Children's home in South Staffordshire

Inadequate

There are serious failures that mean that young people are not protected or their welfare safeguarded. Some young people’s care and experiences are poor and they are not making progress.

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The children's home provision is inadequate because:

 There is widespread and continuing failure to rectify the eight requirements from a previous inadequate inspection in January 2016. Further regulatory shortfalls are identified during this inspection.

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The children's home provision is inadequate because:

 Young people remain at risk of harm because the registered manager and responsible individual have not sought specialist advice from local authority fire services. Young people with fire-setting behaviours have set a fire at the home since the last inspection.  Risk management continues to be poor. Senior staff are unaware of the location of life-saving equipment so that they can respond to self-injurious behaviours.  One young person continues to go missing from the home and is vulnerable to radicalisation.  The registered manager does not work in line with the placing authority’s placement plans.  Staff do not implement agreed arrangements to supervise family home contact. As a result, young people have spent unsupervised time with family members and there are concerns about injury to some of these individuals. Some young people continue to fail to reach their potential because they do not attend full-time education. Staff make no attempt to support an

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The children's home provision is inadequate because:

educational programme at home.  Recruitment is still not robust. Staff working histories and reasons for termination of employment are not known or documented.  Plans and actions to support young people with the skills for their next placements continue to be unsatisfactory.  Managers and staff do not respond to young people’s complaints robustly. Management is poor, as demonstrated by the ineffective response to the shortfalls identified at the last inspection. Leaders do not set a good example to staff or young people. They do not effectively monitor or evaluate the quality of care at the home.

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The children's home strengths

 Structured routines help some young people with Asperger syndrome to attend school and to enjoy a range of activities.

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Statutory requirements

This section sets out the actions which must be taken so that the registered persons 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 persons must comply with the given timescales.

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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 the wider system standard and to ensure that children’s needs are met, the registered person must, and must ensure that staff—

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Requirement Due date

(a) seek to involve each child’s placing authority effectively in the child’s care, in accordance with the child’s relevant plans;

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Requirement Due date

(b) seek to secure the input and services required to meet each child’s needs;

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Requirement Due date

(d) seek to develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate, having regard to the range of needs of children for whom it is intended that the children’s home is to provide care and accommodation. 30/04/2016

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Requirement Due date

6: The quality and purpose of care standard:

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Requirement Due date

In order to meet the quality and purpose of care standard, the registered person must ensure that children receive care from staff who —

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Requirement Due date

(i) understand and apply the home’s statement of purpose;

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Requirement Due date

(ii) protect and promote each child’s welfare;

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Requirement Due date

(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;

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Requirement Due date

(vi) help each child to develop resilience and skills that prepare the child to return home, to live in a new placement or to live 30/04/2016 independently as an adult;

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Requirement Due date

In order to meet the education standard, the registered person must ensure that staff—

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Requirement Due date

(i) help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans;

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Requirement Due date

(ii) support each child’s learning and development, including helping the child to develop independent study skills and, where appropriate, helping the child to complete independent study;

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Requirement Due date

(iii) understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers;

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Requirement Due date

(iv) help each child to understand the importance and value of education, learning, training and employment;

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Requirement Due date

(v) promote opportunities for each child to learn informally;

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Requirement Due date

(vi) maintain regular contact with each child’s education and training provider, including engaging with the provider and the placing authority to support the child’s education and training and to maximise the child’s achievement. 30/04/2016

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Requirement Due date

In order to meet the health and well-being standard, the registered person must ensure that staff help each child to—

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Requirement Due date

(ii) understand the child’s health and well-being needs and the options that are available in relation to the child’s health and well- being, in a way that is appropriate to the child’s age and understanding;

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Requirement Due date

(iv) understand and develop skills to promote the child’s well- being. 30/04/2016

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Requirement Due date

12: The protection of children standard:

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Requirement Due date

In order to meet the protection of children standard, 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 30/04/2016 account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child;

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Requirement Due date

(iii) have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

(b) ensure 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;

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Requirement Due date

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

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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, the registered person must enable, inspire and lead a culture in relation to the children’s home that—

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Requirement Due date

(a) helps children aspire to fulfil their potential; and

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to—

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Requirement Due date

(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;

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Requirement Due date

(b) ensure that staff work as a team where appropriate;

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Requirement Due date

(c) ensure that staff have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

(d) ensure that the home has sufficient staff to provide care for each child;

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Requirement Due date

(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;

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Requirement Due date

(g) demonstrate that practice in the home is informed and improved by taking into account and acting on— 30/04/2016 (i) research and developments in relation to the ways in which the needs of children are best met; and

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Requirement Due date

(ii) feedback on the experiences of children, including complaints received; and

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Requirement Due date

(h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

In order to meet the care planning standard, the registered person must—

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Requirement Due date

(b)(ii) manage and review the placement of each child in the home;

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Requirement Due date

(c) ensure that each child’s relevant plans are followed. 30/04/2016

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home (Regulation 23(1)). 30/04/2016

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Requirement Due date

The registered person must, after consultation with the fire and rescue authority, 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.

