaired by
the company’s Chief Executive and attended by the executive Management team. This group
oversees the adherence of services to internal and external quality and regulatory standards and
monitors and reviews areas such as Health and Safety, physical interventions, clinical audits to
ensure a cyclical approach to learning is adopted.
We are specialists in providing bespoke solutions for people with complex and multiple needs
19
Quality Account 2014/ 2015
Lighthouse Ladder of Achievements
Lighthouse Healthcare has worked towards the following priorities for improving
quality during 2014/15.
Enhancing the
quality of the
service user
journey towards
recovery and
rehabilitation
Delivering our
services in the least
restrictive setting
with the least
restrictive practices
Ensuring that all
our services are
safe and delivered
in line with best
practice
 My Shared Pathway and My Plan implemented across the
group
 Carenotes system in place
 Built on the mandatory staff training programme to
include service specific training
 Improved the function of multi-disciplinary team
 Focused on physical healthcare
 Implemented outcomes monitoring tools including Life
Star and Recovery Star
 Review and revision of the organisations positive
behaviour management interventions programme, MAYBO
 All service users have a Positive Behaviour Support Plan
 Development of pathway of services to ensure that people
do not remain in unnecessarily restrictive hospital
environments any longer than necessary.
 Development of policies and models of care for our robust
community services
 Safeguarding has been prioritised, all staff are trained,
Safeguarding Lead in place and regular analysis of incidents
 Learning from national issues such as Mid-Staffs,
Winterbourne, DOLS and MCA capacity assessments have
been embedded
 Audits of medication and prescribing practice embedded in
audit cycle
 Clinical governance systems improved
 New bespoke environments for service users developed
We are specialists in providing bespoke solutions for people with complex and multiple needs
20
Quality Account 2014/ 2015
Lighthouse Healthcare
2 Floor Bezant House, Bradgate Park View, Chellaston, Derby DE73 5UH
Tel: 01332 706769 | Referrals: 0800 954 2497 | Email: info@lighthouse-healthcare.co.uk
www.lighthouse-healthcare.co.uk
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We are specialists in providing bespoke solutions for people with complex and multiple needs