Children's home run by Castle Homes Care Limited in Hammersmith and Fulham

Inadequate

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

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The children's home provision is inadequate because:

 The registered persons have failed to ensure that any concerns in relation to the care, support and services needed by young people have been escalated to the placing authority. Key documentation and plans for some young people are not current or accurate, undermining the ability of staff and managers to provide the necessary care and support to them.  Admission practices and decisions about new placements are poor and not always in the best interests of those young people already living in the home. Young people themselves report concern at the negative impact of other young people’s behaviours on them.  Allegations against members of staff have not been consistently or robustly responded to by managers. This has placed young people at risk on occasion and does not provide clear support to staff during investigation processes. Managers have failed to ensure that Ofsted is notified of all allegations made. This undermines the regulator’s ability to monitor such

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The children's home provision is inadequate because:

incidents.  Bullying incidents have not been clearly recorded or responded to. This does not provide young people with assurance that such concerns will be dealt with appropriately by staff and managers. They have not been clearly advised of the outcome of either complaints made or reports of bullying.  The manager has failed to ensure that maintenance works are clearly identified, recorded or monitored. Damage to internal areas of the home does not provide a homely or welcoming environment for young people. The manager has further failed to ensure that any potential risks to young people from the external areas of the home have been clearly identified and assessed. This places young people at risk.  Incidents of concerning and risky behaviours by young people have not been clearly or robustly monitored or overseen by the manager. Sanctions and incentives have not been consistently applied, with management oversight

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The children's home provision is inadequate because:

and review of such incidents being poor.

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The children's home strengths

 Some young people’s attendance and engagement in education has improved since moving to live at this home.  Staff strive to support young people to understand their presenting needs and to celebrate their successes with them on a daily basis.

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Statutory requirements

This section sets out the actions that must be taken so that the registered persons meet 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

5. Engaging with the wider system to ensure children's need are met standard In order to meet the engaging with the wider system to ensure children's needs are met standard, the registered person must: (c) if they consider, or staff consider, a placing authority's or a relevant person's performance or response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child's needs are met in accordance with the child's relevant plans. 17/10/2016

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Requirement Due date

The registered person must ensure that the register of children includes the child's address immediately before their being accommodated in the home and their address on leaving the home. (Regulation 37, schedule 4 (1)(c)(d)) 17/10/2016

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Requirement Due date

The registered person must ensure that HMCI is notified without delay if there is an allegation of abuse against the home or a person working there. (Regulation 40(4)(c)) 17/10/2016

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Requirement Due date

The registered person must ensure that when conducting the review, the registered person consults, and takes into account the views, of each relevant person. (Regulation 46(2)) 17/10/2016

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Requirement Due date

The registered person must ensure that full and satisfactory information is available in relation to individual members of staff in respect of each of the matters in Schedule 2. This is with specific reference to Disclosure and Barring Service (DBS) checks. (Regulation 32(3)(d)) 17/10/2016

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Requirement Due date

The registered person must ensure that records maintained for children are kept up to date. This is with specific reference to placement, care plans and individual risk assessments for children. (Regulation 36(1)(b)) 17/10/2016 11. The positive relationships standard (2) In order to meet the positive relationships standard, the registered person must: (xii) ensure that staff understand and communicate to children that bullying is unacceptable; and (xiii) have the skills to recognise incidents or indications of bullying and how to deal with them 17/10/2016

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Requirement Due date

8. The education standard (2) In order to meet the education standard, the registered person must: (viii) ensure that staff help a child who is not attending school to access educational and training support throughout the period of non-attendance and to return to school as soon as possible. 17/10/2016

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Requirement Due date

7. The children's views, wishes and feelings standard (2) In order to meet the children's views, wishes and feelings standard the registered person must: (a) Ensure that staff - (iii) help each child to understand how the child's views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child. 17/10/2016

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Requirement Due date

7. The children's views, wishes and feelings standard (2) In order to meet the children's views, wishes and feelings standard, the registered person (b) must ensure - (iii) that each child is given appropriate advocacy support. 17/10/2016

