Children's home in Gloucester

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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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 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.

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 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.

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 The practice of recording and administration of medication was unsafe and dangerous.

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 Risks to the young person had not been managed effectively.

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 Health plans in place had not been adhered to.

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 Monitoring of the home was ineffective as potential risks were not identified and addressed.

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 Internal monitoring of the home also failed to identify weaknesses in practice, such as those found by the inspectors.

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 Three compliance notices were issued, under Regulations 12, 13 and 23.

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During an unannounced monitoring visit on 27 and 28 June 2016. Inspectors found that young people were still not protected from harm and it was evident that there continued to be ongoing safeguarding concerns and staff practices that are of concern. As a result, the previous three compliance notices under regulations 12, 13, and 23 were reissued.

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On 23 August 2016, a further monitoring visit was completed. 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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During the monitoring visit, Elaine Allison and Michelle Edge, Social Care Regulatory Inspectors, found that since the last monitoring visit the interim manager had resigned from his post with immediate effect. The provider had taken effective action and moved another registered manager within the company to oversee the action plan in place to address the steps identified in the three compliance notices. The current registered manager remains suspended.

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Inspectors found that on 13 July 2016, there was a significant safeguarding incident involving the young person living at the home. The police believed that the young person was at risk of significant harm and the care staff at the home were unable to keep her safe. They used a police protection order, under section 46 of the Children Act 1989, to move the young person with immediate effect to a place of safety. The local authority was in agreement with the plan and identified a new care home. This demonstrates that the children’s home were not able to keep the young person safe or to meet her needs. In addition, the young person did not receive a positive experience of moving on to another placement.

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The new interim manager had revised all documentation in the home, including behaviour management plans, risk assessments and placement plans. Discussions have taken place with all staff about the need to review and update these after any safeguarding concerns. On 8 July 2016, all staff attended safeguarding refresher training. This provided further opportunities for staff to understand their roles around responsibilities in safeguarding and protecting young people. Following the training, the new interim manager provided each staff member with a clear flowchart on how to raise concerns, including timescales and who the safeguarding professionals are. This included the local authority safeguarding professionals, on- call managers and local authority social workers. Although the new interim manager had improved the knowledge base of staff and ensured that they were fully aware of policies and procedures, there have been no young people living at

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the home, so it is not known whether the training has been effective.

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The new interim manager ensured that all staff have received direct one-to-one supervision. During the sessions, it was clear that roles and responsibilities were discussed with all staff. Further discussions included the safeguarding and whistleblowing policies and procedures, the statement and purpose for the home and the basic care needs of young people. Team meetings have also been arranged and the role of all care workers was reinforced. Guest speakers had included managers from other outstanding homes within the organisation, to look at medication practices, risk assessments and care planning.

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Inspectors found that the provider had made progress in the safer administration of medication. All staff have received training and all old medication had been returned to the pharmacist. Control drug books were updated and now include all relevant information. During the inspection, the provider confirmed to the inspectors, that they are planning to close the home voluntarily for at least a three-month period. Because no young people have lived in the home, and the provider has decided to apply to close for a period of time, the provider has not taken all the steps required by the compliance notices for the home. However, the provider is using the three-month period to recruit a new registered manager, continue with the training of all staff and update all of the records, policies and procedures within the home.

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Information about this children's home

This private children’s home accommodates 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) 30/09/2016

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Requirement Due date

In order to meet the positive relationship standard, the registered person must ensure that:

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Requirement Due date

(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. 30/09/2016 (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

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Requirement Due date

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) 12: The protection of children standard 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 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. 30/09/2016 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) 30/09/2016

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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)) 30/09/2016

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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 30/09/2016 the behaviour management policy under review and, where appropriate, revise it. (Regulation 35 (1)(a)(b) (2)) 40: Notification of a serious event

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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) (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) 30/09/2016

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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)) 30/09/2016

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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)) 30/09/2016

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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

T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: www.gov.uk/government/organisations/ofsted

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