Children's Home run by Bayis Sheli Limited in Hackney

Inadequate

There are serious and widespread failures that mean children’s welfare is not promoted or safeguarded.

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The children's home provision is inadequate because:

 The leaders and managers do not demonstrate that they safeguard children effectively.  Children do not always receive care in line with their care and health plan. This exposes them to risks.  The home is failing to meet a number of regulations. Some of these failures have a direct impact on the safety and welfare of children. The risk management processes that underpin the protection and safeguarding of children’s welfare are poor. These include the sharing of the environment with adults who do not work for the home and who have not been vetted.  Children receive care from staff members who have not been appropriately vetted to ensure that they are suitable for that role. This places children at risk.  Children receive care from staff members who have not had appropriate training. This affects the quality of care that children receive and leaves them vulnerable.  There are concerns regarding the practice in relation to behaviour

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The children's home provision is inadequate because:

management, the use of physical interventions and restriction of liberty. This places children at risk of harm.  The leaders and managers lack transparency in their communications with the placing authority and other professionals. Important information concerning children’s safety is not always shared. This affects the quality of working together and the ability of partner agencies to meaningfully contribute to the safeguarding of children.

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The children's home strengths

 The physical environment is spacious and well maintained. It is appropriately equipped to support and promote good care and independence for children with physical disabilities. A range of additional facilities, such as a hydrotherapy pool and sensory and soft-play rooms, provides children with an exciting and stimulating environment.  Children enjoy being engaged in various activities in the home and in the community.  Staff have very positive relationships with the children’s parents. The parents are highly satisfied with the service.

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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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needs are met

In meeting the quality standards, the registered person must, and must ensure that staff— (a) seek to involve each child’s placing authority effectively in the child’s care, in accordance with the child’s relevant plans; and (d) seek to develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate having regard to the range of needs of children for whom it is intended that the children’s home is to provide care and accommodation. In order to meet this quality standard, the registered person must share information more effectively with the placing authority and schools, especially when there are incidents potentially affecting children’s welfare. 14 August

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12 The protection of children standard

(1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe. In order to meet the protection of children standard the registered person must ensure— (b) that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm. In particular, that access to the home environment by persons not employed to work there is restricted. 14 August

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12 The protection of children standard

(1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— 14 August (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. In order to meet the protection of children standard, the registered person must review the risk assessment of the home’s hydrotherapy pool and complete the individual children’s risk assessments in relation to any child using these facilities. These risk assessments must take into account children’s needs and health conditions.

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13 The leadership and management standard

(1) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that— (a) helps children aspire to fulfil their potential; and (b) promotes their welfare. (2) In particular, the standard in paragraph (1) requires the registered person to— (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. In order to meet the leadership and management standard, the registered person must ensure monitoring of any significant incidents is robust and make necessary changes to improve the record keeping and the staff practice in the home. 14 August

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14 The care planning standard

(1) The care planning standard is that children— (a) receive effectively planned care in or through the children’s home. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (c) that each child’s relevant plans are followed. In order to meet this standard, the registered person must ensure that staff do not leave children unattended if their care plan requires them to be under constant staff supervision. 14 August

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16 Statement of purpose

The registered person must— keep the statement of purpose under review and, where appropriate, revise it. In particular, this requirement relates to having accurate information on the staff and their work experience being included in the statement of purpose. (Regulation 16 (3)(a)) 14 August

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16 Statement of purpose

(4) If a home has a website, the registered person must ensure that a copy of the statement of purpose is published on that website unless the registered person considers that such publication would prejudice the welfare of children in the home. (Regulation 16 (4)) 14 August

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20 Restraint and deprivation of liberty

(1) Restraint in relation to a child is only permitted for the purpose of preventing— (a) injury to any person (including the child); (b) serious damage to the property of any person (including the child); or (c) a child who is accommodated in a secure children’s home from absconding from the home. (2) Restraint in relation to a child must be necessary and proportionate. In particular, this requirement relates to stopping any practice of restricting children’s freedom of movement within the home’s environment, unless there is a court order that permits this. The registered person must clearly evidence the proportionality of the use of any other form of restraint. (Regulation 20 (1)(2)(3)) 14 August