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Requirement Due date

12. The protection of children standard (2) In order to meet the protection of children standard, the registered person must ensure that: (d) the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from hazards to the child's health. 17/10/2016 13. The leadership and management standard (1) In order to meet the leadership and management standard, the registered person must enable, inspire and lead a culture in relation to the children's home that – (a) helps children aspire to fulfil their potential; and (b) promotes their welfare. 17/10/2016

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Requirement Due date

13. The leadership and management standard (2) In order to meet the leadership and management standard, the registered person must: (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. 17/10/2016

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Requirement Due date

11. The positive relationships standard (2) In order to meet the positive relationships standard, the registered person must: (iv) help each child to develop and practise skills to resolve conflicts positively and without harm to anyone. 17/10/2016

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Requirement Due date

The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation. (Regulation 39(3)) 17/10/2016

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Requirement Due date

The registered person must provide for records to be kept of an allegation of abuse or neglect, and the action taken in response, and describe the measures which may be necessary to protect children following an allegation of abuse or neglect. (Regulation 34(2)(d)(e)) 17/10/2016

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Requirement Due date

14. The care planning standard (1) In order to meet the care planning standard, the registered person must ensure that children - (a) receive effectively planned care in or through the children's home. 17/10/2016

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Requirement Due date

13. The leadership and management standard (2) In order to meet the leadership and management standard the registered person must: 17/10/2016 (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child.

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Recommendations

To improve the quality and standards of care further, the service should take account of the following recommendations:

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Recommendations

 Ensure that children are offered a wide range of activities both inside and outside of the home, where appropriate, and are encouraged to participate in those activities. (‘Guide to the children’s homes regulations including the quality standards’, page 31, paragraph 6.5)

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Recommendations

 Ensure that staff continually and actively assess the risks to each child and the arrangements in place for them. When there are safeguarding concerns for a child, their placement plan, agreed between the home and their placing authority, must include details of the steps the home will take to manage any assessed risks on a day-to-day basis. (‘Guide to the children’s homes regulations including the quality standards’, page 42, paragraph 9.5)

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Recommendations

 Ensure that the registered person actively seeks independent scrutiny of the home and makes the best use of information from independent and internal monitoring (including under regulations 44 and 45) to ensure continuous improvement. They should be skilled in anticipating difficulties and reviewing incidents, such as learning from disruptions and placement breakdowns. (‘Guide to the children’s homes regulations including the quality standards, page 55, paragraph 10.24)

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Information about this children's home

This privately owned children’s home is registered to provide care and accommodation for up to six children and young people who have emotional and/or behavioural difficulties.

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Recent inspection history

This is the first inspection of this children’s home, since it was registered by Ofsted in December 2015.

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Inadequate

Admission practices and decision-making for new placements are poor, leading to some young people being placed whose needs cannot be safely met. Impact risk assessments do not consider all known or potential risks or concerns for young people. The manager has failed to ensure that staff have the necessary skills and training prior to placements being agreed and made. Some young people have reported high levels of concern and dissatisfaction at the behaviours and negative impact of other young people placed in the home. One young person commented: ‘It makes me upset to see windows boarded up and holes in the windows. I like to see the house all nice with things not broken.’ Young people do not make positive progress in relation to their risk-taking and concerning behaviours while living in this home. This undermines their ability to make positive progress in all areas of their lives. Some young people continue to

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Inadequate

cause extensive damage to both the home and company vehicles. The use of sanctions and incentives to address such concerning behaviours is inconsistent. Such behaviours have a negative impact on other young people living in the home, with some mirroring the concerning behaviours of others. Those not involved in such behaviours report feeling angry and upset at the impact that this has on them and staff. The manager has failed to ensure that placement and care plans for all young people reflect their current needs. During this inspection, it was noted that one young person did not have a local authority care plan and another had an out-of- date placement plan. This does not enable staff to provide care and support to young people relevant to their current needs. One young person spoken with stated that they were not aware of what their care plan was. This does not provide young people with a clear sense of the care and support that they should be

