Children's home run by Blue Mountain Homes Ltd in Ealing

Inadequate

There are serious and widespread failures that mean that children and young people are not protected and their welfare is not promoted or safeguarded. Their care and experiences are poor and they are not making progress.

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The children's home provision is inadequate because:

 There are serious and widespread failures which mean that young people have been put at risk.  Placement matching is poor and the mix of young people does not ensure their safety.  The home have made changes to their statement of purpose and have set out that they will no longer care for young people who are at risk of sexual exploitation. However young people who are vulnerable to sexual exploitation still live at the home.  The location of the children’s home has not been properly considered. For example the area is said by police to be a ‘hotspot’ for child sexual exploitation, yet young people who are at risk of sexual exploitation live in this home. This has left young people at risk.  Risk reduction strategies are poor and has allowed for young people to continue to be unsafe.  Young people have been admitted without a care plan as to how their needs will be met at the home, hindering their progress.

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The children's home provision is inadequate because:

 Where young people go missing, staff do not always realise quickly enough as their supervision of young people is not always effective. In addition, staff do not always look for young people when they become missing. Opportunities to find young people quickly are missed and as a result, they are not appropriately protected.  Staff do not follow documented risk assessments to reduce risks to young people when they go missing.  There are no independent return interviews conducted for young people after they have been missing. The acting manager has not followed this shortfall up with the relevant local authority. Therefore lessons cannot be learned and opportunities to safeguard young people are missed.  Where young people have made safeguarding allegations in the home, these have not been appropriately followed up by staff or reported to the relevant professionals. In addition, the acting manager and senior managers

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The children's home provision is inadequate because:

in the company have been unaware of these allegations.  Staff are not appropriately trained or inducted to meet the specific safeguarding needs of young people. For example, they have received no training in child sexual exploitation, yet young people live at the home who are vulnerable to this.  The arrangements for administering medication in the home are not safe, posing a risk to young people’s health and welfare.  Staff recruitment does not always ensure that staff are safe or suitable to work with young people.  The arrangements for fire protection are not adequate. Where young people smoke in their bedrooms, there are no arrangements for risk reduction to ensure that they will be as safe as possible.  The lighting to the exterior of the building is poor and it is difficult to supervise young people leaving the home. In addition, there is a danger of slips, trips or falls.

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The children's home strengths

 There are some very positive relationships between some young people and staff.

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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

*13 The Leadership and Management Standard (1) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that- (b) promotes their welfare. 04/12/2015

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Requirement Due date

13 The Leadership and Management Standard (2) In order to meet the leadership and management standard, the registered provider must - (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child. 04/12/2015

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Requirement Due date

*12. The Protection of Children Standard (2)In order to meet the protection of children standard, the registered provider must ensure - (a) that staff - (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. 04/12/2015

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Requirement Due date

*12. The Protection of Children Standard (2) In order to meet the protection of children standard the registered provider must ensure - 04/12/2015 (a) that staff - (vi) take effective action whenever there is a serious concern about a child’s welfare

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Requirement Due date

12. The Protection of Children Standard (2) In order to meet the protection of children standard the registered provider must ensure - (c) that the premises used for the purposes of the home are located so that children are effectively safeguarded 11/12/2015

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Requirement Due date

12. The Protection of Children Standard (2) In order to meet the protection of children standard the registered provider must ensure - (d) 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. 11/12/2015

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Requirement Due date

14 The Care Planning Standard (1) In order to meet the care planning standard the registered provider must ensure that children- (a) receive effectively planned care in or through the children’s home. 11/12/2015

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Requirement Due date

*The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety. (Regulation 32(1)) 11/12/2015

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Requirement Due date

Ensure that the registered person compiles a Statement of purpose which covers the matters listed in Schedule 1. The registered person must provide a copy of the statement of purpose to HMCI. (Regulation 16 (1)(2)) 11/12/2015

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Requirement Due date

Ensure that the registered person prepares and implements a policy which sets out the procedure to be followed in the event of any allegation of abuse or neglect. (Regulation 34 (1)(b)) 11/12/2015

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Requirement Due date

Ensure that after consultation with the fire and rescue authority, 11/12/2015 the registered person must take adequate precautions against the risk of fire. (Regulation 25(1)(a))

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Requirement Due date

Ensure that medicine prescribed for a child is administered as prescribed and that a record is kept of the administration of medicine to each child. (Regulation 23 (2)(b)(c)) 11/12/2015

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Requirement Due date

*These requirements are subject to a compliance notice.

