Children's Home run by Tulip Care One Limited t/as TulipCare in Kent

The children's home provision is inadequate because:

  Young people are not protected from harm. Child protection concerns are not reported to the appropriate authorities and allegations made against staff are not investigated.   Management and staff do not recognise when young people are at risk from their peers, or take action to ensure that suitable levels of supervision are maintained.  Risk management is poor. Assessments do not take into account significant events such as fire setting. Staff are provided with limited guidance on how to manage and de-escalate challenging behaviour. Responses to young people going missing are inconsistent.  There are insufficient staff employed to care effectively for the young people. Most staff do not have a relevant qualification, and do not have to sufficient skills to meet the needs of the residents.  The home does not deliver the specialist care and services outlined in the statement of purpose. The stated aim of providing a „therapeutic residential

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The children's home provision is inadequate because:

experience is not being met.  The care planning process is weak, and young people are not cared for in accordance with recommendations made in psychological assessment reports.  Inconsistent management arrangements have resulted in staff not receiving adequate supervision and their training and development needs have not been identified. The Registered Individual has not undertaken contingency planning to address the shortfalls in the quality of care being delivered. Managers fail to work as a team and do not communicate effectively.  There are shortfalls in the processes for monitoring the quality of care being provided. Poor practice is not effectively challenged and there is a lack of forward planning to drive forward improvement.

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The children's home strengths

 Consistent arrangements are in place for young people to have contact with family members, and this is supervised where appropriate.  Robust staff recruitment procedures are maintained.  Leaders and managers have recognised some of the weaknesses within the home and taken some remedial action.

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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

In order to meet the care planning standard, specifically that plans for the day-to-day care of young people take account of the recommendations made in specialist assessments, the registered person must ensure that staff:

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Requirement Due date

(1)(a) ensure that children receive effectively planned care in or through the children's home. 19/08/2015

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Requirement Due date

5: Engaging with the wider system to ensure children's needs are met

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Requirement Due date

In order to meet the engaging with wider system standard, with particular reference to ensuring that placing authorities are provided with reports within agreed timescales, the registered person must ensure that staff: (a) seek to involve each child's placing authority effectively in the child's care, in accordance with the child‟s relevant plans. 19/08/2015

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Requirement Due date

In order to meet the health and well-being standard, with specific reference to arrangements for medication and appointments with health professionals, the registered person must ensure that:

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Requirement Due date

(1)(a) the health and well-being needs of children are met.

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Requirement Due date

(2)(a) (iii) take part in activities, and attend any appointments, for the purpose of meeting their health and well-being needs. 19/08/2015

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Requirement Due date

*12: The protection of children standard 19/08/2015 In order to meet the protection of children standard with particular reference to protection, risk management, supervision and keeping children safe, the registered person must ensure that staff:

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Requirement Due date

(2)(a) (i) assess whether each child is at risk of harm, taking into account information in the child‟s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (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; (vii) are familiar with, and act in accordance with, the home's child protection policies.

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Requirement Due date

(2) (d) that the premises are 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.

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Requirement Due date

*13: The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, with particular reference to the statement of purpose, the skills and qualifications of staff, sufficient staffing levels, and the continuity and quality of care, the registered person must:

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Requirement Due date

(2)(a) lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home's statement of purpose; (b) ensure that staff work as a team where appropriate; (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child; (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 19/08/2015 use this understanding to inform the development of the quality of care provided in the home.

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Requirement Due date

The organisation must ensure that the responsible individual undertakes such continuing professional development as is necessary to ensure that the responsible individual has the skills needed for supervising the management of the home. (Regulation 29 (2)). 19/08/2015

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Requirement Due date

Ensure individuals employed at the home have the appropriate experience, qualification and skills for the work that the individual is to perform. (Regulation 32 (3) (b)). Specifically that staff possess, or are working towards the completion of the Level 3 Diploma for Residential Childcare. 19/08/2015

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Requirement Due date

Ensure that each employee completes an appropriate induction. (Regulation 33 (1) (a)). This particularly relates to the induction of the manager. 19/08/2015

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Requirement Due date

*Ensure the independent person produces a report about a visit which sets out, in particular, the independent person's opinion as to whether- (a) children are effectively safeguarded; and (b) the conduct of the home promotes children's well-being. (Regulation 44 (4) (a) (b)) 19/08/2015

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Requirement Due date

*Complete a review of the quality of care provided for children (“a quality of care review”) at least once every six months. (Regulation 45 (1)) 19/08/2015

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Requirement Due date

* These requirements are subject to statutory requirement 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): Ensure all young people have access to appropriate advocacy support; specifically, ensure young people are provided with information on how to contact an advocacy service. (The Guide to the Quality Standards, page 23, paragraph 4.16)

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Recommendations

 Ensure each child's talents and interests are understood and nurtured, with children selecting activities based on their personal preferences and abilities, so far as is reasonable. (The Guide to the Quality Standards, page 31, paragraph 6.4)

