Children's home in Hammersmith and Fulham

Requires improvement

The children's home is not yet delivering good help and care for children and young people. However, there are no serious or widespread failures that result in their welfare not being safeguarded or promoted.

p.2

The children's home provision requires improvement because:

 Since the full inspection in July 2015, there has been a period of significant challenge and disruption in the home. This has included an extensive company restructuring, which resulted in approximately half of the original staff team leaving. Within the past three months, the registered manager has left and since then, interim management arrangements have been put in place. The lack of clear leadership arrangements during this period has led to confusion in roles and responsibilities and accountability for managers. While some progress has been made, this has been fragmented and inconsistent.  The safeguarding systems in place do not ensure that all concerns are appropriately referred and followed up. The procedures in place do not provide clear instructions to staff in terms of expectations upon them. On one occasion recently, managers displayed a lack of challenge and confusion about their safeguarding responsibilities, resulting in a young person being

p.3

The children's home provision requires improvement because:

placed in a potential situation of risk.  Young people’s challenging and complex behaviour is not consistently managed positively and effectively. While the number of physical restraints has reduced, there are still occasions when staff are not being effective in their use of de-escalation techniques. While the physical restraints are low level, it is questionable whether they are really necessary and comply with the requirement that they should only happen to prevent injury or serious damage. Furthermore, staff do not always adhere to instructions following a manager’s oversight of such incidents and it is not clear if this is a breakdown in communication or a failure to recognise the importance of improving practice in this area, which may be a supervision or training issue.  Not all staff receive appropriate training in key areas prior to working directly with young people. While induction training has improved and staff

p.3

The children's home provision requires improvement because:

speak well of their training opportunities, not all staff receive training in how to respond and manage young people’s behaviour prior to working with young people. This puts young people and staff at risk of harm.  The arrangements in place for handover are poor. The quality of information shared lacks detail. This means that there is an ongoing danger that key information can be lost. This has happened in respect of a complaint made by one young person.  Recruitment processes are not robust enough to ensure that staff are suitable to work with children. For example, not all staff have provided adequate references and gaps in employment history are not fully explored. There is a lack of robust management oversight and sign off to ensure that young people are protected.

p.3

The children's home strengths

 The management team remains highly motivated to make improvements that will benefit young people. The management team is looking forward to supporting young people to move to community houses, which the team feels will make a significant contribution to achieving better outcomes.  The new staff team is settling. Young people are starting to form positive attachments and build trusting relationships. Some new staff are key workers, chosen by young people. Lots of training has been provided and staff are feeling supported.  Most young people are feeling positive about their placement. They are involved in their care plans and attend associated meetings. Young people are being supported to achieve personal targets. Care plans have been improved and they are more aspirational. Young people are receiving good support to make informed decisions about their future. Sanctions have been replaced by a more restorative approach that is meaningful and beneficial to

p.4

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.

p.5

Requirement Due date

6: The quality and purpose of care standard In order to meet the quality and purpose of care standard, (3)(c)(i)(ii) children must receive care from staff who have the experience, knowledge and skills to deliver that care and are under the supervision of a person who is appropriately skilled and qualified to supervise that care. 31 July 2016

p.5

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 acting on any complaints that young people make and keeping them informed of the action being taken and the outcome, (2)(d)(ii) ensure that young people know how to make a complaint or representations in relation to the home or the care they receive and how any such complaint or representations will be dealt with. 31 July 2016

p.5

Requirement Due date

11: The positive relationships standard In order to meet the positive relationships standard, with particular reference to ensuring that all staff fully understand that they may only physically restrain a young person to prevent injury or serious damage to property, (2)(xi) the registered person must ensure that staff de-escalate confrontations with or between children, or potentially violent behaviour by children. 21 July 2016

p.5

Requirement Due date

12: The protection of children standard In order to meet the protection of children standard, with particular reference to making a formal notification to the local authority, the registered person must ensure that staff, (2)(a)(vi) take effective action whenever there is a serious concern about a child’s welfare and (e) that the effectiveness of the home's child protection policies is monitored regularly. 21 July 2016

p.5

Requirement Due date

13: The leadership and management standard In order to meet the leadership and management standard, with particular reference to the staffing of the home and robust 31 July 2016 management oversight that promotes improvements in practice and recording, the registered person must— (1) (2)(a) enable, inspire and lead a culture in relation to the children's home 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; (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

