Children's home in Lambeth

Inadequate

There are serious and widespread failures that mean that children and young people are not protected and their welfare is not promoted or safeguarded. Their care and experiences are poor and they are not making progress.

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The children's home provision is inadequate because:

 Young people in the home do not make progress. Their outcomes are poor in all areas. They do not reduce offending behaviour or engage in education. They are frequently missing from the home. Their experience of care is not positive.  When young people are admitted to the home, the provider does not assess the impact that new arrivals may have on young people who are already living there. They do not assess whether the needs of young people can be met.  A high number of temporary staff work at the home. This means that young people are unable to benefit from a consistent core team of primary carers. This significantly reduces the chances of young people building positive and meaningful relationships with the adults who care for them.  Staff recruitment is poor. Staff do not receive training in key areas of child protection. These shortfalls place young people at risk of harm.  There are insufficient staff on duty to provide the necessary care, support or

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The children's home provision is inadequate because:

supervision needed in order to keep young people safe.  The home’s lone-working risk assessment does not identify the risks associated with lone working. It fails to identify the staffing levels in the home that are necessary in order to safely meet the needs or promote the welfare of the young people living there.  Recording and information systems are not fit for purpose. The manager of the home is unable to access key information in order to have oversight of safeguarding practices. This means that young people are at risk of harm.  The arrangements for reviewing the quality of care in the home are ineffective. Management oversight and monitoring are poor. This means that poor practice goes unnoticed and unchecked.  Managers have failed to address a number of the requirements made at the previous inspection. This demonstrates a lack of capacity and/or commitment to comply with regulation.

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The children's home strengths

 The interim manager has amended the home’s recording format for local care planning. This demonstrates some improvement in care planning.  The interim manager of the home has improved the quality and frequency of team meetings.  The physical environment is clean and well presented.

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Statutory requirements

This section sets out the actions that must be taken so that the registered persons 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 persons must comply within the given timescales.

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Requirement Due date

13: 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 (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; (d) ensure that the home has sufficient staff to provide care for each child; (e) ensure that the home’s workforce provides continuity of care to each child. This is with particular reference to making sure that the use of temporary staff does not prevent young people from receiving consistent care from staff who are well known to them, and who

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Requirement Due date

know them well. This is also with reference to ensuring that there are sufficient staff on duty to meet the needs of each child. 30 September

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Requirement Due date

13: The leadership and management standard (2) In particular, the standard in paragraph (1) requires the registered person to (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 30 September of care provided in the home; (g) demonstrate that practice in the home is informed and improved by taking into account and acting on (ii) feedback on the experiences of children, including complaints received. This is with particular reference to ensuring that the manager of the home responds effectively to address complaints from young people and uses their feedback to improve practice in the home.

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Requirement Due date

13: The leadership and management standard

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child; This is with particular reference to ensuring that all staff have up to date training on child sexual exploitation, risks of radicalisation, fire safety and first aid. 30 September

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Requirement Due date

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 (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; (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; (c) that the premises used for the purposes of the home are located so that children are effectively safeguarded. This is with particular reference to ensuring the home is clear in relation to its approach to lone working and that lone working is demonstrably safe for staff and young people. This is also with reference to ensuring that the home’s location

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Requirement Due date

risk assessment demonstrates that key partners are consulted and 30 September that all risks have identified actions to reduce risk.

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Requirement Due date

12: The protection of children standard.