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23 Medicines

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. This requirement relates in particular to improving the administration of medication practice in the home and setting up a recording system in a way that provides for robust monitoring. (Regulation 23 (1)) 14 August

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31 Staffing of children’s homes

The registered person must ensure that— (a) at all times, at least one person on duty at the home has a suitable first aid qualification. (Regulation 31 (2)(a)) 14 August

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32 Fitness of workers

The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety. (2) The registered person may only— (a) employ an individual to work at the children’s home; or (b) if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children, allow that individual to work at the home, if the individual satisfies the requirements in paragraph (3). (3) The requirements are that— (b) the individual has the appropriate experience, qualification and skills for the work that the individual is to perform. This requirement relates in particular to staff having appropriate training that enables them to develop skills that they need in order to look after children with complex care needs, including autism, epilepsy and other profound health and behavioural needs. (Regulation 32 (1)(3)(b))

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32 Fitness of workers *

The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety. (2) The registered person may only— (a) employ an individual to work at the children’s home; or (b) if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children, allow that individual to work at the home, if the individual satisfies the requirements in paragraph (3). (3) The requirements are that— (d) full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. (7) The registered person may permit an individual to start work at the home despite the fact that the requirement in paragraph 14 August (3)(d) has not been met if— (a) the registered person has taken all reasonable steps to obtain full information about each of the matters in Schedule 2 in respect

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32 Fitness of workers *

of the individual, but the enquiries in relation to any of the matters in paragraphs 3 to 6 of Schedule 2 are incomplete; (b) full and satisfactory information in respect of the individual has been obtained in relation to the matters in paragraphs 1 and 2 of Schedule 2; (c) the registered person considers that the circumstances are exceptional; and (d) the registered person ensures that the individual is appropriately supervised while carrying out the individual’s duties, pending receipt of any outstanding information on the matters in paragraphs 3 to 6 of Schedule 2, which is then considered satisfactory by the registered person. (Regulation 32 (2)(a)(b) (3)(d) (7)(a)(b)(c)(d))

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35 Behaviour management policies and records

The registered person must ensure that— (a) 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— (i) the name of the child; (ii) details of the child’s behaviour leading to the use of the measure; (iii) the date, time and location of the use of the measure; (iv) a description of the measure and its duration; (v) details of any methods used or steps taken to avoid the need to use the measure; (vi) the name of the person who used the measure (‘the user’), and of any other person present when the measure was used; (vii) the effectiveness and any consequences of the use of the measure; and (viii) a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure; (b) within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to

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35 Behaviour management policies and records

do so (‘the authorised person’)— (i) has spoken to the user about the measure; and (ii) has signed the record to confirm it is accurate; and 14 August (c) within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (4) Paragraph (3) does not apply in relation to restraint that is planned or provided for as a matter of routine in the child’s EHC plan or statement of special educational needs. (Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c) (4))

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37 Other records

Schedule 4 sets out the other information that the registered person must keep in relation to a children’s home. (2) The registered person must— (a) maintain in the home the records in Schedule 4. In particular, this relates to having a record in respect of each person working in the home in accordance with the regulation. (Regulation 37 (1) (2)(a) Schedule 4.2(a)(b)(c)(d)(e)(f)(g)) 14 August

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40 Notification of a serious event

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. (Regulation 40 (4)(e)) 14 August

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46 Review of premises

The registered person must review the appropriateness and suitability of the location of the premises used for the purposes of the children’s home at least once in each calendar year taking into account the requirement in Regulation 12 (2)(c) (the protection of children standard). (Regulation 46(1)) 14 August

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46 Review of premises

* This requirement is 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 recommendations:  Conduct a night fire drill to enhance fire safety at the home (‘Guide to the children's homes regulations including the quality standards’, page 15, paragraph 3.9).  Ensure that the home’s safeguarding and child protection policy refers to the current legislation and up-to-date good practice guidance (‘Guide to the children's homes regulations including the quality standards’, page 44, paragraph 9.22).  Ensure that whenever there is a lone worker on duty, a formal assessment of the implications to children’s care, including any likely risks and strategies to address those, is recorded (‘Guide to the children's homes regulations including the quality standards’, page 54, paragraph 10.18).

