Northern Lights Care Home Service Children and Young People Neath Birches Scaniport Inverness IV2 6DL

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1 Northern Lights Care Home Service Children and Young People Neath Birches Scaniport Inverness IV2 6DL Inspected by: Kathleen Sutherland Mary Morris. Type of inspection: Unannounced Inspection completed on: 22 June 2011

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 11 4 Other information 29 5 Summary of grades 30 6 Inspection and grading history 30 Service provided by: Barnardo's 'known as' Barnardo's Scotland Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Kathleen Sutherland Telephone enquiries@scswis.com Northern Lights, page 2 of 32

3 Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 2 Weak Quality of Environment 2 Weak Quality of Staffing 3 Adequate Quality of Management and Leadership 2 Weak What the service does well Management are very willing and keen to improve the service provision. Positive interactions between staff and young people were observed. What the service could do better Written documentation needs to be progressed to gain the views of the young people living at Northern Lights. Written documentation to gain the views of parents, carers needs to progress. The way in which information is recorded to ensure that all elements of Data Protection are met. The aims and objectives of Northern Lights are met at all times. Care plans for young people to be followed, reviewed and put in place for all young people. The recording systems need to improve. Weekly summaries for example had not all been completed. Communication between staff at Northern Lights and other agencies needs to improve. Young people are involved in meaningful activities. Northern Lights, page 3 of 32

4 The way in which young people gain independent living skills needs to improve. The staffing at Northern Lights needs to improve to ensure consistency of staff. The way in which information is recorded about young people needs to improve. The recording of information in the electronic data base needs to be reviewed as when this system is down this impacts on information being recorded and passed on to staff. The Quality Assurance systems that are in place need to improve to ensure that any problematic areas are identified quickly and addressed. What the service has done since the last inspection This was the first inspection since this service was registered with Social Care and Social Work Improvement Scotland. Conclusion Overall, we concluded that there were many areas that this service needed to improve upon. We appreciate that the service is still in the early stages. However, we also are aware that prior to the young people living at Northern Lights there was a period of over a year for systems to be set in place. We concluded that senior management had identified problematic areas and were actively seeking to address these. Who did this inspection Kathleen Sutherland Mary Morris. Lay assessor: Northern Lights, page 4 of 32

5 1 About the service we inspected Northern Lights provides a residential care home service for young people who require to be accommodated away from home. Before the 1 April 2011 this care service was registered with the Care Commission. On this date the new scrutiny body, Social Care and Social Work Improvement Scotland (SCSWIS) took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this care service continued its registration under the new body, SCSWIS. The service was registered with Social Care and Social Work Improvement Scotland on 1 April 2011 and was previously registered with the Care Commission. The service operates from a modern detached house set in a large area of garden grounds in the countryside and is situated about 2 miles from the city of Inverness. There are amenities nearer to the care home in the form of local shops and leisure activity centres. The service is provided by Barnardo's through Barnardo's Scotland, in partnership with the Highland Council to children and young people ages 9 years to 17 years. The purpose of the service is to return young people to the Highlands and nearer to their communities, families and social networks. The service further aims to: Support the transition of young people into Through Care and After are services (Barnardo's Springboard service) and to work closely with the Barnardo's Works service (engaging young adults in employment and training opportunities). This enhanced provision will provide a 24/7 therapeutic residential setting for 5 young people with teaching and educational support input. Northern Lights aims to support young people in their social, emotional and educational (in the broadest sense) development. From the stability offered by the service, the medium to longer term intention will be to enable young people to develop the skills and resources necessary to live more independently in their communities with appropriate support from the range of Barnardo's, the Highland Council, Through care and Aftercare resources. All young people at Northern Lights will be supported by Northern Lights Staff and their Highland Council social worker who remains as the lead professional in terms of having an overview of the young person's plan for their social, emotional and educational development. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 2 - Weak Quality of Environment - Grade 2 - Weak Northern Lights, page 5 of 32

6 Quality of Staffing - Grade 3 - Adequate Quality of Management and Leadership - Grade 2 - Weak Inspection report continued This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Northern Lights, page 6 of 32

