Horsebridge House

Inadequate

There are serious and/or widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded

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The children's home provision is inadequate because:

 One young person is placing himself at serious risk of harm. This includes self-harming behaviours and running onto a busy main road. Leaders and managers have not ensured that staff have received the guidance, support and training in order to meet this young person’s needs and keep him safe.  Leaders and managers have not ensured that the home and garden is safe. They have neither identified the risks to young people who self-harm nor taken measures to reduce them. For example, one young person who self- harms had access to materials that he could use to hurt himself.  Leaders and managers have not ensured that staff are provided with comprehensive behaviour support plans that help and guide them to manage young people’s behaviours and reduce risk. This has resulted in young people assaulting staff, severely damaging the house and placing themselves and others at risk of harm.  The oversight and record keeping of restraint is poor. Staff have not

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The children's home provision is inadequate because:

received training in the home’s preferred method of restraint and de- escalation procedures.  Missing from home protocols are neither individualised nor shared with and agreed by the local police. Young people who go missing do not receive independent return home interviews.  Leaders and managers have failed to refer child-on-child safeguarding concerns to the local multi-agency safeguarding hub in a timely manner.  Leaders and managers have failed to take sufficient action to ensure that a suitable manager is in post and is registered with Ofsted.  Young people are not receiving the education support they need to meet their needs. Staff have taken action to remedy this deficiency.  Young people are living in an environment that is neither homely, decorated nor maintained to a good standard.

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The children's home strengths

 The quality of the newly devised behaviour support plan for one young person is good. Strategies for intervention are clear and encourage staff to engage in early help and support for the young person.

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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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needs are met

5. In order to meet this quality standard, the registered person must, and ensure that staff— (c) if they consider a placing authority’s or a relevant person’s performance or a response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans.

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needs are met

In particular, to challenge providers of education to ensure that children receive their assessed educational needs. 30 June 2016

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The quality and purpose of care standard

6. In order to meet the quality and purpose of care standard, the registered person must— (2)(c) ensure that the premises used for the purposes of the home are designed and furnished so as to— (i) meet the needs of each child;

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The quality and purpose of care standard

In particular, ensure that all areas of the home are homely, well maintained and decorated to a good standard. 31 July 2016

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The education standard

8. In order to meet the education standard, the registered person must ensure— (2)(a)(i) that staff help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans (viii) help a child who is excluded from school, or who is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as 30 June 2016 possible.

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The protection of children standard

12. In order to meet the protection of children standard (with respect to following missing from home protocols), the registered person must ensure that— (2)(v) staff understand the roles and responsibilities in relation to protecting children. In particular, that each young person has an individualised missing from home protocol that has been agreed by the local police. 31 July 2016

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The protection of children standard*

12.In order to meet the protection of children standard the registered person must ensure— (2)(a)(i) that staff assess whether each child is at risk of significant 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.

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The protection of children standard*

In particular, to take measures to reduce the risk of young people placing themselves at risk of self-harm.

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The protection of children standard*

(b) that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect them from harm;

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The protection of children standard*

In particular, to ensure that each young person has an individual, comprehensive and effective behaviour support plan that guides and supports staff in how to manage behaviours, and reduces the risk of harm. In addition, to ensure that young people receive their prescribed medication and that the medicine administration records sheets evidence the correct administration;

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The protection of children standard*

(d) that the premises used for the purpose of the home are designed, furnished and maintained as to protect each child from avoidable hazards to the child’s health;

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The protection of children standard*

In particular, to remove risks such as potential ligature points and items that can be used by young people to self-harm. 30 June 2016

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The leadership and management standard*

13.In order to meet the leadership and management standard, the registered person must ensure that— (2)(c) staff have the experience, qualifications and skills to meet the needs of each child; 28 July 2016 This includes training in: safeguarding; restraint and de-escalation; self-harm; first aid; management of medicines; fire awareness; attachment disorders; -e-safety and food hygiene.

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The leadership and management standard

13.In order to meet the leadership and management standard, the registered person must— (2)(e) ensure that the home’s workforce provides continuity of care to each child; (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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The leadership and management standard

In particular, to undertake a management review of events that led up to two young people going missing from the home without staff’s knowledge, and to act upon the finding of this review to ensure that young people are kept safe. 30 June 2016

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Statement of purpose

16.The registered person must— (3)(b) notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision. 31 July 2016

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Restraint and deprivation of liberty

20. (2) Ensure that restraint in relation to a child must be necessary and proportionate.

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Restraint and deprivation of liberty

In particular, ensure that restraint is not used to enforce young people to comply. 30 June 2016

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Monitoring and surveillance

24. (1) The registered person may only use devices for the monitoring or surveillance of children if— (d) the monitoring or surveillance is no more intrusive than necessary, having regards to the child’s need for privacy.

