Children's Home, Residential special school run by Cotswold Chine School in Gloucestershire

The children's home provision is inadequate because:

 The use of some restraint practice does not meet the Children’s Homes Regulations. It is not clear from restraint records why the need for restraint has been necessary. It is not always clear which de-escalation techniques the staff used in order to manage incidents of children’s poor behaviour. The use of restraint is sometimes excessive and unreasonable. The statement of purpose for the home does not reflect current staff practice in the use of restraint.  The records of follow-up interviews after an incident of restraint do not indicate that staff always help young people to understand why they have been restrained. Some young people have felt the need to call ChildLine as they do not feel listened to or believed by staff when making allegations about inappropriate restraints. Children have few opportunities to talk to professionals independent of the school, for example an advocate or independent visitor.

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The children's home provision is inadequate because:

 Despite it being against the organisation’s policy, staff use restrictive practices to manage inappropriate behaviour. On at least one occasion, a young person has been shut in their bedroom through staff holding the bedroom door handle closed and standing outside the bedroom door so that the young person was unable to come out if they wished. Alarms are fitted on all bedroom doors in some houses and are turned on at 9pm every night to alert staff if young people come out of their rooms. The implementation of this restriction has become universal and is not individually risk-assessed for each young person according to need and risk.  The physical environment is not homely and nurturing. Windows in one house have metal bar restrictors fitted to them and staff manage the behaviour of young people by restricting their access to parts of this home.  Serious incidents are not always notified to Ofsted by managers, as

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The children's home provision is inadequate because:

required by children’s homes regulations.  At the time of this inspection, the mix of young people living in one home is not compatible. Most young people new to the home are placed together in one house. This is determined by their assessed levels of safety, regardless of their compatibility with existing young people and their care needs. This practice does not comply with the home’s statement of purpose.

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The children's home strengths

 Most young people attend school and most make progress towards their educational goals. Some placing authorities are very pleased with the progress made by their young people who previously refused to attend school.  Managers have a plan in place to make further improvements to the homes and the school site. A sports hall is being constructed and the community café, which is sometimes staffed by the young people, is thriving.  A wide range of therapeutic interventions is available to young people on site from therapists employed by the provider. These include music, play and art therapy. Plans are in place to employ therapists in each house to further widen the benefit of therapy to all young people placed there.

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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

The registered person must ensure that no measure of control or discipline which is excessive, unreasonable, or contrary to paragraph (2) may be used in relation to any child, specifically that the use of restraint is proportionate (Regulation 19 (1)). 16/11/15

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Requirement Due date

20: Restraint and deprivation of liberty

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Requirement Due date

The registered person must ensure that restraint in relation to a child is only permitted for the purpose of preventing- (1)(a) injury to any person (including the child); (b) serious damage to the property of any person (including the child); or Regulation 20 (1)(a) (b) (c)) specifically in relation to the use of physical restraint and locked internal and external doors. 16/11/15

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if- there is any incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(e)e)). 16/11/15

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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, the registered person must ensure that staff (2) (b) understand and apply the home’s statement of purpose. 16/11/15

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Requirement Due date

7 The Children’s’ wishes and feelings standard

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Requirement Due date

In order to meet the wishes and feelings standard the registered person must 16/11/15 (2) ensure that staff— (i) ascertain and consider each child’s views, wishes and feelings, and balance these against what they judge to be in the child’s best interests when making decisions about the child’s care and welfare; (iii) help each child to understand how their views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child; (v) help each child to understand how their privacy will be respected and the circumstances when it may have to be limited; specifically in relation to the bedroom door alarms (iii) is given appropriate advocacy support; (iii) inform how each child may access that support or those services and any entitlement the child may have to independent advocacy provision and independent visitors.