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Recommendations

 Ensure the home supports full time attendance at school; specifically ensure young people receive the encouragement and support they need to maintain regular attendance. (The Guide to the Quality Standards, page 28, paragraph 5.14)

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Information about this children's home

This is a privately owned children's home which provides residential care and support for up to five boys with emotional and behavioural difficulties. The home adjoins an independent school, registered for seven male pupils. The school is included in the resources available to young people placed at the home.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

21/11/2014 CH - Interim Sustained effectiveness

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inadequate

There is no consistency of management and staff at the home. High turnover of staff means that young people are unable to build trusted and secure relationships with adults working at the home. A young person reported that he would not speak to staff if he had any worries or concerns. Young people were observed in the lounge playing console games, without staff being present and engaging them in conversation.

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inadequate

Not all young people are familiar with the complaints procedure or the young people‟s guide. They are not aware of the role of an independent advocate, and there is no information displayed about how to access an advocacy service. Young peoples‟ meetings take place, but staff are not pro-active in ensuring young people are empowered to make their wishes and feelings known.

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inadequate

Young people attend the organisation‟s on-site school, which is well equipped and maintained. However, their engagement with education is poor. One young person‟s attendance has dropped from 97% to 19% since December 2014. Limited progress is made in attainment, and one young person is reported to have made „no educational progress at all‟ in the period between his looked after child review meetings.

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inadequate

Care planning is weak and does not reflect recommendations made in young people‟s psychological assessments. Monthly reports to social workers state the need for targets to be set for young people, but this has not happened. Similarly, monthly reports state an intention to address behaviour issues in key-work sessions. However, these sessions are infrequent and do not record any discussion as outlined in the report to the social worker.

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inadequate

Some young people do not have behaviour management plans, leaving staff without guidance on how to respond to challenging behaviour. Consequently, boundaries for young people are not clear and there is potential for inconsistent responses from staff. Records of physical restraint lack clarity and precise description of the incident. The manager was not able to explain a restraint technique used on a young person when questioned.

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inadequate

As a result of poor planning and lack of guidance for staff, young peoples‟ behaviour becomes more challenging. There are frequent incidents of challenging behaviour displayed by young people. This is reflected in the independent visitor‟s reports, and in other documentation such as monthly reports. Incidents include assaults on staff, fire setting and criminal damage.

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inadequate

Young people are not motivated to engage in stimulating or productive activities. Activity plans requested by the manager, had not been completed by staff. A social worker commented that staff had failed to motivate a young person despite the fact that he is „highly engage-able‟. Practice within the home does not consistently promote young peoples‟ health. A social worker reported that staff had failed to inform him that a young person had an appointment with a consultant psychiatrist, or that the young person refused to attend the appointment after being transported to the practice. Furthermore, the consultant was not informed of the young person‟s decision. Had this information been shared, it would have contributed towards the consultant‟s assessment. This shortfall further demonstrates that management and staff do not always communicate effectively with other professionals.

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inadequate

Arrangements for the management of medication are not safe and effective. The failure of staff to collect a prescription meant that a young person did not take prescribed medication for three days. Management were unable to confirm that medical advice had been sought in relation to the possible impact on the young person‟s health as a result of this error. Records also show gaps in the administration of prescribed medication, which staff members could not explain.

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inadequate

Arrangements are in place for all young people to have contact with their families, and where necessary this is supervised by staff. This ensures that young people‟s well-being is promoted during contact. However, both young people stated that problems with the house phone prevented them from easily making calls to family members, which caused them some anxiety. This issue was resolved by the time of the inspection.

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inadequate

There are insufficient numbers of qualified staff with the skills to support young people effectively. The result is staff do not put young people‟s well-being at the centre of their practice and positive attachments are not formed. This has a negative impact on young peoples‟ emotional resilience and prevents them from making good progress across all aspects of their lives.

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inadequate

Risk management is weak. Young people‟s individual risk assessments do not take account of changes in young people‟s behaviour and dangerous incidents. Some dangerous behaviour displayed by young people has not been risk assessed. Behaviour management strategies are not well developed. In some cases, individual behaviour management plans are missing. Staff are not always provided with guidance on how to recognise the triggers for poor behaviour or how to de- escalate confrontational situations and support young people to improve their behaviour.

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inadequate

Young people say they feel safe within the home but not all young people can identify a member of staff they would speak to if they had concerns. While young people describe their feelings of safety, the recorded episodes of their risk taking behaviours demonstrate that they are not always kept safe.

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inadequate

The standard of the home‟s record keeping is poor, and does not give a clear indication of the actions taken in response to safeguarding concerns. Risk assessments and pertinent information to enable staff to safeguard young people is not robust. Records pertaining to the physical restraint of young people lack detail and clarity. One report makes reference to an inappropriate restraint technique being used. The Registered Individual and managers were unable to give an account of the incident. This failure to monitor staff practice increases the potential for young people being harmed when physical restraint is used.