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Requirement Due date

The registered person must ensure that the requirements of the Regulatory Reform (Fire safety) Order 2005 (a) and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the home (Regulation 25(1)(d)(2)(b)). 30/04/2016

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Requirement Due date

The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety and that full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32(1)(2)(3)(d)). 30/04/2016

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Requirement Due date

The registered person must ensure that all employees undertake appropriate continuing professional development; and receive practice-related supervision by a person with appropriate experience; (Regulation 33(4)(a)(b)). 30/04/2016 The registered person must establish a procedure for considering complaints made by or on behalf of children. In particular, the procedure must provide that no person who is the subject of a complaint takes any part in its consideration or investigation, except at the informal resolution stage if the registered person considers it appropriate. The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation (Regulation 39(1)(2)(3)). 30/04/2016

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Information about this children's home

This privately owned home is registered for three children and young people with emotional and/or behavioural difficulties. The statement of purpose details the age range of children and young people from ten to 18 years of age.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

25 March 2015 CH - Interim Sustained effectiveness

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Inadequate

The registered manager and staff remain unable to deliver care that meets the young people’s needs, so that they still do not reach their potential. There is little progress across many aspects of young people’s lives. Their welfare and protection needs are not met, as they continue to go missing, set fires, hurt others and are now vulnerable to radicalisation. Since the last inspection in January 2016, a young person has set fire to the mattress in their bedroom and pretended to make home- made ‘bombs’. This has the potential to affect the safety and welfare of all persons in the home and places young people at serious risk of harm. Young people with a history of risks such as fire setting, self-injurious behaviour, sexualised behaviour and violence to others receive little support or guidance from staff, the home’s therapist or any other agencies. The registered person has not sought advice from the local authority fire service about risks from fire setting.

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Inadequate

Lack of specialist input leaves young people and others at risk of harm. Care plans do not reflect young people’s individualised needs as set out in their placing authority placement plans. The home’s placement plans contain minimal planning and are rather a chronology of events. There is no written clarity about what staff are required to do to support and enable young people to meet their objectives and to make progress, for example to promote good health, or to encourage attendance at education. Local authority pathway plans are now available to staff, but there is no strategy, structure or documented plan to deliver these aims in day-to-day care planning. For example, one young person has no independence plan because the manager says that the young person refuses to engage. The other young person has a weekly activity and meal planner inside a kitchen cupboard. This is a list of household chores, activities and meals. Young people nearing the age of 18 years

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Inadequate

and with Aspergers syndrome have no other care planning tools to support their development and transition to young adulthood. This lack of focus underplays their imminent transition to adulthood with little support for their emotional welfare at this crucial stage of their lives. One young person does not have an education placement and has not attended school or college for an extended period of time. The manager and staff fail to understand this young person’s barriers to education and do not have a plan to motivate him to attend or to engage in any learning. The service is unable to provide any form of alternative education. Other than trips to the gym with the responsible individual, there are no plans or facilities for this young person to complete independent study and to learn informally in the home. This lack of learning results in the young person gravitating towards negative activities such as

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Inadequate

going missing, harassing others on social networking sites and developing an interest in radicalisation. Young people’s health care is chaotic and poorly monitored. Health plans are not up to date, are not based on the local authority health plan, and do not inform staff about how to promote health care. Health plans are, in fact, a health record of past events and appointments. They do not offer any proactive information about how to support young people with ongoing medical conditions such as stomach complaints, acne or the need for strong pain relief after they have sustained injury. Young people frequently visit the GP and return with a range of prescribed medication, which they subsequently do not take. They then seek further medication for the same issue. While this medication is stored by staff, there is little challenge to the GP’s practice or consultation with the looked after children’s nurse in order to safeguard young people’s health and welfare.

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Inadequate

There are positives, as other young people have a consistent history of good school attendance. They also enjoy a range of hobbies and interests. Their parents are happy with the stability and progress of their children.

