Children's home SC063059

Inadequate

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

p.2

The children's home provision is inadequate because:

 Young people’s needs are not being met across aspects of their welfare and development, in particular their safety and emotional well-being.

p.3

The children's home provision is inadequate because:

 In the absence of a registered manager, the provider has failed to ensure effective and efficient management of the home. This hinders improvements in how staff understand and respond to young people’s needs and behaviour, particularly with regard to behaviour management strategies and care planning.

p.3

The children's home provision is inadequate because:

 Young people do not receive the level of care stated in the home’s statement of purpose with regard to therapeutic and psychological interventions.

p.3

The children's home provision is inadequate because:

 Some young people do not access education. This impacts on their progress and ability to reach their full potential.

p.3

The children's home provision is inadequate because:

 Care planning and risk assessments are not robust or effectively reviewed to address the changing emotional and social needs of young people.

p.3

The children's home provision is inadequate because:

 Medication is not administered in line with policy and procedures.

p.3

The children's home provision is inadequate because:

 Staffing is not sufficiently stable to provide consistent care to young people.

p.3

The children's home provision is inadequate because:

 Staff are not sufficiently qualified, skilled or competent to meet the needs of young people.

p.3

The children's home provision is inadequate because:

 Staff, including managers, do not recognise or respond to potential or actual safeguarding concerns within the required timescales. Independent monitoring does not give an accurate picture of how the home is operating to safeguard and support young people.

p.3

The children's home strengths

 Some young people are supported to engage in activities outside of the home, for example a drama club.

p.4

The children's home strengths

 Some refurbishment has taken place in the communal areas.

p.4

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 ‘Guide to the children's homes regulations including the quality standards’. The registered person(s) must comply with the given timescales.

p.5

Requirement Due date

Engaging with the wider system to ensure children's needs are met 5. In order to meet the engaging with the wider system standard to ensure children’s needs are met, the registered person must, and must ensure that staff— (c) if the registered person considers, or staff consider, a placing authority’s or a relevant person’s performance or response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans; and 28/04/2016

p.5

The quality and purpose of care standard

6. (1) The quality and purpose of care standard is that children receive care from staff who— (a) understand the children’s home’s overall aims and the outcomes it seeks to achieve for children; (b) use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential. (2) In particular, the standard in paragraph (1) requires the registered person to— (a) understand and apply the home’s statement of purpose; (b) ensure that staff— (i) understand and apply the home’s statement of purpose; (iii) treat each child with dignity and respect; (iv) provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background; 28/04/2016

p.5

The children's views, wishes and feelings standard

7.—(1) The children’s views, wishes and feelings standard is that children receive care from staff who— (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. 28/04/2016

p.6

The education standard

8.—(1) The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that staff— (i) help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans; (iii) understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers; (x) help each child to attend education or training in accordance with the expectations in the child’s relevant plans; and 28/04/2016

p.6

The education standard

The protection of children standard * 12. (1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe. (2) In particular, the standard in paragraph (1) requires the registered person to 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; (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; (v) understand the roles and responsibilities in 28/04/2016 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;

p.6

The education standard

(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; (d) that 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; and (e) that the effectiveness of the home’s child protection policies is monitored regularly.

p.7

The education standard

The leadership and management standard * 13.—(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— (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 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

p.7

The education standard

each child and use this understanding to inform the development of the quality of care provided in the home; (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. 28/04/2016

p.7

The education standard

The care planning standard * 28/04/2016 * 14.—(1) The care planning standard is that children— (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 provide care and accommodation, as set out in the home’s statement of purpose; (b) that arrangements are in place to— (c) that each child’s relevant plans are followed;

p.7

Medicines

23.—(1) The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. (2) In particular the registered person must ensure that— (c) a record is kept of the administration of medicine to each child; and (3) (b) may be safely self-administered by that child. 28/04/2016

p.8

Fire precautions

25.—(1) After consultation with the fire and rescue authority, the registered person must— (c) make arrangements for persons working at the home to receive suitable training in fire prevention; and (d) ensure, by means of fire drills and practices at suitable intervals, that persons working at the home and, so far as reasonably practicable, children are aware of the procedure to be followed in case of fire. 28/04/2016

p.8

Staffing of children’s homes

31.(1) The registered person must ensure that the employment of any person on a temporary basis at the children’s home does not prevent children from receiving such continuity of care as is reasonable to meet their needs. (2) The registered person must ensure that— (a) at all times, at least one person on duty at the home 28/04/2016 has a suitable first aid qualification.

