Children's home in Westminster

This monitoring visit

On 8 March 2016, Ofsted received concerns from a young person resident at the home about: not feeling safe; about young people who bully and bring knives into the home, and the registered manager’s favouritism towards other young people. Ofsted asked the responsible individual to investigate. The responsible individual reported to Ofsted on 21 March 2016, but the investigation was not thorough. On 16 March 2016, Ofsted also received concerns from the local area designated officer (LADO) for Worcestershire about the registered person’s poor safeguarding practice. These were: the registered manager’s failure to follow safeguarding procedures; causing unacceptable delay and a failure to protect a young person at risk of child sexual exploitation. When the LADO tried to explore the reasons for this with the registered manager and the responsible individual, they were not able to give an acceptable response. The LADO thought that neither recognised the level of

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This monitoring visit

risk to the young person. On 1 April 2016, Ofsted undertook an unannounced inspection visit to the home, to look at safeguarding practice and leadership and management effectiveness in relation to both complaints. Inspectors found significant regulatory failings and uphold the concerns by the young person and the LADO. Shortfalls include: failure to protect young people at risk of child sexual exploitation and at risk from knife crime; failure to implement safeguarding procedures; ineffective risk management documentation and practice; poor judgement to admit more young people to the service; insufficient staffing; not taking children’s concerns about bullying or their safety seriously; failure to notify the police or Ofsted of serious incidents; inadequate direct work with young people about their vulnerability to child sexual exploitation, bullying, or risks from carrying knives; unreliable records

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This monitoring visit

and poor managerial monitoring and decision making. Staff and the registered manager at Rosendale House have not implemented the home’s policy for the protection of children and have failed to protect young people from harm after a disclosure of child sexual exploitation. There was an unacceptable delay of eight days until the registered manager told the local safeguarding team. Young people have been unsafe at the home. Young people, with a history of carrying knives and gang involvement, have brought knives into the home and threatened and bullied other young people. The manager was reliant on young people telling her when knives were present in the home and did not otherwise search for them. Minimal staffing levels, usually two staff for four young people, are not sufficient to allow staff to supervise young people properly, give them the attention they need, or keep them safe. A young person at risk of child sexual exploitation is supposed to

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This monitoring visit

have close staff supervision. The risk assessment for another young person states that two staff must go searching for him when he is missing, because of risk to staff of sexual violence if found with a particular group of friends. The assessment also states that two staff cannot be freed for this task until a third member of staff routinely comes on duty at 9.30pm. The low staffing levels mean that staff have not been able to safely leave the house and must wait until there are enough staff on duty to go looking for young people. It also means they do not have enough time to provide the close supervision required in the house. Inspectors asked the registered manager why she had not increased staffing levels in line with young people’s needs: the registered manager told inspectors: ‘If I could I would have, but couldn’t always facilitate that. Haven’t got enough staff.’ There are not enough staff on duty to supervise, monitor or go looking for young people and

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This monitoring visit

bring them home safely and this puts young people at risk. The police continue to express concerns about the level of supervision provided and that this did not safeguard young people. Risk management documentation and practice is chaotic. Young people leave the home, go missing, buy alcohol, and meet unsafe adults while out on ‘free time’ or when missing, despite known current risk of child sexual exploitation. Poor quality risk assessments do not provide clear guidance for staff about how to protect young people in respect of child sexual exploitation, bullying, access to the internet, online grooming, or when they go missing from care or are at risk from knives. Risk assessments give conflicting guidance about the level of supervision required for young people. The manager had notified to Ofsted that since 25 February, young people at risk of child sexual exploitation had limited access to the internet, no free

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This monitoring visit

time without staff and were, ‘on supervised time out of the home.’ This was not the case. The home’s risk assessment said the same young person was allowed, ‘3 hours free time with friends’. Risk assessments omit any mention of bullying despite active concern. Risk assessments do not include up-to-date information to help staff reduce risk after knives have been brought into the home. These assessments are not effective tools to identify or reducepotential harm. This means young people remain at risk. The registered person has failed to meet young people’s needs behavioural and emotional needs. Records in the home show that the registered manager has underestimated the level of risk and did not believe a young person when they reported child sexual exploitation, or bullying and feeling unsafe. Records of meaningful work with young people are minimal. For example, there is no record of preventative work about bullying, nor of any protective work after the

