Setting 1156094

This monitoring visit

At the full inspection on 15 and 16 December 2015, the home was judged inadequate. A large number of failings were identified including:  There was a lack of effective action taken by managers and staff in response to serious safeguarding concerns leaving young people at risk of harm.  Young people’s needs had not been met across any aspect of their welfare  The practice of recording and administration of medication was unsafe and dangerous.  There was a lack of required care planning and education and health documents to inform practice.  Risks to young people were not identified, understood, and managed.  Behaviour management in relation to restraint practice was unsafe and did not protect young people from risk of harm.

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This monitoring visit

As a result, a notice of proposal to suspend the setting’s registration was issued on 24 December 2015. Further monitoring visits were completed on 29 December 2015 and 3 January 2016, to monitor the progress of the compliance notices. Following a further monitoring inspection on 26 and 27 January 2016, four new compliance notices under the same regulations 12, 13, 14 and 23 were issued. Although it was acknowledged that some progress had been made, the steps under each notice had not been sufficiently met. These notices are the subject of further monitoring by Ofsted.

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This monitoring visit

On 28 January 2016, Ofsted received written representations relating to Ofsted’s proposal to suspend the registration. Claire Thomson, Chief Executive Officer, and Ann Jones, Director of Young People, attended in person at a representations panel meeting held on 11 February 2016 and chaired by John Mitchell, Senior HMI, Social Care. After carefully considering these representations at a representations panel on 11 February 2016, Ofsted’s decision was not to uphold the representations and to proceed with a notice of decision to suspend your registration. This was issued on 24 February 2016.

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This monitoring visit

At the time of this monitoring visit, carried out by Elaine Allison, Social Care Regulatory Inspector and Stella Elliot, Regulatory Inspection Manager, there continued to be serious shortfalls.

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This monitoring visit

During the visit, inspectors found that on 31 January 2016 an incident had occurred, during which staff physically restrained a young person. Documentation completed reported that staff had used managing violence and aggression (MVA) techniques to manage the incident. However, staff used a prone restraint, which is against the provider’s own policies and procedures. On 5 February 2016, the previous responsible individual (RI) took some action to investigate the incident and in section 6 of the investigation report he compiled six recommendations to be actioned. These included:  de-brief sessions to be offered to the young person and staff  disciplinary meeting to be arranged to clarify incident and details of prone restraint  policies and procedures to be addressed  mediation work to be implemented  further staff training to be provided.

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This monitoring visit

However, during discussions with the new RI and interim manager, they both stated that they had no knowledge of the outcome of the investigation or the recommendations. Consequently, no effective action was taken to debrief the young person or to provide him with an opportunity to comment on the incident and to reflect on his behaviours and the potential impact on others. No action has been taken to follow up any disciplinary action for staff or to address concerns involving dangerous practice. This does not demonstrate that appropriate action is taken, after significant incidents, to protect and safeguard young people.

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This monitoring visit

Care planning continues to be poor and fails to promote the continued progress of young people. Although internal care plans are in place in the home, the failure to review and update these plans regularly means that staff have no direction on how to meet the changing needs of individual young people living in the home. Records still fail to provide an insight into young people’s lives. There continues to be limited information from which to measure their progress or to identify the effectiveness of the support in place.

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This monitoring visit

Behaviour management plans, health plans and risk management plans have also not been reviewed and do not identify and support the changing needs of young people. The provider also failed to address the issues of risk or to identify how risks are managed safely to promote consistency of care. On 17 February 2016, an incident occurred in which a young person was reported to have displayed ‘high levels of aggression and violence’ towards staff. This had not been added to any plans to inform practice. Plans also did not demonstrate how the young person’s behaviour, or any further strategies to minimise risks to both young people and staff, had been considered. The lack of clear risk identification and planning to address concerns fails to ensure the safety of young people and potentially places them at risk. A local authority social worker provided information to inspectors regarding concerns about how the health needs of a young person were being met. The

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This monitoring visit

social worker informed inspectors that on 23 February 2016, she received a telephone call from a young person who was distressed. He said that he was asking for ‘medication’. During discussions, the young person indicated that he had bought weight-training tablets with the agreement of staff. The social worker was concerned because the young person had an existing health condition and was on prescribed medication. There had also been no consultation with the young person’s mother or the allocated social worker, despite the young person being accommodated under section 20 of The Children Act, 1989.

