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

Northern Lights Care Home Service Children and Young People Neath Birches Scaniport Inverness IV2 6DL Inspected by: Kathleen Sutherland Type of inspection: Unannounced Inspection completed on: 1 May 2013

Contents Page No Summary 3 1 About the service we inspected 6 2 How we inspected this service 8 3 The inspection 14 4 Other information 25 5 Summary of grades 26 6 Inspection and grading history 26 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 enquiries@careinspectorate.com Northern Lights, page 2 of 28

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 5 Very Good Quality of Staffing 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well Staff at Northern Lights promote the independence of the young people who live there and many young people have successfully moved on. Staff at Northern Lights establish sound, professional relationships with the young people and the Key Worker System (this is where there is a named worker for each young person) provides additional support. The educational element at Northern Lights works very well and young people achieve academic qualifications. Staff at Northern Lights have established close working links with other agencies in the community which assists young people when they move on to independence. Staff at Northern Lights receive very good support from the management team. The management team and staff continually work to find new ways of involving people and commenting on the quality of the service provision. Staff at Northern Lights continue to support young people when they move on into independent living. Staff at Northern Lights encourage young people to follow their hobbies and interests and lead an active lifestyle. Northern Lights, page 3 of 28

What the service could do better The service provider must ensure that any sanctions carried out by staff are fair. Any consequences are considered on an individual basis and should be reflected in the Care Plans. The service provider must ensure that groups of young people are not punished because of the actions of one person. The service provider must ensure that all staff are aware of the policy and procedure that is in place with regards to the collection of young people when they are out. The service provider must ensure that no young person is placed at risk as a result of having to walk home, particularly during the hours of darkness. The service provider must ensure that rules followed by staff are consistent with the policies and procedures that are in place and that rules do not change on a day to day basis dependent on what staff are on duty. The service provider should remind staff of their duty to report unacceptable practice to the management team. Staff should be reminded of the content of the Whistle Blowing Policy and Procedure and the content of the Codes of Practice as set out by the SSSC (Scottish Social Services Council). The service provider should ensure that the use of mobile telephones by staff to record the behaviour of young people ceases immediately. The service provider should ensure that no member of staff uses the electrical trip switch to turn off the electrical supply to young people's bedroom sockets. The service provider needs to continue to create an open and transparent environment where young people and staff feel confident about reporting poor practice. The service provider needs to ensure that communication with field social workers improves and that all messages, especially regarding appointments are relayed to the young people. What the service has done since the last inspection Agency staff are no longer used by the service and there is now a dedicated bank staff which assists with consistency for the young people. Some of the young people have moved on into independent living and are doing well. Some of the young people have attained academic qualifications. Care Plans have been reviewed. Staff training has been carried out in various areas. Northern Lights, page 4 of 28

It has now been confirmed that the re-decoration of the entire building will be carried out in the near future. Young people were fully involved in choosing the colours of their bedrooms and other areas of the house. A day event at Eden Court Theatre in the form of 'Big Brother' style was carried out. Young people, parents and other stakeholders were invited to take part and express their views which were recorded. Conclusion We found at this inspection that Northern Lights on the whole, was providing a good service. However, we also found evidence that there was some areas of practice being carried out by some staff which required to be addressed as a matter of urgency. The concerns that we have highlighted in this report ultimately affected the Grades we awarded for some of the Quality Statements. Who did this inspection Kathleen Sutherland Northern Lights, page 5 of 28

1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at www.careinspectorate.com This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 01 April 2011. Requirements and Recommendations If we are concerned about some aspect of a service, or think it could do more to improve, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service, but where failure to do so will not directly result in enforcement. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 and Regulations or Orders made under the Act or a condition of registration. Where there are breaches of Regulations, Orders or Conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Northern Lights provides a Residential Care Home Service for Young People who require to be accommodated away from home. 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 aged 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 Care services (Barnardo's Springboard service) and to work closely with the Barnardo's Works service (engaging young adults in employment and training opportunities). Northern Lights, page 6 of 28