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Information about this children's home

A private limited company with a charitable status provides this service. The home may accommodate up to 16 children who may have a physical or learning disability. This includes up to eight children under short-break arrangements and up to eight children permanently.

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Recent inspection history

The home was registered in July 2015. This is its first full inspection.

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Inadequate

There are serious and widespread weaknesses in the home’s risk management process. This means that children are at risk of harm. Children do not always receive care that meets their needs. Poor recruitment processes result in children being looked after by staff who have not been robustly vetted. The staff team lacks knowledge and understanding of the children’s vulnerabilities and risks. Despite having clear written care plans, children do not always receive care that is in line with their plans. Examples include not being provided with safe levels of supervision at all times, or being mistakenly given extra medication. Children do not always receive effective support to manage their behaviours. On at least one occasion, staff members inappropriately restricted a child’s freedom of movement; for example, by leaving them alone in a room which they may not have been able to exit without guidance. This is a serious concern. Staff have not sought

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Inadequate

advice regarding strategies for engaging the child more effectively, from either the home’s managers or the social and educational professionals who know this child well. Medication practices have placed children at risk. On two occasions staff members administered in error an extra dose of medication to a child to treat epilepsy. Once discovered, emergency medical advice and treatment were sought and no adverse harm was caused. However, such poor practice raises the likelihood of children suffering the ill effects of an overdose. The environment is well maintained and appropriately equipped to support and promote good care and independence of children with physical disabilities. Sensory equipment, a soft-play room, a hydrotherapy pool, a large fish tank, a pet rabbit, a semi-grand piano, various toys and books provide children with an exciting and stimulating environment. Children do have positive experiences when living in the home or visiting for a

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Inadequate

short break. Numerous photographs show children with happy expressions on their faces. Children have been engaged in various activities in the home and in the community. The home has a very close, positive relationship with the local faith community. Staff are particularly good at meeting and promoting the cultural and faith needs of Orthodox Jewish children. Staff members provide strong, positive role models for children. Children have developed close and trusting relationships with staff. The cultural diversity of the staff team enables children to learn to appreciate and value people from different backgrounds. A headteacher commented how the child who currently lives permanently in the home settled very well. The child comes to school every day and engages in education well. A staff member from the home has recently attended the parents’ evening at the school, together with this child’s parents. The child receives good

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Inadequate

support to learn and make progress. Examples of the progress that he has made include brushing his teeth more willingly and more independently, being more respectful of other children’s personal space and being able to share his computer console with other children. His parents said that they were extremely happy with the care that their son received.

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Inadequate

The service is not safe. Poor practices across different aspects of promoting and safeguarding children’s welfare put children at high risk of harm. Poor staff recruitment practice exposes children to receiving care from adults who have not been appropriately vetted. This includes children having one-to-one support and receiving personal care. There are a number of instances in which the registered provider allowed people to work in the home without having completed appropriate recruitment checks. This places children at risk. Risk management is weak. A lack of written assessments and staff guidance increases the risks of poor and unsafe care. This means that staff fail to be guided by effective, comprehensive and consistently implemented strategies to keep children safe. In addition, there is no risk assessment in relation to the security of the home and access to children from outside and within the building itself.

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Inadequate

Although the premises are registered as a children’s home, they are not exclusively used as such. Another organisation that is not registered with Ofsted also uses the same premises. This organisation has many visiting clients. This increases the risks of unauthorised/unchecked persons having access to children. This is a serious shortfall. The home fails to fully consider the risks associated with allowing members of the public to use some of the children’s home’s facilities. This includes the hydrotherapy pool and sensory room. The large size of the building and the configuration of the space add to the risk. This is another contributing factor to the increased risks posed to children. The home’s policy on the use of the hydrotherapy pool states that ‘a suitably qualified lifeguard must remain on poolside at all times’. This is not followed in practice. The policy also describes completion of assessments for the use of the