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Inadequate

receiving and reflects the lack of challenge of the placing authority by the manager. Not all young people engage in education on a regular basis, despite educational provisions being in place for them. When young people refuse to attend education, staff make regular attempts to get them up and ready for school, with limited success. There is no current structure or plan in place for those young people who refuse to engage in education each day. This further undermines their ability to learn, and records do not reflect the action being taken by managers or staff to address this concern. Some young people do go to school, and attendance has improved since they moved to live at this home. Young people receive support to meet their routines and more complex healthcare needs during their placement. Staff work with professionals to ensure that dental, optical and routine medical appointments are made and kept. There is involvement

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Inadequate

from local child and adolescent mental health services for some young people. When young people have been identified as at potential risk by using ligatures, staff have not been provided with training. This undermines their ability to respond with skill and confidence to any such situations, and could place young people at risk. The manager has failed to ensure that all staff, including waking night staff, have the necessary skills and training in this area. Young people take part in regular meetings with staff to consider their wishes, views and feelings. The manager responds to any issues or requests made by young people from these meetings. Young people also contribute to menu planning and take part in meal preparations with staff. This provides them with skills, which will assist them when they move from this home and into adult life. Young people know and understand the complaints procedures for the home and

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Inadequate

feel confident in using them. Most complaints have been responded to in a timely manner and include formal letters being sent to young people, detailing the actions taken and outcomes. One formal complaint by two young people about an external professional was made in April 2016 and has not been followed up by the manager. Management oversight of complaints is not sufficiently robust and should form part of the management monitoring and review systems. Staff support young people to maintain contact with family and friends. They work with the placing authority to consider and increase free time for some young people, and encourage them to spend time in the local community with friends. This increases their sense of belonging and enables them to maintain key relationships. Some young people do not have any contact with family members. The manager has failed to ensure that such young people have access to

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Inadequate

independent visitors or that independent reviewing officers and placing social workers have fully considered this unmet need. Activity planners for each young person reflect the activities that have been agreed for them to take part in each week. Staff support them to attend local clubs and events on a regular basis. Activity planners also include details of education provisions, setting out their daily routine for education and social events. Staff do not record whether young people have attended education or taken part in agreed activities. It is, therefore, unclear how young people have been supported to engage in activities, or whether there are reasons for their not doing so. The home is decorated and furnished to a good standard and provides ample space for young people. A maintenance team provides support in repairing any reported damage. The manager has failed to put in place a system for the recording and

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Inadequate

reporting of any damage caused in the home though. During this inspection, a broken window, water damage to a ceiling and a fly infestation in one vacant bedroom were noted. The manager was not clear about when such damage had been caused or if it had been reported to the relevant maintenance and support services. This leads to the home presenting in some areas in a poor state and could present risks to young people. There is a lack of robust management oversight of such issues.

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Inadequate

Young people are not adequately safeguarded, due to poor management decisions on new placements and a lack of robust management oversight. There has been an increase in police involvement and a significant number of notifications made to Ofsted since the home became operational in January of this year. These relate to concerning behaviours of young people, absenting themselves or being reported as missing, and extensive damage being caused to the home and company cars. The matching of young people has not taken into account the needs of those young people already resident in the home. Initial impact assessments for one young person have significant gaps in information on the actual or potential risks that they may pose to themselves and others. The manager has failed to seek full information from the placing authority, before agreeing to accept the placement or since the placement commenced. Risk management plans for one young person

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Inadequate

reflect a lack of understanding of the needs and risks posed by the young person and a failure of the manager to secure missing information from the placing authority. When risks in relation to potential self-harm for one young person were identified at the time of their admission, the manager failed to ensure that staff had the necessary training in relation to self-harm and ligatures. Agency waking night staff have been employed specifically to support this young person and their potential risks, but risk assessments have not been updated in a detailed manner to reflect the concerns. Furthermore, agency staff profiles and information about their skills and training do not reflect that they have the necessary skills and experience to respond to such issues. Young people have made several allegations about members of staff. Records do not reflect clearly the actions taken by managers in response to such allegations.