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 5 - Very Good Quality of Staffing - Grade 3 - Adequate Quality of Management and Leadership - Grade 3 - Adequate 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 www.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of our offices. Northern Lights, page 7 of 28

2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection We wrote this report following an unannounced inspection. This was carried out by Inspector, Kathleen Sutherland. The inspection took place on Friday 05 April 2013 between 10.30 am and 5 pm. It continued on Tuesday 09 April from 11 am to 4 pm and Friday 12 April 2013 between 10.30 am and 4 pm. We gave feedback to the Operational Manager, the Care Home Manager and a representative from the Local Authority on 25 April, 2013. As part of the inspection, we took account of the completed annual return and self assessment forms that we asked the provider to complete and submit to us. We sent out 5 Care Standards Questionnaires to the Manager to distribute to young people. Four of the young people sent us completed questionnaires. During the inspection process, we gathered evidence from various sources, including the following: We spoke with 3 of the 4 young people who were accommodated. Two relatives. Two Care Staff. The Manager. The Operational Manager. Three Field Social Workers. We looked at: The Care Files for all the 4 young people who were accommodated. We looked at questionnaires that had been sent out to young people, relatives, staff and other stakeholders. Minutes of meetings. Accident/incident records. Records of when young people had absconded and actions taken. Maintenance records. Northern Lights, page 8 of 28

Staff Rotas. Menus. Employers Liability Insurance. Current Certificate of Registration with the Care Inspectorate. Child Protection Policy and Procedure. Infection Control Policy and Procedure. Records of the administration of medication. Staff training records. Staff supervision records. We toured the premises, spoke with the young people, staff and the management team. All of the aforementioned informed the content of this inspection 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 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 9 of 28

What the service has done to meet any requirements we made at our last inspection The requirement The service provider is required to: (a) Ensure that when all medication is administered this is recorded accurately. (b) Ensure that re ordering of medication is carried out to ensure that there is an adequate supply in stock at all times. (c) Ensure that there are regular audits of how staff are recording the administration of medication and that any issues are addressed immediately with staff. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011: Scottish Statutory Instruments: Regulation 4(1)(a) and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 12 (3) (6)(8). Timescale: Immediate on receipt of this report. What the service did to meet the requirement Additional audit systems had been put in place and this has improved the way in which staff record the administration of medication accurately. Staff training in the administration of medication has been secured for early June 2013. The requirement is: Met The requirement The service provider is required to: (a) Ensure that when there are visitors to the service this is recorded on the appropriate document to ensure the safety of the young people and to comply with Fire Legislation. (b)ensure that when there are visitors to the service that staff are aware of this and also aware of the reason for the visit. Northern Lights, page 10 of 28

(c) Ensure that every opportunity to interact with the young people is taken to develop relationships with the young people and gain information which may inform practice. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011: Scottish Statutory Instruments: Regulation 4(1)(a) and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 4(1). Timescale: Immediate on receipt of this report. What the service did to meet the requirement Front door bell installed. Staff greet all visitors when they enter the building, are asked for identification and the purpose of their visit. The requirement is: Met Inspection report continued 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: Yes - Electronic 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 this inspection. The service had identified areas for improvement and areas of strengths. We were satisfied with the content of the self assessment. Taking the views of people using the care service into account Before this inspection we received 4 completed Care Standards Questionnaires that had been returned directly to us. In the main, the comments made by the young people were positive. Comments noted included the following: I think the only thing that needs improved on is the communication between the staff. My key worker is awesome. My key worker is easy to talk to. My key worker is a great support. Northern Lights, page 11 of 28

