Children's home run by Cambian Autism Services Limited in Hammersmith and Fulham

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 and their care and experiences are poor.

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The children's home provision is inadequate because:

 The child protection policy is not effectively followed. Staff fail to report unknown causes of bruising to the designated safeguarding lead. The manager did not follow the system to monitor the records of these incidents effectively.  Staff do not demonstrate that they have a good understanding of children and young people’s needs in their response to managing behaviour. Some responses from staff escalate the situation. This results in some children and young people being held and/or having a sanction. Not all staff receive behaviour management training before they start working with children and young people. The manager’s analysis of incidents lacks the level of evaluation required to identity learning from weaknesses.  Not all staff make comprehensive records of incidents that take place. A number of records do not provide sufficient detail to explain the reasons why children were restrained or moved.

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The children's home provision is inadequate because:

 The manager does not routinely identify injuries that children and young people sustain during incidents when physical restraint is used as a safeguarding concern. Discussions with children and young people after incidents of physical restraint are poor.  The use of sanctions often restricts children and young people from going to social events in the community. Sanctions do not link to the behaviour displayed and it is not evident that they are an effective behaviour management strategy in this home.  The manager failed to implement additional safeguards while a serious medication error was under investigation.  The recruitment of staff through an agency is not robust. The manager fails to recruit with rigour and have oversight of recruitment checks conducted by the agency. Agency staff who are used regularly do not have effective supervision.  Some internal documents such as placement plans and behaviour support

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The children's home provision is inadequate because:

plans are of poor quality. The needs of children and young people in these plans are not clear. Some plans do not include key information such as gender, identity, and culture.  Staff do not communicate effectively with children and young people, particularly those who use alternative communication methods.  Some of the individual homes do not provide a warm and nurturing environment. Use of locks and prohibited access into some of the kitchens restrict children and young people in their own home. Staff wearing uniforms, identification badges and keys compound this. Mealtimes are not always family style occasions and there are inconsistent reasons given by senior managers for the continued use of plastic cutlery and crockery.

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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

6: The quality and purpose of care standard

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In order to meet the quality and purpose of care standard, the registered person must— 2 (b)(iv) provide personalised care that meets each child's needs, as recorded in the child's relevant plans, taking account of the child's background;

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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; and (ii) enable each child to participate in the daily life of the home;

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in particular that placement plans and risk assessments reflect the current needs of children and young people.

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To ensure a homely rather than institutional feel is achieved, particular attention should be paid to the use of locked doors, signs for staff and a review should be undertaken of the use of clinical observation windows in bedroom doors. 29 July 2016

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In order to meet the positive relationships standard, children are helped to develop and benefit from relationships based on—

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1(b) an understanding about acceptable behaviour

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The responsible person must ensure that staff\\v

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2(a)(i) meet each child's behavioural and emotional needs, as set out in the child's relevant plans; (ix) understand how children's previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive 29 July 2016 relationships with children;

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Requirement Due date

in particular:  that behaviour support plans clearly identity the needs of children and young people;  that staff understand the reasons for behaviour displayed and use effective strategies to promote positive behaviour;  the use of sanctions is reviewed to eradicate a punitive approach.

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In order to meet the protection of children standard, the registered person must ensure that staff—

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2(a)(vi) take effective action whenever there is a serious concern about a child's welfare;

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in particular, that body maps indicating unknown causes for bruises or injuries following an incident are reported to the registered person in line with the child protection policy. 29 July 2016

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13: The leadership and management standard

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In order to meet the leadership and management standard, the registered person must ensure they inspire and lead a culture that—

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(f) understands 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;

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(h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home;

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in particular, critically analyse records and data to identify shortfalls and learning that will improve experiences for children and young people. 29 July 2016

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The following measures may not be used to discipline any child—

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any restriction, other than one imposed by a court or in accordance with regulation 22 (contact and access to communications), on a child’s communications with any persons 29 July 2016 listed in regulation 22(1) (contact and access to communications);

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The registered person must recruit staff using recruitment procedures that are designed to ensure children's safety.

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The requirements are that full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2.

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The registered persons must ensure that all employees—

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receive practice-related supervision by a person with appropriate experience;

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in particular, that agency staff receive supervision.

