Children's home in Gloucester

The children’s home provision is inadequate because:

 Young people’s needs have not been met across aspects of their welfare, particularly their safety, their health and their physical and emotional well- being needs.

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The children’s home provision is inadequate because:

 Staff, including managers, do not recognise or correctly manage potential or actual safeguarding concerns. This is in regard to the failure to act on child protection concerns.

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The children’s home provision is inadequate because:

 Procedures for administering and recording medication are unsafe and place young people at risk. Recording is poor and does not identify when controlled drugs are administered. The current arrangements in place for the transportation of controlled drugs from the setting to the education provision are dangerous and are placing young people at risk of serious harm.

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The children’s home provision is inadequate because:

 Risks to young people are not clearly identified, understood or managed. Behaviour management in relation to the use of sanctions is inadequate. This means that young people are not protected from harm.

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The children’s home provision is inadequate because:

 Health plans in place for young people are not followed. Therefore, staff do not know what young people’s individual health needs are and how they are to be met.

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The children’s home provision is inadequate because:

 Not all incident reports are complete, which means that there is no full account recorded, the way that they are managed, and whether suitable actions are taken to keep young people and staff safe. This means that unsafe care practices could continue unchecked.

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The children’s home provision is inadequate because:

 Monitoring of the home is ineffective as potential risks are not identified and addressed. Internal monitoring of the home fails to identify weaknesses in practice, such as those found by the inspectors.

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The children’s home strengths

 The young person has increased her time in education.  Contact with family members now takes place within the home.  The young person has continued to progress in her horse-riding and has made and maintained friendships through this activity.

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Statutory requirements

This section sets out the actions which must be taken so that the registered person(s) meets the Care Standards Act 2000, Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. The registered person(s) must comply with the given timescales.

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Requirement Due date

(1) In order to meet the health and well-being standard, the registered person must ensure that: (a) the health and well-being needs of children are met (b) children receive advice, services and support in relation to their health and well-being (c) children are helped to lead healthy lifestyles. (2) In particular, the standard in paragraph (1) requires the registered person to ensure: (a) that staff help each child to: (i) achieve the health and well-being outcomes that are recorded in the child’s relevant plans (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. (Regulation 10 (1)(a)(b)(c), (2)(a)(i)(ii)) 24 June 2016

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Requirement Due date

In order to meet the positive relationship standard, the registered person must ensure: (1) That children are helped to develop, and to benefit from, relationships based on: (a) mutual respect and trust (b) an understanding about acceptable behaviour (c) positive responses to other children and adults. (2) In particular, the standard in paragraph (1) requires the registered person to ensure: 24 June 2016 (a) that staff: (i) meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans (ii) help each child to develop socially aware behaviour (iii) encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding (v) communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding (ix) understand how children’s previous experiences

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Requirement Due date

and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children (x) are provided with supervision and support to enable them to understand and manage their own feelings and responses. (Regulation 11 (1)(a)(b)(c), (2)(a)(i)(ii)(iii)(v)(ix)(x))

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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: (1) 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 (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person (vi) take effective action whenever there is a serious concern about a child’s welfare. (b) that the home’s day-to-day care is arranged and 24 June 2016 delivered so as to keep each child safe and to protect each child effectively from harm (e) that the effectiveness of the home’s child protection policies is monitored regularly.

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Requirement Due date

(Regulation 12 (1), (2)(a)(i)(v)(vi)(b)(e))

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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 ensure: (1) 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 (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 (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child (f) understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and 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.

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Requirement Due date

(Regulation 13(1)(a)(b), (2)(a)(c)(f)(h)) 24 June 2016

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Requirement Due date

(1) The registered person must make arrangements for the handling, recording, safe keeping, 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. (Regulation 23 (1), (2)(c)) 24 June 2016

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Requirement Due date

35: Behaviour management policies and records 24 June 2016 The registered person must prepare and implement a policy (‘the behaviour management policy’) which sets out how appropriate behaviour is to be promoted in the children’s home, and the measures of control, discipline and restraint which may be used in relation to children in the home. The registered person must keep the behaviour management policy under review and, where appropriate, revise it. (Regulation 35 (1)(a)(b), (2))

