Children's home run by Tumblewood Project Limited in Wiltshire

The children's home provision is inadequate because:

 Young people frequently go missing from home. When they go missing, they are not offered independent return home interviews, in line with statutory guidance. Managers do not have a clear understanding as to why young people go missing so that they can prevent future occurrences.  Since the previous interim inspection, there have been two occasions where, in the middle of an absconding episode, highly vulnerable young people have been left alone in the community by staff.  Staff frequently use restraint to manage young people’s behaviour. Staff also use unauthorised holds and hold young people on the ground. Medical assistance is not always offered, even when a young person said she was hurt.  The head of care did not adhere to safeguarding procedures in relation to one incident, leaving young people at potential risk.  Staff moved one young person to a different house within the home without her social worker’s permission and knowledge, due to bullying behaviours

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The children's home provision is inadequate because:

from other young people.  Not all young people’s complaints are acknowledged and dealt with by managers.  Staff continue to call the police to manage young people’s behaviour. This has led to a young person being arrested and charged.  The decision-making process regarding referrals for new residents is not robust. Ofsted has not been notified of all significant events.  Five requirements from the previous interim inspection have not been met.

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The children's home strengths

 Some young people have made good progress emotionally and enjoy a variety of community activities. They engage in therapeutic support and are encouraged to express their feelings creatively.  Families are welcomed into the home. The home has good multi-agency relationships with professionals. Social workers and parents report that they see positive changes in their young people and praise the home.  An independent advocate visits the home weekly and young people find this valuable.  Recruitment processes are robust and staff have thorough checks before working with young people. .

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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

*12: The protection of children standard

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Requirement Due date

In order to meet the protection of children standard and ensure children are protected from harm and enabled to keep themselves safe, the registered person must ensure that staff—

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Requirement Due date

(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

(vi) take effective action whenever there is a serious concern about a child’s welfare.

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Requirement Due date

Ensure that young people are not left alone in the community when they abscond and are offered independent return home interviews when they return. *15/08/2016

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Requirement Due date

In order to meet the protection of children standard, the registered person must ensure that children are protected from harm and enabled to keep themselves safe. In particular, the registered manager must ensure that staff—

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Requirement Due date

(ii) help each child to understand how to keep safe; (iii) have the skills to identify and act upon signs that a child is at risk of harm; (iv) manage relationships between children to prevent them from harming each other; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; 15/082016 (vi) effective action whenever there is a serious concern about a child’s welfare;

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Requirement Due date

(vii) are familiar with, and act in accordance with, the home’s child protection policies.

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Requirement Due date

Ensure that safeguarding procedures are followed.

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Requirement Due date

13: The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, the registered person must—

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Requirement Due date

(1) enable, inspire and lead a culture in relation to the children’s home that—

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Requirement Due date

(a) helps children aspire to fulfil their potential; and

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Requirement Due date

(2) (a) lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes set out in the home’s statement of purpose;

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Requirement Due date

(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;

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Requirement Due date

(h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home  Ensure that staff are regularly supervised to ensure staff’s care of young people meets their needs and ensures their safety.  Ensure that staff investigations are fully completed and have clear recommendations. 15/08/2016

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Requirement Due date

In order to meet the care planning standard, the registered manager must ensure that young people—

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Requirement Due date

(a) receive effectively planned care in or through the children’s home; and (b) have a positive experience of arriving at or moving on from 15/08/2016 the home. (2)(b)that arrangements are in place to— (i) ensure the effective induction of each child into the home; (ii) manage and review the placement of each child in the home; and (iii) plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements agreed with the child’s placing authority.

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Requirement Due date

*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. (Regulation 20 (1)(a)(b)(c)(2)) *15/08/2016

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Requirement Due date

The registered provider must appoint a person to manage the children’s home if— (a) there is no registered manager in respect of the home; and (b) the registered provider— (i) is an organisation or a partnership ; (Regulation 27(1)(a)(b)(i)) 15/08/2016

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Requirement Due date

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 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 15/08/2016 (viii) 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

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Requirement Due date

person to do so (‘the authorised person’)― (i) has spoken to the user about the measure; (ii) has signed the record to confirm it is accurate; (c) 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. (Regulation 35(3)(a)(i-viii)(b)(i)(ii)(c))

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Requirement Due date

The registered person must― establish a procedure for considering complaints made by or on behalf of children. (Regulation 39 (1))

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Requirement Due date

Ensure that the complaints procedure is followed when young people make complaints. 15/08/2016

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if—

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Requirement Due date

a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation;

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Requirement Due date

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious;

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Requirement Due date

there is an allegation of abuse against the home or a person working there;

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Requirement Due date

a child protection enquiry involving a child — is instigated; or concludes (in which case, the notification must include the outcome of the child protection enquiry); or there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4) (a-e)) 15/08/2016

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Requirement Due date

The independent person must provide a copy of the independent person's report to― the HMCI. (Regulation 44(7)(a)) 15/08/2016

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Requirement Due date

* These requirements are subject to statutory requirement notice.