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35. Behaviour management policies and records

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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—

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details of the child's behaviour leading to the use of the measure;

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the date, time and location of the use of the measure;

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a description of the measure and its duration;

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details of any methods used or steps taken to avoid the need to use the measure;

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the name of the person who used the measure (‘the user’), and of any other person present when the measure was used; 29 July 2016 the effectiveness and any consequences of the use of the measure; and

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a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure;

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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’)—

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has spoken to the user about the measure; and

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has signed the record to confirm it is accurate; and

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within five 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.

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(Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c)

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In particular, that any incident resulting in physical intervention authorised or not is recorded as described in the above. Children and young people have access to an effective debrief following any restraint irrespective of their communication method.

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The registered person must notify HMCI and each other person without delay if— there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(c)(e)) 29 July 2016

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Information about this children's home

This national private organisation provides care and accommodation for up to 40 students with autistic spectrum disorder and learning difficulties. It operates as a residential special school which also provides accommodation for a number of students requiring 52 weeks’ boarding and is therefore registered as a children’s home.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

26 January 2016 Interim Improved effectiveness

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Recent inspection history

28 January 2015 Interim Improved effectiveness

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Inadequate

Placement plans do not readily identify the complex needs of children and young people. Important information that reflects the personalities and backgrounds of the children and young people is missing. Individual needs such as culture, language, gender and identity are overlooked by staff. This weakness impacts on the level of personalised care children receive. Staff do not routinely use the tools and methods they have to communicate effectively with children and young people. Signs, symbols and picture exchange tools are available but staff do not routinely use them. Inspectors observed spoken language being used too often with a young person when this is not their preferred way of communicating. Mealtimes observed in two of the homes are not positive social experiences for children and young people. These mealtimes did not support children and young people to develop independence skills. Some staff do not sit with children and

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Inadequate

young people during the mealtime. Instead, they walk around, eating food. Tables are not routinely set and children, young people and staff do not wash their hands as part of the mealtime routine. In some homes, children and young people are restricted from entering the kitchen. They cannot help themselves to drinks. Some staff provided children and young people their meals with plastic cutlery and crockery. The staff and children described this as ‘being on plastics’. The reason staff give for their use are inconsistent. Despite some work in the homes, the manager has not yet managed to achieve a homely environment. Restrictions are imposed on children and young people by locking doors such as to the kitchen, ensuite bathrooms, wardrobes containing personal belongings and the arts and crafts cupboards. Due to these restrictions, staff carry keys which are visible and give the impression of the home being

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Inadequate

institutional. Staff also wear a uniform that is more typical of a school environment rather than family style home. There is a lack of consideration about how this environment impacts on experiences of children and young people Children and young people get to experience a variety of activities that are fun. Examples of activities such as going to the park, piano lessons, bowling, swimming and discos are good examples of positive experiences for children and young people. However, not all children and young people have these opportunities regularly because weekday evenings are less structured and activities such as ‘going for a drive’ are less purposeful. The manager has recently employed a nurse who is implementing additional systems to improve the health care arrangements for children and young people. Robust links with external health professionals have a positive impact for children and young people. Emergency protocols for conditions such as epilepsy are clear

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Inadequate

for staff to follow. A parent said that their child is making good progress in this home. In some cases, parents mirror strategies used in the home. This is a good example of working jointly with families. ‘My journey’ scrapbooks show children and young people enjoying activities and smiling. Staff record videos of young people’s achievements and share these at reviews with families and professionals.

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Inadequate

Leaders and managers have failed to recognise some safeguarding concerns and to take effective action to protect children and young people. Records show that on some occasions, children and young people have sustained injuries following incidents and during physical restraint. Leaders and managers did not identify and report these injuries to external professionals as required. Staff are not always clear about their responsibilities to safeguard children and young people. Bruises with an unexplained cause seen on children and young people are recorded on body map records and are not referred as child protection concerns. Leaders and managers do not have an effective system to monitor these records. The manager did not take effective action to minimise risk following a serious medication error. On one occasion, the children and young people living in one home were not given their evening medication as required. Failure to identify the