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inadequate

There is an inconsistent response to young people who go missing. Young people‟s individual care plans and risk assessments do not reflect the home‟s written procedures. They give conflicting advice for staff, on the steps to take when a young person goes missing. As a result, staff do not always take urgent enough action to search for young people when they go missing, or report their absence to the police in a timely manner.

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inadequate

Missing person incident reports lack clarity and do not provide a detailed account of the circumstances surrounding missing episodes. Insufficient information is given about conversations held with young people on their return to the home, and do not indicate whether an independent return home interview has taken place.

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inadequate

Management and staff are not collating information which would assist in more effective assessment of the risks associated with young peoples‟ missing episodes.

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inadequate

The premises are not well maintained and present risks to safety and well-being of young people and staff; this included a broken call point on the fire alarm system not previously identified by staff. Management arranged for the repair of the alarm system on the second day of the inspection, once this had been brought to their attention.‟ Inspectors also observed damaged and crumbling plaster on a wall surrounding a light switch and broken wall light fittings in the lounge. Recruitment procedures are thorough, and minimise the risk of inappropriate adults being employed in the home. Checks are undertaken to verify an applicant‟s suitability, and full employment histories are obtained prior to appointments being made. Judgement grade

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inadequate

The leadership and management arrangements of the home are weak. Since the interim inspection in November 2014 two successive managers have resigned. The registered person has determined that it is timely to arrange temporary closure of the home whilst a new manager is sought.‟

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inadequate

Insufficient staffing levels result in young people receiving lack of continuity and consistency of care. A social worker stated that one young person had no „meaningful relationships‟ with staff as a result of many staff leaving. Of the three permanent staff employed, one was on long term sick-leave; one was on full-time hours and the other on part-time hours. The introduction of waking nights has necessitated greater reliance on bank‟ or agency staff in the short term. Efforts are made to ensure that there is consistency in the staff used.

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inadequate

Leaders and managers cannot demonstrate that staff receive the support and training needed to meet the individual needs of young people. The undated training matrix indicates that core mandatory training in safeguarding, medication and health and safety is „ongoing‟ for some staff, but gives no indication who has completed these courses, or when. Inspectors were shown the outline agenda for two „workshops‟ which would support staff in delivering the therapeutic model, but these contained no information about who was delivering these, or which staff attended. The training matrix shows that only one member of staff has a qualification equivalent to the level three diploma in children and young people‟s residential care. It does not indicate that other staff have been enrolled on this, or an equivalent training course.

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inadequate

Insufficient training leaves staff without the knowledge and skills to provide effective care for young people. The manager said that when he came into post, approximately eight weeks before this inspection, he had identified this problem. Despite the manager informing inspectors that he had begun to address the issue through team meetings and staff supervision, a review of relevant documentation indicated that this process was neither systematic nor robust.

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inadequate

Staff do not have written personal development or training plans in place, and no written records of staff supervision, stated to have been undertaken by the current manager were available during this inspection. Staff supervision has been inadequate over a prolonged period. Supervision recording completed in January 2015, by the previous manager indicates that no reflective discussion was taking place, and staff development needs were not recognised within these records. The Registered Individual does not have sufficient oversight or understanding of the deficits in supervision practice standards. Records of staff team meetings do not always provide details of discussions that have taken place, and do not contain actions with set timescales for completion. Where an action has been agreed, the manager does not effectively monitor to ensure this is progressed.

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inadequate

The manager did not consider his induction to have been helpful in taking up the role, and documentation seen supported his view.

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inadequate

Processes for monitoring the quality of care are ineffectual, and in some cases have not been implemented. An independent visitor monitors the quality of care within the required timescales, but the reports provide little analysis or evaluation of the findings. They record which documents have been viewed such as risk assessments, but provide no commentary on the quality of these. The report for April 2015 notes the child protection concern but has not evaluated the effectiveness of the homes actions taken.

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inadequate

The independent monitoring reports do not indicate that the visitor effectively challenges managers regarding shortfalls in practice. For example, reports from March – May 2015 identify that managers were not undertaking internal monitoring of the quality of care. At this inspection it was confirmed that the issue had not been addressed. No internal monitoring reports had been completed since the last inspection in November 2014.

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inadequate

Two other requirements were made at the inspection in November 2014. One relates to notifying relevant authorities about significant events. Records examined showed that there was a significant delay in the reporting of a child protection concern to Ofsted. The requirement made in November 2014 has not been met. A requirement was also made regarding the need to notify Ofsted of any change in the statement of purpose and this has been complied with.

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inadequate

Inadequate leadership and management has meant young people do not have a positive day-to-day experience, and make little or no progress. Staff do not have the skills to promote young people‟s well-being or protect them from harm. The Registered Individual confirmed that the home‟s weaknesses had been identified prior to this inspection and a decision taken to end the placements of both young people at the home. Notice had been served to one placing authority, and the other authority will be notified of the decision within the next few days. A new manager and staff team will be recruited in due course.

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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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