Swanwick Lodge

Unique reference number SC038719 Inspection date 22/01/2014 Inspector Shaun Common / Philip Cass Type of inspection Full Provision subtype Secure Unit

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Date of last inspection 31/07/2013 Website: www.ofsted.gov.uk

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This document may be reproduced in whole or in part for non-commercial educational purposes, provided that the information quoted is reproduced without adaptation and the source and date of publication are stated.

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Brief description of the service

This secure children's home is managed by a local authority. It is approved by the Department for Education to restrict young people's liberty. As well as the living accommodation, education is provided on site in dedicated facilities.

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Brief description of the service

The children's home can accommodate up to 16 young people, who are aged between 10 and 17 years. Admission of any young person over the age of 10 but under 13 years of age requires the approval of the Secretary of State.

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The inspection judgements and what they mean

Outstanding : a service of exceptional quality that significantly exceeds minimum requirements Good : a service of high quality that exceeds minimum requirements Adequate : a service that only meets minimum requirements Inadequate : a service that does not meet minimum requirements

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Overall effectiveness

The overall effectiveness is judged to be inadequate .

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Overall effectiveness

Improvements required at the last inspection have not all been actioned due to a Lack of robust leadership and management. There has been a missed opportunity to address a security matter that has placed young people at potential risk and lack of robust monitoring means other shortfalls have not been identified and addressed.

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Overall effectiveness

A number of improvements have been made including: how records are kept; young people being able to write their comments on records; the home having sufficient staff on duty at all times; ancillary staff trained in child protection; a formalised approach for the assessment, development and promotion of skills for adulthood and the search policy being implemented.

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Overall effectiveness

Young people continue to make good progress and their health outcomes and educational achievement are positive. They have access to a range of services and are provided with good support from staff. There are good relationships between staff and young people and young people are consulted about the running of the home and their care.

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Overall effectiveness

Young people's needs are assessed on admission and plans developed for their care that are implemented in practice. Those assessed as vulnerable receive close care and support during the day to keep them safe. However, risk assessments relating to self-harm lack rigour in order to guide night staff in the level of observations required to keep young people safe. The checks undertaken by night staff lack consistency and place young people at potential risk.

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Overall effectiveness

Young people are supported to develop skills for adult life and to assist them when they return to the community. Contact with family is promoted and supported so that young people can stay in touch with people important to them.

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Overall effectiveness

Strong links continue with the Local Safeguarding Children Board (LSCB), which supports the home to deliver better care to young people. Child protection matters are dealt with appropriately and referred to the local authority which helps to keep young people safe. However, records of actions taken by managers are lacking and do not show the steps taken in order to comply with their own policy and procedure.

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Overall effectiveness

Formal support for staff continues to be lacking and inconsistent. Formal supervision is not carried out to the frequency set out in the home's policy. As a result staff are not adequately supported in their work with vulnerable young people. Some staff have undertaken training in supporting young people who self-harm. Not all care staff have not had this opportunity, which would give them improved knowledge and skills to support young people with these needs.

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Overall effectiveness

Young people are supported to develop positive behaviour. Physical restraints and sanctions are appropriately used and are well monitored. Single separation is used in line with the home's policy, but records kept do not always show that the criteria for using this measure of control are met on all occasions.

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Statutory Requirements

This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Children's Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must comply with the given timescales.

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Reg. Requirement Due date

(2001) ensure the children's home is conducted in line with the regulation; specifically that risk assessments pertaining to children at risk of suicide or self-harm are robust and fully implemented (Regulation 11(1)(a)) 24/01/2014

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Reg. Requirement Due date

(2001) promote and make proper provision for the welfare of children accommodated; specifically, ensure night care staff complete full and accurate records of checks carried out in line with the relevant risk assessments, on young people that are assessed as vulnerable (Regulation 11(a)) 28/02/2014

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Reg. Requirement Due date

(2001) promote and make proper provision for the welfare of children accommodated; specifically, ensure a relevant and appropriate procedure is in place that addresses safety and security in the 31/01/2014 sports hall (Regulation 11(a))