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Requirement Due date

(1) The registered person must maintain records (‘case records’) for each child which: (a) include the information and documents listed in Schedule 3 in relation to each child (b) are kept up to date (c) are signed and dated by the author of each entry. (Regulation 36(1)(a)(b)(c)) 24 June 2016

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Requirement Due date

(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 (c) there is an allegation of abuse against the home or a person working there (d) a child protection enquiry involving a child: (i) is instigated (ii) concludes (in which case, the notification must include the outcome of the child protection enquiry) (e) there is any other incident relating to a child which the registered person considers to be serious. (5) A notification made under this regulation: (a) must include details of: (i) the matter (ii) the other persons, bodies or organisations (if any) 24 June 2016 who or which have been notified (iii) any actions taken by the registered person as a

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Requirement Due date

result of the matter (b) must be made or confirmed in writing. (Regulation 40 (4)(a)(b)(c)(d)(e), (5)(a)(i)(ii)(b))

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Requirement Due date

44: Independent person: visits and reports

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Requirement Due date

(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 (b) the conduct of the home promotes children’s well-being. (Regulation 44 (4)(a)(b)) 24 June 2016

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Requirement Due date

{an asterisk is added in the table above where compliance = ‘Y’}

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Information about this children’s home

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

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

23 February 2016 Interim Sustained effectiveness

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Inadequate

Despite the serious shortfalls identified in this report, the young person has made some measured progressed in important aspects of her life. The young person was previously frequently missing from care, but she has not been missing since the last inspection. Her school attendance has increased to 97% attendance, although her levels of attainment are still very low, with no clear plan in place for the home’s staff to support her in additional study. Staff are unable to support the emotional and psychological health of young people, because 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. The health plan in place for the young person is limited and does not note that she has attention deficit hyperactivity disorder and requires

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Inadequate

medication. The plan contains phone numbers for health professionals and appointment dates, but no action recorded from appointments. For example, the young person requires additional dental treatment, as stated by a member of staff on shift, but details and actions are not recorded on the outcome of the dental appointment, so the plan does not reflect current health needs. This fails to promote young people’s physical and emotional well-being. During the inspection it became clear that the young person was suffering from a highly contagious medical condition. The staff failed to seek appropriate medical advice until five days after the young person had brought it to their attention. Despite there being a previous medical advice notice in the young person’s file stating what action needed to be taken, staff failed to follow the advice to contain the condition and therefore further placed the young person, staff and visitors to

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Inadequate

the home at risk of infection. Staff fail to provide individualised care for the young person living in the home. Risk management and placement plans do not address her specific and individual needs. The young person’s records omit important information about her previous history and current needs. Furthermore, placement plans, risk assessments, and health and behaviour management plans lack sufficient detail. For example, current and previous issues around child sexual exploitation are not considered and appropriate strategies are not put in place. This places young people at risk of significant harm. The young person is supported to spend time with her family. Supervised contact, which previously took place in a ‘contact centre’, now takes place within the home. The young person commented, ‘It’s better seeing my mum in here.’ This positive contact helps the young person to identify with extended family members and

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Inadequate

helps her to build a picture of her family background.

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Inadequate

The young person continues to enjoy horse-riding and has advanced in this by attaining the next level in her programme. During these pursuits she has gained and maintained friendships with her peer group in the community. These experiences, which are bespoke to individual young people’s preferences, add to their overall feeling of well-being and increases their self-esteem.

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Inadequate

Safeguarding practice in this home is poor and does not promote the welfare and safety of young people. On several occasions, staff have failed to follow their own child protection procedures following serious safeguarding concerns. For example, on return home from school the young person informed staff that a teacher at her school had bought her a new pair of training shoes and planned to take her for a haircut. Despite the staff member stating, ‘I felt very uncomfortable and it did not sit right with me,’ she failed to take appropriate action and did not follow the home’s own policies and procedures. On a second occasion, the young person’s school taxi driver was heard making both threatening and inappropriate comments towards both the young person and staff on duty. Staff failed to take any further action and allowed the young person to continue to travel to school in the same taxi. Despite there being further