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This monitoring visit

Inspectors spoke with the new RI, the interim manager and the in-house social worker regarding these concerns. The in-house social worker confirmed that the young person had returned to the home with 30 tablets, believed to be ‘slimming tablets’. The in-house social worker said, ‘We took the tablets off him and the staff spoke with Bob (the previous RI) that night. He told them to create a MARS sheet and Google (internet search engine) the tablets and if they (staff) felt okay [about it] then they could give them to him.’ Inspectors discussed concerns about staff being prepared to allow a young person to take an unknown substance and to assign it medication status, without establishing what the medication was. Staff had also failed to secure appropriate advice and guidance from a qualified medical professional who had knowledge of the young person’s current and historical health needs. Staff also did not consider any contraindication to how this may have

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This monitoring visit

affected his current medication and health. This fails to promote young people’s health and well-being and potentially places them at risk of significant harm.

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This monitoring visit

During transition planning for a young person to a new placement, the placing social worker was made aware by the in-house social worker that he was no longer allowed to travel on a one-to-one basis in a car. This disrupted the transition plan, as there were insufficient staff to transport him, and the local authority social worker had to make alternative arrangements. Although the local authority had requested documentation, including the young person’s risk management plans, to substantiate this decision, staff failed to provide this. During the visit, inspectors also requested sight of the risk assessment and incidents that led to the decision. The in-house social worker said, ‘I made the decision. There is no paperwork’. Consequently, young people do not receive a positive experience when moving on from the home, as the lack of effective planning affected this young person’s opportunities to visit, prior to the planned move.

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This monitoring visit

During previous monitoring visits, senior managers reported that they had introduced daily checklists for senior residential care workers to complete at the end of their shifts. These identified any safeguarding concerns, incidents and important information to be handed over. However, inspectors found that they were still ineffective, as they had been left blank in several sections, including reporting on any safeguarding concerns. On 26, 27 and 28 February 2016, the section ‘Are there any safeguarding concerns?’ was left blank. As these checklists were not completed as required, they did not demonstrate that either the senior managers or staff have any oversight of potential issues that may have occurred during shifts. When the blanks were highlighted to the new RI, she said, ‘Yes, well, there are still some issues with staff recording,’ and the interim manager said, ‘I don’t believe it. It’s a simple form.’ This does not demonstrate that effective use of

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This monitoring visit

the provider’s new audit tool is having an impact on practice and identifying any potential concerns about practice .

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This monitoring visit

At the full inspection and subsequent monitoring visits, inspectors have continued to identify a failure to notify Ofsted of all relevant incidents, under regulation 40 of The Children’s Homes (England) Regulations 2015, specifically those made to the local authority designated officer. Ofsted has received three notifications of referrals to the local authority designated officer. However, a further four referrals which have not been notified to Ofsted have been made by the provider to the local authority designated officer. During this visit, requests were again made by inspectors to provide all notifications required under this regulation, including the local authority designated officer referrals and those requiring police involvement. Ofsted is yet to receive the outstanding formal notifications. A failure to share information with all relevant people compromises the safety and welfare of young

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This monitoring visit

people. Furthermore, the regulator is unable to carry out its monitoring function to ensure that the provider is taking all appropriate action to safeguard young people.

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This monitoring visit

Senior managers have updated the home’s statement of purpose. This now accurately reflects the service and contains the correct legislation. However, leaders and managers have still not taken sufficient steps to review records and to oversee practice so that safeguarding concerns are readily identified and addressed. Further action is needed to ensure that monitoring systems identify shortfalls in practice and that the action taken results in improvements, so that young people are adequately safeguarded and their welfare promoted.