My key worker is always up for a laugh. The manager is fun and easy to talk to. I am very happy here and think I am doing well. Inspection report continued When we spoke with 3 of the young people who were present at the time of this inspection, they told us that overall they were happy living at Northern Lights. However, there was some areas that they thought the staff could do better. Comments noted included the following: I am doing OK here and I think I will learn how to live on my own. Most of the staff are great but some staff do things that I don't think are right. I am not sure if they can do this or not. I know they can do this in a Secure Unit but I don't think they can do it here. Some of the staff turn off the electric sockets in our bedrooms when we play our music too loud or if we play it late at night or early in the morning. Some staff make up the rules as they go along. Sometimes the rules are not fair and we get punished even if it is not our fault. Can they video us on their mobile phones. Do you know, somebody did this and we kicked up a right stink about it. They can't do this unless we agree, right. Taking carers' views into account We spoke with family members during this inspection. Comments noted included the following: I have had many issues with the home but am able to discuss these with the management team and usually they get sorted out. Communication between me and some of the staff could improve. Some staff welcome me more than others. Sometimes rough play gets out of hand but this depends on which staff is on duty. Glad they are not using so many agency staff now. Overall, things are a lot better. We spoke with field social workers during this inspection. Comments noted included the following: I am very happy with the way staff work with... Northern Lights, page 12 of 28

I speak regularly with staff and am kept up to date with what is going on. Think staff need to record appointments better as messages don't get to... sometimes.... has come on in leaps and bounds since going to Northern Lights. Northern Lights, page 13 of 28

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 Grade awarded for this theme: 2 - Weak Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We found at this inspection that there were many strengths and we observed some very good practice being carried out by staff. However, in contrast to this, after speaking to some of the young people, parents and after looking at various documents, we found evidence of weak practices being carried out by some staff. This has impacted on the overall grade for this Quality Statement and as a result we awarded the Grade of 2 - Weak. As we said, we found many areas of strengths in relation to this Quality Statement and observed very good practice being carried out by staff during this inspection. The staff we spoke with had a keen interest in the young people and were dedicated to improving their lives. The management team supported the young people and staff very well and we confirmed this after speaking to some of the young people and staff. All young people were registered with a Doctor and Dentist soon after they arrived at Northern Lights. The Looked After Children Nurse Co ordinator was also informed when new young people went to live at Northern Lights and a health care assessment carried out. Staff were aware of the health care needs of the young people and information about this was recorded on the live link system. We saw when we looked at the case notes for young people that this was the case. Any changes in health care needs were also recorded. Staff promoted a healthy lifestyle and encouraged young people to eat a healthy diet. For example, there was fresh fruit on offer and we were told that the young people were getting better at eating fruit as opposed to crisps. Strong links had been made with the community dietician who visited the unit regularly to advise staff and young people. Young people were supported by staff to gain independent living skills through learning how to budget and buy their own food for the week. We saw this during one of our visits and saw Northern Lights, page 14 of 28

that young people enjoyed this experience. Young people were encouraged to take part in outdoor activities. For example, horse riding, swimming, walking and ball games. Young people were supported by staff to continue with previous interests. For example, one young person was musically talented and received regular music lessons. Young people were supported by staff to maintain friendships in the community. Young people confirmed this and said that they met up regularly with their friends. Staff encouraged young people to stop smoking and gave them information about the impact of this on their health. There was a no smoking policy in place for all staff and young people. There was a Child Protection Policy and Procedure in place and all staff had received training in respect of child protection. This was updated regularly to take account of any changes in legislation. We spoke with staff about what they would do if there were child protection concerns and the staff we spoke with demonstrated a sound understanding of this. We looked at various other records and this included how medication was recorded. At the previous inspection we identified this as an area for improvement. At this inspection we saw that this had been addressed and that additional training had been identified for all staff with regards to the administration and recording of medication. There was an Infection Control Policy and Procedure in place based on NHS guidelines. All staff who prepared food had the relevant Food Hygiene Certificate. Areas for improvement Inspection report continued During the course of this inspection, we identified many examples of very good practice being carried out by staff. We also observed very good examples of interaction between staff and the young people. We also saw that Care Plans had been reviewed and that the management team monitored these and other documentation to ensure they were up to date. However, in saying this, we also found evidence to the contrary. We found that there were examples of practice being carried out by some staff which were unacceptable. When we spoke with some of the young people and a parent they told us that: On one occasion when they were down in the town, they had to walk back to the home as staff would not go to collect them earlier than planned. This resulted in them having to walk along a dangerous road during the hours of darkness. The care home is a considerable distance from the town centre and once leaving the street lighting, this road presents a great risk to the young people. Northern Lights has a very clear procedure in place with regards to the collection of young people. However on this occasion, this had not been followed. (See Requirement 1) Northern Lights, page 15 of 28

