Children's home run by Benjamin UK Ltd in Hammersmith and Fulham

Inadequate

There are serious failures that mean children and young people are not protected.

p.2

The children's home provision is inadequate because:

 The home‟s location risk assessment lacks a full review of the potential risks and hazards to children. It fails to demonstrate how identified risks can be reduced or inform the potential impact on new admissions.  A lack of sufficient action has been taken following some children placing themselves at risk by running into the road near the home. While staff safeguarded children at the time of the incidents, there has been no action taken to reduce a reoccurrence. This is a serious omission which has undermined children‟s physical safety.  A lack of sufficient action has been taken following some children placing themselves at risk by getting on to the roof of the home. No changes have been made to the physical environment and layout of the home to prevent a reoccurrence. There is also a lack of robust action to address with children the potential risk that they are placing themselves at. This is a serious

p.3

The children's home provision is inadequate because:

omission which has undermined children‟s physical safety  On occasion, staff have failed to de-escalate children‟s challenging behaviour effectively or implement identified strategies.  A lack of robust staff challenge to address some children‟s behaviour has resulted in repetitive damage to certain areas of the home. While the organisation has tried to maintain high standards of furnishing, this has been not been effective throughout.  Staff have not had effective and regular supervision. The manager provides informal support, but this does not ensure that staff are provided with an opportunity to discuss their professional development or raise concerns in a formal meeting.  Some staff have not completed the level 3 diploma within the relevant dates required, which is a breach of regulation.  Young people‟s health needs are not consistently met due to their refusal to attend health appointments.  There are some shortfalls in respect of recording of medication and ensuring

p.3

The children's home strengths

 The manager has developed strong links with other key professionals. This ensures that there is a unified approach to the children‟s care.  Children‟s views, wishes and feelings are apparent in all decision making that affects them. Children feel listened to.  Staff provide children with a structured daily routine, and praise their achievements. All children have made progress in their educational attendance and achievement from their starting points.  Children speak positively about the care that they receive from staff. They have positive relationships with staff and can identify individuals that they would talk to if they had a concern.  The staff provide children with an environment where they can express themselves and explore their awareness of diversity and equality.  The registered manager actively includes the staff and children regarding decisions about the home, to make improvements to the service provided.

p.4

The children's home strengths

 The management team takes appropriate actions when child protection concerns are raised. Records held within the home demonstrate robust investigation and clear decision-making processes.

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 the „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

6: The quality and purpose of care standard In order to meet the quality of care standard— (2) In particular, the standard in paragraph (1) requires the registered person to— (c) ensure that the premises used for the purposes of the home are designed and furnished so as to— (i) meet the needs of each child. 24 June 2016

p.5

Requirement Due date

10: The health and well-being standard In order to meet the health and well-being standard— (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that staff help each child to— (iii) take part in activities, and attend any appointments, for the purpose of meeting the child‟s health and well-being needs. 24 June 2016

p.5

Requirement Due date

11: The positive relationships standard In order to meet the positive relationship standard— (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that staff— (ii) help each child to develop socially aware behaviour; (iv) help each child to develop and practise skills to resolve conflicts positively and without harm to anyone; (ix) understand how children‟s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children; 27 May 2016 (xi) de-escalate confrontations with or between children, or potentially violent behaviour by children.

p.5

Requirement Due date

12: The protection of children standard In order to meet the protection of children standard— ( 2) In particular, the standard in paragraph (1) requires the registered person to ensure— (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. This is with particular regard to young people accessing the home‟s roof and the road. 6 June 2016

p.6

Requirement Due date

13: The leadership and management standard In order to meet the leadership and management standard— (2) In particular, the standard in paragraph (1) requires the registered person to— (f) understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home. 24 June 2016

p.6

Requirement Due date

The registered person must make arrangements for the recording and safe administration of medicines received into the children‟s home (Regulation 23 (1)). 24 June 2016

p.6

Requirement Due date

The registered person must review the appropriateness and suitability of the location of the premises used for the purposes of the children‟s home at least once in each calendar year taking into account the requirements in Regulation 12 (2)(c) (the protection of children standard) (Regulation 46 (1)). 27 May 2016