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Requirement Due date

12. —(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— (a) that staff— (vi) take effective action whenever there is a serious concern about a child’s welfare This is with particular reference to ensuring the availability of staff when young people are missing from the home 30 September

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Requirement Due date

12: The protection of children standard (2) In particular, the standard in paragraph (1) requires the registered person to ensure (e) that the effectiveness of the home’s child protection policies is monitored regularly. This is with particular reference to ensuring that the home’s procedures in relation to dealing with allegations against staff specify actions that the home will take to investigate and follow up allegations. The procedure should also be clear about how they take advice to inform decisions about whether to suspend staff while investigations are underway. 30 September

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Requirement Due date

45: Review of quality of care (1) The registered person must complete a review of the quality of care provided for children (‘a quality of care review’) at least once every six months. (2) In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating (a) the quality of care provided for children; (b) the feedback and opinions of children about the children’s home, its facilities and the quality of care they receive in it; and (c) any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for 30 September children. (3) After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (‘the quality of care

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Requirement Due date

review report’). (4) The registered person must (a) supply to HMCI a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed; and (b) make a copy of the quality of care review report available on request to a placing authority, if the placing authority is not the parent of a child accommodated in the home. (5) The system referred to in paragraph (2) must provide for ascertaining and considering the opinions of children, their parents, placing authorities and staff.

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Requirement Due date

32: Fitness of workers* (1) 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 (a) the individual is of integrity and good character; (b) the individual has the appropriate experience, qualification and skills for the work that the individual is to perform; (c) the individual is mentally and physically fit for the purposes of the work that the individual is to perform; and (d) full and satisfactory information is available in relation to the

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Requirement Due date

individual in respect of each of the matters in Schedule 2. This is with particular reference to the need for the provider to provide evidence of safe recruitment practice for all staff employed in the home, including the manager and any *30September temporary, bank or agency staff.

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Requirement Due date

14: The care planning standard (1) The care planning standard is that children (a) receive well-planned care from the home; and (b) have a positive experience of admission and transition processes. (2) In particular, the standard in paragraph (1) requires the registered person to ensure (a) that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care, as set out in the home’s statement of purpose In order to meet the care planning standard, the registered person should only accept placements for children when they are satisfied that the home can respond effectively to the child’s assessed needs as recorded in the child’s relevant plans and when they have fully considered the impact that the placement will have on the existing group of children. 30 September

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Requirement Due date

44: Independent person: visits and reports* (1) The registered person must ensure that an independent person visits the children’s home at least once each month. (2) When the independent person is carrying out a visit, the registered person must help the independent person (a) if they consent, to interview in private such of the children, their parents, relatives and persons working at the home as the independent person requires; and (b) to inspect the premises of the home and such of the home’s records (except for a child’s case records, unless the child and the child’s placing authority consent) as the independent person requires. (3) A visit by the independent person to the home may be unannounced. (4) 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 (a) children are effectively safeguarded; and

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Requirement Due date

*30 September (b) the conduct of the home promotes children’s well-being. (5) The independent person’s report may recommend actions that the registered person may take in relation to the home and timescales within which the registered person must consider whether or not to take those actions.

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Requirement Due date

37: Other records* (1) 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; (b) ensure that the records are kept up to date; and (c) retain the records for at least 15 years from the date of the last entry. In order to meet this requirement, the provider must ensure that records of all staff rosters are available. They must also ensure that information in respect of young people admitted to or discharged from, the home is accurate and up to date. *30 September

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Requirement Due date

5: Engaging with the wider network to ensure children’s 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; (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 standard, the provider must develop and maintain positive working relationships with the professional network. In order to do this, they must communicate effectively and demonstrate a willingness to learn from constructive feedback. 30 September

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Requirement Due date

24: Monitoring and surveillance 30 September (1) The registered person may only use devices for the monitoring or surveillance of children if (a) the monitoring or surveillance is for the purpose of safeguarding and promoting the welfare of the child concerned, or other children; (b) the child’s placing authority consents in writing to the monitoring or surveillance; (c) so far as reasonably practicable in the light of the child’s age and understanding, the child is informed in advance of the intention to do the monitoring or surveillance; and (d) the monitoring or surveillance is no more intrusive than necessary, having regard to the child’s need for privacy. This relates specifically to the use of mobile phones to make video recordings of young people without their knowledge or consent, or consent from the placing authority.