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Inadequate

error quickly meant that staff did not seek medical advice about the impact the error could potentially have on the children. The manager reminded staff about the importance of administering medication but did not implement additional safeguards to reduce the risk of this happening again while the incident was investigated. Ofsted was not notified of this serious incident. Leaders and managers do not recognise that some records of physical intervention are missing or incomplete. These weaknesses have a significant negative impact and reduce the managers ability to recognise child protection concerns. Some behaviour management records fail to describe clearly the events leading up to and during a physical intervention. The system to monitor such failures is weak and lacks critical analysis. Not all staff receive training in behaviour management and de-escalation techniques before they start caring for children and young

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Inadequate

people. As a result, some staff do not fully understand the reasons for children and young people’s complex behaviour or have the skills to support them. Inspectors identified that some staff’s responses to children and young people caused incidents to escalate resulting in physical intervention or a sanction. Some children and young people who are physically restrained are not debriefed following an incident. Young people do not get the opportunity to explore their feelings about being physically restrained. Some staff do speak with children and young people but these discussions are often of a punitive nature. Some records do not show that staff have asked how children and young people feel or if they have concerns about their care. In addition, staff do not have strategies in place to consult on these matters with children and young people that do not communicate through speech. The strategies that staff use to promote positive behaviour are ineffective and

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Inadequate

punitive. Some staff are not clear about the purpose of star charts nor do they provide children and young people with rewards that are meaningful to them. Sanctions are used widely across the homes. They do not help children and young people to understand positive behaviour. Sanctions imposed include removal of activities that are important to children and young people such as going to the disco or swimming. Some children and young people have had the telephone removed from their individual home so that access to contacting people outside of the home is restricted. Some documents that detail the needs of children and young people in relation to risk are poor. Risk assessments and behaviour support plans do not always correlate with the placement plan. Some staff do not follow strategies described in behaviour support plans when caring for children and young people. Staff manage some behaviours in ways that are not detailed in behaviour

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Inadequate

support plans or placement plans. Leaders and managers do not check for themselves the suitability of the staff that they employ through an agency. Leaders and managers do not have oversight of the checks conducted by the agency. They rely on the agency to undertake the checks and do not verify that all of the required checks are undertaken. Leaders and managers do not have any oversight of the quality of references from previous employers for agency staff. The manager has good links with professionals whose role it is to safeguard children and young people. There are some good examples of working with the local authority designated officer to protect children and young people from harm. Staff understand the whistleblowing policy and use it appropriately. In these circumstances, the manager acts swiftly and staff against whom an allegation has been made are removed from the premises immediately, pending investigation.

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Inadequate

The manager has been in post since October 2015 and has previously been a registered manager of children’s homes for other organisations. She is making some positive changes to the quality of care such as improving the process to admit children and young people into the home. However, there are some significant weaknesses in how well children and young people are protected.

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Inadequate

The leaders’ and managers’ monitoring of the quality of care is inadequate. The level of analysis they apply to records and direct practice is failing to identify weaknesses in the care and experiences children and young people have in the home. The system to monitor records such as behaviour management records is not effective. In addition, the registered manager has no oversight of incidents and physical interventions that occur with resident children and young people during the school day.

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Inadequate

Staff supervision is regular for those staff on permanent contracts. When there has been a concern about a member of staff’s practice, this is not routinely followed up in supervision. Supervisors do not revisit actions from internal investigations relating to safeguarding concerns; this leaves questions surrounding performance management systems. Staff employed through an agency do not receive regular and effective supervision although they routinely work in the home.

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Inadequate

The manager recognises the difficulties in retaining staff and is working hard to preserve the workforce and provide children and young people with a stable team of carers. The manager’s review of current working patterns has initiated a consultation about how to improve the provision. This work shows effective management abilities. As a result, staffing is starting to be stabilise. High staffing ratios enable children and young people to take part in activities out in the community.

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Inadequate

A large number of staff are unqualified to the Level 3 Diploma For Residential Childcare (England) or equivalent. The registered manager has these members of staff training as a priority in the workforce development plan.

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Inadequate

Good links are forming with external agencies that support children and young people who live in the home. The manager is working with the local police to consult them when reviewing key documents such as the location risk assessment and ‘prevent duty’ risk assessment.

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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 children looked after children is safeguarded and promoted. Minimum requirements are in place. However, the children's home is not yet delivering good protection, help and care for children and young people. A children's home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

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What the inspection judgements mean

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

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Information about this inspection

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

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Information about this inspection

Homes (England) Regulations 2015 and 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

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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