p.6

Requirement Due date

For the purposes of paragraph (3)(b), an individual who works in the home in a care role has the appropriate qualification if, by the relevant date, the individual has attained the Level 3 Diploma for Residential Childcare (England) (“the Level 3 Diploma”) or a qualification which the registered person considers to be equivalent to the Level 3 Diploma. The relevant date is in the case of an individual who starts working in a care role in a home after 1st April 2014, the date which falls 2 years after the date on which the individual started working in a care role in a home; or in the case of an individual who was working in a care role in a home on 1st April 2014, 1st April 2016 (Regulation 32 (4)(a)(b) 1 November and (5)(a)(b)).

p.6

Requirement Due date

The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience (Regulation 33 (4)(b)). 24 June 2016

p.7

Requirement Due date

The registered person must maintain records (“case records”) for each child which are kept up to date (Regulation 36 (1)(b)). 24 June 2016

p.7

Information about this children's home

The home is owned by a private company. It provides therapeutic care for up to four young people between the ages of 11 and 18 years who have emotional and behavioural difficulties. Education is available in the college operated by the managing organisation.

p.8

Recent inspection history

Inspection date Inspection type Inspection judgement

p.8

Recent inspection history

17 December 2015 Interim Improved effectiveness

p.8

Inadequate

A lack of robust and proactive action to address some children‟s risk-taking behaviour has impacted on the overall judgement of the home. Some children currently living at the home, and some who have since left the home, have placed themselves at significant risk by climbing onto the home‟s roof. In addition, some children have run into the road near to the home when in crisis. Managers have not taken effective action to prevent a reoccurrence. As a result, children are potentially at serious risk of harm. All children are registered with a doctor, dentist and optician. However, some children have repeatedly refused to attend important health appointments, such as dental checks and, on occasion, hospital appointments. Staff remake appointments and encourage children to attend and offer to take them. However, there is a lack of consideration of potential alternative strategies and options to help support

p.9

Inadequate

children to attend. This does not ensure that all children‟s health needs are fully met. The procedures for the safe and effective administration of medication are mainly well managed. However, on occasion, the recording of medication is not in line with the home‟s guidance. For example, not all records have the required two staff members‟ signatures. While there has been minimal impact on the children concerned, this is a breach of regulation which makes mistakes more likely. The home is warm and welcoming. Children‟s recent challenging behaviour has impacted on some of the furnishings of the home, despite regular maintenance being provided. Measures of control implemented by staff have failed to be effective to reduce the amount of damage caused by some children. The children enjoy good relationships with staff and managers, who are warm and supportive to them. All children spoken to could identify staff who they can talk to

p.9

Inadequate

if they had a concern. The children are positive about the care that they receive. Some children view the home as more than a house and see it as their home. The children‟s dignity and privacy are respected; they feel listened to and know that staff care about them. Staff ensure that children are provided with an opportunity to have individual key work sessions to support their emotional needs. The children are further supported by the organisation‟s psychotherapist‟s weekly visits to the home. When children are not willing to engage, the therapist spends time with the staff. This provides staff with support and specialist advice to enable them to support children effectively. The staff promote healthy eating and menus are balanced. They take into account children‟s cultural needs and preferences. Some children smoke cigarettes or misuse substances. The staff inform children of the effects of this on their physical and psychological health. This is through

p.9

Inadequate

providing workshops held by experienced professionals within the staff team and by accessing external agencies to visit and engage with the children. This has resulted in some children‟s slight reduction of use. The staff and manager continue to be creative and research other intervention techniques that may support children to cease smoking and substance misuse. For example, one child accessed training held for staff. During the inspection, a child attended an appointment with a smoking cessation nurse and was positive about stopping smoking cigarettes. The staff and management work hard to gain children‟s views, and this is a strength of the service. A child said that he felt that staff really listened to his views. The staff support children to have their views heard by other professionals in their life, and are strong advocates for children. For example, one child would like his future plans to be different. Staff are supporting him to ensure that his