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Inadequate

Young people are not safe because safeguarding practice and strategies are not robust. The manager and staff fail to address fundamental safety needs or the escalating behaviours of young people. The registered manager does not follow correct safeguarding procedures. While she contacted the placing authority and local police, concerns for young people missing from care and at risk of radicalisation were not reported to the host authority safeguarding children board. Young people are at risk of criminalisation and their families are not safe because staff do not protect their welfare during home visits. There are periods of time when staff have left young people alone on contact visits, despite direction from the placing authority to supervise contact fully, due to a history of aggression and risk of harm to family members. The registered manager has also increased another young person’s family contact without placing authority consent. This is

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Inadequate

despite significant risks for this young person and others when the young person returns to the family’s local community. Risk management is weak. Managers have assessed self-injurious behaviour risks, including ligature use, for young people in the home. These assessments require staff knowledge about the location of ligature cutters to save life. However, senior staff are unaware of the actions to take should an incident occur, or of where ligature cutters are kept. This means that a young person could seriously harm themselves because staff are not able to intervene safely. Managers fail to understand and strategically plan work with young people to keep them and others safe. Staff make unwise decisions without consultation, and do not understand their responsibility to seek guidance and authority for untested activities. For example, they have taken young people on ad hoc trips without risk assessment or consent from the placing authority and parents. This has fuelled

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Inadequate

young people’s obsessional behaviour. For example, despite ongoing therapeutic work about fixated behaviour around girls, staff have taken young people to talk to strangers about how to meet girls. Other risk assessments to support the local authority’s plan to allow young people to go by themselves to the local pub are not good. Staff do not have good guidance because the risk assessment is not easy to find. It is not signed, approved or dated, and the young person’s name is unclear. The document was located in another young person’s file. Lack of clarity places this young person at risk and compromises monitoring of staff practice in line with essential risk management strategies. The registered manager underestimates the level of risk when young people go missing from the home. The home is isolated, has no street lighting and the only access is via a long dirt track. Delay in responses from staff places young people at

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Inadequate

continuing risk of harm; they are at significant risk of being injured by passing traffic on a very busy road, and exposure to the elements if they go across fields. Staff rely on the police to search for and locate young people, as do the young people, who often call the police rather than the home when they want to return. The registered manager has not taken up an offer of help from the police about risk management. Risk assessments for what to do when young people go missing are unclear, do not make a distinction between unauthorised absence and missing, and contain out-of-date curfew times. Staff are not trained in what to do if young people go missing from care. Consequently, they do not always respond promptly to ensure young people’s safety. This combination of shortfalls compromises the rigour that is essential in managing young people with persistent missing from care behaviours. They often remain at risk and do not experience a clear sense of

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Inadequate

safety due to a lack of consistency from staff. Records of incidents are dispersed and duplicated: for example, the length of missing episodes, timing of staff response, and the potential links to radicalisation. These hamper tracking of young people’s behaviour. This lack of clear records also compromises the manager’s ability to monitor whether staff are effectively implementing the home and local authority missing-from-care policy or procedure. This inconsistent understanding and response in the event of young people going missing undermines their safety. The registered manager externalises her responsibilities for safeguarding young people. Young people believe, from what she tells them, that Ofsted tells the manager to remove dangerous cables and lighters from their bedrooms. The registered manager and staff take no direct responsibility for keeping young people safe from their self-injurious and fire setting behaviours.

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Inadequate

In addition, and on notification of significant events, such as going missing and potential radicalisation, the registered manager cites placing authority monitoring or liaison with the police as actions to prevent further occurrence. There is no mention of the actions taken in the home that will directly have an impact on the safety of young people and prevent further harm. Arrangements for the safe storage, administration and recording of medication are not sufficiently robust. The home stockpiles a range of prescribed medication, some of which are no longer used by young people, including large supplies of painkillers. Recording is poor. For example, tallies of painkilling medication far exceed the tablets available in the medication cabinet.

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Inadequate

The responsible individual’s and registered manager’s failure to manage this home is widespread. Eight of the nine regulatory failings identified by Ofsted in January 2016, and which remain failings, include: ineffective risk management; poor leadership; unsafe recruitment; fire safety; ineffective quality of care, and lack of education for young people. In addition to these continued failures, there are now further regulatory shortfalls. These include: insufficient and incompetent staff, failure to promote young people’s health, poor care planning and lack of professional support and supervision for the registered manager. Leadership is poor, with significant concerns about managerial conduct. Concern about professional standards extends from the responsible individual and registered manager through to the deputy and the staff team. Staff conflict, poor practice by managers and a lack of adherence to the organisation’s own directives

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Inadequate

and procedures result in poor teamwork. This in turn provides poor and inconsistent quality of care to young people. For example, the responsible individual and the registered manager have given warnings to each other about their conduct in front of young people at the home. The responsible individual confirms in writing to the local authority designated officer that the registered manager accepts his feedback about inappropriate conduct towards a young person. However, on this inspection the registered manager states that she disagrees and would act in the same way again, shouting, threatening and banging on young people’s doors. Young people witness poor staff practice, and this undermines their sense of well-being and does little to model positive behaviour. Some staff have expressed their concerns about management of the home through the formal grievance process. Their grievances go unheard due to long-term

