Children's Home run by Adecyn Children’s Homes Limited in Birmingham

Inadequate

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

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The children's home provision is inadequate because:

 Gaps in leadership since the last inspection mean team working lacks focus and has limited impact on improving outcomes for young people.

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The children's home provision is inadequate because:

 Managers fail to ensure staff assess risk effectively.

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The children's home provision is inadequate because:

 Staff do not act in accordance with guidance to minimise risk.

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The children's home provision is inadequate because:

 Managers fail to ensure staff have the key skills and appropriate qualifications.

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The children's home provision is inadequate because:

 The staff team‟s management of young people‟s behaviour is inconsistent. Consequently, young people do not receive the right support to manage their emotions.

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The children's home provision is inadequate because:

 Recruitment practice is poor and fails to safeguard young people.

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The children's home provision is inadequate because:

 There are frequent changes of manager. This change mean managers do not get to know young people sufficiently well.

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The children's home provision is inadequate because:

 Staff turnover is high and affects adversely on the continuity of care for young people.

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The children's home provision is inadequate because:

 Joint working with partner agencies is not effective in meeting the needs of young people.

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The children's home provision is inadequate because:

 Young people‟s complaints are not treated seriously.

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The children's home provision is inadequate because:

 Notifications of serious incidents are not sent to Ofsted in accordance with regulations.

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The children's home provision is inadequate because:

 Reports completed by the manager on the quality of care do not have sufficient focus on improving the service or young people‟s experiences.

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The children's home provision is inadequate because:

 Managers have not consulted with local relevant agencies as part of their development of a location risk assessment.

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The children's home provision is inadequate because:

 The decorative state of the home is poor; this does not provide a homely and nurturing setting for young people.

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The children's home strengths

 The provider has been sensitive to the needs of one young person by temporarily limiting the number of placements in the home.

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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 „Guide to the children's homes regulations including the quality standards‟. The registered person(s) must comply within the given timescales.

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Requirement Due date

5: Engaging with the wider system to ensure children‟s needs are met In order to meet the engaging with the wider system standard, with particular reference to securing services required to meet each young person‟s needs, the registered person must ensure that staff—

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Requirement Due date

(b) seek to secure the input and services required to meet each child's needs. 17 June 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, with particular reference to the suitability of admissions, the registered person must—

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Requirement Due date

(2)(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. 17 June 2016

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Requirement Due date

7: The children‟s views, wishes and feelings standard

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Requirement Due date

In order to meet the children's views, wishes and feelings standard, with particular reference to acting on complaints, the registered person must ensure that children receive care from staff who—

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Requirement Due date

(1)(c) take their views, wishes and feelings into account in relation to matters affecting the children's care and welfare and 17 June 2016 their lives.

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Requirement Due date

In order to meet the positive relationships standard, with particular reference to support for staff, the registered person must ensure that staff—

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Requirement Due date

(2)(a)(x) are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same. 17 June 2016

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Requirement Due date

In order to meet the protection of children standard, with particular reference to the safety of young people, the registered person must ensure—

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Requirement Due date

(2)(a) that staff— (i) assess whether each child is at risk of harm, taking into account information in the child's relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (ii) help each child to understand how to keep safe; (iii) have the skills to identify and act upon signs that a child is at risk of harm; (vi) take effective action whenever there is a serious concern about a child‟s welfare. 17 June 2016

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Requirement Due date

13: The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, with particular reference to staffing in the home, the registered person must—

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Requirement Due date

(2)(e) ensure that the home's workforce provides continuity of care to each child. 17 June 2016 The registered person must compile in relation to the children‟s home a statement (“the statement of purpose”) which covers the matters listed in Schedule 1. (Regulation 16(1)) 17 June 2016

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Requirement Due date

The registered person must notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision (Regulation 16 (3)(b)). 17 June 2016

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Requirement Due date

The registered person may only use devices for the monitoring or surveillance of children if the child's placing authority consents in writing to the monitoring or surveillance (Regulation 24 (1)(b)). 17 June 2016

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Requirement Due date

The registered provider must appoint a person to manage the children's home if there is no registered manager in respect of the home (Regulation 27 (1)(a)). 17 June 2016

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Requirement Due date

The registered provider must ensure that full and satisfactory information is available in relation to staff recruited, in respect of each of the matters in Schedule 2 (Regulation 32 (3)(d)). 17 June 2016

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Requirement Due date

The registered person must recruit staff who the appropriate experience, qualification and skills for the work that the individual is to perform. (Regulation 32 (3)(b) 17 June 2016

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Requirement Due date

The registered person must prepare and implement a policy (“the behaviour management policy”) which sets out the measures of control, discipline and restraint which may be used in relation to children in the home (Regulation 35 (1)(b)). 17 June 2016

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if there is any other incident relating to a child which the registered person considers to be serious (Regulation (40)(4)(e)). 17 June 2016