p.8

Employment of staff

33.—(4) The registered person must ensure that all employees— (a) undertake appropriate continuing professional development; and (b) receive practice-related supervision by a person with appropriate experience; and 28/04/2016

p.9

Behaviour management policies and records

35.—(1) The registered person must prepare and implement a policy ("the behaviour management policy") which sets out— (a) how appropriate behaviour is to be promoted in the children's home; and (b) the measures of control, discipline and restraint, which may be used in relation to children in the home. (2) The registered person must keep the behaviour management policy under review and, where appropriate, revise it. 28/04/2016

p.9

Notification of a serious event

40.—(4) The registered person must notify HMCI and each other relevant person without delay if— (a) a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation (b); an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; 28/04/2016

p.9

Independent person: visits and reports

44.—(4) The independent person must produce a report about a visit ("the independent person's report") 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. 28/04/2016

p.9

Independent person: visits and reports

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

p.9

Information about this children's home

This is a privately run children’s home for four young people with emotional and behavioural difficulties.

p.10

Recent inspection history

Inspection date Inspection type Inspection judgement

p.10

Recent inspection history

11 August 2015 Full Requires improvement

p.10

Recent inspection history

12 March 2015 Interim Sustained effectiveness

p.10

Inadequate

Since the last inspection, the manager has not taken effective action to meet any of the requirements and recommendations. Young people’s positive progress has not been sustained, and this has directly impacted on their welfare, development and safety.

p.11

Inadequate

Contrary to the admissions policy and procedures, not all young people have benefited from a comprehensive referral, compatibility risk assessment or a thorough appraisal of their needs prior to admission . Young people have moved into the home without any relevant paperwork, including local authority documentation or suitable arrangements in place to support them. Consequently, some young people have been inappropriately placed and staff are not aware of their individual needs. In addition, prior to moving to the home, some young people do not have the opportunity to visit. Staff and other young people were not aware that a young person was moving in until he arrived. One young person said, ‘the first I knew was when I came out of my bedroom and this new lad was stood there.’

p.11

Inadequate

Transition planning for young people moving into and out of the home is poor. Young people are not involved in the planning process and do not have an opportunity to discuss their wishes and feelings. Since the last inspection, two young people have moved out of the home. There was a significant delay in one young person moving on to his semi-independent provision due to a lack of clear plans. When young people move into the home, staff failed to provide appropriate advice and support to help them settle. They did not monitor what the young person had brought with them, including what clothes or personal possessions they had. During initial key-working sessions, a young person was informed that ‘if he misbehaved he could be restrained’. This does not demonstrate how staff are nurturing young people or meeting their basic care needs.

p.11

Inadequate

The absence of care planning documents has resulted in the lack of bespoke interventions for young people that are based on their assessed needs. An example of this is a young person who is living in the semi-independent on-site flat. There was no pathway plan or risk assessment to identify how he is supported in his accommodation, and how staff will maintain his safety and emotional well-being. Despite there being evidence of a weekly independence review sheet, this was blank. Some staff were unaware of its existence. They did not have any knowledge of how the young person was to be supported, or the expectations within their role in maintaining his safety and well-being.

p.11

Inadequate

Some young people’s records omit important information about their previous history and current needs. Furthermore, local authority documentation is not routinely obtained and placement plans, risk assessments and behaviour management plans lack sufficient detail. For example, current and previous issues around ‘violent and aggressive behaviours’, ‘sexually harmful behaviours’ and ‘self- harmful behaviours’ were not considered and appropriate strategies were not put in place. This places young people, staff and others in the community at risk of significant harm.

p.12

Inadequate

Educational progress varies. While one young person had engaged in education, other young people were not making measurable process or reaching their full potential. Staff did not have a clear understanding of all of the young people’s education needs. The home did not have education plans in place and young people did not benefit from a clear structure or routine to support their attendance and learning. This was specifically evident for young people who did not have any education provision identified. Young people remained in bed and staff showed no clear expectations around their attendance. Young people do not have a structured daily routine in their lives for when they return to their education setting. Staff do not demonstrate high aspirations for young people’s learning and do not actively prepare and support them to re-engage. One young person said, ’I don’t have to go to school, they can’t make me.’

p.12

Inadequate

Staff are unable to support the emotional and psychological health of young people. They lack the knowledge and training necessary to enable them to promote positive changes through effective engagement. There were no clear health plans to identify young people’s health needs or any strategies available to support them. For example, outstanding appointments were not followed up and records do not show the action taken to address all health requirements. This fails to promote young people’s physical and emotional well-being.

p.12

Inadequate

Arrangements for managing medication were ineffective. On occasion, staff had not administered prescribed medication. Records lacked an explanation as to why this was not given. There were also discrepancies in the total amount of medication held by the home. Records have been changed and altered without any clear explanation. This is a breach of the home’s own medication polices and does not ensure that young people are provided with medication as prescribed.