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Requirement Due date

In order to meet the leadership and management standard the registered person must 2 (a) lead and manage the home in a way that is consistent with the approach and ethos, and deliver the outcomes set out in the home’s statement of purpose. 16/11/15

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Requirement Due date

In order to meet the care planning standard the registered person must 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 provide care and accommodation, as set out in the home’s statement of purpose; specifically in relation to assessing the compatibility of children placed together. 16/11/15

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Requirement Due date

16 The Registered Person must update the statement of purpose to comply with Regulation 16 (1). 16/11/15

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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 homes should as far as possible maintain a domestic rather than an institutional environment. (Guide to the Quality Standards page 15 3.9)

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Recommendations

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Information about this children's home

This independent school is also registered as a children’s home. The school follows the principles of care and education developed by Rudolf Steiner. It is registered to provide care and accommodation for up to a maximum of 42 children and young people with emotional or behavioural difficulties or complex needs. The accommodation for children and young people is provided across seven houses located on or near to the main school site.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

30/03/2015 CH - Interim Improved effectiveness

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Recent inspection history

25/03/2014 CH - Interim Satisfactory Progress

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people living in the home are

At times, behaviour is managed not through trusting, caring, nurturing relationships from which young people can learn and make progress, but through restraint and restrictive practices, which do not meet the Children’s Homes Regulations. At times, staff are not able to manage children’s behaviour without this escalating into the restraint of children being held face down on the floor.

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people living in the home are

On arrival at the home, young people are assessed according to their levels of safety. Young people are admitted to one of seven houses that are in combination registered as a children’s home and are operated by the organisation according to young people’s assessed safety grading rather than consideration of their compatibility with those young people already living in that house. The most vulnerable and challenging young people all live together in one house. This is now having a negative impact on some of these young people. Compatibility and the potential negative impact of placing certain young people together are not taken into account by managers.

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people living in the home are

Young people now regularly witness their peers being restrained and displaying behaviour that challenges staff. Staff do not always succeed in calming down young people who display poor behaviour. As a result, the young people’s poor behaviour is then made worse through the use of restraint, which is not always proportionate or reasonable. One young person said, ‘Being here isn’t one of my better experiences; it is hectic here and there are lots of arguments between young people.’

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people living in the home are

Some young people report that staff do not listen to them. House meetings are held but not all requests made at these meetings are granted, or an explanation given to young people as to why their requests have not been followed up. For example, young people have repeatedly asked at house meetings for a full-length mirror and a toasted sandwich maker. To date, staff have not provided these items or an explanation as to why these items have not been made available to the young people living there. Few young people, many of whom are placed a long way from home, have external advocates whom they can speak to if they have concerns.

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people living in the home are

Young people in one house now go to their bedrooms at 7.30 pm regardless of their age. Door alarms are switched on at 9.00pm. The restrictive practice of the use of door alarms is not individually risk-assessed as being necessary. Young people perceive this as unfair and raise the concern of early bed times at house meetings. Staff have not fully responded to this. Young people resent the use of door alarms because they feel they are not necessary and they do not understand why they are used.

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people living in the home are

Some young people do not agree with the decision that they are unable to watch television in their home. Managers state this restriction is due to the trauma previously experienced by the young people and that they may be further traumatised due to the upsetting content of some programmes. As a result of this restriction, they are unable to learn how to choose which television programmes are appropriate for their age. This restriction does not appear in the home’s statement of purpose. However, young people regularly witness their friends and peers being excessively restrained by staff which results in young people feeling traumatised.

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people living in the home are

Young people attend the school operated by the organisation. Attendance is high and most make progress. One young person said, ‘Since coming here, I have learned to read.’ Another young person said, ‘Staff help me with maths so I can do them now.’

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people living in the home are

Staff provide support to enable young people to gain access to a range of activities in the community, such as visits to the cinema, exhibitions, scouts and horse riding. Families are able to visit young people at the home by appointment and young people are able to telephone their families when they wish, if this is risk-assessed as appropriate.

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people living in the home are

Therapy is provided and is available to all young people from a team of qualified and registered therapists. Therapies include play therapy, art therapy, life story work and music therapy. Therapists hold twice weekly clinical meetings to discuss each young person and how best to help them use therapy. Therapy goals are documented and reviewed as young people make progress. For example, incidents of young people self-harming have reduced following therapeutic intervention. Young people’s physical health care needs are met through regular visits to the dentist, optician and general practitioner. Medication is generally well managed, with the exception of one recent incident where a medication overdose was accidentally given to a young person. This incident has been thoroughly reviewed and action taken to prevent a re-occurrence. The member of staff concerned has been thoroughly de-briefed and has received further training.