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Monitoring and surveillance

In particular, ensure that bedroom door alarms are not used unnecessarily and that this is kept under constant review. 30 June 2016

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Appointment of manager

27. (1) The registered person must appoint a person to manage the children’s home. 15 July 2016

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Policies for the protection of children

34. (1) The registered person must prepare and implement a policy which— (a) is intended to safeguard children accommodated in the children’s home from abuse or neglect. In particular, to refer any safeguarding concerns in respect of child-on-child safeguarding concerns to the local multi-agency safeguarding hub and the placing authority in a timely manner. 30 June 2016

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Behaviour management policies and records

35. (3) (a) Ensure that within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes— (iii) the date, time and location of the use of the measure; (v) details of any methods used or steps taken to avoid using the measure; (vii) the effectiveness and any consequence of the measure; 30 June 2016

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Notification of a serious event

40. (4) The registered person must notify HMCI and each other relevant person without delay if— (e) there is any other incident relating to a child which the registered person considers to be serious. 30 June 2016

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Notification of a serious event

* These requirements are subject to statutory requirement notice.

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Recommendations

To improve the quality and standards of care further, the service should take account of the following recommendation(s):

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Recommendations

 Ensure that any child who has been restrained is given the opportunity to express their feelings about their experience of the restraint as soon as practicable, ideally within 24 hours of the restraint incident, taking the age of the child and circumstances of the restraint into account (‘Guide to the children’s homes regulations including the quality standards’, page 50, paragraph 9.60).

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Information about this children's home

This service is operated by a private company which is part of the CareTech group, a national social care agency. It is registered to provide care and accommodation for up to four young people who have emotional or behavioural difficulties.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

16 March 2016 Interim Declined in effectiveness

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Recent inspection history

16 December 2014 Interim Declined in effectiveness

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Inadequate

Young people receive inadequate care and help. Leaders and managers do not ensure that young people have positive outcomes. Young people have not been supported to manage their behaviour and feelings safely. They have not been set clear and consistent boundaries. This has resulted in young people behaving in a manner that places themselves and others at significant risk of harm.

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Inadequate

Leaders and managers have failed to meet the health needs of one young person. The administration of medication is inadequate. The young person’s medication records do not evidence that he is receiving his prescribed medication when he should. On occasions, these records show that he has received more than the prescribed amount of medicine. This compromises his health and well-being. In addition, there is no consistency in where the administration of his medicines is recorded. This approach does not ensure that there is an audit trail to confirm the safe administration of his medication.

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Inadequate

One young person’s education provision is poor. He is currently receiving an outreach service from the organisation’s in-house school. Leaders and managers have failed to ensure that the young person receives appropriate education. He is receiving between three and six hours of formal education per week that is reliant on the teacher’s availability. There is no plan in place to increase this provision. Care staff are required to deliver additional learning sessions to the young person. Leaders and managers have not assessed that care staff have the skills to deliver this work. This approach severely compromises the progress that he makes in his education. The headteacher and virtual head were contacted during this inspection and these concerns were raised with them. The responsible individual said that he will take immediate action to remedy this deficiency. The outreach service provided for the young person is inadequate.

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Inadequate

Young people live in an environment that is neither homely, decorated nor maintained to a good standard. In particular, both young people’s bedrooms have damage to walls and broken furniture and the rooms are not personalised. One young person’s bedroom was dirty. There was smoking in the room. Another young person’s bedroom does not have curtains or blinds fitted and there are clothes strewn across the floor. It is evident that both bedrooms have not been cleaned for some time. The independent visitor previously raised this concern with staff but insufficient action has been taken to improve the situation. The first-floor bathroom, although clean, is neither welcoming nor child friendly. It is neither decorated nor presented to a good standard. There is no soap or towel available for young people to wash and dry their hands.

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Inadequate

Young people know how to make a complaint and are able to demonstrate the action that they would take if they were unhappy.

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Inadequate

Leaders and managers ensure that young people are supported to maintain contact with their families. One young person regularly visits his family, and staff support and encourage this contact. A social worker said, ‘There is good communication between mum and the home.’

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Inadequate

Young people are placing themselves at significant risk of harm. This is because staff have not received robust guidance and support in the management of young people’s behaviours. They have not received the required training to provide them with the skills and knowledge to keep young people and themselves safe. This has resulted in young people engaging in high-risk activities including self-harm, assaults on staff and significant damage to the home’s environment. Leaders and managers have failed to notify Ofsted of the vast majority of the high-risk incidents that have occurred.

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Inadequate

At the time of this inspection, the home’s environment was not safe. In particular, access to potential ligatures such as pull cords in bathrooms, broken fence panels in the garden with exposed nails and unsecured telephone wires outside the house posed significant risk to young people living in the home. These risks were brought to the attention of senior staff and action was taken at the time of the inspection to make the environment safe.

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Inadequate

Until very recently, leaders and managers have failed to ensure that both young people have comprehensive, individualised behaviour support plans and risk assessments. The plans that staff were previously using did not explicitly inform them how to manage young people’s behaviour and to reduce risks. The home’s behaviour support lead has now developed a comprehensive behaviour support plan for one young person. This plan has been implemented, however, not all staff have signed to say they have read it and confirm that they have an understanding of how to provide good support to the young person.

