Setting in Wolverhampton

children and young people since the most recent full inspection

This home was judged Requires improvement at the full inspection. At this interim inspection Ofsted judge that it has Declined effectiveness .

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children and young people since the most recent full inspection

Inspectors were aware during this inspection that a serious incident that occurred, while in the care of staff employed by the setting since the previous inspection, is under investigation by the appropriate authorities. While Ofsted does not have the power to investigate incidents of this kind, actions taken by the setting in response to the incident were considered alongside the other evidence available at the time of the inspection to inform inspectors‟ judgements.

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children and young people since the most recent full inspection

This inspection identified widespread concerns that relate to the management of the home and the safety and wellbeing of young people in the home.

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children and young people since the most recent full inspection

There has been no registered manager in post since May 2015. This has led to a lack of robust managerial oversight of everyday practice in the home. The consequence of this is a lack of scrutiny of staff practice, a failure to review events in the home to identify shortfalls, lack of managerial support and leadership for staff and a failure to identify and effectively follow up on safeguarding matters. The manager in post at the time of inspection had been working in that role for two months. She had not submitted a completed application for registration to Ofsted. Staff and young people report that the manager is not available or accessible and does not provide good leadership, particularly in times of conflict with young people.

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children and young people since the most recent full inspection

A member of staff had raised concerns with the manager in respect of another member of staff‟s practice, such as escalating confrontation with a young person. The manager has not addressed these concerns. In addition, the manager had been aware of an occasion when this member of staff and one other did not get up in time, having slept in, to take a young person to her work placement. This led to the young person climbing out of the lounge window and walking to the placement, on a busy and dangerous road, by herself. This put the young person at significant risk.

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children and young people since the most recent full inspection

The electric gates situated at the front of the property have not worked since 1 September 2015. This has not ensured that reasonable precautions have been taken to protect young people from walking straight out on to the road and has not provided protection against unsuitable adults accessing the home and engaging with young people. The gates were repaired shortly after the death of a young person who was accommodated in the home.

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children and young people since the most recent full inspection

None of the young people accommodated at the home at the time of this inspection are currently in education or employment. This does not promote their life chances and opportunities for adulthood.

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children and young people since the most recent full inspection

There are staff who have not received effective practice-related supervision. The records demonstrate a lack of reflection on practice, no in depth discussion about the impact of care on young people‟s needs, risks posed to young people, review of policies, documents and risk assessments. There is no practice-related supervision in December 2015, January or February 2016 for one member of staff. This is despite a practice concern being raised by another member of staff in January 2016. Two new members of staff have not had any practice-related supervision since they commenced their posts in January 2016, despite the death of a young person living at the home occurring. The supervision does not provide robust managerial oversight and practice concerns have not been addressed.

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children and young people since the most recent full inspection

One young person has been sleeping in a bed that was propped up by pieces of wood and books. Another young person‟s room was in a very poor state, with broken furniture. A member of staff confirmed this had been the case for a number of months and had not been addressed. Another member of staff described themselves as „disgusted‟ when it came to their notice. This does not promote young people‟s wellbeing or support them to feel valued.

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children and young people since the most recent full inspection

Records reflect that there was no room search carried out for a young person, despite staff being aware that she was under the influence of a substance, thought to be cannabis. There is no incident report for this and no detail of the follow up by staff in respect of how and where the young person obtained cannabis.

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children and young people since the most recent full inspection

There is a lack of reflection and robust oversight of physical restraint. Three incidents of restraint that have been confirmed on inspection do not have any report and there is no reference in the restraint log or the report log. In one of these incidents, one young person alleges she was dragged through glass. Lack of accurate recording fails to safeguard young people. It does not enable objective monitoring, review of physical restraint or ensure that staff practice is safe.

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children and young people since the most recent full inspection

Complaints made by young people relate to allegations against staff. They have been notified to the Local Area Designated Officer but have not been notified to Ofsted. This has prevented Ofsted, as the regulator, from having oversight of the events in the home and obstructed opportunities to safeguard young people. In addition, the organisation failed to report, without delay, the death of a young person accommodated at the home in line with the reporting of injuries, diseases and dangerous occurrences regulations 2013 (RIDDOR). An incident took place relating to a young person being visited at the home by a male who demanded money for cannabis. Although it was recorded in the daily log and referred to the police, there is no detail of the outcome and the individual risk assessment has not been updated as a result. This has not promoted the young person‟s safety.

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children and young people since the most recent full inspection

There is no consultation by the independent visitor with young people‟s parents. This means opportunities for additional layers of safeguarding have been missed.