Some staff members used their personal mobile telephones to video young people when they were 'toy fighting'. Young people and a parent told us that they did not think this was right and that this should never have happened. Young people questioned the legality of such practices and stressed that they had not given permission nor were they happy with what had taken place. When we spoke with the management team about this they were not aware of the incident. The management team agreed that such practices were not acceptable and that they would cease immediately. (See Requirement 2) If the young people were playing their music too loud or at unacceptable times of the day and night, some staff used the electrical trip switch to turn off the electricity sockets in their bedrooms. This practice is not acceptable and alternative ways need to be considered to address this issue. (See Requirement 3) Grade awarded for this statement: 2 - Weak Number of requirements: 0 Number of recommendations: 0 Requirements 1. The service provider should ensure that at all times, young people are not exposed to unacceptable risk and that all staff follow the procedures that are in place with regards to the collection of young people when they are away from home. This in accordance with: SSI 2011/2010 regulation 4(1)(a) (b) - a requirement that the provider shall make proper provision for the health and welfare of service users and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 6. Timescale: Immediate on receipt of this report. 2. The service provider should ensure that the use of personal mobile telephones to record young people's behaviour ceases immediately. This in order to comply with: Inspection report continued SSI 2011/2010 Regulation 4(1)(a) - a requirement that the provider shall make proper provision for the health and welfare of service users and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 6(9) and 7(1) and the Main Principles of the National Care Standards: Care Homes for Children and Young People: Dignity, Privacy and Respect. Northern Lights, page 16 of 28

Timescale: Immediate on receipt of this report. 3. The service provider should ensure that the use of the electrical trip switch to turn off electrical supplies to bedroom sockets ceases immediately. This in order to comply with: SSI 2011/2010 Regulation 4(1)(a) - a requirement that the provider shall make proper provision for the health and welfare of service users and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 8(1) and 8(3). Timescale: Immediate on receipt of this report. Recommendations 1. The service provider should ensure that communication, particularly with field social workers, improves and that young people are kept informed about appointments. This in accordance with: Inspection report continued The National Care Standards: Care Homes for Children and Young People: National Care Standard: 3. Northern Lights, page 17 of 28

Quality Theme 2: Quality of Environment Grade awarded for this theme: 5 - Very Good Statement 2 We make sure that the environment is safe and service users are protected. Service strengths The grade awarded for this Quality Statement was 5 - Very Good. We found that there were systems in place to ensure that the environment was safe and that young people were protected. For example, the remote location of Northern Lights resulted in additional systems of security. An outdoor sensory light was in place and access to the unit is secure with a lockable gate and large wooden fence which surrounded the property. Any visitors to the unit are required to sign the Visitors Book and this records the time of entry and time of exit. All visitors are asked for identification by staff if they are not known and entry into the unit is via a door bell. All staff employed at Northern Lights have been the subject of Barnardo's recruitment processes and these are robust. All staff had received training in Crisis and Aggression, Limitation and Management (CALM). The concept of CALM structures the residential living environment, the focus of intervention on creating a positive environment which allowed young people to feel safe, protected and able to meet their potential. We noted that at Northern Lights there had been no physical restraint used. Staff at Northern Lights used the environment to de-escalate potential crisis at the earliest opportunity. For example, the large unit and garden areas enabled staff to move to another part of the building or go for a walk in the garden. When we looked at the case files for the young people, we saw that there were appropriate risk assessments in place and this also identified any potential areas which would require staff intervention. There were documents in place to record accidents, incidents and absconding and these records were monitored by management to see if there were emerging patterns which would inform and allow staff to consider strategies to support the individual young people. The building is maintained by the Health and Safety Officer and all faults are reported to the Properties and Facility Management Team for action. We looked at records of faults during this inspection and saw that remedial action was carried out. All necessary Health and Safety checks, to include equipment and vehicle maintenance were carried out. We looked at the records of these checks during the inspection and saw that this was carried out weekly. There was an Infection Control Policy and Northern Lights, page 18 of 28