p.5

Requirement Due date

32: Fitness of workers The registered person must ensure that an individual who works in the home in a care role has an appropriate qualification, the level 3 diploma for Residential Childcare, by the relevant date. (Regulation 32 (4) (5)) 30 June 2017

p.6

Requirement Due date

32: Fitness of workers The registered person must recruit staff using recruitment procedures that are designed to ensure children's safety. In particular, full and satisfactory information must be available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32 (3)(d)) 21 July 2016

p.6

Requirement Due date

35: Behaviour management policies and records The registered person must 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 with includes details of the child's behaviour leading to the use of the measure, a description of the measure and its duration, details of any methods used or steps taken to avoid the need to use the measure, the effectiveness and consequences of the use of the measure and a description of any injury to the child or any other person, and any medical treatment administered as a result of the measure. 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 must ensure that the user has been spoken to about the measure and has signed the record to confirm it is accurate. Within five days of the use of the measure, the registered person or the authorised

p.6

Requirement Due date

person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(ii)(iv)(v)(vii)(viii)(b)(i)(ii)(c)) 31 July 2016

p.6

Information about this children's home

The home is operated by a large private provider of healthcare, social care and education. It provides care and accommodation for up to 14 children, irrespective of gender, who have a range of emotional and behavioural difficulties. Some may also have learning needs. Education facilities are also provided on the same site.

p.7

Recent inspection history

Inspection date Inspection type Inspection judgement

p.7

Recent inspection history

23 February 2016 Interim Declined in effectiveness

p.7

Requires improvement

The overall experiences and progress of children and young people are not consistently good for all young people. This relates to the lack of clear leadership arrangements which has slowed down progress, inconsistent role modelling to develop good practices and the failure to really learn lessons and drive forward improvements to benefit young people. This is apparent in several key areas such as managing young people’s complex and challenging behaviour and in ensuring that really robust safeguarding procedures are always followed. While there is better management oversight of serious incidents, there is inconsistent evidence of the impact of such oversight in improving practices. The arrangements in place for handover in-between staff changes are not of a consistently good standard. The quality of information shared lacks detail and is task focused and not child centred. From an observation of a handover and an

p.8

Requires improvement

examination of handover reports, it is apparent that not enough emphasis is placed on the importance of communicating information about young people that supports consistently good practice. Role modelling is not sufficiently robust to develop best practice. There remains the risk of new staff developing practices that do not reflect good childcare. For example, while physical restraints have reduced, those that have occurred recently do not feel like a ‘last resort’ by staff to prevent injury or serious damage occurring. There is also evidence that poor practices reoccur even when managers have instructed that they should not and have given very informed reasons why not. This is apparent in practices that involve a young person being ‘guided’ to their bedroom to calm. Not all staff are suitably trained, experienced or qualified. While staffing arrangements have improved over the past six months, some shortfalls continue to

p.8

Requires improvement

exist. For example, two staff members who have worked at the service for more than two years have only recently commenced their level 3 diploma. Not all new staff receive appropriate training in how to manage challenging behaviour prior to working directly with young people. Management decisions about staff appointments, both in terms of recruitment and following their probationary period, are not consistently robust. These combined factors have an impact on the progress and experience of young people. There is a complaint policy in place and young people know how to complain. However, there is an inconsistent response to young people when complaints are made. For example, one young person who recently made a written complaint has not had any response and her written complaint has been lost. Another young person who made two complaints is not clear what happened as a result of her complaints and does not feel satisfied that her complaints were taken seriously or

p.8

Requires improvement

the outcome communicated to her. Records relating to complaints are confusing and information requested by inspectors could not be provided during the two days of the inspection. Young people are being encouraged to build trusted and secure relationships with adults working in the home. Stability is improving and some new staff are key workers and have established very positive relationships with young people. Young people do have a sense of belonging. There are three separate living areas, each with its own character. Bedrooms are personalised and reflect young people’s interests. For example, many of the young people have their own pets, which they keep in their rooms. Other young people enjoy staff bringing in their pets. Having opportunities to learn about animal welfare and take direct responsibility for their care is a positive and rewarding experience. School attendance is good and young people are making progress within school and also through the range of activities

p.9

Requires improvement

that staff provide out of school hours. Good support is also being given to those young people who are due to leave school and start a college placement.