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children and young people since the most recent full inspection

The updated location risk assessment is not sufficient to ensure that the young people are effectively safeguarded. Despite the death of a young person, the update is minimal, has not involved key stakeholders, and does not include information that should have been considered. This has not provided staff with clear mitigating actions to reduce known risk from the road. Staff are unaware of the content of the risk assessment.

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children and young people since the most recent full inspection

Young people‟s individual risk assessments contain gaps and out of date information and have not been updated after incidents that should have triggered such an update. For example, missing incidents, including one incident of missing for five days. This fails to ensure that young people are protected from harm as far as possible.

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children and young people since the most recent full inspection

There is no evidence that young people who have been missing have had independent return interviews and no evidence that the staff have pursued return interviews for young people. This means that staff miss opportunities to ensure that young people have not been harmed. Additionally, it does not support staff to identify strategies to avoid future risks.

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children and young people since the most recent full inspection

The training records do not show any training has taken place regarding missing children. The manager confirmed staff have not had training in managing missing children, despite the risk assessment for one young person stating explicitly that all staff will be trained in missing. This does not give staff the skills they need to manage complex behaviours that have high levels of risk attached.

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children and young people since the most recent full inspection

The fire risk assessment does not consider the fact that the young people are refusing to evacuate during fire drills. Therefore, staff do not have clarity on how to manage a situation when there is a real fire, should young people refuse to evacuate.

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children and young people since the most recent full inspection

Staff are permitted to smoke in the garden, when young people are present in the home. This does not provide a good role model for young people.

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children and young people since the most recent full inspection

The policies that staff refer to in the home are not up to date. This does not support them to ensure their practice is in line with current legislation and directives.

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children and young people since the most recent full inspection

The full inspection identified three requirements and two recommendations. The requirements in respect of the location risk assessment and risk management for individual young people have not been met. The recommendations in respect of consultation with young people and ensuring that staff have the skills to manage high risk behaviour have not been met. Young people‟s views do not inform monitoring of the care provided.

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children and young people since the most recent full inspection

At the end of this inspection, the responsible individual was asked by inspectors to take immediate action to follow up concerns about staff practice and to put in place a robust management system as a matter of urgency.

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Information about this children's home

The home is privately owned by a small organisation and caters for up to four children with emotional and behavioural difficulties.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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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 (England) Regulations 2015 and the Guide to the children's homes regulations including the quality standards. The registered person(s) must comply with the given timescales.

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Requirement Due date

5. Engaging with the wider system to ensure children‟s needs are met

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Requirement Due date

In meeting the quality standards, the registered person must, and must ensure that staff—

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Requirement Due date

(a) seek to involve each child‟s placing authority effectively in the child‟s care, in accordance with the child‟s relevant plans; (b) seek to secure the input and services required to meet each child‟s needs; (c) if the registered person considers, or staff consider, a placing authority‟s or a relevant person‟s performance or response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child‟s needs are met in accordance with the child‟s relevant plans. 14/03/2016

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Requirement Due date

6. The quality and purpose of care standard

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Requirement Due date

In order to meet the quality and purpose of care standard, with particular reference to staff interaction with young people, the registered person to ensure that staff:

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Requirement Due date

(2) (b) (ii) protect and promote each child‟s welfare; (iii) treat each child with dignity and respect. 14/03/2016

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Requirement Due date

7. The children‟s views, wishes and feelings standard

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Requirement Due date

In order to meet the children‟s wishes and feelings standard, with particular reference to consultation with young people, the registered person must:

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Requirement Due date

(2) (a) (iv) regularly consult children, and seek their feedback, about the quality of the home‟s care. 14/03/2016

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Requirement Due date

8. The education standard 14/03/2016 In order to meet the education standard, with particular reference to promoting employment, the registered person must ensure that staff:

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Requirement Due date

(2) (a) (iv) help each child to understand the importance and value of education, learning, training and employment.

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Requirement Due date

In order to meet the protection of children standard, with particular reference to assessing and mitigating known and potential risks to young people, the registered person must ensure that staff

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Requirement Due date

(2) (a) (i) assess whether each child is at risk of harm, taking into account information in the child‟s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; (b) that the home‟s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm. 14/03/2016

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Requirement Due date

In order to meet the protection of children standard, with particular reference to providing an environment safe from hazards and where risks are mitigated, the registered person must ensure:

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Requirement Due date

(2) (d) that the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child‟s health. 14/03/2016

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Requirement Due date

13. The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, with particular reference to promoting and enabling a positive culture for young people, the registered person must ensure that staff:

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Requirement Due date

(1) (a) help children aspire to fulfil their potential; and (b) promote their welfare (2) (a) lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home‟s statement of purpose; 14/03/2016 (f) understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home.