Procedure in place and this was based on the National Health Service (NHS) guidance. Staff who prepared food had the relevant Food Hygiene Certificate. When we spoke with the young people they told us that they felt safe in the unit and parents we spoke with confirmed this. In the Care Standards Questionnaires returned to us young people strongly agreed that they felt protected from bullying, protected from abuse. Young people told us that "I can lock my door if I want and that people don't take things without my permission". All the young people strongly agreed that Northern Lights was a nice place to stay. Young people thought that the Keyworker system also assisted in them feeling safe and secure in the environment. One young person referred to their Keyworker as "awesome". Areas for improvement Inspection report continued The service provider could improve the Visitors Book by making it clearer when there are visitors to the unit. The service provider should continue to maintain the current very good practice. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Northern Lights, page 19 of 28

Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Although we identified many strengths with regards to the quality of staffing and observed some very good practice being carried out by staff, this contrasted with evidence we found after speaking to some of the young people and their parents. This resulted in a grade of 3 - Adequate being awarded for this Quality Statement. We have identified the areas for improvements and requirements in Quality Theme 1, Quality Statement 3. Staff who worked at Northern Lights were suitably qualified and were registered with the Scottish Social Services Council (SSSC). All staff had a copy of the SSSC Codes of Practice and were aware of the conditions of registration. All staff had access to a copy of the National Care Standards, Legislation and Best Practice guidance. All staff had copies of the organisational Policies and Procedures issued by Barnardo's and this included, Whistle Blowing and Service User Protection. Since the last inspection, staff had received training to include, Child Protection, Food Hygiene, Nutrition and 2 staff had been accredited as CALM trainers. Further training had been arranged and this included training in the recording of medication. This was an area for improvement that we identified at the last inspection. Each member of staff had a Personal Development Plan and this was updated after one to one meetings with management. We looked at a selection of one to one meetings with management and saw that this was carried out on a monthly basis. When we spoke with staff they told us that they received very good support from the management team and that they could approach them at any time if they had concerns. We noted during our inspection visits that the open door policy was well used by staff. The staff that we spoke with during this inspection were clearly motivated and keen to provide a good service and demonstrated a very good understanding of the needs of the young people they cared for. Northern Lights, page 20 of 28

Areas for improvement During this inspection we found that there was many strengths with regards to this Quality Statement. However, we also found evidence to the contrary. When we spoke with some of the young people and a parent we were told that there was several areas that they were not happy with. For example: We were told that there was a lack of consistency, by some staff, in the application of rules and sanctions. We were told that "the rules changes every day and it depended on what staff were on duty". We were told that young people thought some of the rules were not fair. For example, when one young person did something wrong, and if the others complained, then they were all subject to sanctions and we were concerned that young people felt dis-empowered and accepting of these sanctions without the right to question. (See Requirement 1) Staff received very good support from the management team and received regular one to one supervision sessions, staff meetings held and informal contact on a daily basis. However, we were concerned that no member of staff had brought concerns about unacceptable practice issues to their attention. There is a very clear Whistle Blowing Policy and Procedure in place but this had not been used by staff. This would lead us to question whether or not there is an open and transparent environment where staff feel confident in reporting poor or unacceptable practice. (See Requirement 2) Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 0 Requirements 1. The service provider must review their use of consequences, rules and sanctions and any future use must take account of the young persons age and be linked to clear learning outcomes. Care Plans must clearly reflect how consequences will impact on individual young people. This is in order to comply with: SSI 2011/2010 regulation 4(1)(a) (b) - a requirement that the provider shall make proper provision for the health and welfare of service users and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 15 (9) and (10). Timescale: within 1 week of receipt of this report. Inspection report continued Northern Lights, page 21 of 28