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Reg. Requirement Due date

(2001) make proper provision for the care, education, supervision and, where appropriate, treatment, of children accommodated; specifically, ensure all doors that provide security in the children's homes are kept locked shut and staff are aware of their responsibilities to check and 'prove' door locks are fully engaged (Regulation 11(b)) 24/01/2014

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Reg. Requirement Due date

(2001) ensure the written child protection procedure is fully implemented; specifically, that accurate and detailed records are kept of any allegation of abuse or neglect, and of the action taken in response (Regulation 16(2)(d)) 28/02/2014

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Reg. Requirement Due date

17B (2001) implement the written behaviour management policy which sets out the measures of control which may be used in a children's home; specifically, keep an accurate record of all uses of single separation (Regulation 17B(1)(a)) 17/03/2014

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Reg. Requirement Due date

(2001) ensure that all persons employed receive appropriate supervision (Regulation 27(4)(a)) 17/03/2014

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Reg. Requirement Due date

(2001) maintain the system for monitoring the matters set out in this regulation; specifically, ensure all matters in Schedule 6 are robustly monitored to ensure the quality of care provided improves. (Regulation 34) 17/02/2014

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Recommendations

To improve the quality and standards of care further the service should take account of the following recommendation(s):

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Recommendations

 ensure staff are equipped with the skills required to meet the needs of the children; specifically, ensure all care staff undertake training in self-harm. (NMS 18.1)

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Outcomes for children and young people

Outcomes for young people are adequate .

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Outcomes for children and young people

Night time supervision of the young people is not sufficiently robust, managed or monitored. This means there is potential risk to young people.

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Outcomes for children and young people

Young people become healthier during their time at the home. They develop better physical health because they have access to a range of health care services and support from staff. They are provided with education about the effects of illicit drug use and alcohol and tobacco. This ensures they can make healthier lifestyle choices and keep themselves safe. Emotional health and well-being also improves with young people provided support by staff and relevant professionals who assess and meet their individual needs. As young people grow in self-esteem, they begin to make positive health choices and learn to take responsibility for their own health. Over time, young people develop improved social skills. They become better able to regulate their emotional responses and cope with setbacks. As young people grow in emotional resilience they demonstrate improved behaviours. Risk taking behaviours reduce over time. Young people learn to take pride in their achievements. A young

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Outcomes for children and young people

The home has clearly agreed and recorded contact arrangements. This means that young people benefit from visits and telephone calls from family and others who are important to them. The welfare of young people is promoted because staff are good at helping young people to build better relationships with their families. Young people also make progress in developing life skills. Improvements have been made to the independence skills programme so that it better reflects and supports young people to meet the challenges they face as they move into adulthood.

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Outcomes for children and young people

Young people make a positive contribution to the home. Young people’s meetings are used well to gather their views, wishes and feelings. Managers respond positively to the opinions and requests of young people. For example, their views are central to menu and activity planning. Although the home’s youth council is not currently in operation as young people do not wish to attend, it has been used effectively to make improvements to the young people’s guide. The home has good consultation processes and therefore young people feel valued and respected.

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Outcomes for children and young people

When young people are admitted to the home with a significant history of truancy and resistance to education, they are supported to understand the value of going to school. Educational outcomes are strong with young people making good progress from the point they are admitted. Many young people gain qualifications that enable them to access further education or employment when they leave the home.

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Quality of care

The failure to adequately monitor vulnerable young people at night impacts upon the quality of care provided.

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Quality of care

Interactions between staff and young people are warm and nurturing. Young people form trusting relationships with staff and feel able to confide in them. Consequently, they make healthy attachments that lead to improved self-esteem. Young people are comfortable and relaxed in the company of staff and there is a pleasant and welcoming atmosphere in the home. Young people are confident to raise concerns directly with staff, or where necessary, by using the formal complaints procedure. Young people say that they trust staff, because they respond quickly to their concerns. Staff are skilled at helping young people to understand why it may not be possible to act on their wishes in all cases.