p.12

Inadequate

Some young people are supported to maintain relationships with important people in their lives. However, some contact records provided conflicting information in regard to young people’s contact plans. For example, in one young person’s file it was documented that he could have contact with his parents. However, another document indicated that ‘no contact was allowed’. This lack of accurate information places young people at risk as it does not demonstrate how young people are helped to maintain appropriate levels of agreed contact.

p.13

Inadequate

Some young people take part in activities in the community, for example attendance at a local drama class and a skating rink. However, it was not clear from the records what other young people were interested in or how they had been supported to access appropriate activities. Staff were unable to elaborate on this. This does not show that all young people have access to activities in the community to promote their social skills and build positive friendships.

p.13

Inadequate

Safeguarding practice in this home is poor, and does not promote the welfare and safety of young people. Child protection procedures are not followed to address serious safeguarding concerns. For example, a young person informed staff that an unknown adult male had contacted him on a social media site. Staff failed to take appropriate action, and did not follow their own safeguarding policies and procedures. This has significant implications for the young person’s safety and does not demonstrate safe practice within the home.

p.13

Inadequate

In addition, during a staff supervision session it was documented that a staff member had allowed young people to use their personal mobile phone to access internet ‘hotspots’. This meant that young people were allowed unrestricted and unmonitored access to the internet. Although there was evidence of a discussion with the individual staff member, no further action was taken to address this with the team and policies were not updated to include this as safeguarding concern. There was further evidence of young people sending texts to staff members’ personal mobile phones to question the actions of staff on shift. This was discussed with the support manager and responsible individual, who both confirmed that workers do not have business mobile phones, and that this practice was unacceptable and contrary to the home’s own policies and procedures.

p.13

Inadequate

Staff failed to implement clear and consistent boundaries or use effective behaviour management strategies, including physical restraint. In addition, the numbers of restraints have increased for some young people. For example, to manage a behaviour in the ‘negative consequence log’ it states that a young person ‘demanded a lift’. The response recorded by staff was, ‘I am not going to spend any positive time with you, due to negative behaviours.’ There were no further recordings or details provided to clarify the incident. In addition, records did not provide a clear overview of the behaviour that led to such measures, the proposed time frame, or the young person’s views. Neither had the manager evaluated the appropriateness or effectiveness of the measures used. Consequently, staff continue to use ineffective behaviour management strategies and young people are not learning to reflect upon and improve their behaviour.

p.14

Inadequate

Following incidents of physical intervention, young people alleged that staff had caused them harm and they had sustained an injury. Staff had failed to complete restraint and accident forms, recording the incidents as complaints. They had also failed to follow their own safeguarding policies and procedures in notifying the local designated officer and the placing social worker. When this was brought to the attention of the support manager, she was unaware that the incidents had occurred and that staff had failed to take appropriate action. This fails to safeguard young people.

p.14

Inadequate

Poor relationships between staff and some young people were observed throughout the inspection. This was evident from young people’s persistent abusive and demanding behaviour, and staff’s lack of sufficient challenge and redirection. Young people made comments such as; ‘I can do what I want’, and ’they can’t tell me what to do.’ Staff had little impact on young people’s behaviour and failed to address the inappropriate language they were using and the inappropriate sexualised innuendos. Due to an escalation in young people’s behaviour around the home, on occasions staff had felt it necessary to call the police to manage behaviours. Young people have spent time in police custody, and have appeared and been charged in court. As a result, young people have been criminalised. This further impacts on the positive relationships between young people and staff, and can adversely affect young people’s future life chances.

p.14

Inadequate

The home’s staff fail to follow their own policies and procedures when young people are missing from care. Individualised risk assessments and action plans did not give clear direction to staff on what action they should take when a young person goes out into the community for any period of time. For example, staff do not contact young people until they fail to return home on time. This can be from first thing in the morning until late at night. Staff cannot account for young people’s whereabouts and safety in the community, nor whom they are associating with.

p.14

Inadequate

When young people go missing from care there are no clear strategies in place to follow to minimise further risks. Documentation is confusing and provides different strategies on what needs to happen. This does not ensure that all staff follow the same procedure in ensuring that young people are safe. For example, one young person had been missing from care for a period of four days. He was classed as ‘absent from care’ until day three, although the staff had no knowledge of his whereabouts. This is against the home’s own policies. Records did not say what action staff had taken to try to locate the young person to ensure that he was safe.

p.15

Inadequate

When young people return after ‘missing from care’ episodes, independent ‘return to home’ interviews are not consistently arranged. In addition, the manager does not review the episodes, to assess if appropriate action had been taken. This means the manager and staff are not using learning from episodes of missing to reduce risks or amend strategies to reduce the risk to young people.