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people are helped and protected

Some young people are regularly forced to the floor during restraints and held face down. On one occasion, a restraint by up to three members of staff who held a young person’s arms and legs lasted for twenty-five minutes. Staff use restraint techniques that are included in their accredited training but the regular use of such techniques now exceeds the home’s policy. Staff restrain young people to manage their behaviour as a result of incidents that escalate due to ineffective behaviour management. One young person said, ‘it’s ok here, but I don’t feel safe because of a restraint. I didn’t like it, it went on too long…they wouldn’t let go; I thought they were going to hurt me…I am scared if I do something wrong they will restrain me again.’

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people are helped and protected

Incidents of restraint are monitored by the head of safeguarding who has undertaken a comprehensive review of the use of restraint at the school. As a result of this work, the frequency of restraint has fallen and there is a commitment from leaders and managers to work towards a policy of no restraint.

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people are helped and protected

Some young people report that staff do not listen to their concerns and they do not feel safe. One young person reported that his concerns about a restraint were dismissed by a member of staff who said, ‘Just forget about it; tomorrow is another day.’ One young person said, ‘My friend and I called ChildLine because we did not feel safe.’

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people are helped and protected

Staff actions are responsive and effective when young people are missing from the home. There are good links in place with the local police; and, placing authorities are kept informed if a young person goes missing. Staff are keen to try to find out where young people have been and who they have been with. Staff report they are confident that they know what to do and are familiar with safeguarding policies and procedures if a young person goes missing. Incidents of missing are monitored and evaluated by the head of safeguarding and have reduced over time.

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leaders and managers

The home’s statement of purpose does not detail the use of the ‘sanctuary model’ that is now driving care practice in the school and children’s home operated by the trust. Information provided by the trust states that the sanctuary model is founded on ‘a non-violent, democratic and therapeutic community.’ The current use of restraint in the home does not support this model in practice. The children’s guide does not give information about the use of the sanctuary model and lists ‘rewards and praise’ as ‘restraint and praise’ in the index.

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leaders and managers

Young people do not benefit from living in a homely environment. Windows in one house are fitted with external metal bars that are used as window restrictors and the appearance of these detracts from a homely appearance. Signage such as fire exit signs and health and safety at work signs are prominently displayed, detracting from a homely atmosphere. Areas in one house that are used by young people, such as the computer room, are locked by staff and therefore not readily available to them. The gate leading to one of the houses is locked from the inside and requires a staff key fob to open it. The back door is also locked and only able to be opened by staff using a key fob.

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leaders and managers

Since the previous inspection, managers have not always notified Ofsted of significant events in line with regulations. This omission means Ofsted is not always aware of serious events that happen in the home.

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leaders and managers

A development plan is in place that details how improvements in, for example, safeguarding will be achieved. A comprehensive review of restraint in the school has been undertaken and there is extensive evaluation of behaviour management through the ‘behaviour watch’ programme which analyses trends and patterns of young people’s behaviour to inform placement planning.

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leaders and managers

The staff team is stable. Staff rotas indicate appropriate staffing levels for each house. Agency and bank staff are not used. Staff recruitment processes are thorough, follow safer recruitment procedures and prevent unsuitable people working with young people. References are verified and any gaps in employment are fully explored. Staff report that they feel well supported by managers and are able to access a comprehensive training programme. Staff report that they receive regular supervision and supervision notes support their comments that supervision is helpful to them.

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leaders and managers

Following some difficulties with the local community, leaders and managers have worked hard to engage with the community and this work has improved relationships. For example, a café has been opened on the edge of the school site and is well used by local people. The chief executive has regular meetings with representatives of the community to discuss any concerns.

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leaders and managers

The registered manager holds a degree in social work and is currently undertaking the level 5 qualification in leadership and management. The registered children’s home consists of seven houses. A clear management structure is in place with five care supervisors overseeing the seven houses and a senior care worker on each shift in all houses.

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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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