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Quality of care

The home is adequately decorated and maintained. Communal areas are comfortable and equipped with a good range of leisure activities including a pool table and games consoles. This means that young people can take part in a range of constructive and enjoyable activities in the home. In addition young people have access to exercise equipment and a large sports hall. This helps young people to keep fit and healthy. Young people are able to personalise their bedrooms and said that they like their rooms.

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Quality of care

Placement planning is of a good standard. As a result, staff have a very good understanding of the complex needs of young people. Care plans are regularly updated and staff respond well to the changing needs of young people. They fully understand and meet the individual needs of young people relating to their culture, heritage or background. Keyworker sessions are used effectively to discuss placement plan objectives. Staff demonstrate great empathy and compassion and they address sensitive issues well. Young people make progress towards developing emotional resilience, because staff are skilled at helping them to cope with the impact of early childhood issues.

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Quality of care

Health care services provided to young people are good. Primary health needs are addressed by the home’s nurse, General Practitioner, dentist and optician. In addition, young people have access to specialists in mental health, emotional health, substance misuse and diet. These services ensure that the overall health of young people improves following admission to the home. Substance misuse services have become more consistent, so young people are better supported to address any drug and alcohol needs. The home has also improved its response to medical emergencies through the commissioning of a specialist response service. This has impacted positively on the support provided to young people with self-harming behaviours.

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Quality of care

Young people are helped to succeed at school. Education and care staff work together effectively to support young people. Information is shared promptly so that education is tailored to the specific needs of young people. Following consultation with young people, the home has improved its education reward programme and approach to exclusion. There is now greater flexibility in decision making so that young people are excluded less often and for shorter periods. This improves education attendance and ensures that young people are given every opportunity to achieve their potential.

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Safeguarding children and young people

The service is inadequate at keeping children and young people safe and feeling safe.

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Safeguarding children and young people

Young people raised no concerns about bullying. The home has an appropriate bullying policy that sets out how matters will be managed and addressed. Managers and staff have a commitment to ensuring that if bullying behaviour becomes evident, that they will address it fully and quickly to help keep young people safe.

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Safeguarding children and young people

Upon admission to the home, staff assess each young person's needs and identify any concerns about suicide or self-harm. A risk assessment is devised and reviewed on a very regular basis to include any new and relevant information. During daytime routines, staff fully implement risk assessments to help keep young people safe. However, with regards to night time routines, risk assessments are not thorough or robust. They do not indicate how often night staff should check on a young person who is vulnerable or a risk to themselves. Night care logs are completed for each young person. However, records and closed circuit television (CCTV) show that checks are not carried out in line with the home's expected practices. Records of checks are not consistent with CCTV. The lack of robust risk assessments and the lack of consistent checks by night care staff, place highly vulnerable young people at risk of potential harm.

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Safeguarding children and young people

The home has a child protection procedure and guidance for staff to follow if they have any concerns or suspicions a young person is at risk of harm. There have been four child protection concerns since the last inspection. All of these concerns have been referred to the local authority and appropriate measures taken to ensure matters are addressed and young people are kept safe. However, only two of these have been appropriately and fully recorded. The records relating to two incidents do not evidence that the home's procedures have been fully implemented. For example, there is no record of the dialogue with the local authority child protection team and the direction provided by them or decision making that would permit a senior staff member at the home to instigate a fact-finding exercise, including interviewing young people and interrogating CCTV footage.

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Safeguarding children and young people

The Registered Manager continues to have strong links with the Local Safeguarding Children Board (LSCB). She is a member of a sub-committee of the Board, working with them to improve safeguards to young people in the area. The home continues to provide regular information on physical restraint to the LSCB and this ensures the Board continues to support the home to improve practices.

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Safeguarding children and young people

The use of physical intervention is appropriate and staff are trained in the techniques used to ensure young people are kept safe. There are no pain compliance methods used at the home as confirmed by the Registered Manager. Full and detailed records of each incident are kept in a suitable format and young people see these records and are able to add their comments. Young people are now debriefed by someone not involved in the incident, so any learning can be gained and support provided. Every incident of restraint is reviewed by the Registered Manager and head of care. CCTV and records are examined to ensure practice is appropriate, approved methods are used, any learning points can be identified and good practice is shared with the staff team.