p.15

Inadequate

Health and safety within the home has been compromised. Staff have failed to carry out fire drills on a regular basis to ensure that all young people and staff are aware of what action to take if there is a fire. New staff are not always shown the procedures and did not know what action to take. There were also rodent traps in the garden area that staff were unaware of, and had not taken action to ensure that they were managed safely. This places both young people and staff at potential risk.

p.15

Inadequate

The home has recently undergone refurbishment of the communal areas and young people had been consulted about the colour schemes. However, young people’s bedrooms were dirty and unhygienic. They did not have appropriate bedding, and pillows and mattress were engrained with dirt. There were clothes strewn across the floor and dirty plates with the remnants of old food left lying on the floor. A further bedroom was found to have animal footprints and faeces on the mattress. Staff were unaware of the condition of any of the bedrooms. This is not conducive to a warm and welcoming environment, and may possibly be a risk to young people’s health and safety.

p.15

Inadequate

The staff do not have up-to-date knowledge and skills to safeguard young people adequately and meet their assessed needs. The majority of staff have not had up- to-date training on issues of safeguarding, child sexual exploitation or restraint. Although the provider had arranged training for five staff members in safeguarding, all five had failed to attend the training. Additionally, staff have not received up-to-date training in first aid, medication, food safety and fire awareness. This lack of basic mandatory training compromises the young people’s safety as staff do not have the skills to fulfil their role.

p.15

Inadequate

Young people live in a home that is not effectively managed. There is currently no registered manager in place. There are significant failures in senior management oversight and monitoring of the home, to identify weaknesses and to take decisive action to correct these. As a result, young people’s progress and safety have been compromised.

p.16

Inadequate

The home does not meet the aims and objectives of their Statement of Purpose which states: ‘The Psychologically Informed Care-Planning and Intervention (PICI) Model is now being used for new admissions. This involves a structured assessment of the needs of each child placed with us. From this, we further develop the Care Plan document giving their story and a set of strategies to manage and support their presenting issues, as well as undertaking regular outcome measurement. Safe and Sound Care is aimed at improving the quality of care provided.’ ‘As an introduction, every staff member will get 2 days of training from a Clinical Psychologist about attachment, trauma and the impact of maltreatment.’

p.16

Inadequate

Staff are unclear about the ethos and philosophy of the home, and said that they had not received training in ‘attachment, trauma and the impact of maltreatment’. They were unable to demonstrate an understanding of the home’s therapeutic approach. A social worker questioned the validity of the therapeutic approach being provided in this home, specifically in relation to their placed young person.

p.16

Inadequate

The majority of staff have not received supervision or been provided with an opportunity to attend team meetings for a significant period of time. The support manager, who had recognised this shortfall but only facilitated group supervision for senior care workers in March 2016, confirmed this. This is not in line with the provider’s policies and procedures, which say that ‘staff will receive supervision on a monthly basis’. It also fails to provide an opportunity for all staff to reflect on their practice and to promote better outcomes for young people. The managers do not have sufficient overview to ensure that staff have the necessary skills and abilities to care for young people.

p.16

Inadequate

There had been several changes in the staff team and a number of staff were absent from work. This impacts on the consistency and continuity of care for young people. Staff duty rosters also fail to reflect the actual staff on duty accurately and lack transparency. This prevents a clear audit trail of who is working within the setting, when and where. For example, on the 26 and 27 March 2016 the rota failed to indicate which staff members were on duty. During discussions with the support manager, she confirmed that it would have been agency staff members. However, there was no paperwork within the home to identify who these people were. On other occasions, young people and staff were unaware of who was working within the home, as staff from other homes within the company were deployed at short notice. One staff member said, ‘I did not know who was here last night, I have never seen her before, let alone the kids.’ The lack of

p.17

Inadequate

transparency of who is on duty potentially places young people at risk and compromises the continuity of care.

p.17

Inadequate

The internal monitoring of the home and the independent visits are ineffective. They have failed to identify the weaknesses in practice found during this inspection. For example, the information provided by the placing authority that is maintained on the young person’s file is in relation to a previous placement. It does not identify the young person’s current needs. There are also several pieces of paperwork including accident forms and incident reports that have not been completed, for example following injuries during restraint. More robust systems are needed to ensure that the safety and well-being of the young people is promoted at all times.

p.17

Inadequate

The home’s admission and discharge book is not up to date and fails to record the required information. While this does not affect young people directly, it does not provide an accurate and true record of who is living at the home.

p.17

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’.

p.18

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

p.18

What the inspection judgements mean

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

p.18

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

p.19

Information about this inspection

Homes (England) Regulations 2015 and ‘Guide to the Children's Homes Regulations including the quality standards’. procedures set out in 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 0300 123 4234, or email enquiries@ofsted.gov.uk .

p.19

Information about this inspection

regulates and inspects to 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

p.20

Information about this inspection

Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

p.20

Information about this inspection

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

p.20

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

p.21