p.9

Requires improvement

There continue to be shortfalls in how well young people are helped and protected. There are no serious shortfalls, but the management team must demonstrate consistent improvement in these areas as some have been a repeated feature of recent inspections. Safeguarding referrals are not consistently made in a formal or timely way. The procedures in place do not give clear instructions to staff in terms of expectations upon them. This has meant that on one occasion recently, there was a lack of challenge from managers resulting in staff starting to investigate a safeguarding issue themselves, when their role is to make a referral to those charged with the powers to investigate safeguarding concerns. This resulted in one young person being placed in a potential situation of harm. The safeguarding policy in place for staff is not robust enough to ensure that staff are clear about what steps they should take or not take if they are concerned about a child. The policy requires

p.9

Requires improvement

updating and further work with staff around this issue is required. While the number of physical restraints have reduced significantly, which is very positive, when they do occur it remains questionable as to whether they are the ‘last resort’ or whether staff need to be more effective in their de-escalation techniques. There is better monitoring of these incidents, although not all records include details of staff and young people debriefs. Also, what is not apparent is how this monitoring is improving practice to further reduce physical restraints occurring. For example, following an incident on 5 May 2016 when a young person was physically ‘guided’ back to his bedroom, the responsible individual’s review stated that the ‘young person should not be directed to their bedroom unless they request this and instead staff should explore with the young person what is wrong. Their bedroom should not be somewhere we take them to fill with negative

p.9

Requires improvement

feelings.’ However, on 27 June 2016 the same senior member of staff guided the same young person to their bedroom. In respect of going missing from care incidents, while incidents are low, there is not a consistent approach to ensuring that young people have access to an independent return home interview. The managers have failed to escalate and resolve this issue with the local authority. The arrangements in place for safer recruitment are not consistently robust. There is a reliance on a computer system, which results in poor quality and missing references and gaps in employment not being explored. There is a lack of management oversight or accountability in this area of practice and as a result recruitment is not consistently safe. Managers and staff have reviewed their approach to the use of sanctions. A more restorative approach is taken, discussing with young people what would be a natural consequence and what additional measures can be put in place to help

p.10

Requires improvement

young people to manage their emotional reaction to events.

p.10

Requires improvement

Leadership and management have been very fragmented since the interim inspection in February 2016. The registered manager left at the beginning of April 2016. While satisfactory interim arrangements have been put in place, these have been disrupted due to a combination of factors. The lack of clear leadership arrangements in the absence of a registered manager has led confusion in roles and responsibilities and lines of accountability. This has contributed to inconsistent practices and a sense of confusion was apparent throughout the inspection. For example, information was given to inspectors and then changed in relation to what had actually happened following a recent safeguarding concern being identified. While there has been some positive progress, this has not been consistent or at a good rate. Nor has the impact of action taken by leaders and managers been consistently effective. For example, it was not clear what action was taken by

p.10

Requires improvement

managers following a recent safeguarding issue which involved the supply of e- cigarettes to a young person. While the matter was formally referred to the local authority safeguarding officer, it was passed back to the home to investigate and respond to internally. The inspectors were told that a memo had been sent to staff, but when asked some staff could not recall it and could not produce a copy for the inspectors. At the time of the inspection, a new allegation of the same nature had just been received. There are currently 20 care staff, including three senior staff. Of these, eight have a level 3 diploma and six are currently part way through it, including two members of staff who have exceeded the requirement that they should have the qualification within two years of working in residential childcare. Staff morale is improving and new staff are settling and becoming more skilled. Some staff have taken on key

p.10

Requires improvement

working roles and some young people made positive comments about them. One young person said that their new key worker was ‘great’. However, there is a need for managers and leaders to be more robust when signing off staff on completion of their probation. For example, areas of poor practice should be carefully considered alongside the need to provide further training. In appointing senior staff, careful consideration needs to be given to the experience, qualifications and skills required to fully undertake such duties. The independent visitor reports are thorough and child centred. They provide a robust monitoring of the service. They identify where good practice exists and also some very pertinent shortfalls. It is disappointing that the leaders and managers do not always take timely action to respond to these shortfalls. Many are repeated from one month to the next and many are themes that have repeatedly been

p.11

Requires improvement

identified during Ofsted inspections. For example, these include the appropriateness of physical interventions, the reporting of safeguarding incidents, the quality of staff handovers and the quality of report writing.

p.11

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’.

p.12

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

p.12

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.

p.12

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

p.13

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 .

p.13

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,

p.14

Information about this inspection

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

p.14

Information about this inspection

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

p.14

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

p.14