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Safeguarding children and young people

The home's incentive scheme is well known and understood by young people. The scheme has a range of levels through which young people can progress. This starts with pre-bronze level then moves on to bronze and through to platinum-plus. Each level has progressive rewards and benefits which encourages and supports young people to develop positive social skills and behaviour.

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Safeguarding children and young people

Sanctions are considered and used by staff in response to any negative behaviours exhibited by the young people. Staff apply a restorative approach where possible, encouraging young people to put right or make good what they have done wrong. Sanctions used are varied and relevant to the misdemeanour. Full and accurate records are kept of all sanctions imposed in a suitable format. Positively, young people now have the opportunity to have their comments recorded in the records, which encourages and supports them to develop understanding and responsibility.

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Safeguarding children and young people

The home has appropriate policies and procedures regarding the searching of young people, their rooms and communal areas in order to promote safety and wellbeing. Searching of young people is underpinned by a risk-led approach. There have been no full searches involving young people having to remove their clothing and searches that have taken place involve a pat down and/or use of an electronic wand. This promotes young people's dignity. Records are kept of all searches showing the rationale, type of search and other relevant details. Searches of bedrooms and communal areas are carried out at least weekly in line with the home's policy in order to promote the safety of all.

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Safeguarding children and young people

The home's policy for the use of single separation is commensurate with government guidance in that young people are only placed in single separation when there is a risk to them, others, or there is significant damage to property. Records kept by the home show that in most cases, the use of single separation is fully justified and appropriate. However on some occasions, records do not demonstrate the criteria is met. For example, a young person arguing with others or when in single separation for a sustained period, positive behaviour is exhibited demonstrating the criteria no longer apply. Managers monitor every incident of single separation to ensure that the criteria for its use are met and therefore there appears to be poor recording in some instances. A recommendation was made at the last inspection about this issue and as has not been fully addressed, a requirement is raised about this matter.

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Safeguarding children and young people

Not all security matters in the home have been managed effectively. A weakness in the home's security arrangements was exploited by young people who very recently entered an area where there were risks to their safety and wellbeing. A similar event occurred some months earlier. Managers missed the opportunity to act robustly by learning from the first event and taking action by developing procedures to ensure the possibility of a repeat event was eliminated. Action has now been taken but relevant procedures have not been developed to guide staff. A further lapse in security was observed during the inspection when a secure door was left open. This could have provided young people with the opportunity to access an area where prohibited items were located with the potential of risk to others. Managers addressed this situation immediately.

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Safeguarding children and young people

There have been no incidents of absconding since the last inspection. The home has a procedure and protocol with the local police that supports staff to keep young people safe should there be any incident.

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Safeguarding children and young people

Five new staff have been recruited since the last inspection. Records kept by the home demonstrate there is clear process and procedure for the recruitment and selection of new employees. This helps to ensure that the right people are employed to work with vulnerable children.

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Leadership and management

The leadership and management of the children's home are inadequate .

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Leadership and management

The home is not effectively led and managed as matters raised at previous inspections have not all been acted upon and further shortfalls have not been identified through robust monitoring. This means the quality of care and potentially the safety and wellbeing of young people are compromised.

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Leadership and management

The manager of the home was recently registered with Ofsted and is in the process of acquiring the relevant management and childcare qualifications for this role. She is supported by an experienced, child-focused head of care who shows a strong commitment to improving the service provided to young people. The management team has been further strengthened recently by the external line manager being permanently based at the home, providing direct support.

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Leadership and management

Suitable action has been taken to address three of the six requirements made at the last inspection. For example, a number of new staff have been recruited and there are improved working agreements with external partners to provide additional resources to facilitate hospital visits. This, combined with effective rota planning, ensures young people’s known and emerging needs can be met on a day-to-day basis. All care and ancillary staff have undertaken child protection training. As a result, staff are able to respond to and appropriately manage emerging safeguarding concerns. The detail contained in sanction records has improved and now includes an evaluation of the effectiveness of the use of any measure. This ensures sanctions are proportionate and have a positive impact on young people’s behaviour.

