Children's Home run by PCT Care Services Limited in Norfolk

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:

 The recruitment process is not effective and leaves children at risk of being cared for by unsuitable adults.  A recent fire risk assessment identified a number of issues which have been outstanding since the previous year and some of these have still not been addressed.  Children‟s files lack records of some major incidents. This information would not be available in the future should concerns be raised, or if children wanted to look at their records to help them gain an understanding of their childhood. Nor is this information available to inform children‟s reviews and risk assessments.  The failure of the home to manage challenging behaviour effectively has a negative impact on children‟s progress and wellbeing. The home has failed to ensure that all children know how to make a complaint.  Records of physical interventions do not include any evaluation or any record of staff being spoken to by managers after the event to help them

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The children's home provision is inadequate because:

reflect on their practice. Some records do not contain sufficient detail of the intervention.  Leaders and managers have failed to recognise and address these significant failures, which are undermining children‟s safety and wellbeing.  Some areas of the home require attention and maintenance.  The manager has failed to notify Ofsted appropriately of some significant events.  The home has not used risk assessments to identify how staff should respond to individual children who go missing from care, taking into account their particular vulnerabilities. This limits the ability of staff to keep children safe. It has also failed to fully consider the risks of lone working.  Staff do not have guidance on how to have appropriate physical contact with children.  Not all staff are effectively engaged in an appropriate induction process.  Internal and external monitoring of the home has not been effective at

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The children's home provision is inadequate because:

identifying some significant shortfalls.  The home is not operating to its statement of purpose.  There has been a high turnover of staff, which means that children‟s relationships with those who care for them are disrupted.

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The children's home strengths

 There are some good relationships between staff and children. This helps staff to provide emotional support for children.  Some children are making good progress for example self-harming behaviour is reducing.  All children are attending and engaging in education.  There is good use of links with external professionals to provide important and helpful information for staff. For example, there has been work with the local coastguard to improve the safety of children near the sea.

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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 within the given timescales.

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Requirement Due date

7. The children‟s views, wishes and feelings standard: In order to meet the children‟s views, wishes and feelings standard with particular reference to the complaints procedure, the registered person should ensure that each child— (2)(b)(ii) has access to the home‟s children‟s guide, and the home‟s complaints procedure, when the child‟s placement in the home is agreed and throughout the child‟s stay in the home. 22/07/2016

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Requirement Due date

13. The leadership and management standard: In order to meet the leadership and management standard with particular reference to the consistency of staffing, the impact of the stability of the home on children and monitoring of the service, the registered person should— (2)(e) ensure that the home‟s workforce provides continuity of care to 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. 29/07/2016

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if there is an allegation of abuse against the home or a person working there. A notification made under this regulation must include full details of the matter (Regulation 40 (4)(a) (5)(a)(i)). 22/07/2016

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Requirement Due date

12. The protection of children standard: In order to meet the protection of children standard with particular reference to the use of comprehensive risk 22/07/2016 assessments, the registered person should ensure that staff— (2)(a)(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.

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Requirement Due date

The registered person should 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 the effectiveness and any consequences of the use of the measure and within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (“the authorised person”) has spoken to the user about the measure and has signed the record to confirm it is accurate (Regulation 35 (3)(a)(vii)(b)(i)(ii)). 22/07/2016

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Requirement Due date

The registered person must ensure that the requirements of Regulatory Reform (Fire Safety) Order 2005 and any regulations made under it are complied with in respect of the home. This relates to the implementation of actions identified in the fire risk assessment (Regulation 25 (2)(b)). 22/07/2016

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Requirement Due date

The registered person must recruit staff using recruitment procedures that are designed to ensure children‟s safety. The registered person may only employ an individual to work at the children‟s home if in respect of the individual there are full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32(2)(a)(3)(d))*

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Requirement Due date

The registered person must ensure that each employee completes an appropriate induction and that all employees undertake appropriate continuing professional development. This relates to training in food hygiene and awareness of appropriate physical contact with children (Regulation 33 (4)(a)). 29/07/2016

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Requirement Due date

6. The quality and purpose of care standard: In order to meet the quality and purpose of care standard with particular reference to implementing the statement of purpose and the condition of the home, the registered person should— (2)(a) understand and apply the home‟s statement of purpose; (b) ensure that staff— 05/08/2016 (i) understand and apply the home‟s statement of purpose (c)(i) ensure that the premises used for the purposes of the home are designed and furnished so as to meet the needs of each child.

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Requirement Due date

The registered person must ensure that the reports of the independent person who visits the children‟s home set 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)(b)). 29/07/2016

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Requirement Due date

The registered person must keep the statement of purpose under review and, where appropriate, revise it, and notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision (Regulation 16 (3)(a)(b)). 22/07/2016

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Requirement Due date

* These requirements are subject to a 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:  Ensure that staff understand the importance of careful, objective and clear recording ensuring that information regarding the child is recorded in a way that will be helpful to the child. In particular, this refers to records of significant events relating to the child while in the home („Guide to the children‟s homes regulations including the quality standards‟, page 62, paragraph 14.4).