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Requirement Due date

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 children are effectively safeguarded; and the conduct of the home promotes children's well-being (Regulation (44)(4)(a) and (b)). 17 June 2016

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Requirement Due date

The registered person must complete a review of the quality of care provided for children (“a quality of care review”) at least once every 6 months (Regulation 45(1)). 17 June 2016 After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (“the quality of care review report”) (Regulation 45(3)). 17 June 2016

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Requirement Due date

The registered person must supply to HMCI a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed (Regulation 45(4)(a)). 17 June 2016

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Requirement Due date

When conducting the review of premises report, the registered person must consult, and take into account the views of, each relevant person (Regulation 46(2)). 17 June 2016

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Recommendations

To improve the quality and standards of care further, the service should take account of the following recommendations:  Create a nurturing and supportive, homely and domestic environment („Guide to the children's homes regulations including the quality standards‟, page 15, paragraph 3.9).  Ensure all restrictions of liberty of movement, are recorded as restraint („Guide to the children's homes regulations including the quality standards‟, page 47, paragraph 9.42).

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Information about this children's home

The home provides care for up to three young people who have emotional and/or behavioural difficulties. The home is operated by a private company.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

11 December 2015 Interim Declined in effectiveness

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Recent inspection history

23 March 2015 Interim Improved effectiveness

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Inadequate

Young people do not receive the personalised care they require to meet their needs. Managers and staff fail to take account of young people‟s backgrounds and their assessed needs. Managers also fail to consider the particular needs of young people who live a long way from their home authority. These failings have resulted in an unsuccessful short-term placement, which caused disruption to all the young people.

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Inadequate

Most placements end when young people are at a time of crisis in their lives. The abrupt nature to the end of placements means that young people do not have the opportunity to leave the home in a positive and considered way. Consequently, young people experience poor transition planning that leaves them inadequately prepared for a move.

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Inadequate

Staff do not always listen to young people or consider their views. For example, a young person‟s expressed wish to make a formal complaint was not acted on. This leaves the young person with no confidence in the home‟s complaint procedure.

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Inadequate

The responsible individual has failed to ensure that young people receive consistent care. The majority of the staff team have left in the last four months. This has resulted in an increased reliance on using agency staff to cover vacancies. This has had an adverse impact on young people‟s relationships and feelings of safety.

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Inadequate

Managers do not work collaboratively with partner agencies to obtain the necessary information to guide their practice. For example, the advice and experience of mental health specialists have not been used to good effect. In one case, managers did not ensure staff were aware of possible triggers that might escalate behaviours. The staff team was not adequately informed about the methods hospital staff used to manage the extreme behaviour of one young person. Consequently, the young person‟s health, behaviour and safety needs were not met. Young people‟s day-to-day experiences of care are variable. One young person continues to succeed in education. However, another one young person recently admitted does not have a school placement.

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Inadequate

The quality of relationships between staff and young people has deteriorated due to seven previously well-established staff members leaving the home This has left young people without a consistent and stable staff team to secure meaningful relationships.

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Inadequate

The decorative state of the home is poor. Paintwork is worn, chipped, and shows signs of wear and tear. Young people do not respect their surroundings when staff fail to maintain the home to a good level. Judgement grade

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Inadequate

Managers and staff fail to make effective assessments of the risks faced by young people. Despite the provision of up-to-date information from placing authorities, decisions taken by managers fail to take proper account of the risks identified. In one case, a placing authority insisted that the primary condition of the young person‟s placement must be that the home is in a remote and isolated community. The local authority‟s intention was to use this location to curb the young person‟s prolific number of missing episodes. Despite this clear request, the home offered a placement in the full knowledge it was cited on a main road in a city suburb, fifty yards from a bus stop. The staff team‟s inadequate approach to the management of risk compromises the safety of young people.

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Inadequate

Staff do not have sufficient knowledge or understanding of how they can assist vulnerable young people. For example, staff were not aware of how to intervene safely in extreme cases of self-harm. Staff members did not know what ligatures were, and had not received training on the use of ligature cutters. This leaves young people at risk of harm because staff are ill prepared to respond effectively in the event of a serious incident.

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Inadequate

When risk is assessed and recorded, staff do not always act in accordance with the young person‟s assessment. In one case, decision making by staff did not follow the written advice to limit the time a vulnerable young person should spend away from the home. While in a park setting, having been away from the home for longer than was recommended, the young person‟s behaviour escalated, resulting in threats to commit suicide by drowning. Staff were only able to prevent this by using a prolonged holding technique. Staff had taken another young person from the home with them on this outing. Consequently, two young people and staff members were put at risk of considerable harm. A lack of proper planning resulted in an avoidable, reactive response to a difficult situation. Young people are not protected when staff fail to act on the detail contained in risk assessments.