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This monitoring visit

Since the last monitoring visit, senior managers report that they have another new RI in place. The provider reached a decision that the last RI should return to another position within their adult setting. The interim manager also reported that he had started to complete the required documentation, to process his application as a registered manager. However, he was awaiting health information before this could be progressed. The provider needs to ensure that appointments to the position of registered manager have the necessary skills, experience and qualifications to manage the home in line with its statement of purpose and to deliver improved outcomes for young people.

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This monitoring visit

A training matrix is now in place to ensure that staff, including night staff, have received training in safeguarding, MVA and medication. This means that the provider has taken some positive measures to equip staff with the necessary skills and knowledge to meet the individual needs of young people. However, there is limited noticeable impact at present, as serious errors are continuing to occur. For example, during incidents of MVA, staff have failed to follow the techniques taught in the course and have instead used a technique that is not approved. This does not demonstrate that training is informing practice appropriately and safeguarding young people.

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This monitoring visit

In Ofsted’s view, there has been a continued failure to meet the steps as set out in the compliance notices. Although it is acknowledged that some attempts have been made to comply with the steps specified under each notice, Ofsted is not satisfied that the necessary improvements have been made to demonstrate that young people are safe and protected while living in the home.

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This monitoring visit

As a result, the previous four compliance notices under regulations 12, 13, 14 and 23 will be re-issued. Ofsted was not satisfied that the steps under each notice have been sufficiently met, and there continues to be ongoing safeguarding concerns and staff practices that are of concern. These notices are the subject of further monitoring by Ofsted.

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Information about this children's home

The service is privately owned and provides residential accommodation for up to ten young people 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 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 must comply with the given timescales.

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Requirement Due date

12: The protection of children standard *

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Requirement Due date

In order to meet the protection of children standard the registered person must ensure

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Requirement Due date

(1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to ensure—

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Requirement Due date

(v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; (vi) take effective action whenever there is a serious concern about a child's welfare; and (vii) are familiar with, and act in accordance with, the home's child protection policies.

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Requirement Due date

(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 26/02/2016 from harm.

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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, the registered person must ensure:

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Requirement Due date

(1) that the registered person enables, inspires and leads a culture in relation to the children's home that—

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Requirement Due date

(a) helps children aspire to fulfil their potential; and

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to—

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Requirement Due date

(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;

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Requirement Due date

(c) ensure that staff have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

(d) ensure that the home has sufficient staff to provide care for each child;

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Requirement Due date

(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

(Regulation 13(1)(a)(b)(2)(a)(c)(d)(f)) 26/02/2016

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Requirement Due date

In order to meet the care planning standard the registered person must ensure - 26/02/2016 (1) (a) that children receive effectively planned care in or through the children's home; and

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Requirement Due date

(b) have a positive experience of arriving at or moving on from the home.

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Requirement Due date

(1) The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children's home.

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Requirement Due date

(2) In particular the registered person must ensure that—

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Requirement Due date

(a) medicines kept in the home are stored in a secure place so as to prevent any child from having unsupervised access to them;

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Requirement Due date

(b) medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child; and

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Requirement Due date

(c) a record is kept of the administration of medicine to each child.

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Requirement Due date

(3) Paragraph (2) does not apply to medicine which—

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Requirement Due date

(a) is stored by the child for whom it is provided in such a way that other persons are prevented from using it; and

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Requirement Due date

(b) may be safely self-administered by that child.

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Requirement Due date

(Regulation (23)(1)(2)(a)(b)(c)(3)(a)(b)(4)a)(b)) 26/02/2016

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Requirement Due date

{an asterisk is added in the table above where Compliance = 'Y'} * These requirements are subject to statutory requirement notice.

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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.

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Information about this inspection

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Information about this inspection

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Information about this inspection

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Information about this inspection

T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: www.gov.uk/government/organisations/ofsted

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