Children's home in Gloucester

Inspector Elaine Allison and Michelle Edge

At the full inspection on 25 and 26 May 2016, the home was judged inadequate. A large number of failings were identified including:

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Inspector Elaine Allison and Michelle Edge

 The young person’s needs have not been met across aspects of her welfare, particularly her safety, her health and her physical and emotional well-being needs.  There was a lack of effective action taken by managers and staff in response to serious safeguarding concerns, leaving the young person at risk of harm.  The practices of recording and administration of medication were unsafe and dangerous.  Risks to the young person were not identified, understood, or managed.  Health plans in place for the young person were not followed.  Monitoring of the home was ineffective, as potential risks were not identified and addressed. Internal monitoring of the home also failed to identify weaknesses in practice, such as those found by the inspectors.  Three compliance notices were issued, under Regulations 12, 13 and 23.

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Inspector Elaine Allison and Michelle Edge

In order to evaluate progress made by the home in addressing the notices, an unannounced monitoring visit took place on 27 and 28 June 2016. The purpose of this monitoring visit was to assess the progress made by the home regarding the three compliance notices issued under section 22A of the Care Standards Act 2000.

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Inspector Elaine Allison and Michelle Edge

During the monitoring visit, the inspectors found that young people are not adequately protected from harm. It was evident that there continue to be serious shortfalls.

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Inspector Elaine Allison and Michelle Edge

Following an incident that had taken place on 15 June 2016, staff failed to take appropriate action or adhere to their own policies and procedures. During the incident, it was recorded that a young person’s behaviour escalated and two male staff, including the new interim manager and a registered manager from one of the provider’s other homes, restrained her. The recording on the incident sheet stated that the young person was ‘physically removed from the office then held in her bedroom, for a further 2 minutes’. During the incident, the young person was shouting ‘rape’. There was no further information contained within the document or any evidence of what further action had been taken, including discussions with other professionals involved. Restraint records were not completed and there were no records detailing the holds used or any evidence of a full debrief with the young person involved. Staff failed to update all relevant documentation, including daily

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Inspector Elaine Allison and Michelle Edge

care plans and a risk assessment around all potential risks factors, including lone working. This placed both the young person and staff at potential risk. It is also in breach of the home’s own safeguarding policies and procedures, which stipulate that any safeguarding concerns need to be raised with the appropriate safeguarding professionals and all documentation needs to be updated to inform practice. The lack of action by managers concerning this incident fails to ensure that young people are kept safe and potentially places them at risk.

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Inspector Elaine Allison and Michelle Edge

There had been a previous incident on 1 June 2016, when staff made the decision to remove the young person’s phone due to concerns about her safety. However, the manager had made the decision to return the phone and charger to the young person, with no further indication of why the decision was overturned. Both the young person’s care plan and risk assessments stated that the young person should have ‘no unsupervised access to a mobile phone, due to the high risks she places herself at’. Staff spoken to during the inspection stated that, ‘the paperwork is confusing and the documents all say something different’. The lack of clear risk identification and inconsistencies in both care and practice fail to ensure the safety of the young person and potentially place her at risk.

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Inspector Elaine Allison and Michelle Edge

Individual plans, including behaviour management plans, risk assessments and placement plans, do not identify and support the changing needs of the young person. Although the documents were under review, they still failed to include all new and current risks. The information contained within them continues to be conflicting and does not clearly identify the young person’s needs and appropriate strategies to manage them. The lack of narrative on the assessments and the continued use of a ‘tick box’ approach mean that staff do not have the clarity or information needed to keep the young person safe. For example, the risk assessment for child sexual exploitation indicated that the risk is medium, and the risk assessment for missing from care indicates that the risk is low. This was despite the local authority care plan and placement plan clearly highlighting the significantly high risks that the young person was known to be at from both child

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Inspector Elaine Allison and Michelle Edge

sexual exploitation and missing from care. During discussions with both the interim manager and operations manager, they both agreed that the information recorded was not accurate and that the young person was ‘high risk’. The continued confusion within working documents places the young person at risk of harm and does not ensure that all staff have the correct information to provide appropriate and safe levels of care to the young person.