2. The service provider must ensure that all staff are encouraged and supported to report poor practice issues to the management team. Work needs to continue to create an atmoshpher of openness and transparency within which staff can fully comply with the Main Principles of The National Care Standards. This is in order to comply with: SSI 2011/2010 regulation 4(1)(a) - a requirement that the provider shall make proper provision for the health and welfare of service users and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 7 and SSSC Codes of Practice 3:2 and 3.5. Timescale: within 1 week of receipt of this report. Inspection report continued Northern Lights, page 22 of 28

Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 3 - Adequate 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 The grade awarded for this Quality Statement was 3 - Adequate. We found that there were systems in place to assess the quality of service provided and this included: An annual service review and quality assurance questionnaires distributed twice yearly to young people, parents and other stakeholders and any feedback evaluated. We looked at a selection of these during this inspection and saw that the evaluation also included actions to be taken and by whom. Young people who had moved on from Northern Lights were sent out a questionnaire to gain their views about the quality of service provision. These questionnaires were also sent out to relevant professionals and parents (where this was appropriate). Feedback from the questionnaires was discussed at team meetings and also with individual staff during one to one meetings if this was required. The management team of Northern Lights were aware of their responsibilities to make notifications to the SSSC and the Care Inspectorate. Areas for improvement We saw that there was systems in place which were used by the management to assess the quality of service provision. During this inspection we discussed the concerns that we had relating to various aspects of staff practice and we were told by the management that this had not been brought to their attention. We were told that if they had been informed then immediate action would have been taken. We noted that once management at Northern Lights were aware of the issues highlighted in this report, that they did take action. However, it is clear that the current quality assurance systems that are in place are not robust enough to identify issues at an early stage and address these as a matter of urgency. The service provider needs to ensure that the quality assurance systems are strengthened to ensure that any areas of poor practice are identified and addressed as a matter of urgency. (See Requirement 1) Northern Lights, page 23 of 28

Other areas for improvement which have implications for the management of this service have been identified in the requirements made in Quality Theme 1, Quality Statement 3 and Quality Theme 3, Quality Statement 3. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 0 Requirements 1. The service provider needs to ensure that the Quality Assurance systems that are in place are robust enough to address areas of poor practice when they arise. This is in order to comply with: SSI 2011/2010 Regulations 4(1)(a) and the National Care Standards: Care Homes for Children and Young People: National Care Standard: 7(6). Timescale: 3 months from receipt of this report. Northern Lights, page 24 of 28

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 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 the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Northern Lights, page 25 of 28

5 Summary of grades Quality of Care and Support - 2 - Weak Statement 3 2 - Weak Quality of Environment - 5 - Very Good Statement 2 5 - Very Good Quality of Staffing - 3 - Adequate Statement 3 3 - Adequate Quality of Management and Leadership - 3 - Adequate Statement 4 3 - Adequate 6 Inspection and grading history Date Type Gradings 19 Nov 2012 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 25 Jun 2012 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 14 Oct 2011 Unannounced Care and support 3 - Adequate Environment 4 - Good Staffing 3 - Adequate Management and Leadership 3 - Adequate 22 Jun 2011 Unannounced Care and support 2 - Weak Environment 2 - Weak Staffing 3 - Adequate Management and Leadership 2 - Weak Northern Lights, page 26 of 28

All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Northern Lights, page 27 of 28

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 the Care Inspectorate. You can get more copies of this report and others by downloading it from our website: www.careinspectorate.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: enquiries@careinspectorate.com Web: www.careinspectorate.com Northern Lights, page 28 of 28