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This monitoring visit

disclosure of sexual exploitation. Records in the home are also not clear when young people have told the manager that there are knives in the home, or when they have been located. Some records, including local authority risk assessments, are over written, or illegible. Important records relating to young people are stored separately on the registered manager’s computer. Some records about young people use pejorative, suspicious language that claim young people lie and ‘fabricate’ stories, despite credible evidence. The registered manager did not respect their views, wishes and feelings. The registered manager has not notified Ofsted of serious incidents. For example, the registered manager found a knife in a young person’s room on 16 February 2016 and decided not to tell Ofsted. There is no record that she told the police or the placing authority about this. Leadership and management is weak. The responsible individual’s investigation

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This monitoring visit

response on 21 March, did not address whether young people were safe. The investigation report gave conflicting dates when knives were found at the home. Managerial evaluation of safeguarding practice also lacks conclusive rigor. The learning drawn after incidents, or when concerns are raised, is unlikely to lead to improved practice because the conclusions are not thorough. The responsible individual reported that different treatment of young people in their use of house transport, and the complaint of favouritism, was explained by an active behavioural incentive scheme for one young person. The inspection found no record of any such incentive scheme. Instead, inspectors found evidence to support that the registered manager did extend a more positive, trusting attitude to one young person and was more likely to disbelieve another, despite evidence to the contrary. The responsible individual did make recommendations to improve practice about

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bullying, but did not reach a clear judgment about whether the registered manager had taken enough action. Inspectors found no evidence of work with young people after complaints of bullying in the home, including serious online bullying and threats to life, after one young person told that another was carrying a knife. The responsible individual did not draw any conclusion about the adequacy of the registered manager’s response to finding the first knife on 16 February, but did make suggestions for improvement. The investigation did not consider whether the police should have been involved at that point, or whether the advice of a peer manager not to notify Ofsted, was correct. The registered person has not met the requirement or recommendations made at the last inspection. The quality of admission decision making is still not child focused. Staffing levels have not improved. The quality of managerial review and learning

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This monitoring visit

after incidents and placement difficulties is still ineffective. The quality of care at the home has seriously declined. Poor decision making about admissions of new young people to the home has been a consistent feature at this home since it was registered in April 2014. Despite increasing risks for two young people since February 2016, and staffing shortages, the registered person admitted a fourth young person to the home in March. There has been no increase to staffing levels to take account of this young person’s recent history of violence towards staff, or risks from going missing from care. The registered manager said that this young person had been admitted, because the placements of the two other young people, most at risk, were ending. The responsible individual has told Ofsted on 4 April 2016 that the registered manager has been suspended, pending an external investigation. Ofsted has restricted the accommodation of any new young people for six weeks so that no

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This monitoring visit

young people can be placed in this home and consequently exposed to risk. The home is unstable, in crisis and is currently an unsafe setting for any new young people. Ofsted will visit to monitor the restriction within six weeks.

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Information about this children’s home

This privately operated children’s home is registered to provide care for five young people with emotional and behavioural difficulties. The home’s statement of purpose describes an age range of 10-18 years.

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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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Reg. Requirement Due date

QS 7 7 In order to meet the children’s views, wishes and feelings standard, in respect of acting on children’s concerns, the registered provider must ensure that children receive care from staff who— (1) (a) develop positive relationships with them; (b) engage with them; and (c) take their views, wishes and feelings into account in relation to matters affecting the children’s care and welfare and their lives. 31/05/2016

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Reg. Requirement Due date

QS 11 11 In order to meet the positive relationships standard, in respect of effectively managing bullying, so that children are helped to develop, and to benefit from, relationships based on— (1) (a) mutual respect and trust; (b) an understanding about acceptable behaviour; and (c) positive responses to other children and adults.

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Reg. Requirement Due date

2(a) the registered provider must ensure that staff:

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Reg. Requirement Due date

(iv) help each child to develop and practise skills to resolve conflicts positively and without harm to anyone (vi) help each child to understand, in a way that is appropriate according to the child’s age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful; 31/05/2016 (vii) help each child to develop the understanding and skills to recognise or withdraw from a damaging, exploitative or harmful relationship; (xii) understand and communicate to children that bullying is unacceptable; and (xiii) have the skills to recognise incidents or indications of bullying and how to deal with them; and (b) that each child is encouraged to build and maintain positive relationships with others. QS 12 12 In order to meet the protection of children standard so that children are protected from harm and enabled to keep themselves safe, in respect of bullying, child sexual exploitation, missing, and risk

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Reg. Requirement Due date

from knives, the registered person must ensure that staff: (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; (ii) help each child to understand how to keep safe; (iii) have the skills to identify and act upon signs that a child is at risk of harm; (iv) manage relationships between children to prevent them from harming each other; (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; (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.