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Requirement Due date

25: Fire precautions (1) After consultation with the fire and rescue authority, the registered person must (c) make arrangements for persons working at the home to receive suitable training in fire prevention; and (d) ensure, by means of fire drills and practices at suitable intervals, that persons working at the home and, so far as reasonably practicable, children are aware of the procedure to be followed in case of fire. 30 September

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Requirement Due date

* These requirements are subject to 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 recommendation(s):

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Recommendations

 The registered person should have a workforce plan, which can fulfil the workforce-related requirements of regulation 16, schedule 1 (paragraphs 19 and 20). The plan should: ─ detail the necessary management and staffing structure, (including any staff commissioned to provide health and education), the experience and qualifications of staff currently working within the staffing structure and any further training required for those staff, to enable the delivery of the home’s statement of purpose; ─ detail the processes and agreed timescales for staff to achieve induction, probation and any core training (such as safeguarding and health and safety and mandatory qualifications); ─ detail the process for managing and improving poor performance; ─ detail the process and timescales for supervision of practice (see regulation 33(4)(b)) and keep appropriate records for staff in the home. The plan should be updated to include any new training and qualifications

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Recommendations

completed by staff while working at the home, and used to record the ongoing training and continuing professional development needs of staff, including the home’s manager (‘Guide to the children’s homes regulations including the quality standards (2015)’, page 53, paragraph 10.8).  Those with a leadership and/or management role should be visible and accessible to staff and able to deliver their leadership and/or management responsibilities. Any registered manager employed in the home should have sufficient capacity to ensure that the quality standards are met for each child in the home (‘Guide to the children’s homes regulation including the quality standards (2015)’, page 52, paragraph 10.7).

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Information about this children's home

This is a privately run home, registered to provide care and accommodation for up to four young people who have emotional and behavioural difficulties.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

09/02/2016 Interim Declined in effectiveness

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Recent inspection history

12/03/2015 Interim Sustained effectiveness

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Inadequate

A high number of temporary staff work at the home. The staff rota for the four- week period leading up to the inspection evidenced that 18 different staff members had provided care for young people. This means that young people are not able to form meaningful relationships with a consistent core group of carers. As a result, they have limited engagement with staff and do not make progress. The young people admitted to the home have complex needs. In many instances they are admitted with a history of absconding, challenging behaviour and offending behaviour. These behaviours do not reduce and, as a result, the outcomes for young people are predominantly poor. They are frequently missing from care. They continue to commit offences in the home and in the community. One young person was able to stay in the home for a short time and move on positively to another residential home, but all other recent admissions either

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Inadequate

moved on to secure accommodation as a result of offending behaviour, or are mostly missing from care. None of the young people engage with education. Because young people have limited engagement with staff, they do not benefit from healthy routines or lifestyles. Their experience of care in the home is poor. They are missing frequently, sometimes for long periods. When young people return to the home, staff are unable to enforce reasonable boundaries or help them to learn from incidents of poor behaviour. As a result, there are high numbers of incidents of challenging behaviour. These sometimes require police involvement and lead to young people being arrested and facing criminal charges for offences committed in the home. There are occasions when young people are admitted for short-term placements. The aim is to keep them safe, stabilise a crisis situation and help them to move on to a placement that can meet their long-term needs. However, with one exception,

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Inadequate

these young people continue to engage in risk-taking behaviour and do not receive nurturing care in a stable environment. As a consequence, they move on in an unplanned way and remain in crisis. When young people are admitted to the home, the provider fails to assess the impact of new admissions on young people already living there. They do not assess how they can manage the dynamics of the group of young people in their care. One placing social worker remarked that she was surprised that the home accepted a young person because his care plan suggested that he needed to be outside of the London area, due to frequent absconding, offending behaviour and gang affiliation. Managers admitted the young person and placed him with three other young people who had similar behaviours and who were not making any progress or keeping themselves safe. This means that young people are accepted into the home when it is clear that staff cannot keep them safe or help them to

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Inadequate

make progress. This is detrimental to their well-being and welfare and places them at risk of harm. The physical environment provided is well presented and clean. The young people’s bedrooms are suitably furnished and kept in good order.