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Information about this children's home

This children‟s home provides care and accommodation for up to six young people with emotional and/or behavioural difficulties and learning disabilities. The home is owned by a private company.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

18 March 2016 Interim Declined in effectiveness

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Recent inspection history

2 February 2015 Interim Improved effectiveness

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Inadequate

The home is failing to ensure that all children are making satisfactory progress. External professionals raised concerns about the failure of the home to manage behaviour effectively. Disruptive incidents in the home are having a negative impact on children. Some external professionals felt that the impact of one placement in particular has been an issue. Furthermore, children are upset when they witness violence towards staff or self-harming behaviours. There are also some altercations between children in the home. The impact of this has limited some of their progress. The previous inspection identified a shortfall in the matching process and a requirement was set. Since that time, there have not been any new children move into the home. However, the manager has changed the process for assessing new placements to make it more thorough. There has been a significant turnover of staff, with 11 new staff in the last 12

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Inadequate

months. This level of change makes it harder for children to form attachments and risks negative feelings when staff to whom they are attached leave the home. There are some good relationships between children and staff who are currently at the home, but the quality and extent of these is limited by the turnover of staff. Staff take an interest in and spend time with the children. The significant shortfalls identified in other sections of this report have an impact on children‟s overall experiences and progress. Some children do make good progress. A health professional described one child as becoming more assertive and developing her sense of identity. Another child has significantly reduced the level of her self-harming behaviour. There are good links with specialist health services, such as mental health, which help to ensure that some children‟s health needs are met well. Children‟s views are listened to and

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Inadequate

acted upon. For example, one child wanted to be able to walk to the shop on her own, so staff have been working with her on her road safety awareness. Another child has been able to influence her contact with family and friends. The children‟s guide does not include information on how children can make a complaint and one child stated in her response to an internal survey that she did not know how to make a complaint. There has not been any follow up to this. While some children are aware of and use the complaints process, others are not aware and their ability to raise issues of dissatisfaction is limited. All children are attending education. One child attends college for 25 hours a week and the other three children attend school for 30 hours a week. The behaviour of some children and incidents in the home does have an impact on some children‟s education. They are making overall progress in their education, but this could

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Inadequate

potentially be better if it were not for some of the disruption in the home. One school spoke of a child‟s significantly improved behaviour. Another school has raised concerns with the placing social worker about children arriving at school upset due to incidents in the home. Children have opportunities to take part in a range of activities including guitar lessons, gymnastics and going out with staff. Some particularly enjoy going to car boot sales. Three of the children have recently been on holiday. The fourth child decided that she would rather have a spa day. Being able to take part in activities such as this helps children to have normal childhood experiences and to have fun. One child has detailed a pathway plan to help her prepare for her future independence. Younger children get chances to develop skills that they will need for adulthood through activities such as cooking with staff or playing shops.

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Inadequate

The home‟s processes for recruitment checks on staff are inadequate and do not protect children from being cared for by unsuitable adults who may pose a risk to them. The shortfalls include:  Routinely not obtaining written references before staff start work.  Using a Disclosure and Barring Service check from previous employers which had not asked for information from the children‟s barred list.  Not getting full employment histories and not seeking explanations of any gaps.  Not recording any assessment of previous convictions. A fire risk assessment of the home was carried out by an external contractor on 18 April 2016. The assessment identifies a number of issues which were outstanding from the previous year. Some of these have still not been addressed. They include the practice of wedging fire doors open and a lack of signs to fire doors. While there are regular checks of fire equipment and fire evacuation drills, failing to act

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Inadequate

upon the recommendations in the fire risk assessment limits the overall protection for children and shows that leaders and managers are failing to recognise and act on serious weaknesses which could leave children at risk. In addition to the work required by the fire risk assessment, there are maintenance issues within the home which have not been addressed. While there has been some recent decoration to some areas, the bathroom has numerous marks to the walls and broken fittings. This does not provide a pleasant environment for children to live in. Records of physical intervention do not contain any evaluation or discussions between the manager and staff to help them reflect on their practice and consider ways to reduce the need for such interventions. Furthermore, some records do not provide sufficient detail of the incident and others are not kept in the correct file. This further limits the effectiveness of any monitoring and review of the times

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Inadequate

when staff have to hold children. The manager responds quickly and robustly to any concerns about safeguarding once they are identified. This includes liaison with the appropriate agencies. However, notifications of serious events are not always sent to Ofsted and do not always contain sufficient detail of the incident. This prevents Ofsted, as the regulator, from having full information on which to base decisions, such as the timing of inspection. Some major incidents are not recorded on children‟s files. They would not be available should there be any future concerns or if the child wanted to look at their records in the future to help them understand their childhood. There are a low number of incidents of children going missing from care and records indicate that on the few occasions when they have, staff have taken appropriate action. However, children‟s risk assessments do not provide clear and

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Inadequate

individualised information for staff on how to respond to the varying needs and vulnerabilities of each child should they go missing from care. While the limited responses to date have been appropriate, lack of such individualised information means that staff may not act appropriately in every occasion for each child, particularly given the wide age range of children in the home. There has not been appropriate risk assessment of staff lone working, including taking a child away alone, but with back up support available. This prevents possible risks being clearly identified and action taken to reduce them. Staff do not have access to clear guidance on how to have safe physical contact with children. Physical contact and reassurance is important for children in care, but the lack of guidance for staff means that they may not act safely and may not identify when a colleague is acting in an unsafe way. This puts children at a potential risk.