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Reg. Requirement Due date

QS 13 13 In order to meet the leadership and management standard, the registered person must enable, inspire and lead a culture in relation to the children’s home that— (a) helps children aspire to fulfil their potential; and (b) promotes their welfare. (2) In particular, the standard in paragraph (1) requires the registered person to— (a) lead and manage the home in a way that is 31/05/2016 consistent with the approach and ethos, and delivers the outcomes, set out in the home’s statement of purpose; (d) ensure that the home has sufficient staff to provide care for each child; (e) ensure that the home’s workforce provides continuity of care to each child; (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; (g) demonstrate that practice in the home is

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Reg. Requirement Due date

informed and improved by taking into account and acting on— (i) research and developments in relation to the ways in which the needs of children are best met; and (ii) feedback on the experiences of children, including complaints received; and (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. QS 14 14 In order to meet the care planning standard, in respect of robust pre-admission assessments and child-focused admission decisions, the registered provider must ensure that children- (1) (a) receive effectively planned care in or through the children's home; and (b) have a positive experience of arriving at or moving on from the home. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to

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Reg. Requirement Due date

provide care and accommodation, as set out in the home's statement of purpose; (b) that arrangements are in place to— (i) ensure the effective induction of each child into the home; (ii) manage and review the placement of each child in the home; and (iii) plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements 31/05/2016 agreed with the child's placing authority; (c) that each child's relevant plans are followed. 34 The registered person must prepare and implement a policy which is intended to safeguard children accommodated in the children’s home from abuse or neglect; and sets out the procedure to be followed in the event of an allegation of abuse or neglect. The procedure to be followed in the event of an allegation of abuse or neglect must, in particular provide for liaison and co-operation with any local authority which are, or may be,

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Reg. Requirement Due date

making a child protection enquiry in relation to a child accommodated in the home; provide for the prompt referral of an allegation about current or ongoing abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the home is located; provide for records to be kept of an allegation of abuse or neglect, and the action taken in response; describe the measures which may be necessary to protect children following an allegation of abuse or neglect; and describe how and to whom staff are to report, without delay, any concern about abuse or neglect of a child. (Regulation 34 (1)(2)(a)(b)(d)(f)) 15/05/2016

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Reg. Requirement Due date

40 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; or there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40(4)(a)(b)(e)) 15/04/2016

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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

 Actively seek independent scrutiny of the home and make best use of information from independent and internal monitoring (including under regulations 44 and 45) to ensure continuous improvement. They should be skilled in anticipating difficulties and reviewing incidents, such as learning from disruptions and placement breakdowns. They are responsible for proactively implementing lessons learned and sustaining good practice. Consider better reflection in formal reporting of results of consultation with all stakeholders: parents, young people and all placing authorities and review of learning after placement endings. (The Guide to the Quality Standards, page 55, paragraph 10.24)

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Recommendations

 Plan staffing levels to ensure that they meet the needs of children and can respond flexibly to unexpected events or opportunities. Staffing structures should promote continuity of care from the child's perspective. (The Guide to the Quality Standards, page 54, paragraph 10.15)

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Recommendations

 Only accept placements for children where the registered person is satisfied that the home can respond effectively to the child's assessed needs as recorded in the child's relevant plans and where they have fully considered the impact that the placement will have on the existing group of children. Challenge (under regulation 5(c)) any placing authority who asks them to accept a child in the absence of a complete and current relevant plan, as the expectation that a placement of a child without the necessary information would go ahead (in circumstances other than an emergency) is inadequate in relation to their role. It is essential that homes understand what will be required of them before they accept responsibility for a child's placement, to avoid disruption and instability for the child in future and for other children in the home. (The Guide to the Quality Standards, page 56, paragraphs 11.4 and

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Recommendations

 Staff should be familiar with the home’s policies on record keeping and understand the importance of careful, objective, and clear recording. Staff should record information on individual children in a non-stigmatising way that distinguishes between fact, opinion and third-party information. Information about the child must always be recorded in a way that will be helpful to the child. (The Guide to the Quality Standards, page 62, paragraph 14.4)

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Information about this inspection

The purpose of this visit was to investigate two complaints made about the quality of care at the home.

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Information about this inspection

This inspection was carried out under the Care Standards Act 2000. 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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