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Inadequate

concerns raised with staff about the taxi driver, who explained to the young person how to make a petrol bomb, no further action was taken until ten days later. This has significant implications for the young person’s safety, as she continued to travel with the same taxi driver to school, and does not demonstrate safe practices within the home. Following a notification from school that the young person was known to have inappropriate obscene adult images on her mobile phone, staff again failed to take any appropriate action. Concerns were not reported to any safeguarding professionals and the staff failed to follow their own safeguarding policies and procedures, leaving the young person at risk of potential harm. Both incentive charts and the home’s message book indicated that the young person had not washed or brushed her teeth for six days. Staff who were monitoring this used the forms available as a tick box exercise and did not do

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Inadequate

anything to address the needs of the young person. A staff member commented ‘When I came on shift I noticed that (name) smelt really bad, she had clearly not had a wash for a significant time. I checked the records and it said she had not had a wash or cleaned her teeth. I’m not sure why others did not deal with it as she clearly smelt and her hair was greasy and dull.’ This fails to demonstrate how staff are providing a safe nurturing standard of care in order to meet young people’s basic care needs and is neglectful practice. Medication is managed unsafely and fails to comply with the provider’s own policies and procedures. There were found to be a number of significant errors. These included the recording of the date medication had been obtained. Although the amount was added a day after they had been collected from the chemist, records did not show this. There were also errors in both the amount and times they were

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Inadequate

given to the young person. On some occasions, the young person had been given two tablets in a day, but on others only one. There was no clear explanation of why this was taking place. Records are not clear on why controlled drugs are missing. For example the medication records stated that drugs were dropped on the floor. There was no further information recorded regarding the disposal of the tablets and the staff member responsible failed to sign the entry made. During discussions with a member of staff, inspectors were informed that a box containing 30 Medikinet 30 mg tablets (controlled drugs) were given to the school escort to transport to school. Within the records, there was no recording of drugs or amounts given by the home. Subsequently, staff were advised by the school, who had raised concerns about the actions of the staff at the home, that the escort had given the tablets directly to the young person to give to teaching staff.

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Inadequate

However, she refused to give them to school staff initially, and this led to an incident. Although a member of staff informed the young person’s social worker via email of this incident, no further action was taken and there were no documents in the home to indicate that this incident had taken place.

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Inadequate

The home’s own medication policy, dated 2016, is clear about how controlled drugs are to be administered and clearly states, ‘if given to another party they must be transported safely and handed to an appropriate professional’. The policy clearly states that medication should be delivered to the school by staff in advance.

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Inadequate

The home’s policy also states that medication should not be stockpiled. Scrutiny of the controlled drugs book held by the home revealed that at times there were 270 drugs held in the cabinet. The registered manager had failed to carry out any management audits on the medication as per the provider’s policies and procedures. This is a failure to follow the home’s own policies and procedures for the handling, recording, safe keeping and safe administration of medicines and potentially places the young person at serious risk.

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Inadequate

The young person is not kept safe while in the community or while accessing the internet on the home’s own computer. Risks to the young people are not clearly identified, understood and managed. There was conflicting information on the risk assessments, missing from care assessments and care planning documents, despite them being updated in May 2016. For example, on the young person’s missing from care action plan it states that she is on a 1:1 staffing ratio at all times. However, within the weekly progress report and behaviour management plan it stated, ‘(young person) enjoyed free time in the community with friends.’ When discussed with the registered manager she said ‘she is not on a 1:1. I have not had time to change the plans.’ This lack of comprehensive care planning has failed to safeguard the young person and does not lend itself to a consistent approach by staff to meet her needs. The young person’s placement plan states that she should not have access to

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Inadequate

social media sites on any internet-enabled device. However during the inspection, inspectors observed the young person on a social media site. Staff who were observing this did not take any action. On 24 May 2016, the daily record sheet stated, ‘(young person) spent the evening on the computer, she engaged occasionally with staff. She was chatting to her friends on Facebook, but would not let staff see what she was doing.’ There was no evidence available to indicate how staff had addressed this. The lack of coherent plans to safeguard the young person while on the internet and the lack of management overview of staff’s inaction has further placed the young person at risk of significant harm. Staff fail to implement clear and consistent boundaries or effective behaviour management strategies. For example, it was noted ‘YP stopped from going in the car.’ There were no further recordings or details provided to clarify how the

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Inadequate

incident was managed effectively. 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. Health and safety within the home has been compromised. Staff have failed to carry out fire drills on a regular basis to ensure all young people and staff are aware of what action to take if there is a fire. The home’s annual health and safety risk assessment and fire risk assessment have not been updated since 26 February 2015. These failures in health and safety potentially place young people, staff and visitors to the home at risk of harm.