7 2 How we inspected this service The level of inspection we carried out In this service we carried out a medium intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection The current RSA (Regulatory Support Assessment) level for this service is now high. We undertook this unannounced inspection between the 16 and 23 June The inspection was carried out by Kathleen Sutherland (Lead Inspector) and Mary Morris (Second Inspector) Social Care and Social Work Improvement Scotland. Before the inspection visit we had gained the views of the young people who lived in the care home and also the views of placing social workers and other health care professionals. We also took account of the Self Assessment that had been returned to us. During the inspection we spoke with all the young people who were there, staff on duty, the manager of the service and the operational manager of Barnardo's. We observed the interaction between staff and young people and toured the premises. We viewed the relevant policies and procedures and other documentation to inform this report to include: Care Plans for the young people. Contact Records, Daily Recordings for young people. Communications Book. Certificate of Registration (the service needs to download the new Certificate which contains the name of Social Care and Social Work Scotland as opposed to the Care Commission). Central to this inspection was discussion between us and the project manager and all of the aforementioned informed the content of this report. Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Northern Lights, page 7 of 32

8 Inspection Focus Areas (IFAs) Inspection report continued In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at Northern Lights, page 8 of 32

9 What the service has done to meet any recommendations we made at our last inspection Not applicable. First inspection since being registered with Social Care and Social Work Improvement Scotland. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: No Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. We received a completed self assessment before the inspection and we were satisfied with the content. Areas of strengths and areas for improvement had been identified. Taking the views of people using the care service into account Before the inspection visits we wrote out to placing social workers and other professionals involved with Northern Lights. Some of the professionals told us that they had not really been involved with the service and comments noted from others included the following: I am not happy with this service at all. I am concerned that the young person I have placed there is going backward instead of forward. I do not think there is good communication between staff. I do not think there is enough work being carried out to progress the independent living aspect of this service. I am concerned that when there is a handover the door of the office is shut although young people know they are being spoken about. It does not seem right that these young people who are adults are placed in the position where staff are speaking about them and they are not aware of what is being said. I have no concerns about the service but have not had much involvement yet. We concluded after speaking with these professionals that there were concerns around the quality of the service provision and issues that required to be addressed. Northern Lights, page 9 of 32

10 When we spoke with young people and the following comments were noted: I was far happier where I was. At least they were trying to prepare me for life on my own. We are not really allowed to do very much in the way of cooking. Staff make most of the meals and we only get to cook if we don't like what the staff have made. I cooked for all of us in my last place. I planned the meal. Budgeted for it and made a meal for us all. I really don't like it here. I don't really do anything as you can see. Some staff are OK but others are not. If you ask for something one member of staff says yes then the other says no. I have not had a key worker for sometime now. Staff don't really listen to what we say. Some staff are OK. I like living here but there's not much to do. Most of the staff are very nice. Taking carers' views into account See the views of people using the service. Northern Lights, page 10 of 32

11 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Overall grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths Young people who live at Northern Lights were given the opportunity to express their views in various ways. For example, informal contact with staff, weekly meetings with both young people and staff and the use of a suggestions box. Young people also had the opportunity to speak with the Who Cares Scotland worker who visited the service on a monthly basis. Young people could also contact the Who Cares Scotland worker out with these times and were given her mobile telephone number. There was an appointed visitor who visited the service and the first residents meeting was scheduled for 23 June We spoke with the appointed visitor before this inspection. Young people had regular contact with their social workers and we spoke with the social workers before the inspection. Although there were systems in place for people to express their views in the form of meetings there were no systems in place to gain the views of other important people who played a part in the lives of the young people who lived at Northern Lights. We were told that written questionnaires were in the process of being developed but we were disappointed that this had not been finalised as although young people were resident after February 2011, staff had been recruited and in place for over a year. The service provider should therefore develop and put in place written questionnaires for young people, their families (where appropriate) and other relevant agencies in order that their views can be gained and evaluated to inform future practice. The Unit Development Plan was still being developed but it did not appear that young people were being involved in this. The service provider needs to ensure that the young people living in Northern Lights are an integral part of this plan before it is finalised. Northern Lights, page 11 of 32