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Inadequate

Some children do become safer in some aspects of their lives while they are at the home, in particular from risks of self-harming. Children have good relationships with staff which enable them to seek out staff to talk to when they are distressed. This helps to provide some effective emotional support for children. There are clear and detailed behaviour management plans to help staff work with children. They also use a behaviour reward system to help children address their behaviours. The manager arranged for staff from a school to speak with staff from the home to help identify effective behaviour management strategies for one child. The home‟s statement of purpose refers to the home using a restorative approach in behaviour management. This is not carried out in practice; most sanctions include the loss of an activity or privilege. Failure to act in the way set out in the statement of purpose questions the managers and staff awareness of it.

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Inadequate

The monitoring of the home by the independent visitor and the manager has not identified many of the shortfalls included in this report. These include significant shortfalls regarding the recruitment of staff and the fire risk assessment. This has prevented the shortfalls from being addressed and left children at potential risk of harm. The independent visitor does not include in his reports his opinion as to whether children are effectively safeguarded and whether the conduct of the home promotes children‟s well-being. Consequently, this information is not provided for the responsible individual to support his oversight of the home. There is a manager in post. He has submitted an application for registration to Ofsted, but the assessment of his fitness and suitability has not yet been completed. There are sufficient staff to provide cover and appropriate care for children, although this can be stretched at times when one child may be distressed

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Inadequate

and require more staff attention. Staff are not all engaged in comprehensive inductions to prepare them for their work. While some staff spoke of a good induction, others were vague about what their induction included, other than shadow shifts. Furthermore, some staff induction records, while signed by managers, did not have any staff signatures on them. At best, this calls into question the active involvement of staff in the process. As there have been 11 new staff in the last 12 months, inconsistent induction of staff has the potential to significantly impact upon the practice and care of children. Some staff spoke of high levels of pressure at times due to the expectations on them and the challenges of caring for the children. Although there was a general view from staff that this has improved very recently and that managers are now more involved and able to provide practical support at times of high demand.

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Inadequate

Team meeting minutes show this is being discussed, but the long term efficacy of it is not yet known. Some staff spoke of high levels of support from managers. Managers provide regular and appropriate practice-related supervision for staff and the manager receives his supervision from an appropriately experienced external person. Regular supervision helps people to reflect on their practice and consider ways of developing. Staff receive training in areas such as de-escalation and restraint, safeguarding, first aid and administration of medicines. The manager has also made good use of external professionals to provide training sessions for staff. This has included an education establishment coming to talk about how they have managed a child‟s behaviour, helping staff to learn from them and ensure consistency for the child across the home and school. It has also included a talk from the coastguard about how staff can reduce the risk to children of the nearby

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Inadequate

sea. Some staff do not have food hygiene training. As they cook for and with children, this not only limits their awareness of safe food handling, but prevents them from passing this information on to the children. There is a statement of purpose for the home which the manager updated in April 2016. Copies of revisions have not been sent to Ofsted. Also, although the statement was last reviewed in April 2016, it is out of date. At least three staff whose details are included in it have resigned and left the home. As stated above, the home is not operating fully in line with its statement of purpose. Altogether, this prevents those people who have access to the statement of purpose from having a clear and up-to-date picture of the home, how it intends to operate and the experience and qualifications of staff. The home has good links with the local police and with most external agencies. There have been issues over communication between some other agencies and the

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Inadequate

home. They mostly report that this is improving. There are still some issues in some cases, but the home and the external professionals involved are making efforts to address this through dialogue and meetings. Failure to ensure good working relationships will have a negative impact on children as communication and consistency will prevent their needs being identified and met effectively. In most cases the home does have regular meetings with others working with children so that progress or lack of it can be identified and where necessary addressed. There is some monitoring of individual children‟s progress, for example numbers of incidents and physical interventions, but as referred to above, and monitoring overall is not good enough to identify shortfalls and potential improvements in the care of children. While children do make progress from their starting points, this has not been consistent for all of them. In one case, this has

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Inadequate

been identified and there has been a meeting between the professionals involved to review the situation. This is positive in prioritising children‟s needs. However, as stated above for some children, their progress is limited by events and dynamics in the home.

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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 that 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, 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

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

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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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