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Inadequate

The young person lives in a home that is not effectively managed. The staff are unclear about the ethos and philosophy of the home as described in the statement of purpose. There have been failings in management oversight and monitoring of the home to identify areas of weakness and to take decisive action to resolve these. As a result, the young person’s progress and safety is compromised. The registered manager is appropriately qualified and experienced to undertake her role. However, her lack of presence within the home has led to the serious failings found during this inspection. For example, there have been a clear lack of management oversight into safeguarding concerns, serious medication errors and a lack of daily management overview. Staff commented, ‘The manager is not here all the time’, ‘We really need a manager here full time to guide us in the right direction. Unfortunately, we never know when she is visiting.’ A sample from the

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Inadequate

records in the home of the period from 25 April to 24 May 2016 indicated that the total hours spent by the registered manager within the home was 20 hours 30 minutes. Care planning is poor and does not promote the continued progress of the young person. Internal placement plans and risk management plans are not reviewed effectively to identify the changing needs of the young person. They also fail to address the issues of risk and how these should be managed safely to promote consistency of care. Records do not provide an insight into the young person’s life. There is limited information to measure their progress or identify the effectiveness of the support being provided. Staff are not trained to meet the needs of the young person living in the home. For example, one staff member stated that she had not received training on child sexual exploitation despite the young person being deemed at high risk of child

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Inadequate

sexual exploitation. The registered manager was unable to produce a training matrix for staff. This lack of management overview of staff training needs has a direct impact on the care and support provided to the young person. Quality internal monitoring does not take place regularly, and as a result the quality and standard of care has fallen to an unacceptable level. The manager has not reviewed records in the home or evaluated incidents that have occurred, to identify shortfalls and highlight patterns and trends. Subsequently, areas for development are not clearly highlighted, and there is no meaningful development plan to address areas of concern. This means that leaders and managers are not taking action continually to improve the experiences, care and safety of young people. There are serious deficits in the home’s external monitoring and auditing systems. This process has failed to identify the shortfalls highlighted in this inspection, such

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Inadequate

as the discrepancies in missing from care documents, which wrongly state the young person is on 1:1 staffing at all times, and the inappropriate sanctions used to address the young person’s behaviour. Significant events involving young people resident in the home have not been reported to Ofsted. A failure to share information with all relevant people compromises the safety and welfare of young people. Furthermore, the regulator is unable to carry out its monitoring function to ensure that all appropriate action is being taken by the provider to safeguard young people. This lack of rigour has not helped the home to sufficiently protect young people and maintain good enough standards of care. More robust systems are needed to ensure that the safety and well-being of the young person is promoted at all times. The registered manager’s view of the home’s strengths and weaknesses is limited. This has resulted in key weaknesses in care practice going unchallenged.

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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, but the children’s home is not yet delivering good protection, help and care for children and young people. A children’s home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

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What the inspection judgements mean

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

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people living in the children’s home. Inspectors considered the quality of work and the difference adults make to the lives of children and young people. They read case files, watched how professional staff work with children, young people and each other and discussed the effectiveness of help and care given to children and young people. Wherever possible, they talked to children, young people and their families. In addition the inspectors have tried to understand what the children’s home knows about how well it is performing, how well it is doing and what difference it is making for the children and young people who it is trying to help, protect and look after. This inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service and to consider how well it complies with the Children’s

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Information about this inspection

Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. the guidance ‘Raising concerns and making complaints about Ofsted’, which is available from Ofsted’s website: www.gov.uk/government/organisations/ofsted . If you would like Ofsted to send you a copy of the guidance, please telephone 0300123 4234, or email enquiries@ofsted.gov.uk .

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Information about this inspection

achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, work- based learning and skills training, adult and community learning, and education and training in prisons and other secure establishments. It inspects services for children looked after and child protection. If you would like a copy of this document in a different format, such as large print or Braille, please telephone 0300 123 4234, or email enquiries@ofsted.gov.uk . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team,

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Information about this inspection

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

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Information about this inspection

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

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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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