12 We spoke with the young people when we carried out this inspection and we were told that, yes, we do have meetings but nothing is done about what we say. We have asked for various things but nothing happens. We don't think our views are being listened to and we get mixed messages from staff. One says one thing and another says something different. When we spoke with social workers and other professionals we were told that there was often a lack of communication or miscommunication with staff and that this had led to difficulties. The service provider should improve lines of communication to ensure that staff, young people and other professionals are clear about what is being said. We discussed our concerns with regards to this Quality Statement with senior managers of Barnard's and we were told that they were aware of some problems and that action was being taken to address this. The service providers acknowledged that this was an area in which they were under performing. We will work closely with Barnardo's to improve the current situation. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Statement 2 We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential. Service strengths In the self assessment we were told that young people had individual choices and given opportunities based on individual interests, for example, skateboarding which was encouraged and facilitated. Northern Lights worked closely with other Barnardo's Services in the area to address moving onto independence, training and employment. Each young person was allocated a through care and aftercare project worker who worked closely with the young person and the residential team in moving them forward into independent living. There were policies and procedures in place with regards to through care and after care planning. The young people living at Northern Lights had been returned to the Highlands from out of authority placements. Northern Lights aimed to act as a stepping stone for young people to re integrate them with their communities, re establish and or develop positive links with family, school and community. To support the transition Northern Lights, page 12 of 32

13 into through care and aftercare services and to work closely with Barnardo's Works Service, engaging young adults in employment and training opportunities. However, we found during this inspection that Northern Lights was not performing well in this area and this was confirmed when we looked at documentation, spoke with young people and other professionals. We saw when we looked at Care Plans and other contact records that the young people at Northern Lights were not as actively involved in constructive ways which promoted independent living and most of the activities they were taking part in were not planned and more provided on an ad hoc basic when staff came on shift. When we carried out our visits we seen that the young people were either watching TV, in their rooms or smoking outside chatting to each other. We observed one young person in the living room watching Jeremy Kyle on the TV and the member of staff who was present was reading the newspaper. We seen from daily contact records that young people did not have a daily routine and were going to bed late and getting up late. It had also been recorded that young people were not sleeping well and in one instance staff recommended that the young person make an appointment with their doctor to discuss this lack of sleep. Specific recordings taken from contact sheets: Did not rise till 2pm and then spent most of the day watching TV. Rose at 10.30am and spent much of the time between the computer playing games and watching TV in the company of another resident. Asked to go out and was told that this would be dependant upon what plans the back shift had and whether or not they made an effort to reduce or stop shouting and swearing toward staff. Discussed what we would do today as they are by themselves in the house. Staff purchased ticket for the cinema, not able to just give money for the ticket, young person queried this as this had not been done before. Nothing planned in advance, staff were trying to make the week end as good as possible. Young person expressed a lot of anger toward not being given a choice to live at Northern Lights and the lack of organisation by management which they believed interfered with their day to day care. Did not want the macaroni cheese that had been cooked for dinner so they cooked themselves a pizza and chips. We observed an evening meal time and we saw that the food was being prepared by staff and with the young people looking on. When we spoke with some of the young people they told us that they would like to do more cooking. One young person told us that they did lots of cooking in their last placement and this included costing the food, buying it and then cooking for all the unit. Young people told us that they did not feel well prepared to live on their own and that they were not prepared for Northern Lights, page 13 of 32