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Inadequate

Young people are not safe. They lack consistency of care and do not develop nurturing or trusting relationships with staff. This means that they do not engage with staff interventions to help them to change harmful behaviours. Young people are frequently missing from the home and at risk in the community. When young people are missing from care, staff are inconsistent in their partnership work with the police and placing authorities. A missing person’s coordinator from the police reported that managers did not inform them that a young person had returned after being missing for four weeks. She noted that there was an arrest warrant issued for the young person, and that the home had a legal duty to inform the police of his return but did not do so. This is a significant shortfall and one that fails to keep young people safe or assist them to address their criminal behaviour. The staff in the home sometimes go out into the community to look for young

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Inadequate

people who are missing. When they do this, no staff are in the home. This means that if young people return home or telephone the home for help, nobody is there to let them in or advise them. This demonstrates a disregard for the safety and well-being of young people. An allocated social worker raised concerns that, on a number of occasions, he had been unable to contact staff in the home. He relayed similar complaints from an education provider. He also reported that he had repeatedly asked the provider to send monthly progress updates for a young person, yet had to wait three months before he received them. Poor communication with the placing authority and the police undermines the ability to implement a multi-agency approach to safeguarding, and places young people at risk. The lone-working risk assessment for the home does not clearly state the home’s approach to lone working. It does not identify potential risks or suggest effective

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Inadequate

measures to reduce risk. When investigating an allegation against a member of staff, the local authority designated officer raised concerns in relation to lone working. She questioned whether it was appropriate to have only one member of staff on the premises, particularly since that person was supposed to be providing education for the young person that morning as well as being in charge. This suggests that, at times, the service does not have sufficient staff to keep young people safe or to support them to attend education. When young people make allegations of ill treatment against staff, managers do not follow agreed procedures or work in partnership with the placing authority to ensure that an independent investigation takes place. The home’s internal procedures for following up and reviewing practice in light of allegations are unclear. Following one investigation by the designated officer, the home did not

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Inadequate

complete its own investigation into a complaint made by a young person. In addition, the safeguarding procedure does not explain the process to follow if the allegation is about the manager. This means that the provider misses opportunities to reflect on and learn from allegations in order to improve practice and better understand the young person’s perspective. The local authority designated officer expressed concerns, when investigating the allegations against staff, that the child ‘was blamed for the incident’. She went on to remark that, considering this was a home for children with behavioural concerns, there was no real insight. Young people lack opportunities to express their views. Other than allegations against staff, the home has no record of complaints from young people. A placing social worker indicated that he had raised with the provider a number of complaints on behalf of a young person. He felt that managers were defensive in

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Inadequate

their response to him and did not feel that the issues were addressed with him or explored with the young person. The failure to record or suitably address complaints means that young people cannot make their views heard. Consequently, practice in the home is not informed by the experience of the young people living there. The provider is unable to provide evidence that all staff are suitably trained and qualified in key areas of child protection. They have not all had training on the risks of child sexual exploitation, radicalisation, fire safety or first aid. This means that young people fail to be cared for by staff who routinely have the knowledge and skills to keep them safe. The provider is unable to evidence that all staff working in the home have been subjected to appropriate checks and vetting, to ensure that they are suitable for the role. This places young people at risk of harm. The location risk assessment for the home does not identify interventions to reduce

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Inadequate

all identified risks. It does not demonstrate that managers have consulted with key partners in the community to inform an assessment that the home is in a safe and suitable location. The approach to the giving of medicines is poor. If young people need medication, staff ensure that they receive it as prescribed by medical practitioners. However, the recording system for handling medications does not ensure that the provider can keep track of all medicines that are received or disposed of. In addition, the system fails to ensure that only trained staff administer medications. This raises the risk of inappropriate and unsafe practice. The approach to health and safety is weak and places young people and staff at risk. The manager undertakes regular health and safety checks. While a qualified contractor services gas appliances, managers have not addressed faults identified in the home’s central heating boiler. This runs the risk that the boiler will fail or

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Inadequate

become unsafe. The fire risk assessment is incomplete and does not specify the frequency of testing of all fire safety equipment. Staff conduct regular fire drills. However, there is no evidence that all staff have received training in fire prevention or that they are aware of the procedures to be followed in case of fire.