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Inspector Elaine Allison and Michelle Edge

Further concerns were highlighted around the amount of agreed ‘free time in the community’ the young person has. The placement plan indicated that the young person should have ‘no free time in the community’. However, the young person was attending the horse riding stables at a weekend, for up to four hours unsupervised. She did not have access to a phone while there and had no money, The interim manager indicated that he had carried out a risk assessment at the stables and had obtained phone numbers of staff working there. However, a staff member from the home commented that, ‘she is dropped off and then checked on by ringing the stables every two hours. Sometimes they do not answer, but we keep trying. It is difficult though as they might not actually be on the site when we call them.’ This lack of appropriate supervision places the young person at risk of harm and does not keep her safe.

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Inspector Elaine Allison and Michelle Edge

During the inspection, it was evident that during a recent team meeting safeguarding roles and responsibilities were discussed. However, staff had not had the opportunity to attend any training to update their knowledge base around child sexual exploitation. This is scheduled for July 2016. There continues to be a lack of action with regard to safeguarding concerns. These include the inaction to address concerns with regard to the unrecorded restraint and the failure to report all required incidents to other safeguarding professionals.

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Inspector Elaine Allison and Michelle Edge

Inspectors found that the provider has made some progress in the safer administration of medication. They have trained staff, and returned the ‘stockpiled’ medication to the pharmacist. However, medication continues to be managed unsafely and fails to comply with the provider’s own policy and procedures. For example, the controlled drugs register indicated that on 13 and 17 June 2016 the young person refused to take medication. However, the records do not indicate where the drugs were then disposed of. Furthermore, the daily logbook dated 6 June 2016 stated, ‘YP broke the tablet into quarters and took 75mg spat out 25mg’. Staff in this instance did not know exactly how much or how little of the medication was actually taken by the young person. They were only able to estimate the actual dosage. This does not demonstrate the safe administration or recording of medication. This could potentially place the young person at risk of

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Inspector Elaine Allison and Michelle Edge

Inspectors found that the registered manager remains suspended from her post at the home. A new interim manager has been in place for 14 days. However, neither he nor the operations manager had seen the compliance notices issued. Therefore, they were unable to address the steps required to meet the notices.

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Inspector Elaine Allison and Michelle Edge

The lack of management oversight continues to have an impact on the day-to-day running of the home. For example, the lack of an up-to-date training matrix, staff’s failure to follow safeguarding procedures and the continued errors in the recording and administration of medication. This lack of rigour has not helped the home to sufficiently protect the young person and maintain good enough standards of care. More robust systems are needed to ensure that the safety and well-being of the young person are promoted at all times.

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Inspector Elaine Allison and Michelle Edge

In Ofsted’s view, there has been a continued failure to meet the steps as set out in the compliance notices, although it is acknowledged that some attempts have been made to comply with the requirements from the full inspection. Ofsted is not satisfied that the necessary improvements have been made to demonstrate that young people are safe and protected while living in the home.

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Inspector Elaine Allison and Michelle Edge

As a result, the previous three compliance notices under regulations 12, 13 and 23 will be re-issued. Ofsted was not satisfied that the steps under each notice have been sufficiently met, and there continue to be ongoing safeguarding concerns and staff practices that are of concern. These notices are the subject of further monitoring by Ofsted.