14 independent living. Clearly the aims and objectives of Northern Lights are to assist young people to move into Independence and gain the necessary skills to do so. Little evidence that this was taking place was found during this inspection. (See Requirement 1). Care Plans that we looked at were not being followed and other professionals we spoke with also expressed concerns about the lack of preparation for independent living. We appreciated that time needed to be taken to enable young people to make choices and that very often they would change their minds. However, it is only by having alternative ways in place where young people can try different options that they will ultimately be able to achieve their individual potential. ( See Requirements 2). On the day of the first inspection visit we were told by young people that the kitchen and the educational room (the area where the computer is stored) were locked at night. Young people told us if they were thirsty they had to get a drink of water from the sink in their bathroom. They were also not able to have anything to eat if they were hungry. We had been alerted to this by another professional we spoke with before this visit. We discussed this with senior management and were told that this practice would cease immediately. However, on our next visit we were told by the young people that the kitchen and the educational room were still being locked. We again stressed with the senior manager that unless there were very good reasons and appropriate risk assessments in place this practice should stop immediately. This practice has now stopped. (See Requirement 3). Northern Lights differs from other residential units in that the emphasis is on preparing young people to move into independent living and be supported emotionally to do this. Staff working in this field need to have the necessary knowledge and skills to promote this. Staff need to allow young people gain the necessary skills to promote independent living such as: doing their own cooking, washing, buying food and learning from any mistakes they will no doubt make. (See Requirement 4 We further saw from young peoples care plans that although the placing social worker had stipulated details of contact between young people and their parents, this was not being adhered to. From the daily contact records we seen that some young people had contact with family members out with the recommendations of the placing social worker. The service provider should therefore ensure that the contact detailed in the Care Plan is followed as directed by the placing social worker and any alterations to this agreed with the placing social worker. (See Requirement 5). Northern Lights, page 14 of 32

15 Grade awarded for this statement: 2 - Weak Number of requirements: 5 Requirements 1. The service provider should, ensure that the service is provided in a manner which promotes and respects the independence of service users and, so far as it is practicable to do so, affords them choice in the way in which the service is provided to them. This in accordance with SSI 114 Regulation of Care Scotland Act 2002, 2, Principles and National Care Standards: Care Homes for Children and Young People: National Care Standard: 9:1 and National Care Standards: 17(2)(4). 2. The service provider should, ensure that the aims and objectives of the service provision are being met in that, young people are fully supported in the transition into through care and aftercare services to engage young people in employment and training opportunities. This in accordance with SSI 114 Regulation of Care Scotland Act, 2002, 3, Aims and Objectives and National Care Standards: Care Homes for Children and Young People: National Care Standard: 8:7 and National Care Standards: The service provider should, ensure that unless there are specific reasons for rooms to be locked then these rooms are available to young people at all times and this includes the kitchen. Should there be any incident which affects this then appropriate risk assessments should be put in place. This in accordance with SSI 114 Regulation of Care Scotland Act, 2002, 4(1)(a)(b) and National Care Standard: Care Homes for Children and Young People: National Care Standard: The service provider should ensure that management, and staff have the relevant knowledge and skills to encourage and promote independent living. This in accordance with SSI 114, Regulation of Care Scotland Act, 2002, 7(d) and 9(2)(b) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 7(8) and National Care Standards: 17(4). 5. The service provider shall notify the service user and any representative consulted under paragraph (2)(c) of any such revision to the care plan. In this regulation, representative means any person appearing to the provider to act on behalf of the service user. This in accordance with the Regulation of Care Scotland Act 2002, Regulation (5)(2)(d) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 4(1). Statement 3 We ensure that service user's health and wellbeing needs are met. Service strengths Inspection report continued Young people were registered with a local doctor and dentist and the Looked After Children Health Care Professional was informed when a young person came to Northern Lights, page 15 of 32

