Children's Home run by Pebbles Care Limited in North Yorkshire

Requires improvement

The children's home is not yet delivering good help and care for children and young people. However, there are no serious or widespread failures that result in their welfare not being safeguarded or promoted.

p.2

The children's home provision requires improvement because:

 Young people are at risk due to parts of the home not being safe. Not all windows have restrictors fitted and some broken windows are not repaired in a timely way, leaving young people exposed to hazards and potentially unsafe.  There is insufficient supervision of young people that has led to some serious incidents of inappropriate behaviour.  Young people’s needs are not fully established at the time of admission. As a result, young people’s safety and welfare are seriously affected.  There is ongoing delay in securing an education placement for a young person residing at the home. This has not been escalated with the placing or host authority in a timely way.  Behaviour support plans are not consistently evaluated regarding the effectiveness of the strategies used.  Risk assessments are unwieldy and not consistently evaluated to address their effectiveness.  Strategies used to manage young people’s behaviour are not consistently

p.3

The children's home provision requires improvement because:

evaluated. Placement plans are not clear at evidencing how young people’s cultural needs are met.  Physical conditions within the home have deteriorated to an unacceptable level leaving the home looking poorly maintained and unkempt.

p.3

The children's home strengths

 Staff have successfully supported one young person to reduce their misuse of harmful substances and to gain employment.  Good staff support has led to one young person making good progress with his independent living skills and social development.  Staff intervention has led to some young people improving their attendance at school and their behaviours.  Young people receive help to maintain contact with their families.  The manager has established links with the police and designated officer for the local authority, helping to safeguard young people.  Young people’s rights to complain are respected, taken seriously responded to in a meaningful way.  Timely action taken by the homes managers in relation to staff conduct has helped keep young people safe.  The manager’s ability to professionally challenge the police means they advocate strongly on behalf of young people.

p.4

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 must comply within the given timescales.

p.5

Requirement Due date

6: In order to meet the quality and purpose of care standard, with particular reference to ensuring that the home is in a good state of repair and decorated and furnished to a high standard, the registered persons must— (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. 29 July 2016

p.5

Requirement Due date

12: In order to meet the protection of children standard, with particular reference to safeguarding young people during the night, by ensuring that staff do not carry out tasks that compromise their primary responsibility to supervise young people. By removal of the hook and making safe the broken window within the outbuildings. By the provision of an approved system for maintaining safe water temperatures, approved by a qualified tradesman, ensuring that electrical wall sockets within the home’s pantry are safely beyond use and affixing window restrictors in young people’s bedrooms. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (b) that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm; (d) that the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child

p.5

Requirement Due date

from avoidable hazards to the child’s health. 29 July 2016

p.5

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 details of the 29 July 2016 child’s behaviour leading to the use of measure and the effectiveness and any consequences of the use of the measure. (Regulation 35 (3)(a)(ii)(vii))

p.5

Requirement Due date

The registered person must notify the HMCI and each other relevant person without delay if there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(e)) In particular, when a young person’s placement ends due to their being the victim or perpetrator of a serious assault, and incidents relating to serious self-harm. 29 July 2016

p.6

Recommendations

To improve the quality and standards of care further, the service should take account of the following recommendations:  Where the placing authority or another relevant person does not provide the input and services needed to meet a child’s needs during their time in the home or in preparation for leaving the home, the home must challenge them to meet the child’s needs. Staff should act as champions for their children, expecting nothing less than a good parent would. The registered person should consider the use of an independent advocate, if the child’s needs are not being met. In particular, revise the home escalation policy so that there is no unnecessary delay that prevents the registered manager from contacting the director of children’s services when there are significant issues preventing a young person from going to school (‘Guide to the children’s homes regulations including the quality standards’, page 12, paragraph 2.8).