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Information about this children's home

This children’s home operates as a therapeutic community for a maximum of 15 girls with emotional and behavioural difficulties. The community is run by a private organisation that offers residential care alongside therapeutic intervention including counselling, play therapy and psychiatric support. Children and young people attend the on-site school.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

22/03/2016 Interim Declined in effectiveness

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Recent inspection history

19/02/2015 Interim Improved effectiveness

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Inadequate

This home is made up of four houses, although one of these houses is closed, due to significant damage. Of the 10 young people who are resident, some have had to move houses for reasons such as bullying or incompatibility. One young person said that she has lived in all four houses and another young person recently moved houses, against the wishes of her social worker. Moving around the houses in response to crises does not help young people feel settled and secure.

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Inadequate

Managers issued placing local authorities a notice to leave for the last five young people who moved from the home. None of the young people, except one, had a positive or planned transition in line with the aims of their care plan. Managers gave notice because they were unable to keep the young people safe. The Registered individuals have commissioned an independent review of the ending of one of these placements given that the young person had been prepared for a planned move at the time of the previous inspection.

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Inadequate

Some young people have raised complaints which have not been dealt with. The complaints procedure has not been followed and managers have not acted on their concerns. When complaints are dealt with appropriately, the head of care has sent outcome letters to the young people. These letters lack sensitivity and are not in tune with the home’s therapeutic ethos. A requirement was made regarding complaints at the previous full inspection.

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Inadequate

Staff struggle to manage young people in distress. Managers have reviewed procedures regarding police involvement with the home in line with a requirement made at the previous inspection. However, this requirement remains unmet as staff continue to contact the police to help manage young people’s behaviour. This action has led to the unnecessary arrest and charging of young people, which further increases their vulnerability.

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Inadequate

The registered individuals ensure that the building is regularly maintained. However, fire evacuation signs continue to be displayed throughout the houses, and these detract from the overall homely appearance and newly refurbished areas of the home. Young people report that they now have access to food cupboards that were previously locked. Individual risk assessments are now completed for all children. The use of door alarms and sensors are only used when risk assessments dictate. One young person still had an activated floor alarm outside her bedroom, despite this not being part of her risk assessment. The registered individuals stated that this was a mistake and agreed to deactivate it during the inspection. Community meetings are held daily and attended by young people and, on some occasions, led by young people. This involvement helps them to feel empowered and increases their confidence. The registered individuals employ an advocate to

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Inadequate

visit the home on a weekly basis to meet with young people and promote their views. The use of the advocate resulted in one young person receiving horse riding lessons.

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Inadequate

Young people say that they like it in the home. One young person has made progress in school, and enjoys football and drama clubs in the community. Another young person with complex needs has made good progress and is now able to enjoy work experience at the stables twice a week. The registered individuals and staff work creatively to help young people express their views and feelings. Some young people who have been resident in the home stay in contact with the registered individuals. This includes one young person who left recently and an adult who left over 30 years ago.

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Inadequate

Young people’s families are welcomed into the home and staff see it as an important part of their role to support young people’s relationship with their families. Parents are pleased with the progress that young people have made. One parent said, ‘they support our daughter well. They are brilliant’.

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Inadequate

Young people frequently go missing from the home. Since the previous full inspection, young people have absconded 96 times. Most young people have absconded from the home and at times in groups. A requirement was made at the previous interim inspection because young people were not offered independent return home interviews in line with statutory guidance. At the time of this inspection, young people were still not offered such interviews. Therefore, they do not have an opportunity to privately explore their reasons for running away with someone who does not work in the home. Staff follow young people when they leave the home without permission in accordance with the home’s missing procedures. However, on two separate occasions young people have been left by staff to find their own way home in the middle of a missing episode. One young person, who had lived in the home for seven months, was told for the first time that she would be moving placement the

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Inadequate

following day. The young person absconded and the staff member followed for about an hour. The staff member then left the young person in a shop alone and returned to the home at the request of the deputy manager, due to lack of senior staff cover. On another occasion, two other young people were left alone in the community by staff. The young people were in a distressed state and were left because staff could not manage their distress. One of the young people, to whom staff are contracted to provide one-to-one support because of their level of vulnerability, was left to make her own way home. The other young person was brought home by the police. Therefore, the young people suffered emotional harm and were placed at unacceptable risk due to serious weaknesses in practice and decision-making.