16 Northern Lights. Health care assessments were carried out and all health records, appointments were recorded on the electronic system, Live Link, Barnardo's database. Young people were involved in the planning of meals. Each young person had a lifestyle membership for swimming and the gym. There was a no smoking policy and procedure and young people were discouraged from smoking. Young people were encouraged to self medicate where this was appropriate. Inspection report continued As we previously stated more activities needed to be in place to promote the well being and fitness levels of the young people living at Northern Lights. The service provider identified in the self assessment that bicycles were going to be purchased and that young people would be asked what activities they wanted to do. The service provider needs to progress this as young people had also told us that they wanted more activities. (See Requirement 1). Staff had received training from the Community Dietitian and the self assessment informed us that he would also be coming to speak to young people. The service provider should progress this and ensure that young people are provided with the opportunity of learning about the values and benefits of healthy eating. (See Recommendation 2). Staffing within Northern Lights had been affected by staff sickness and other reasons. As a result, agency staff had been drafted in to ensure staffing levels were maintained. We spoke with one agency worker when we carried out the inspection. Although we observed positive interactions between the agency worker and the young people we did not think that the worker had the specialist skills and knowledge that were required at Northern Lights. We also questioned whether or not the agency worker would have had the opportunity of viewing the care plans for the young people which were held on a secure data base. We fully appreciated that staffing levels were being maintained and that the service provider had endeavoured to meet the staffing levels but care needs to be given to staff working in Northern Lights who do not have these required skills and knowledge. We also noted from the daily contact records that the use of agency staff had had a direct impact on young people. For example, one young person went to the cinema but her key worker could not collect her as this would result in only an agency worker being left in the house. (See Requirement 2). We noted from information contained in care plans, daily contact records that loss had played a major part in some young peoples lives, yet, there was little to no evidence that one to one work was being carried out to emotionally support these young people. One care plan that we looked at had identified very clear concerns about the emotional well being of one young person yet there were no strategies in place as to how this would be dealt with. (See Requirement 3). Northern Lights, page 16 of 32

17 One young person who lived at Northern Lights had no care plan and we were told that this was due to their frequent absconding. We were very concerned that any young person had been accepted to live at Northern Lights without a plan of care being in place. Some care plans were not signed by the young person and this would question whether or not they had been involved when it was drawn up. The outcome of one care plan identified that the behaviour of the young person needed to improve yet there were no strategies in place as to how this outcome would be met. (See Requirement 4). There is a no smoking policy and procedure in place at Northern Lights and during the inspection we observed that many of the young people smoked. This is not an easy area to address and staff can only advise young people of the health issues connected with smoking. We saw from the policies and procedures in place that there was clear staff guidance to follow regarding young people smoking in the presence of staff. During this inspection we saw that staff were present, outside, with young people when they were smoking and this was contrary to the policy and procedure that was in place. Staff must not be seen to condone smoking and the service provider needs to ensure that their policies and procedures are followed. Grade awarded for this statement: 2 - Weak Number of requirements: 4 Requirements Inspection report continued 1. The service provider should ensure that there are adequate opportunities, equipment to make proper provision for the health and welfare of service users. This in accordance with SSI 114 Regulation of Care Scotland Act 2002, regulation 13(a) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 15:2. 2. The service provider shall, having regard to the size and nature of the service, the statement of aims and objectives and the number and needs of service users - ensure that at all times suitably qualified and competent persons are working in the care service in such numbers as are appropriate for the health and welfare of service users. This in accordance with SSI 114 Regulation of Care Scotland Act 2002 Regulation 13 (a) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 4(1) and National Care Standard: 7(8). 3. The service provider shall make proper provision for the health and welfare of service users. This in accordance with SSI 114 Regulation of Care Scotland Act 2002, Regulation 4(1)(a) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 11(12). 4. A provider shall, after consultation with each service user and, where it appears to the provider to be appropriate, any representative, within one month of the date on Northern Lights, page 17 of 32

18 which the service user first received the service prepare a written plan (the personal plan) which sets out how the service users health and welfare needs are to be met. This in accordance with the Regulation of Care Scotland Act 2002, Regulation 5(1). Recommendations 1. Young people should be provided with the opportunity of learning about healthy eating, diet and nutrition. This in accordance with National Care Standards: Care Homes for Children and Young People: National Care Standard: 11:2. Statement 4 We use a range of communication methods to ensure we meet the needs of service users. Service strengths This Quality Statement has been reported within Quality Statements 1.1, 2.1 Please refer to these Quality Statements for further detail. The same as those identified in Quality Statements 1.1 and 2.1. Grade awarded for this statement: 2 - Weak Number of requirements: 0 Statement 5 We respond to service users' care and support needs using person centered values. Service strengths This Quality Statement has been reported within Quality Statement 1.3. Please refer to this statement for further detail. The same as those identified in Quality Statement 1.3. Grade awarded for this statement: 2 - Weak Number of requirements: 0 Statement 6 Inspection report continued People who use, or would like to use the service, and those who are ceasing the service, are fully informed as to what the service provides. Northern Lights, page 18 of 32