p.6

Recommendations

 Ensure care which meets each child’s needs and promotes their welfare, taking into account the child’s gender, religion, ethnicity, cultural and linguistic background, sexual identity, mental health, any disability, their assessed needs, previous experiences and any relevant plans. In particular, that young people’s needs due to their ethnicity and culture are fully reflected within their placement plans and how these are met (‘Guide to the children’s homes regulations including the quality standards’, page 14, paragraph 3.2).  For children’s homes to be nurturing and supportive environments that meet the needs of their children, they will, in most cases, be homely, domestic environments. Children’s homes must comply with relevant health and safety legislations (alarms, food hygiene and so on). However, in doing so, homes should seek as far as possible to maintain a domestic rather than ‘institutional’

p.6

Recommendations

impression. In particular, make clear within the home’s statement of purpose what the home does to ensure a good standard of accommodation is maintained (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9).  Staff should understand factors that affect children’s motivation to behave in a socially acceptable way. Staff should encourage an enthusiasm for positive behaviour through the use of positive behaviour strategies in line with the child’s relevant plans. In particular, consistently evaluate the effectiveness of any strategies within young people’s behaviour support plans and where possible do so with young people (‘Guide to the children’s homes regulations including the quality standards’, page 39, paragraph 8.13).  Staff should continually and actively assess the risks to each child and the arrangements in place to protect them. Where there are safeguarding concerns

p.6

Recommendations

for a child, their placement plan, agreed between the home and their placing authority, must include details of the steps that the home will take to manage any assessed risks on a day-to-day basis. In particular, ensure that risk assessments are easily understood live working documents that are regularly and consistently evaluated and when to do so with young people (‘Guide to the children’s homes regulations including the quality standards’, page 42, paragraph 9.5).  Ensure that the registered person should only accept placements for children where they are satisfied that the home can respond effectively to the child's assessed needs as recorded in the child's relevant plans and where they have fully considered the impact that the placement will have on the existing group of children. In particular, obtain all relevant information about a prospective young person making clear the impact of any newly admitted young person for

p.7

Recommendations

the existing group of young people living at the home that also takes account of young people’s gender and developmental needs (Guide to the children’s homes regulations including the quality standards’, page 56, paragraph 11.4).

p.7

Information about this children's home

The home is operated by an independent provider. It is registered to accommodate up to four children and young people with emotional and/or behavioural difficulties.

p.8

Recent inspection history

Inspection date Inspection type Inspection judgement

p.8

Recent inspection history

18 February 2016 Interim Sustained effectiveness

p.8

Recent inspection history

30 November 2015 Full Requires improvement

p.8

Requires improvement

Outcomes for young people are mixed. For example, one young person stopped misusing substances and gained employment as a result of support from staff. Conversely, an escalation in the young person’s underlying behavioural difficulties affecting other young people led to an unplanned discharge. This situation was not used to best effect as there was no sharing of information by staff about the young person’s needs with the new placement. Nor was the young person provided with any meaningful keepsakes such as photos reflecting the positive aspects of his time at the home. While assurance was given that these deficits would be addressed, this type of ending to a placement only serves to reinforce young people’s attachment difficulties. A significant factor leading to this outcome was poor pre-admission planning for young people admitted to the home in an emergency situation. This means that decision making about the potential impact for existing young people is flawed.

p.9

Requires improvement

The resulting inappropriate match causes increased anxieties, inhibiting progress and the abilities of staff to respond effectively to young people’s arising needs. A member of staff said, ‘A young person used to get singled out quite a lot, they got very down about it and used to sit with staff.’ Education outcomes are mixed. One young person has been out of school since February 2016. This has led to a reduced motivation for them to take part in any meaningful academic work. Additionally, the lack of any social interaction with school peers compounds their emotional and behavioural difficulties. This places the young person at a severe disadvantage in comparison to their peers. A tutor said, ‘She was disappointed when she found out she was not going to college and other issues came to the fore. I have seen a notable deterioration in her behaviour.’ A social worker said, ‘The young person hasn’t really made any

p.9

Requires improvement

progress.’ A lack of decisive action by the home and other professionals has compromised a young person’s access to education. The home’s escalation policy and procedure allows too much time to elapse before any action is taken. This is at odds with the manager’s delegated authority to act as a good parent and to challenge at an early stage to avoid any negative impact on young people. A positive outcome from this challenge is that the young person’s in-house education hours have been increased to 25 hours a week. Some young people achieve regular school attendance. Staff persistence with promoting morning routines results in these young people’s full participation. For one young person, there is also marked improvement in behaviour increasing their likelihood of academic success. A social worker said, ‘It’s the first time he is not on report for concerning behaviour and that is real progress for him.’