p.10

Inadequate

views are heard. Key work sessions and resident meetings enable children to have a formal forum to have their views heard and to be part of the day-to-day running of the home. For example, in the meals that they eat, activities they do and suggestions to improve the home. One child has recently requested that part of the home has gym equipment to help keep healthy and this is currently being considered. All children make progress in their educational attendance and achievement from their starting points. The manager works solidly to challenge placing authorities when there is a delay in an educational provision being identified. This ensures that all children have an educational provision to attend. Some children, who have attended education sporadically historically, have individualised packages to support their re-introduction to education. A recent development of the home is a separate building, which has been adapted into a school room, where children

p.10

Inadequate

attending the organisation‟s college receive some of their education. Staff report that this has been beneficial for children, and children have engaged better and are more focused as they have a designated area outside of the home to learn. Children make progress in other significant areas of their lives. Some children have reduced their aggression towards staff and now see the staff as a positive influence in their lives. Other areas of progress include significant reduction in incidents of going missing, engagement in activities, improved sleeping and daily routines and improvement in self-esteem and confidence. This is because there is a consistent and stable staff team who spend quality time with children and provide them with routine and structure. Staff support children to have contact with their family and friends, in line with care plans. Staff value the importance of family relationships to children‟s success.

p.10

Inadequate

Where children are not in contact with their biological family members, staff support them to maintain key relationships. The children make progress in developing their independence skills, in line with their age and ability. Some children have recently started an independent living programme as part of a transition package. This guides and informs children through different elements of independence. They receive information about accommodation, looking after themselves, banking and their legal rights. The children develop skills in budgeting and cooking meals with staff support. Therefore, all children learn skills that they can carry into adulthood and which provide them with an increased level of independence.

p.10

Inadequate

Some children currently living at the home, and some that have recently left the home have placed themselves at significant risk on occasion. This is because they have climbed onto the roof of the home. While the staff took some action previously, this has failed to reduce children‟s ability to access this area. Since this time, the organisation has failed to make further adjustments to the physical layout and environment of the home. The manager has not robustly and effectively addressed with children the potential risk of serious harm that they are placing themselves at. At the time of the inspection, there was no up-to-date risk assessment regarding this risk. This was completed during the inspection, providing staff with clear instruction of the action to take if this reoccurred until a longer-term solution is agreed. Some children, when presenting with challenging behaviour or in crisis, have run

p.11

Inadequate

into the road at the end of the driveway and refused to move. While the staff worked tirelessly to ensure that at these times children are kept safe, there has been a lack of proactive action taken to reduce a reoccurrence. Children‟s risk assessments and the home‟s location risk assessment fail to identify this change in some children‟s behaviour. A lack of action to make potential adjustments to the physical environment, to provide staff with resources to keep themselves and the children safe at these times and lack of effective and robust work with children has continued to place children at significant risk of harm. On occasion, staff have not consistently implemented the home‟s behaviour management policy or worked within the strategies provided to support children. This has failed to de-escalate situations. For example, staff have turned the electricity off when children have tried to take the kettle and toaster to their

p.11

Inadequate

rooms. No other action has been considered. In some events, the lack of de- escalation has resulted in young people‟s challenging behaviour increasing. This has put them at risk by accessing the home‟s roof or running into the road. The children value the praise and rewards that they receive for positive behaviour and achievement. They are clear on the behaviour management system within the home. This is based on a token economy policy and some children strive to reach the highest level. They know that the staff are proud of their achievement. This is because staff praise their efforts and progress, no matter how small. Some children have individual contracts to support them in individual identified areas of needs, and this is very successful for one child who has significantly reduced his challenging and risk-taking behaviour. Children spoken to felt that the home is managed fairly in this area. Staff are trained in behaviour management, including physical intervention, and

p.11

Inadequate

how to maintain sufficient records. The manager, within staff meetings, provides staff with opportunities to consider as a team known triggers for children and what strategies have been effective. Staff are provided with information, through workshops, regarding looking at why the children are presenting with challenging behaviour. However, on occasions, in particular when some children‟s behaviour has been challenging over a longer period of time, some staff have not implemented this knowledge and therefore children‟s behaviour has not been appropriately managed. This results in behaviour escalating. The staff are well informed of policies and procedures through induction and training. They know how to protect children from abuse and the procedures to follow in partnership with other agencies. An appointed designated safeguarding lead within the organisation provides clarity and oversight to safeguard children.