19 Service strengths Before young people came to live at Northern Lights staff made contact with the young person's social worker to inform them as to what the service provided. Young people visited Northern Lights to look round and meet staff and ask questions. Parents (if appropriate) were also encouraged to visit. Further visits then overnights were arranged to make the move easier for young people. Inspection report continued The Welcome Booklet for young people had not been finalised and this needs to progress. (See Recommendation 1). Information provided to parents and placing social workers to be further developed and should be reader friendly and accurate. Any information, Welcome Booklet needs to be available in different communication formats. Evaluations in the form of feedback from young people, parents and other professionals needs to be gained to inform whether or not the information is helpful. There was no transitional plans in place when young people moved on. This had been identified as an area for improvement in the self assessment returned to us. (See Recommendation 2). Number of requirements: 0 Recommendations 1. The service provider to ensure that the initial information booklet and information to parents, carers and placing social workers is developed. This in accordance with National Care Standards: Care Homes for Children and Young People: National Care Standard: 1:1. 2. The service provider to ensure that there are plans in place when young people make the transition from Northern Lights into independent living. This in accordance with National Care Standards: Care Homes for Children and Young People: National Care Standard: 7 and 9. Grade awarded for this statement: 2 - Weak Northern Lights, page 19 of 32

20 Quality Theme 2: Quality of Environment Grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths Northern Lights operates from a large detached house which is set in the countryside and is surrounded by grass areas and trees. Currently, a vegetable patch garden is being developed. Although young people may not always be able to choose their own room they have a say in how it is decorated. The house is well furnished and decorated to a high standard. All but two of the bedrooms have en suite facilities and there is ample space for individual or group activities. There is a no smoking policy. In the questionnaires returned to us young people told us that they wanted some kind of sports equipment in the garden area. When we visited Northern Lights we seen that there was extensive garden grounds but no outdoor equipment for young people to exercise with. The service provider should therefore listen to what the young people have said and make a concerted effort to improve the potential of the garden area and provide an additional opportunity for exercise and enjoyment. (See Recommendation 1). The lounge area within the house is extremely large. We were told by staff that there were plans to section off part of this area which would make it more homely. The service provider should progress these plans. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service provider needs to make more use of the garden area to enable young people to take part in outdoor activities and should also provide suitable outdoor equipment for young people to enjoy. This in accordance with National Care Standards: Care Homes for Children and Young People: National Care Standard: 5. Statement 2 Northern Lights, page 20 of 32

21 We make sure that the environment is safe and service users are protected. Service strengths The property which Northern Lights operates from is a large detached house which was built to a high standard. Before Northern Lights was registered with Social Care and Social Work Improvement Scotland the property was inspected and altered in accordance with building regulations. Fire Officers visited the property and adjustments, alterations were made to take fire safety into account. The entire property is surrounded by a fence and there is a large gate at the entrance which can be locked. We noted during this inspection that the property was clean and well maintained. Risk assessments have been carried out with regards to the busy road which runs alongside the property and road signs are to be erected outside the property. There are appropriate policies and procedures in place with regards to infection control, child protection and fire drills are carried out with the staff and young people. Staff have undergone basic First Aid and Elementary Food Hygiene training. During the night there are two members of staff on duty, one sleeping and one waking. There is a dedicated Health and Safety Officer and all faults are reported to the Properties and Facility Management team of Barnardo's. Accidents, incidents and absconding recorded on the electronic data base. There is a visitors book in place and people are asked to sign this when they enter the property. The Youth Development Officer from the Northern Constabulary visits the unit. Systems are in place to record serious incidents and staff would be be briefed as soon after the event as possible. Young people would be listened to and reassured and comments recorded in their daily notes. Internet access is monitored by staff with certain sites blocked. Inspection report continued Again we would highlight the way in which records are maintained on the electronic data base as an area for improvement. We seen when we looked at this that there were various documents in place to record information. For example, incidents, restraint, absconding and accidents were recorded separately. This makes it very difficult to evaluate this information. We would suggest that this system is looked at and improved on to ensure total quality assurance. Although there are risk assessments in place to ensure the safety young people. For example, monitoring of the use of the Internet by staff. We found that the way in which risk was assessed was not being carried out appropriately. The locking of the kitchen and the locking of the education room which housed the computer led us to believe that the culture of Northern Lights was risk aversion. The service provider should therefore consider the ways in which risk is assessed in order that risk aversion does not Northern Lights, page 21 of 32