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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 that when a child returns to the home after being missing from care or away from home without permission, the responsible authority must provide an opportunity for the child to have an independent return home interview. Homes should take into account of information provided by such interviews when assessing and putting arrangements in place to protect each child. (The Guide to the Quality Standards, page 45, paragraph 9.30)  Ensure that staff are familiar with and understand the importance of careful, objective and clear recording. (The Guide to the Quality Standards, page 62, paragraph 14.4)

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Information about this children's home

The home is privately owned and aims to provide care to four young people with emotional and behavioural difficulties.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

06/01/2015 Interim Improved Effectiveness

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Inadequate

The progress and experiences of young people living at this this home is inadequate. The safety and welfare of young people have not been paramount concerns for managers and staff. Staff have been unable to positively influence some young people’s risk taking behaviour, such as their patterns of missing and sexualised behaviour. These behaviours have negatively impacted on young people’s ability to engage in education, leisure activities and have positive experiences within the home and their community. An example of this is that one staff reported that a young person’s educational progress was currently hindered because of the impact of other young people’s negative behaviour towards them. This has led to more behavioural outbursts and difficulties at school. A young person told the inspector ‘if one young person has not gone in two weeks, I am going’, telling the inspector that they had ‘packed their bag’.

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Inadequate

The arrangements for the administration of medication are not safe. Where new young people are admitted, there is no clear audit trail of what medication young people are prescribed. For controlled medication, the prescription instructions are not clear. There is an example of where some tablets are without a box and with no instructions. Staff have given the medication anyway without fully understanding the directions. The medication administration records do not always show that medication has been appropriately given. Where it is recorded that young people have not received medication, the amount of tablets left over does not tally. Records are very unclear. Should there be a medical emergency, staff would not be able to give clarity to medical professionals should they require such information. Some aspects of young people’s health have been well considered. Regular appointments have ensured that they have received help with a number of

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Inadequate

their health related issues, such as their sexual health and physical wellbeing.

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Inadequate

There are examples of where young people have made some progress. For example, one young person had been engaging and attaining well in their education, whereas they had been out of school for some time before coming to the home. One teaching professional reported that one young person’s educational progress is ‘generally good’. They attributed this improvement to work that staff have done to assist the young person to regulate their own behaviour.

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Inadequate

Where progress has been made, this is attributed to trusting relationships between young people and staff. Most young people report some very positive relationships with staff. Their comments include ‘staff are amazing’ and ‘welcoming and nice’. However, other young people feel that they have not had the same positive relationships and have felt that staff don’t always want to talk to them.

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Inadequate

Young people are at risk whilst living at this home. A full account of presenting behaviours and risks are not considered at the point of admission. Therefore, young people have been admitted who are not compatible with others who live in the home. This has resulted in young people encouraging and influencing each other to engage in behaviours such as going missing, placing them at risk of harm. One placing authority said that one young person ‘is in a terrible place’ with regard to their welfare.

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Inadequate

When young people are at risk of sexual exploitation, these risks are not properly considered by staff. Staff do not always appropriately, and closely, supervise young people. They also do not always realise quickly enough when they have gone missing. An example is where staff did not supervise two young people for half an hour and did not realise that they were missing. In addition, staff do not always look for young people when they become missing. Opportunities are missed for finding young people quickly and protecting their welfare.

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Inadequate

Where young people already have documented risk assessments in place for their safety and welfare, these are not consistently followed by staff. For example one young person’s risk assessment said that they should be reported missing to the police straight away if they become missing. On one occasion, they were not reported to the police for five hours. The police said they were concerned that their opportunities to find young people at the earliest opportunity were missed. Young people also do not receive independent return interviews. Information about their safety and welfare cannot be established as a result, preventing patterns being monitored and lessons being learned. The acting manager has not followed this up with placing authorities.

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Inadequate

Young people newly admitted to the home do not have their needs, welfare and risky behaviours assessed properly. One young person was admitted to the home and there were no risk assessments or care planning completed for the duration of their placement. Another young person was admitted to the home with very little information. Whilst there was a basic risk assessment and care plan produced based on this information, it did not set out plans for risk reduction. The care plan contained a series of very brief lines of information, rather than an actual plan which sets out how young people should be cared for and how they can make progress. Risks for that young person had not been fully considered, placing them at potential harm. Staff have not received training on child sexual exploitation, despite several young people being at risk of this. This could have a major impact on how staff ensure their welfare is promoted and protected, as they do not fully understand the

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Inadequate

seriousness and risks associated with this area. Additionally, one staff member is not trained in the home’s method of physical intervention. Should a young people require restraining, this staff may not be able to do it safely.

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Inadequate

The risks of fire in the home are not properly considered. Young people smoke in their bedrooms and there are no risk reduction strategies to minimise this risk. This does not effectively safeguard young people, staff and visitors from the risk of fire.