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Inadequate

The management oversight of restraint and the records pertaining to the use of restraint is poor. This places young people at risk of harm. One restraint record suggests that a ground restraint was used and another record suggests that restraint was used to enforce a young person to comply with a request from staff. These concerns were discussed with senior managers. They agreed to investigate these incidents further. Leaders and managers have failed to ensure that all staff have received training in the use of restraint prior to using such measures and not all staff have received regular refresher training. There are widespread weaknesses in the recording of the use of restraint. These weaknesses include failing to record the location and time of each restraint, details of any methods used or steps taken to avoid using the measure, and the effectiveness and any consequences of the measure. In addition, records do not always confirm young people’s views on the

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Inadequate

use of restraint. Some entries identify that more than one restraint was used to manage a particular incident. Therefore, this does not give a true reflection as to the actual number of restraints being used by staff.

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Inadequate

Leaders and managers have failed to refer child protection concerns in line with ‘Working Together to Safeguarding Children (2015)’. For example, an incident relating to two young people was referred to the local area designated officer (LADO), as opposed to the local multi-agency safeguarding hub. This referral was made a number of weeks after the incident. The LADO advised that an internal investigation be completed. This investigation is still ongoing.

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Inadequate

The missing from home protocols for young people are not individualised and have not been shared or discussed with the local police to ensure an agreed approach. Since the previous inspection, there has been one recorded incident of young people going missing from the home. Staff took appropriate action to safeguard them and the young person returned safely. The police visited them to undertake a welfare check. However, leaders and managers have not ensured that young people have received an independent return home interview.

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Inadequate

Young people’s bedroom doors have monitoring devices fitted. However, it is unclear how the use of this measure and its appropriateness are monitored by staff.

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Inadequate

Staff are not provided with clear guidance and strategies to support young people to use the Internet safely. One young person uses his personal smartphone unsecured when outside of the home and staff caring for him are not clear how to monitor and manage this.

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Inadequate

Young people said that they feel safe living in the home and do not identify bullying as a concern. Judgement grade

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Inadequate

Leaders and managers have not taken sufficient action to ensure that a suitable manager is in post and registered with Ofsted. The home has been without a registered manager since March 2015. This issue was identified at the interim inspection and continues be a concern. Since the previous inspection, the manager has resigned. The home is currently without a permanent manager.

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Inadequate

There is insufficient evidence that the responsible individual has closely monitored the performance of the home. Until recently, senior managers’ oversight of the home has been poor. They have failed to identify the concerns, strengths and weaknesses of the home and to remedy them in a timely manner.

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Inadequate

Leaders and managers have failed to ensure that they provide staff with mandatory and specialist training to meet the needs of the young people living in the home. Senior managers and training records confirm that not all staff have received training in the following areas: safeguarding; restraint and de-escalation; first aid; food hygiene; fire awareness; self-harm; epilepsy; medication administration; e-safety; and, attachment disorders. As a result, staff are not well prepared to care for the young people and this places them and the young people at risk of significant harm.

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Inadequate

Since the previous inspection, senior managers have started to undertake a review of the quality of care provided in the home. To date, their findings identify substantial weaknesses in record keeping and, in particular, concerns in respect of the safety and well-being of the young people. A senior manager is working in the home to remedy some of the weaknesses. Staff speak positively about the support and direction this manager is providing.

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Inadequate

The independent visitor has identified a number of weaknesses during her visits to the home. At her visit in April 2016, she reported, ‘I do not believe that effective arrangements to safeguard and promote the well-being of young people are in place. I have raised my concerns with the responsible individual in the absence of the substantive manager.’ This report had not been received by Ofsted at the time of this inspection.

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Inadequate

Leaders and managers have not been able to confirm that, following the previous inspection, a comprehensive internal investigation was completed in respect of two young people who were missing from the home without staff’s knowledge. This was a requirement at the previous inspection. Three other requirements made at the previous inspection have not been met.

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Inadequate

Leaders and managers have failed to challenge their in-house school provision. As a result, one young person’s education has been severely compromised. He has not received the agreed education provision. Leaders and managers are not achieving the aims and objectives as set out in the statement of purpose. This document and the young person’s guide have been reviewed and are both dated May 2016. However, leaders and managers have failed to ensure that Ofsted has been provided with these updated documents as required.

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Inadequate

Leaders and managers have failed to ensure that young people have received continuity and consistency of care from staff. There are a number of staff vacancies and a number of staff on sick leave from the home’s core staff team. To manage this, staff from other homes within the organisation have been deployed to work at the home. Therefore, young people are not always familiar with the staff who support them on a day-to-day basis.

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Inadequate

The responsible individual and the organisation’s senior managers have developed an action plan to deal with the weaknesses that they, the independent visitor and the previous inspection have identified. Leaders and managers acknowledge that the four requirements that were made at the previous inspection have not been met. The action plan has been shared with Ofsted, but the impact of the action plan is yet to be measured.

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Inadequate

The LADO confirms that there has been a good relationship with the manager. Placing authorities report good and effective communication between them, the manager and the staff team.

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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.

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What the inspection judgements mean

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.

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What the inspection judgements mean

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.

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What the inspection judgements mean

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 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.

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Information about this inspection

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 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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