22 become the norm. We have made a previous Requirement with regards to this subject. We noted from the self assessment that alarms were to be fitted to the bedrooms of the young people. Again, we would ask that detailed risk assessments are carried out which justify this drastic action and the service provider should, only if there are justifiable reasons install such devices. (See Requirement 1). The installation of a front door bell and an outside light would further ensure the safety of young people. Grade awarded for this statement: 2 - Weak Number of requirements: 1 Requirements 1. The service provider to carry out detailed risk assessments to ensure that the alarm systems that are being considered are necessary to ensure that there is proper provision for the health and welfare of service users and that services are being provided in a manner which respects the privacy and dignity of service users. This in accordance with the Regulation of Care Scotland Act, 2002, Regulation 4(1)(a)and(b) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 8(1). Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths This Quality Statement has been reported within Quality Statement 2.2. Please refer to Quality Statement 2.2 for further detail. The same as those identified in Quality Statement 2.2. Grade awarded for this statement: 2 - Weak Number of requirements: 0 Statement 4 The accommodation we provide ensures that the privacy of service users is respected. Northern Lights, page 22 of 32

23 Service strengths Young people had their own room which could be locked. There was a lockable set of drawers in each bedroom. Three of the five bedrooms had their own en suite bathrooms and the remaining two were occupied by the same gender and shared a bathroom. Information about young people was stored electronically and any other information was stored in a locked cupboard. Inspection report continued The service provider should continue to maintain the current good practice and take into consideration the comments in Quality Statement 2.2 with regards to the installation of alarms in the bedrooms of young people. Grade awarded for this statement: 4 - Good Number of requirements: 0 Northern Lights, page 23 of 32

24 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths This Quality Statement has been reported within Quality Statement 1.1. Please refer to Quality Statement 1.1 for further detail. The same as those identified in Quality Statement 1.1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Statement 2 We are confident that our staff have been recruited, and inducted, in a safe and robust manner to protect service users and staff. Service strengths The recruitment practices within Barnardo's are safe and robust and all staff were recruited in adherence to the strict guidelines set by Barnardo's. The service provider should continue to maintain the current very good practice and ensure that the use of Agency Staff does not impact on the service provision. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Northern Lights, page 24 of 32

25 Service strengths Staff working at Northern Lights are all well qualified and receive regular training. Staff are all registered with the appropriate bodies. Social care staff with the SSSC (Scottish Social Services Council) and educational staff with the GTC (General Teaching Council). Inspection report continued The staff that we spoke with during this inspection were clearly motivated and keen to offer a good service. However, the use of agency staff should be considered carefully as they may not have the relevant training to carry out the work they are doing. All staff who require to should continue to gain the relevant SVQ's (Scottish Vocational Qualifications) to meet the requirements of the SSSC (Scottish Social Services Council).. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Statement 4 We ensure that everyone working in the service has an ethos of respect towards service users and each other. Service strengths There were appropriate policies and procedures in place and we viewed these before this inspection. We observed staff interacting with young people when we carried out this visit and saw that staff were respectful toward the young people. Young people were also observed to respect staff. The staff that we spoke with spoke about young people with respect. The service provider needs to ensure that the way in which daily information is recorded about young people in that the ethos of respect is not lost. Grade awarded for this statement: 4 - Good Number of requirements: 0 Northern Lights, page 25 of 32

