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
Inspection report continued
Contents
1
2
3
4
5
6
Page No
3
5
7
11
29
30
30
Summary
About the service we inspected
How we inspected this service
The inspection
Other information
Summary of grades
Inspection and grading history
Service provided by:
Barnardo's 'known as' Barnardo's Scotland
Service provider number:
SP2003003405
Care service number:
CS2009195687
Contact details for the inspector who inspected this service:
Kathleen Sutherland
Telephone
Email [email protected]
Northern Lights, page 2 of 32
Inspection report continued
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
Quality of Management and Leadership 2
Adequate
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
Inspection report continued
• 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
Inspection report continued
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
Inspection report continued
Quality of Staffing - Grade 3 - Adequate
Quality of Management and Leadership - Grade 2 - Weak
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
www.scswis.com or by calling us on 0845 600 9527 or visiting one of our offices.
Northern Lights, page 6 of 32
Inspection report continued
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 2011. 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
Inspection report continued
Inspection Focus Areas (IFAs)
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
www.firelawscotland.org
Northern Lights, page 8 of 32
Inspection report continued
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
Inspection report continued
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
Inspection report continued
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 2011. 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.
Areas for improvement
• 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
Inspection report continued
• 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
Number of recommendations: 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.
Areas for improvement
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
Inspection report continued
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
Inspection report continued
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
Inspection report continued
Grade awarded for this statement: 2 - Weak
Number of requirements: 5
Number of recommendations: 0
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: 17.
3. 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: 12.
4. 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
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
Inspection report continued
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.
Areas for improvement
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
Inspection report continued
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
Number of recommendations: 0
Requirements
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
Inspection report continued
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.
Areas for improvement
The same as those identified in Quality Statements 1.1 and 2.1.
Grade awarded for this statement: 2 - Weak
Number of requirements: 0
Number of recommendations: 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.
Areas for improvement
The same as those identified in Quality Statement 1.3.
Grade awarded for this statement: 2 - Weak
Number of requirements: 0
Number of recommendations: 0
Statement 6
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
Inspection report continued
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.
Areas for improvement
• 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
Number of recommendations: 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
Inspection report continued
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.
Areas for improvement
• 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
Inspection report continued
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.
Areas for improvement
• 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
Inspection report continued
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
Number of recommendations: 0
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.
Areas for improvement
The same as those identified in Quality Statement 2.2.
Grade awarded for this statement: 2 - Weak
Number of requirements: 0
Number of recommendations: 0
Statement 4
The accommodation we provide ensures that the privacy of service users is respected.
Northern Lights, page 22 of 32
Inspection report continued
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.
Areas for improvement
• 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
Number of recommendations: 0
Northern Lights, page 23 of 32
Inspection report continued
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.
Areas for improvement
The same as those identified in Quality Statement 1.1.
Grade awarded for this statement: 3 - Adequate
Number of requirements: 0
Number of recommendations: 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.
Areas for improvement
• 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
Number of recommendations: 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
Inspection report continued
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).
Areas for improvement
• 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
Number of recommendations: 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.
Areas for improvement
• 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
Number of recommendations: 0
Northern Lights, page 25 of 32
Inspection report continued
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.
Areas for improvement
The same as those identified in Quality Statement 1.1.
Grade awarded for this statement: 3 - Adequate
Number of requirements: 0
Number of recommendations: 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.
Areas for improvement
• 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
Inspection report continued
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 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.
Areas for improvement
The same as those identified in Quality Statements 3 and 4.2.
Grade awarded for this statement: 4 - Good
Recommendations
Number of requirements: 0
Number of recommendations: 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.
Areas for improvement
• 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
Inspection report continued
• 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
Number of recommendations: 0
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
Inspection report continued
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
Inspection report continued
5 Summary of grades
Quality of Care and Support - 2 - Weak
Statement 1
3 - Adequate
Statement 2
2 - Weak
Statement 3
2 - Weak
Statement 4
2 - Weak
Statement 5
2 - Weak
Statement 6
2 - Weak
Quality of Environment - 2 - Weak
Statement 1
3 - Adequate
Statement 2
2 - Weak
Statement 3
2 - Weak
Statement 4
4 - Good
Quality of Staffing - 3 - Adequate
Statement 1
3 - Adequate
Statement 2
5 - Very Good
Statement 3
3 - Adequate
Statement 4
4 - Good
Quality of Management and Leadership - 2 - Weak
Statement 1
3 - Adequate
Statement 2
4 - Good
Statement 3
4 - Good
Statement 4
2 - Weak
6 Inspection and grading history
Northern Lights, page 30 of 32
Inspection report continued
All inspections and grades before 1 April 2011 are those reported by the former
regulator of care services, the Care Commission.
Northern Lights, page 31 of 32
Inspection report continued
To find out more about our inspections and inspection reports
Read our leaflet 'How we inspect'. You can download it from our website or ask us to
send you a copy by telephoning us on 0845 600 9527.
This inspection report is published by SCSWIS. You can get more copies of this report
and others by downloading it from our website:
www.scswis.com or by telephoning 0845 600 9527.
Translations and alternative formats
This inspection report is available in other languages and formats on request.
Telephone: 0845 600 9527
Email: [email protected]
Web: www.scswis.com
Northern Lights, page 32 of 32