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Inadequate

In response to the acute distress of the same young person, staff resorted to locking the doors of the home, as a measure of restraint. Two staff members were supervising the young person during this time. Advice and guidance for staff on the use of this measure are not included in the home‟s behaviour management policies. This demonstrates an unplanned approach to behaviour management and adds another element of risk to manging difficult situations. Locking of doors does not encourage young people to have trust in the staff team to keep them safe. It also impacts negatively on the liberty of other young people who do not require the imposition of such a measure.

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Inadequate

Even when the risks to a young person are clear and there is a serious concern about a child‟s welfare, staff do not take effective action to prevent the risk of harm. A recent example resulted in the closure of a young person‟s placement when they went missing after less than 24 hours in the home. The young person was inappropriately allowed access to online information with which she planned her departure. The staff team‟s inability to ensure she was supervised and safeguarded resulted in this exceptionally vulnerable young woman going missing for a week.

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Inadequate

Staff are not safely vetted before they start work in the home. Managers fail to investigate gaps in employment histories. For example, references are not fully verified. Managers do not have an understanding of the checks required by the regulations. This means that young people are at risk from potentially unsafe adults.

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Inadequate

For the past four months, the home has been without a registered manager. During this time, the responsible individual is acting as the home‟s manager. He is the second acting manager of the home since the departure of the registered manager. In addition to the lack of management stability, a number of experienced staff have chosen to leave the home over the same period. Managers‟ efforts to recruit replacements have not been successful, leading to a reliance on a number of part-time bank staff and agency staff. Staff vacancies remain unfilled. The level of change in the staff team does not aid consistency in the care provided to young people. This lack of consistency undermines young people‟s abilities to form positive relationships.

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Inadequate

Managers and staff are not effective in securing the input or services on behalf of young people in their care. In one case, managers discovered that a health assessment that they believed had been ongoing for the past year had not even started. In another example, staff failed to obtain crucial information from a hospital on the care required by a young person who had been discharged to the home‟s care. The impact for young people is that their health needs are not met.

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Inadequate

Young people‟s needs are not met due to the staff team‟s failure to liaise effectively with partner agencies. Door alarms to monitor the movements of young people are used without the required knowledge or consent of placing authorities. The use of such a system has implications for the privacy of young people.

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Inadequate

The home‟s review of premises report is not informed by the required consultation. This includes consulting the local police and placing authorities. This missed opportunity means collaborative working with other services is not secured and young people safety is not enhanced.

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Inadequate

Managers do not provide staff with the required support through regular supervision. Supervision has little focus on the progress and experiences of young people that helps staff to reflect on their care practice.

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Inadequate

Managers have no plans in place to ensure that all staff are provided with opportunities to obtain the appropriate qualifications. This leaves young people without the care and support they need from staff that are skilled and knowledgeable.

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Inadequate

The home‟s statement of purpose lacks many of the elements required by regulation. The model for therapeutic support is not clear. Information is out of date and includes references to obsolete legislation and arrangements for an independent advocate. The statement of purpose does not mention the provider‟s approach to children‟s rights. This means young people and placing authorities are not well-informed about the service provision. Although the statement of purpose was revised recently, copies have not been sent to Ofsted or the placing authorities. Similarly, notifications of significant incidents are also not sent in a timely manner to Ofsted. This demonstrates a lack of attention to detail across a range of important areas.

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Inadequate

Managers‟ monitoring and review systems to assess and report on the quality of care are ineffective, with no clear understanding of the home‟s strengths and weaknesses. The reports do not accurately represent the quality of care provided in the home. Additionally, the reports fail to reflect the many deficiencies evident at inspection. For example, they do not demonstrate how continuous improvement is to be achieved and fail to include the views of young people. The six monthly reports are also submitted late to Ofsted. Young people do not make sufficient and sustained progress from their starting point because of poor decision-making about admissions and matching.

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What the inspection judgements mean

The experiences and progress of children and young people are at the centre of the inspection. Inspectors will use their professional judgement to determine the weight and significance of their findings in this respect. The judgements included in the report are made against „Inspection of children's homes: framework for inspection‟.

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What the inspection judgements mean

An outstanding children's home provides highly effective services that contribute to significantly improved outcomes for children and young people who need help and protection and care. Their progress exceeds expectations and is sustained over time. A good children's home provides effective services that help, protect and care for children and young people and have their welfare safeguarded and promoted. In a children's home that requires improvement , there are no widespread or serious failures that create or leave children being harmed or at risk of harm. The welfare of looked after children is safeguarded and promoted. Minimum requirements are in place, however, the children's home is not yet delivering good protection, help and care for children and young people. A children's home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

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What the inspection judgements mean

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

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Information about this inspection

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

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Information about this inspection

Homes (England) Regulations 2015 and „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 0300 123 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 looked after children and child protection. If you would like a copy of this document in a different format, such as large print or Braille, please telephone 0300 123 4234, or email enquiries@ofsted.gov.uk . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team,

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Information about this inspection

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

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Information about this inspection

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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