26 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths This Quality Statement has been reported within Quality Statement 1.1. Please refer to Quality Statement 1.1 for further detail. The same as those identified in Quality Statement 1.1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Statement 2 We involve our workforce in determining the direction and future objectives of the service. Service strengths Weekly team meetings were held. However due to the rota basis of staff it was not always possible for all to staff attend on a weekly basis. There was a pre set agenda and all staff were encouraged to contribute to this. Minutes were taken and staff signed these to confirm they had seen them and understood them. Staff are involved in the workforce service reviews, the development plan and policy making. Staff are informed of research reports and they have access to the Internet. Staff share information with the rest of the team. Staff questionnaires to be developed and given out to staff. Consideration given to team development days to ensure that staff who do not have the opportunity of attending the team meeting are fully involved in commenting on the direction and future objectives of the service. Northern Lights, page 26 of 32

27 Grade awarded for this statement: 4 - Good Number of requirements: 0 Statement 3 To encourage good quality care, we promote leadership values throughout the workforce. Service strengths This Quality Statement has been reported within Quality Statement 3 and 4.2. Please refer to these Quality Statements for further detail. The same as those identified in Quality Statements 3 and 4.2. Grade awarded for this statement: 4 - Good Recommendations Number of requirements: 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths A review of the service is completed annually by Barnardo's and senior managers at Barnardo's review the service provision at Northern Lights. Feedback from young people also informs the quality assurance systems. Because the quality assurance systems within Barnardo's are good, senior management had identified several areas where Northern Lights was under performing. The service provider acknowledged this when we spoke with them and ongoing work is taking place to address this. Social Care and Social Work Improvement Scotland are working closely with senior managers to ensure there are improvements to this service. Inspection report continued We identified in Quality Statement 1.1 that there had been no written questionnaires developed for other stakeholders and this should be progressed to ensure that the feedback is evaluated to inform future practice and identify any concerns at an early stage. Northern Lights, page 27 of 32

28 The quality assurance systems that were in place at Northern Lights are not robust enough to ensure that issues, concerns are identified and acted upon at an early stage. The service provider needs to ensure that any quality system in place specific to Northern Lights is robust enough to ensure the well being of young people. (See Requirement 1). Most of the information relating to young people to include care plans, daily contact records and other significant information are electronically recorded. We found it very difficult to track and evaluate the information relating to young people when we carried out this inspection and were very concerned that recently, this electronic information system was not accessible. Some staff we spoke with also told us that at times, they could not access information about young people as the computer was being used by staff for other purposes. Although we appreciate that this system operates throughout Barnardo's we were concerned that the remote location of Northern Lights may affect its availability. For example, we were told by staff that access to the system was not possible over a week end period. It is vital that all staff are aware of the needs of the young people, plans for young people and any other information that is significant to their well being. We would therefore encourage the service provider to consider using an alternative method to record information about young people to ensure that this is accessible to all staff, at all times. Grade awarded for this statement: 2 - Weak Number of requirements: 1 Requirements 1. The service provider should ensure that the quality assurance systems that are in place are robust enough to ensure any problematic areas are identified at an early stage to make proper provision for the health and welfare of service users. This in accordance with the Regulation of Care Scotland Act, 2002, Regulation, 4(1) and National Care Standards: Care Homes for Children and Young People: National Care Standard: 7:2. Northern Lights, page 28 of 32

29 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information We were not informed of any referrals which were of a child protection nature when we carried out this inspection. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Northern Lights, page 29 of 32

30 5 Summary of grades Quality of Care and Support Weak Statement 1 Statement 2 Statement 3 Statement 4 Statement 5 Statement Adequate 2 - Weak 2 - Weak 2 - Weak 2 - Weak 2 - Weak Quality of Environment Weak Statement 1 Statement 2 Statement 3 Statement Adequate 2 - Weak 2 - Weak 4 - Good Quality of Staffing Adequate Statement 1 Statement 2 Statement 3 Statement Adequate 5 - Very Good 3 - Adequate 4 - Good Quality of Management and Leadership Weak Statement 1 Statement 2 Statement 3 Statement Adequate 4 - Good 4 - Good 2 - Weak 6 Inspection and grading history Northern Lights, page 30 of 32