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Inadequate

Staff frequently use restraint to manage the behaviour of young people. Records of restraint do not clearly explain what behaviour management and de-escalation strategies were used by staff to avoid the need to restrain a young person. Since the previous inspection, there has been a 40% increase in the number of restraints. The home’s records indicate that negative group dynamics between young people account for 35% of restraints. Staff restrain young people using unauthorised holds. They do not always release a young person when they fall to the ground during a restraint, and so the young person is then held on the ground by staff. Some holds continue for an excessive amount of time. On one occasion, a member of staff held a young person’s nose in order to make them stop biting another member of staff. Other young people witness these restraints and sometimes become involved, either to protect their peers or a favourite member of

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Inadequate

staff. Young people are not always offered the opportunity of a medical assessment following a restraint. On one occasion, this was not offered to a young person even though she said she was hurt. Records of restraint are not evaluated for patterns or trends. Managers do not challenge members of staff following the use of a non-accredited hold, or question why medical assistance was not offered to a young person. The head of care did not adhere to safeguarding procedures during a recent incident. In addition to not notifying Ofsted, she did not consult with one of the young people’s social workers; interviews were not recorded and the incident closed without proper investigation or consultation with the relevant agencies. As a result, young people were potentially placed at risk. Following a monitoring visit to the home, a meeting was held on 14 April 2016 between Ofsted inspectors and the registered individuals. The compliance notice

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Inadequate

issued following the previous interim inspection was lifted at this meeting. The registered individuals and manager have worked hard to ensure that all staff know what to do to keep young people safe if young people lock themselves in a room. Transparent discussions have taken place with young people too, so that they understand how to keep themselves safe. No further incidents of this nature have occurred.

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Inadequate

A significant proportion of the staff team has recently started at the home in a move to reduce the number of agency staff being used. The home has dedicated human resources personnel; recruitment procedures are robust and ensure that new staff are thoroughly vetted.

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Inadequate

The process for new admissions does not evidence clear decision-making on how the home will meet the needs of newly arriving young people. The impact upon those young people already resident is not sufficiently considered either. For a recent admission, the head of care did not review the paperwork in depth or recognise information gaps, which were identified by the inspectors. The head of care had not learned from a previous mistake in decision-making when a young person was admitted without the full information. When further information came to light, the head of care was clear that she would not have agreed to the referral as the home could not meet the young person’s needs. The situation culminated in the young person being moved following significant incidents. The head of care agreed to bring the most recent admission forward, despite young people already resident only being informed the day before of the new arrival. Fortunately, staff

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Inadequate

were skilled in addressing young people’s anxieties and supported them to welcome the new person.

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Inadequate

Managers and leaders continue to fail to notify Ofsted of all significant incidents, including an allegation against staff, police involvement in the home and a child protection enquiry. A third consecutive requirement is now made in relation to the notification of serious events.

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Inadequate

One allegation concerning a member of staff was not notified to Ofsted and the manager did not produce a robust investigation report with clear recommendations. Corresponding supervision records demonstrate infrequent supervision and lack of challenge to poor practice. Targets are not set and, as a result, managers do not effectively manage performance, potentially placing young people at risk. The registered individuals report that that the home’s independent visitor continues to provide external scrutiny to the home and produces monthly reports. Their value in supporting managers to improve the home is unknown as Ofsted has not had sight of these reports since April 2016. This is another unmet requirement.

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Inadequate

The home has operated without a registered manager for over eight months. The responsible individuals have recently appointed an experienced interim manager, with a view to making this a permanent appointment. The registered individuals have a ‘hands on’ approach and are caring, committed and knowledgeable. They have embarked on a full audit of the home. They recognise that the current recording systems inhibit management oversight and monitoring. However, the registered individuals are not at the stage to clearly identify all necessary areas for improvement within an action plan.

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Inadequate

The registered individuals, head of care and staff have positive relationships with other agencies and facilitate a multi-agency approach to supporting young people. Social workers report that they are regularly sent information about young people and one social worker described the home as ‘fantastic’.

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Inadequate

A number of qualified and skilled staff have been appointed since the interim inspection, which has reduced the shortages in staffing. Staff say they feel supported by the new interim manager. One staff member said ‘the new manager is consistent and does not undermine staff decisions’.

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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 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 that 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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