p.9

Requires improvement

Young people take part in a range of meaningful activities. These include visits to places of interest and using local amenities. This promotes young people’s emotional and physical well-being and helps them to learn how to make the most of their free time. A young person said, ‘I like going for drives out.’ Young people’s rights to stay in touch with their families are respected and promoted. Staff provide the necessary support and when needed supervise these arrangements. This meets young people’s developmental needs and preserves a sense of belonging within their families. A young person has sustained their participation in therapeutic work. This support alongside input from staff is helping to increase their own and other young people’s safety. This has improved the young person’s social skills leading to increased confidence and the development of independent living skills. A young person said, ‘I am semi-independent so I get money for shopping, £25 a week. I

p.10

Requires improvement

do my own shopping.’ Young people recognise that staff are invested in building trusting relationships and helping them to achieve positive outcomes. This is noted through the levels of one-to-one support from staff, which promotes trust and helps to build young people’s self-esteem.

p.10

Requires improvement

Relationships between some young people have been turbulent with high levels of verbal and physical aggression. This resulted in a young person staying away from the home in order to feel safe. These experiences reinforce young people’s trauma and make them feel unsafe. In addition, it has resulted in a further placement breakdown for one young person. A member of staff said, ‘He is doing alright and he got a bit upset. He was gutted that he moved and said that it was the best placement that he been in.’ Ineffective risk management and a lack of understanding from staff about the complexity of young people’s underlying behaviours places them at increased risk. For example, staff failed to recognise and misinterpreted scapegoating behaviour, which they believed was a strong indicator of disinterest by a young person towards their peer. As a result, effective measures were not proactively taken to adequately supervise young people at night. This led to incidents of inappropriate

p.10

Requires improvement

sexual behaviour between some young people. A member of staff said, ‘We never thought anything like that would happen.’ Risk assessments about young people’s needs are unwieldy and not consistently evaluated. This means that the effectiveness of any strategies aimed at reducing risk is not fully understood. Similarly, young people’s behaviour support plans are not evaluated as to the effectiveness of the measures used. This places young people at increased risk as not enough account is taken about what young people communicate about their underlying needs through their behaviour. When asked about why he thought a young person had punched him in the arm in open view, the member of staff said, ‘It’s strange because he didn’t do it when he first came.’ Young people’s behaviour is not criminalised. The staff do not have an over- reliance on the police when this is not necessary as previously recommended. The

p.10

Requires improvement

manager of the home challenges the police when there are concerns about unfair treatment. This respects young people’s rights as citizens aiding their understanding about what level of support they are entitled to. The manager and staff recognise the importance of promoting a calm atmosphere following a significant period of unrest and they are in the process of reinforcing boundaries aimed at promoting this. A social worker said, ‘My main concern has been other young people. They are going to allow the place sometime to settle and not admit anyone else for a while. I spoke to the manager about this. I do feel that things have started to calm down.’ This was echoed by the manager who said, ‘I know we can’t admit other young people at the moment.’ Staff carry out periodic checks of the external grounds aimed at ensuring young people’s safety. However, some aspects of the home are potentially hazardous. For

p.11

Requires improvement

example, a hook from the rafters within an open roofed adjacent outbuilding and a recently broken window covering have not been made safe. Two young people’s upstairs bedroom windows are not fitted with restrictors. Excessively hot water temperatures are reliant on staff running off water to lower the temperature. These potential hazards place young people at risk and do not promote a safe environment. Improvements made to the majority of the downstairs windows means they can now be opened. This is more in keeping with a domestic setting and meets a previous recommendation. Although physical interventions are rare as staff try to distract and defuse situations, the effectiveness of any holds that do take place is not clear. Insufficient reflection about the consequences for the young person concerned reduces staff’s understanding about alternative, more effective strategies. Written records of disciplinary measures sometimes used in response to a young

p.11

Requires improvement

person’s behaviour are incomplete. For instance, details about the events leading up to the behaviour are not consistently clear. Although staff are moving away from using sanctions towards a more restorative approach, these omissions are a lost opportunity to gain further understanding about young people’s needs. Staff use incentives to promote good behaviours and routines. This furthers young people’s understanding about the choices that they make. A member of staff said, ‘We have a points system. We encourage young people to earn them. If there is any negative behaviour they will have a key worker session.’ This helps young people understand the impact of such behaviours. Young people know how to complain. Their views are taken seriously and acted upon. The manager ensures young people are informed about the outcomes. This helps them to restore trust and confidence in the systems designed to protect