p.12

Inadequate

Where there have been child protection concerns, the manager has appropriately referred the concerns to the local authority designated officer. Investigations have been completed to a good standard. Records held within the home detail all action taken and the decision-making process. Therefore, the children are kept safe. The manager has taken further action, meeting with the local authority designated officer to identify possible trends and patterns. Because of this multi-agency working, changes were made to the staff rota and to some key worker roles for children. As a result, there has been a recent reduction in the number of allegations made and improved relationships with children.

p.12

Inadequate

A lack of robust and proactive action to address some children‟s risk-taking behaviour has placed children at risk. Managers have not taken effective action to prevent a reoccurrence. As a result, children are potentially at serious risk of harm. The registered manager has been in post since December 2015, has over six years‟ experience of working with children and is in the process of completing the level 5 diploma in Leadership and Management. The manager is passionate about the service provision and works hard to support the staff and children. The staff and children speak highly of the manager and the support and accessibility that she provides. For example, following an individual key work session with a child regarding their emotional needs, the manager now sends a positive quote each day to help wake him and see his day in a positive way. It is the individualised support that helps children to feel special and cared for.

p.12

Inadequate

The statement of purpose provides information about the ethos and objectives of the home, and resources available to support children in placement. The children, on admission to the home, are provided with a guide which clearly explains the service they will receive. The manager has taken some action to meet the previous requirements made. The staff provide a clear and structured routine for all children. As a result, all children are informed of the expectations and attend their educational provisions. The manager has not fully met the requirement with regard to individual risk assessments. While children‟s risk assessment now includes all known risks, they are not up to date in line with current behaviour. Therefore, not all action required to reduce potential risks to children has been identified. The manager has not met the third requirement regarding the furnishings of the home. While all children are

p.13

Inadequate

now provided with the appropriate furniture, their behaviour has impacted on the overall decor of the home. The organisation is working to address this shortfall. The manager ensures that when she is on leave there is a manager who provides supervision to staff. However, recently not all staff have received formal supervision. Therefore, staff are not provided with a formal meeting to discuss their personal development or to raise concern within a formal meeting. The children are cared for by a stable and dedicated staff team who know them well. There are always enough staff on duty at all times and this enables staff plenty of opportunities to spend quality time with the children. The management team, including senior management within the organisation, provides clear structure, accountability and delegated lead roles that provide good support to the staff. The staff report that training provided is of a good quality and supports them

p.13

Inadequate

to meet the needs of the children. In addition to mandatory training, staff have received more specialised training such as self-esteem for children delivered by the organisation‟s psychotherapist, solvent abuse training and report writing. However, no staff member within the home, apart from the manager, has attained the level 3 diploma in Residential Childcare. The manager is aware of this shortfall and all staff are working towards attaining the qualification. Monitoring systems are in place, including weekly and monthly checks. The manager completes some data analysis to identify trends and patterns. However, due to the recent high needs of the children, the manager has been required to support the children and staff. Therefore, monitoring of progress for children and management duties of the home is lacking. This shortfall has already been identified by the organisation and an additional manager is currently providing

p.13

Inadequate

support to address the shortfalls identified within this report. There is clear reporting of significant incidents. Necessary professionals and agencies are promptly notified and records demonstrate actions taken. The children‟s records are stored securely. However, not all children‟s case records are up to date, for example, children‟s placements plans. Therefore, while there is limited impact on children as the staff knowledge of their needs is sufficient, this does not ensure that children‟s records capture the life of the child within the home.

p.13

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.14

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.14

What the inspection judgements mean

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

p.14

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.15

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 .

p.15

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,

p.16

Information about this inspection

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

p.16

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.16

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.16