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Inadequate

Referrals have been made to the placing authority and designated officer, but internal investigations do not consistently reflect the actions taken, outcomes or learning. An example of poor practice involves one member of staff allegedly physically assaulting a young person. Records state that the staff member was not to work alone with the young person, pending the investigation outcome. There is no risk assessment in place and no records held on the staff member’s file to indicate how this was responded to. When staff members have been sent home following an allegation being made, records do not reflect the decision-making of the manager for staff to return to work. This places young people and staff at risk and does not reflect positive or strong management oversight or responses to such incidents. When young people have behaved in a risky or unsafe manner, placing themselves or others at risk, risk management plans have not been reviewed or updated in a

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Inadequate

timely or consistent manner. Those seen during this inspection often had hand- written comments on them, made following a serious incident, with no clear sense of who had considered the plan or how staff would know of any changes to the risk assessment. An example of this relates to one young person placing themselves at risk when out in the company car with staff. The risk assessment stated that they were not to travel in the car, but the young person was seen to do so with staff during this inspection. Staff and young people are, thus, placed at risk, with unclear and potentially unsafe practices not being overseen by the manager. Team meeting records do not reflect a detailed discussion taking place in relation to the current or changing risks posed by young people. Records considered during this inspection of recent meetings provided minimal information on young people and their current needs and concerns. This does not provide staff with an

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Inadequate

opportunity to fully consider and understand the very complex, challenging and changing needs of each young person living in this home. A number of agency staff are currently being used to supplement permanent staffing vacancies and sickness leave. Information recorded, relating to agency staff used, is inconsistent and does not provide a clear sense of their skills or experience. An allegation was made by a young person about an agency staff member recently. There was no evidence recorded of all relevant checks being provided by the agency for this person. The manager was subsequently able to locate the missing information, but it is of great concern that this was not known or recorded initially.

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Inadequate

The manager of the home came into post in April 2016, following an internal promotion of the previously registered manager. An application for registration of the new manager has very recently been received by Ofsted. The manager has experience of working with children and young people in residential and other settings. He does not currently have a level 5 diploma, and would be required to undertake this if successfully appointed as registered manager, following interview. He presents as committed to ensuring positive experiences and outcomes for young people, but this inspection has identified a significant number of management shortfalls. The manager has failed to challenge the placing authority in relation to concerns about missing information and key documentation for some young people. When there have been concerns about the home not being able to provide safe and appropriate care and support to young people, the manager has failed to serve

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Inadequate

notice on placements or request urgent meetings with the placing authority. A placing social worker for one young person stated: ‘There is evidence, for all to see, that the match is not right or safe for this young person or other young people in this placement.’ It is of great concern that such views of a placing authority have not been challenged by the manager to ensure that young people’s needs are met. Management oversight and monitoring systems are poor and do not provide a clear sense of the concerns or actions being taken to address them. Management monitoring reports present inaccurate information. The most recent one stated that there had been no reported incidents of bullying. This is incorrect and does not reflect the bullying logs and records. The report also stated that risk assessments are regularly reviewed and updated. Several seen during this inspection had not been reviewed or updated and presented as unclear and out of date.

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Inadequate

An independent visitor comes to the home each month and provides a report, outlining any concerns and recommendations for improving the quality of care provided. Such reports provide valuable insight for the manager about all aspects of the care provided. The report from the independent visitor from June 2016 identified concerns about staff’s and managers’ ability to safeguard young people. It is of concern that several of the concerns raised from this visit have been identified during this inspection. This does not reflect strong or robust management oversight or action being taken to safeguard and promote the welfare of young people. A location risk assessment is in place for the home. The home is located next to a working farm, which could pose risks of harm to young people. There are also regular shooting parties, which take place at certain times of the year in the area. The manager has failed to ensure that such potential risks have been considered or

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Inadequate

included in the location risk assessment. This could place young people at risk of significant harm. Staff receive regular supervision and annual appraisals. Following allegations of staff abuse of young people, records do not consistently reflect what actions the manager has taken to ensure the safety of young people or the support offered to those members of staff. There is a lack of clarity about when staff have been allowed to return to work in the home. There is no evidence of risk assessments for some incidents when lone working with young people was stated as not being appropriate, and there is no clear reflection of outcomes of investigations by managers. Young people could potentially remain at risk due to such poor management oversight and practices.

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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

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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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