p.11

Requires improvement

them. Staff know what action to take should young people make a disclosure or raise safeguarding concerns affecting their safety or well-being. Staff understand their responsibilities and promote safe care practice. This was noted through the swift action taken by the manager to investigate the inappropriate conduct of a member of staff. This is an added protective factor in keeping young people safe. Young people sometimes leave the home or go missing for short periods. When this happens, staff know what to do to ensure that young people return safe and well to the home. At this time, none of the young people are subject to or at risk of child sexual exploitation.

p.12

Requires improvement

The registered manager is suitably experienced and is working towards completion of the necessary qualifications, aiming to attain this by the beginning of next year. The manager has been in post since February 2015. Staff feel well supported by this individual. The home conditions are not in line with the description in the statement of purpose. The need for significant maintenance and improvement work was noted at the start of the inspection. Decorators, a gardener and the home’s maintenance person arrived on the first day of the inspection and started to replace broken furniture and restore the home to an acceptable standard. This resulted in worthwhile improvements before the end of the second day, although further improvements are still required. The quality of the home environment gives a negative message to young people about their worth and undermines feelings of belonging. Not all placement plans are clear on how young people’s cultural and ethnicity

p.12

Requires improvement

needs are to be met. A lack of forethought and planning about how to support this aspect of identity is likely to increase the young person’s difficulties. Aside from this omission, placement plans do identify areas to focus on through purposeful one-to-one sessions with young people. This approach builds trust, making the most of opportunities for young people to explore the impact of the choices that they make. The regulator is not always notified about serious matters affecting young people. For example, Ofsted have not been informed about a young person’s placement ending due to the significant concerns the individual posed to other young people. Similarly, neither was a notification sent to Ofsted about an incident involving a young person’s serious risk-taking behaviour. This does not demonstrate transparent practice and has prevented the regulator from intervening at an earlier stage. Staff understand that the importance of partnership working with other

p.12

Requires improvement

professionals is in the best interest of young people. An example of this is how they work closely with clinical nurse specialists who offer young people advice and guidance on sensitive matters regarding their sexual, physical and emotional well- being. A nurse commented how impressed she was when a young person stated they wanted their key worker to take part in the session. This demonstrates that staff respect the young people’s rights to influence the care that they receive. This approach increases the likelihood that young people will engage with services that promote their well-being. Young people’s family members and social workers receive regular updates from staff keeping them informed of any difficulties and any progress. This means that there is shared understanding about young people’s experiences and agreements reached about how to proceed. About support for a young person a social worker

p.13

Requires improvement

said, ‘They have been really good at getting the young person’s medication reviewed, which is really positive.’ A planned induction programme and ongoing training is in place for new and established staff. This ensures that staff know and understand the home’s policies and procedures and continue their professional development. A new member of staff said, ‘I think the training is working really well. If I want to do any other training then they just put me down for it.’ Young people live in an area with low crime levels that is relatively safe. Effective links with the local police and specialist officers responsible for preventing child sexual exploitation mean that there is good understanding of the local area and the potential risks that vulnerable young people may be exposed to. This proactive approach to working with police means that staff can help young people to safely use the local amenities.

p.13

Requires improvement

Systems are now in place and monitored by the manager to ensure the safe storage of food and cleanliness within the kitchen area. This promotes young people’s health and well-being and helps them to learn about food hygiene, meeting a previous recommendation.

p.13

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’.

p.14

What the inspection judgements mean

An outstanding children's home provides highly effective services that contribute to significantly improved outcomes for children and young people who need help and protection and care. Their progress exceeds expectations and is sustained over time. A good children's home provides effective services that help, protect and care for children and young people and have their welfare safeguarded and promoted. In a children's home that requires improvement , there are no widespread or serious failures that create or leave children being harmed or at risk of harm. The welfare of looked after children is safeguarded and promoted. Minimum requirements are in place. However, the children's home is not yet delivering good protection, help and care for children and young people. A children's home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

p.14

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.

p.14

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

p.15

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 .

p.15

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,

p.16

Information about this inspection

The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

p.16

Information about this inspection

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

p.16

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

p.16