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Information about this children’s home

This is a privately run children’s home registered for three young people with emotional and behavioural difficulties

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Statutory requirements

This section sets out the actions that 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

In order to meet the health and well-being standard, the registered person must ensure that:

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Requirement Due date

(1)(a) the health and well-being needs of children are met (b) children receive advice, services and support in relation to their health and well-being (c) children are helped to lead healthy lifestyles. (2) In particular, the standard in paragraph (1) requires the registered person to ensure: (a) that staff help each child to: (i) achieve the health and well-being outcomes that are recorded in the child’s relevant plans (ii) understand the child’s health and well-being needs and the options that are available in relation to the child’s health and well- being, in a way that is appropriate to the child’s age and understanding. Regulation 10 (1)(a)(b)(c) (2)(a)(i)(ii) 8 August 2016

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Requirement Due date

In order to meet the positive relationship standard, the registered person must ensure that: 8 August 2016 (1) children are helped to develop, and to benefit from, relationships based on: (a) mutual respect and trust (b) an understanding about acceptable behaviour (c) positive responses to other children and adults.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to ensure: (a) that staff: (i) meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans (ii) help each child to develop socially aware behaviour (iii) encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding (v) communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding (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 relationships with children (x) are provided with supervision and support to enable them to understand and manage their own feelings and responses.

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Requirement Due date

Regulation 11 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(v)(ix)(x)

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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 the registered person must ensure that:

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Requirement Due date

(1) 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: (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 8 August 2016 the child (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person (vi) take effective action whenever there is a serious concern about a child’s welfare (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 (e) that the effectiveness of the home’s child protection policies is monitored regularly.

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Requirement Due date

Regulation 12 (1) (2)(a)(i)(v)(vi)(b)(e)

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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 ensure that:

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Requirement Due date

(1) 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 (b) promotes their welfare.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to: (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 (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child (f) understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

Regulation 13 (1)(a)(b) (2)(a)(c)(f)(h) 8 August 2016 23: Medicines *

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. In particular, the registered person must ensure that a record is kept of the administration of medicine to each child. (Regulation 23 (1) (2)(c)) 8 August 2016

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Requirement Due date

35: Behaviour management policies and records

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Requirement Due date

The registered person must prepare and implement a policy (‘the behaviour management policy’) which sets out how appropriate behaviour is to be promoted in the children’s home; and the measures of control, discipline and restraint which may be used in relation to children in the home. The registered person must keep the behaviour management policy under review and, where appropriate, revise it. (Regulation 35 (1)(a)(b) (2)) 8 August 2016

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Requirement Due date

The registered person must maintain records (‘case records’) for each child, which include the information and documents listed in Schedule 3 in relation to each child: are kept up to date and are signed and dated by the author of each entry. (Regulation 36 (1)(a)(b)(c)) 8 August 2016

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if: (a) a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation (b) an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious (c) there is an allegation of abuse against the home or a person working there (d) a child protection enquiry involving a child: (i) is instigated (ii) concludes (in which case, the notification must include the outcome of the child protection enquiry) 8 August 2016 (e) there is any other incident relating to a child which the registered person considers to be serious.

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Requirement Due date

(5) A notification made under this regulation: (a) must include details of: (i) the matter (ii) the other persons, bodies or organisations (if any) who or which have been notified (iii) any actions taken by the registered person as a result of the matter (b) must be made or confirmed in writing.

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Requirement Due date

Regulation 40 (4)(a)(b)(c)(d)(i)(ii)(e) (5)(a)(i)(ii)(iii)(b)

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Requirement Due date

44: Independent person: visits and reports

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Requirement Due date

The independent person must produce a report about a visit (‘the independent person’s report’) which sets out, in particular, the independent person’s opinion as to whether children are effectively safeguarded and the conduct of the home promotes children’s well-being. (Regulation 44 (4)(a)(b)) 8 August 2016

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Requirement Due date

* These requirements are subject to statutory requirement notice.

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Information about this inspection

The purpose of this visit was to monitor the action taken and the progress made by the children’s home since its last Ofsted inspection. This inspection was carried out under the Care Standards Act 2000. in 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 this guidance, please telephone 0300 123 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, work- based learning and skills training, adult and community learning, and education and training in prisons and other secure establishments. It inspects services for children looked after 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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