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Inadequate

The responsible individual of the home does not provide the leadership or management necessary to improve the service. He does not provide the necessary support to ensure that the interim manager can undertake the work required to deliver improvement. He does not ensure that monthly visits take place by an independent person to review the quality of care provided to young people. The responsible individual makes the final decision in respect of new admissions to the home. He does not ensure that young people are well matched or that the service can safely meet their needs. The management information systems do not allow the managers to access the information they need to lead the service effectively. This raises serious questions as to the provider’s willingness and/or ability to meet regulatory requirements. The home lacks effective leadership and direction. Since the last inspection in April a number of additional significant shortfalls have been identified. The continuity of

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Inadequate

care provided by staff is poor and the home is not working effectively in partnerships with the professional network to safeguard young people. It is of further concern that, since the previous inspection, the home admitted a number of young people who could not reasonably be expected to thrive, stay safe or make progress in the home. The outcomes for these young people were predominantly poor. This means that the quality of care provided by the home, judged inadequate at the previous inspection, has deteriorated. The provider has failed to make the necessary progress in relation to meeting the requirements from the previous inspection. Lone-working risk assessments remain poor. There are still insufficient staff to meet the needs of young people. The provider cannot evidence that staff are suitably trained to keep young people safe or that they were safely recruited. In addition, the management information

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Inadequate

systems remain unfit for purpose, management monitoring is poor and quality assurance systems remain ineffective. Key professionals who work with the home raised a number of concerns in relation to the quality of care and partnership work. Common themes reported by these professionals include poor communication, lack of responsiveness to requests and a defensive attitude when faced with constructive feedback or complaints. This raises serious concerns about the provider’s ability to work effectively in partnership to safeguard and promote the welfare of young people. The manager of the home is not always the lead person when dealing with the professional network, as this is often the responsible individual. The interim manager of the home has been in post for a short period and has had limited time to make a positive impact on the quality of care provided by the home. This situation is exacerbated by the fact that he spends a considerable amount of

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Inadequate

time working in a residential support worker role. This limits the time that he has available to undertake the necessary management tasks that are required to improve the service. The home’s statement of purpose does not accurately reflect practice in the home in relation to the use of surveillance or video to monitor young people. It does not describe how any images gathered may be used or shared. This means that young people may be subjected to electronic surveillance without their knowledge or permission from the placing authority social worker. The interim manager does not have a workforce development plan for the service. This means that there are no clear strategies in place to ensure that there are sufficient staff who are suitably trained to meet the needs of the young people in the home. Monitoring of the home is poor. The quality of care review undertaken by the interim manager does take into account feedback from young people, parents,

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Inadequate

staff or key professionals. It does not analyse key practice areas in relation to safeguarding or outcomes for young people. The interim manager does not use his review to inform service improvement. This undermines his ability to identify when things go wrong and to take remedial action. Despite there being a pool of 18 staff to work in the home, there are times when no staff are in the building and there are no arrangements in place to provide care or support for the young people who live in the home. This demonstrates poor day-to-day management of resources, and this is detrimental to the well-being and experience of young people who live in the home. The interim manager has made some improvements to recording formats for care plans and risk assessments. These are not embedded in practice and therefore do not make a significant impact on safeguarding practice or the quality and purpose of care provided to young people. He has also improved the quality and frequency

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Inadequate

of team meetings. He ensures that staff have opportunities to share their views and to discuss strategies for interventions with young people. However, only a small proportion of staff who work in the home attend. This means team meetings do not significantly improve the consistency of care for young people.

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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 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 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 whom 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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