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Inadequate

Staff recruitment does not ensure young people’s safety. Where agency staff are used, staff do not routinely check their identification and managers have not seen the documents related to their recruitment process. Therefore they have not established staffs’ safety and suitability to work with young people. One staff working at the home had a conviction. The manager and senior manager present during the inspection were both unaware of this, yet the staff member was already working with young people.

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Inadequate

The arrangements for dealing with allegations of abuse are not effective. One young person has recently alleged to staff, abuse by people outside of the home. This information had not been acted on, leaving that young person open to further abuse.

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Inadequate

Lighting to the outside of the building is poor and it is therefore difficult to monitor young people leaving the home. There is also the potential for slips, trips and falls because steps to the front of the building are not well lit.

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Inadequate

There has been no registered manager in the home since August 2015. The current acting manager is aware of his responsibility to apply to Ofsted for registration and his application is currently underway. He is completing his level five Diploma in Management course, demonstrating his commitment to undertaking the role effectively

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Inadequate

Poor leadership and management has meant that serious failures highlighted in this inspection have been allowed to happen. The acting manager says he expected a judgement of inadequate at the Ofsted inspection. There has been a lack of understanding about who is responsible for assessing the suitability of new admissions to the home. This confusion has led to placements being accepted which are not safe or appropriate. The acting manager said that decisions about new admissions have been made ‘over his head’ and that this is partly what has led to the shortfalls. Young people who have already experienced multiple placements have not thrived because they have not been safe. Therefore some placing authorities have made decisions to move them from the home. For some young people, this has meant that they have experienced yet another failed placement.

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Inadequate

The home’s statement of purpose has been changed without informing Ofsted. The acting manager and staff have identified that they find it very difficult to keep young people safe with regards to those at risk of sexual exploitation. Therefore a decision has been made to not accept young people who have these associated risks. Ofsted have been unaware that young people were living in a home which was not set up to deal with their needs and have not been able to follow this up.

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Inadequate

The training and development programme is not robust. For example there are shortfalls in training for staff in child sexual exploitation and physical intervention. In addition, new staff do not receive a proper induction to ensure that they know how to care for the vulnerable young people in their care.

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Inadequate

Case records are variable in quality. Despite some giving the reader a very clear picture of what happened and when, there are large gaps, where young people’s behaviour and staff actions cannot be accounted for. If young people want to look at their records at a later date, they will not be able to see what happened and when. In addition, this does not allow for the manager to properly monitor events in the home.

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Inadequate

Staff do receive formal supervision. The organisation has taken action where there have been allegations or complaints made about staff. The company disciplinary procedure is used effectively in some instances. However, where there are shortfalls identified in this inspection regarding staffs’ practice, as a result of ineffective challenge from leaders. This does not ensure that appropriate staff development encourages the right environment for good practice to thrive.

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Inadequate

The location of the home has an effect on young people’s safety. Police, staff and the acting manager confirm that there is a problem with child sexual exploitation in the area. The manager said that ‘this was rife’. The home’s location risk assessment does not take into account, or mention, this key safety information. The document states ‘young women will be safe in this area’, demonstrating a lack of understanding and action to protect young people.

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Inadequate

The acting manager and senior managers within the organisation are now fully aware and accepting of the home’s shortfalls, especially now that Ofsted have brought these to their attention. It is positive that managers fully accept the issues set out in this report and that they understand where the shortfalls are.

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Inadequate

Professionals have made some very positive comments about the acting managers practice so far and staff also report that he is already making a difference saying ‘I have a lot of respect for him‘ and ‘the issues are from before he came’. Young people feel very able to discuss their concerns with the manager, and already have. They feel that he listens to them. One young person stated ‘he is a good manager and a good man’.

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Inadequate

There have also been some positive comments from other professionals which indicate that there are some examples of good joint working, which have enabled young people to make progress, for example with their education and behaviour. One social worker said staff are really good, they ring me if there is a problem.

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What the inspection judgements mean

The experiences and progress of children and young people are at the centre of the inspection. Inspectors will use their professional judgement to determine the weight and significance of their findings in this respect. The judgements included in the report are made against Inspection of children's homes: framework for inspection.

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What the inspection judgements mean

An outstanding children's home provides highly effective services that contribute to significantly improved outcomes for children and young people who need help and protection and care. Their progress exceeds expectations and is sustained over time. A good children's home provides effective services that help, protect and care for children and young people and have their welfare safeguarded and promoted. In a children's home that requires improvement , there are no widespread or serious failures that create or leave children being harmed or at risk of harm. The welfare of looked after children is safeguarded and promoted. Minimum requirements are in place, however, the children's home is not yet delivering good protection, help and care for children and young people. A children's home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

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What the inspection judgements mean

harmed or at risk of harm or result in children looked after not having their welfare safeguarded and promoted.

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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 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

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Information about this inspection

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

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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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