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Inadequate

pool for each individual child. This has not been completed. Taking into account the children’s high and complex health needs, including having epileptic seizures and absences, the lack of a clear approach to managing their vulnerabilities increases the risk of harm. Behaviour management practice is poor. An incident in which two staff members locked themselves in a room with a child shows their inability to effectively engage children without resorting to restricting their freedom of movement. This is a worrying practice that disregards the basic care values of respecting and promoting children’s choice and freedom. No staff have had training on deprivation of liberty. Less than half of the staff team members have had training in behaviour management. The poor quality of the records relating to physical interventions means that the home does not demonstrate safe behaviour management practice. The records do

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Inadequate

not demonstrate that the use of physical interventions in the home is appropriate, proportionate and safe. For example, a daily observation record for one child states that he ‘became aggressive, pulling staff hair and hitting. He was restrained by one of the staff and was taken out to a different environment.’ This restraint has not been logged or referred to in any other document. No further information is available, such as the name of the member of staff who carried out the physical intervention, what hold was used, what was the duration of the restraint and if any injuries were sustained during the incident. Such poor record keeping undermines scrutiny and monitoring of restraint practice and stops any learning that would have come from those processes. Children have experienced poor care. Incidents have happened which raise concerns about the staff’s ability to effectively promote children’s welfare. On one

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Inadequate

occasion, a staff member left a highly vulnerable child unattended. While being on his own in the room, the child then accidentally locked himself in. This prolonged the time for the staff to be able to re-establish the direct one-to-one supervision that this child needs at all times. The home has not had a night-time fire drill. This means that staff have not had the opportunity to practice evacuation when children are woken up by an alarm at night. Daytime drills have been carried out. Other health and safety checks are regularly held. The premises are maintained to an appropriate standard. The home does not demonstrate that the risks created by lone working have been formally assessed. There is no clear plan with regards to managing those risks. Having only one waking night staff member contributes to the increased risks to the current child. This is particularly pertinent if the staff member is not first-aid

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Inadequate

trained. The home’s safeguarding and child protection policy refers to out-of-date legislation and guidance, such as the National Minimum Standards for Children’s Homes 2002. These standards were revoked more than a year ago. Judgement grade

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Inadequate

The registered persons have not been effective at providing a safe service to children. They do not fulfil the home’s statement of purpose or the conditions of registration. The statement of purpose is out of date and is not available on the company’s website. The home does not have a stable and sufficiently experienced staff team to effectively deliver its statement of purpose. The staff team is weak in a number of ways. The retention of staff is poor. In particular, changes to senior staff have had a negative impact on the team’s overall skills-base and consistency of good practice. The posts for a deputy manager and a senior worker are vacant. The only other senior worker has been absent from the home for five weeks. Many staff members are still completing their induction programme. They have not completed all of the mandatory training. The incidents that have happened show the staff’s lack of skills and understanding

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Inadequate

of safe care. The risks are compounded by the children’s complex disabilities, health needs and challenging behaviours, such as those associated with autistic spectrum disorder, epilepsy and other conditions. Not having a first aider on each shift in those circumstances raises the risks to children. Monitoring of the quality of the practice in the home is not thorough. The gaps in the provision of leadership through direct practice and poor record keeping have contributed to the registered persons’ poor oversight. On some occasions, the registered manager has signed off the records without questioning the inconsistency and poor quality of the information contained within them. The independent visitors with the quality assurance role have also omitted to identify the shortfalls during their regular monthly visits. A number of required records are not in place. In addition to the deficiencies already noted in this report, a register of staff is not kept. The arrangements that

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Inadequate

are in place for record keeping relating to medication do not support efficient monitoring. Managers fail to notify others of significant incidents when they occur. This includes the placing authority, other professional services and Ofsted. This undermines the ability of others to effectively monitor how well children are safeguarded in the home. The registered manager sought feedback from various local agencies in relation to the appropriateness and suitability of the location of the premises. However, the locality assessment has not been reviewed since May 2015, despite some additional feedback received since it had been initially completed. The registered manager is a qualified social worker with many years of experience of managing children’s homes. He has accepted all the shortfalls and expressed a strong commitment to put things right.

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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

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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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