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Inadequate

sickness from work and lack of clarity regarding the grievance and disciplinary process. Reasons for staff sickness are inaccurately reported to inspectors, and this further undermines the manager’s integrity. Other staff have informally raised issues with the registered manager about discrimination by the responsible individual and incorrect wages. Ofsted is currently looking at a complaint about the financial viability of the home. Such levels of managerial and staff conflict are not conducive to promoting a stable environment for young people to live and thrive in. Some staff have left before completing their notice period. There was ineffective planning by the registered manager to ensure proper handover of significant information about young people and the supervision of staff. The registered manager is often unaware of the location of key pieces of information. This hampers her ability to monitor meaningfully the operation of the home and

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Inadequate

outcomes for young people. The deputy and the responsible individual both breach the organisation’s policy for use of personal mobile phones at work. This policy states that staff mobile phones must be locked away in a cabinet. Both use their personal mobile phones to make to and receive calls from young people. This undermines the safety of young people and staff and diminishes their authority with junior staff. The registered manager has an unrealistic evaluation of the strengths and weaknesses of the service. For example, she informed inspectors of developments in independence programmes and improvement in the organisation of both personnel and young people’s files. In reality, all three areas had significant shortfalls that required further regulation. Records are extremely poor, and lack of guidance for staff in these records places young people at risk. Young people’s care and support needs are not reflected

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Inadequate

meaningfully in their records. The lack of rigour in the recruitment files has not been addressed fully from the previous inspection. Staff recruitment records still do not evidence robust practice or legal minimums. Full working histories are not in place for all staff. Applicants do not complete full application forms. Reference practice is weak and does not seek the most appropriate reference relevant to the person’s role at the home. There is lack of rigour in investigating and evidencing reasons for previous disciplinary proceedings or dismissals. Applicants fill in their application form at the time of interview. This shows little regard for good safer recruitment and safeguarding practice. No records were available to evidence how the home’s consultant therapist and agency staff have been safely recruited Improvement is stagnant because the registered person does not make use of independent monitoring visits to the home. Shortfalls from these reports concur

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Inadequate

with previous and current inspection findings. Young people’s care and safety is compromised because the manager fails to reflect and address shortfalls within the home. The management team fails to reflect on areas of weakness or address improvement after weekly placing authority monitoring visits raise concerns about the home. For example, the placing authority challenged the registered manager because she handed the home’s keys to a visiting independent reviewing officer and left them alone in the house with a young person, while she left the home on non-urgent business. The registered manager was dismissive of these concerns, and the placing authority has now asked the responsible individual for an explanation to ensure that appropriate action is taken. External monitoring by the placing authority since the January inadequate inspection judgement finds ‘not a lot of movement in improvement’. There is little

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Inadequate

evidence of how the management team responds to the weekly visits and feedback to drive improvement, because the management team does not take notes. The registered manager fails to understand the gravity of her actions and to address points of feedback. The placing authority is also disappointed that repeated reminders to ensure that cleaning products are kept safely away from young people with significant risks and a history of self-injurious behaviours have been ignored. Arrangements for resolving young people’s concerns and tracking the outcomes of complaints remain inadequate. Young people’s individual daily records now capture their complaints but also show quick dismissal of their concerns. There is no clear record regarding the action taken by the registered manager in response, or the outcome of investigation into this young person’s complaint. Staff turnover and poor recruitment practice weakens further the capacity of the

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Inadequate

staff team to meet young people’s needs. Long-standing staff have left. The home is now reliant on inexperienced or temporary staff. The smaller staff team means that staff work for extensive periods of time without a rest day, and that young people have little choice, or change in the adults who care for them. Professional supervision of staff is poor. Responsibility for staff supervision is dispersed among the staff team, despite low numbers of staff. Some staff have minimal records of supervision or training since their employment at the home. The manager says that she has not received supervision since December 2015, and could not recall the full name of her supervisor or provide any evidence regarding her professional supervision prior to this time. The registered manager has experience of managing childcare settings and holds a diploma in management studies as a suitable qualification. Recent training for staff in child sexual

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Inadequate

exploitation, fire setting and self-injurious behaviours has been delivered promptly by local police and a therapist working for the home. Lack of monitoring by the registered manager leads to a poor understanding of how staff competence and knowledge impacts on the quality of young people’s care. Examples are the failure of senior staff to complete essential training in fire safety, or to manage risk in relation to family contact and when young people are missing from care. Lack of partnership working contributes to the ongoing decline of safeguarding practices in the home. Police compare this home poorly to others in the area and identify more proactive partnership working as a point for improvement. Comments from the police include, ‘This home doesn’t ask. They haven’t taken the help that is offered.’ The manager has consistently failed to consult with the local authority fire service despite previous and fresh risk from fire setting. There is clear risk of harm

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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 children looked after 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 that 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 whom 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

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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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