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Leadership and management

A failure to address three requirements has impacted significantly on the judgement for leadership and management. There continue to be shortfalls in risk assessments pertaining to young people at risk of suicide or self-harm. Consequently, young people’s welfare is not consistently protected and they are unnecessarily exposed to potential risk. Systems for robust monitoring by the Registered Manager are not sufficiently robust. The reporting format that evidence's this monitoring has been improved but application of the process lacks rigour and does not sufficiently identify and address shortfalls in practice or recording. Some progress is noted in relation to staff supervision. However, this is inconsistent with a significant number of staff still not receiving regular, formal supervision.

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Leadership and management

A large majority of the recommendations from the previous inspection have been addressed. Behaviour management records, including single separation, restraint and sanctions are now in formats that cannot be tampered with after the event. Young people are encouraged to contribute to these records by having their views and opinions recorded. Following incidents of restraint, these views are gathered by an adult not involved in the incident. These developments help to ensure records are accurate and young people have the opportunity to comment on and raise concerns about their care, should they choose to do so. The home’s policy for weekly room searches is consistently put into practice ensuring hazardous items are removed and young people’s safety is not compromised. A more formalised approach for the assessment, development and promotion of skills for adulthood has been introduced. As a result, young people are better prepared to move on from the home. Minutes of

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Leadership and management

young people’s meetings confirm they are fully involved in the day-to-day running of the home. They clearly evidence that young people’s views have been listened to and action has been taken to meet any reasonable requests.

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Leadership and management

One recommendation from the previous inspection has not been addressed. Records of single separation do not always evidence that the criteria for separation is met and that this continues to be met during longer periods of separation.

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Leadership and management

The Statement of Purpose suitably informs interested parties of what the home offers and the statement reflects how the home operates in practice. Additional information is available for young people in the form of a children’s guide. This guide has been developed by young people and gives a child-friendly insight into what it is like to live at the home.

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Leadership and management

External monitoring of the home is good. It includes regular consultation with young people and their families. A development plan is in place, areas of weakness have been highlighted and there is a clear vision of the progress and direction desired. Recently, there has been an increased emphasis on challenging shortfalls through performance management and managers are working closely with human resources professionals to ensure practice shortfalls are appropriately challenged.

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Leadership and management

Young people are looked after by a suitable number of competent staff. New staff have benefited from an induction process that affords them a good introduction to working with young people in the secure environment. For example, they are given basic training in safeguarding, behaviour management, the homes therapeutic model of working, as well as being given time to familiarise themselves with the environment and the home’s policies and procedures. Continuous learning and development is promoted through the completion of the Children’s Workforce Development Council’s induction standards. New staff commented that this is a positive improvement to practice and that as a result they feel well prepared for, and supported in their new role.

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Leadership and management

Staff qualification levels are good. Unqualified staff are well supported to ensure they can complete the relevant qualifications for their role. All staff have undertaken mandatory training in key areas of practice including child protection, physical intervention and first aid. The organisation has developed a children’s safeguarding training pathway which it is in the process of rolling out to all staff. This will help ensure staff receive the appropriate level of safeguarding training relevant to the amount of contact they have with young people. Service specific training is available. For example, records confirm that 11 full-time staff have completed training in working with young people who self-harm. However, given the needs of the young people currently living at the home, all staff would benefit from this training to equip them with the relevant knowledge and skills.

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About this inspection

The purpose of this inspection is to assure children and young people, parents, the public, local authorities and government of the quality and standard of the service provided. The inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service and to consider how well it complies with the relevant regulations and meets the national minimum standards.

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About this inspection

The report details the main strengths, any areas for improvement, including any breaches of regulation, and any failure to meet national minimum standards. The judgements included in the report are made against the Inspections of children’s homes – framework for inspection and the evaluation schedule for the inspection of children's homes.

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