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Requirement Due date

13. The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, with particular reference to scrutiny of practice and incidents, the registered person must:

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Requirement Due date

(2) (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. 14/03/2016

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Requirement Due date

13. The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, with particular reference to listening to young people‟s views, the registered person must:

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Requirement Due date

(g) (ii) demonstrate that practice in the home is informed and improved by taking into account and acting on feedback on the experiences of children, including complaints received. 14/03/2016

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Requirement Due date

If the Regulatory Reform (Fire Safety) Order 2005 (a) applies to the home the registered person must ensure that the requirements of that Order and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the home. (Regulation 25 (2) (b)) 14/03/2016

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Requirement Due date

The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience (Regulation 33 (4) (b)) 14/03/2016

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Requirement Due date

The registered person must keep under review and, as necessary, revise the home‟s child protection policies. (Regulation 34 (6)) 14/03/2016

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Requirement Due date

The registered person must keep the behaviour management policy under review and, where appropriate, revise it. (Regulation 35 (2)) 14/03/2016

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Requirement Due date

The registered person must ensure that within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes— (i) the name of the child; (ii) details of the child‟s behaviour leading to the use of the measure; (iii) the date, time and location of the use of the measure; 14/03/2016 (iv) a description of the measure and its duration; (v) details of any methods used or steps taken to avoid the need to use the measure; (vi) the name of the person who used the measure (“the user”), and of any other person present when the measure was used; (vii) the effectiveness and any consequences of the use of the measure; and (viii) a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure; (b) within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (“the authorised

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Requirement Due date

person”)— (i) has spoken to the user about the measure; and (ii) has signed the record to confirm it is accurate; and (c) within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3) (a) (b) (c))

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if a child is involved in or subject to, or is suspected of being involved in or subject to sexual exploitation, an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious, there is an allegation of abuse against the home or a person working there. (Regulation 40 (4) (a) (b) (c)) 14/03/2016

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Requirement Due date

If a child dies, the registered person must without delay notify each other relevant person (Regulation 40 (1) (g)) 14/03/2016

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Requirement Due date

When the independent person is carrying out a visit, the registered person must help the independent person, if they consent, to interview in private such of the children, their parents, relatives and persons working at the home as the independent person requires. (Regulation 44 (2) (a)) 14/03/2016

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Requirement Due date

In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating the feedback and opinions of children about the children‟s home, its facilities and the quality of care they receive in it. (Regulation 45 (2) (b)) 14/03/2016

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Requirement Due date

When conducting the review, the registered person must consult, and take into account the views of, each relevant person. (Regulation 46 (2)) 14/03/2016

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What the inspection judgements mean

At the interim inspection we make a judgement on whether the home has improved in effectiveness, sustained effectiveness, or declined in effectiveness since the previous full inspection. This is in line with the Inspection of children's homes: framework for inspection.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people living in the children's home. Inspectors considered the quality of work and the difference adults make to the lives of children and young people. They read case files, watched how professional staff work with children, young people and each other and discussed the effectiveness of help and care given to children and young people. Wherever possible, they talked to children, young people and their families. In addition the inspectors have tried to understand what the children's home knows about how well it is performing, how well it is doing and what difference it is making for the children and young people who it is trying to help, protect and look after. This inspection focused on the effectiveness of the home and the progress and experiences of children and young people since the most recent full inspection.

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Information about this inspection

This 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 Children's Homes (England) Regulations 2015 and the Guide to the children's homes regulations including the quality standards. the guidance raising concerns and making complaints about Ofsted, which is available from Ofsted's website: www.gov.uk/government/organisations/ofsted . If you would like Ofsted to send you a copy of the guidance, please telephone 0300123 4234, or email enquiries@ofsted.gov.uk .

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Information about this inspection

achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children's social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, workbased learning and skills training, adult and community learning, and education and training in prisons and other secure establishments. It inspects services for looked after children and child protection. If you would like a copy of this document in a different format, such as large print or Braille, please telephone 0300 123 4234, or email enquiries@ofsted.gov.uk . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team,

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Information about this inspection

The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

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Information about this inspection

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

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Information about this inspection

Store Street Manchester M1 2WD T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: www.gov.uk/government/organisations/ofsted

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