Children's Home run by Bristol City Council in Bristol

inspection

Compliance notice issued under section 22A of the Care Standards Act 2000 on 8 July

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Inadequate

There are serious and/or widespread failures that mean that 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:

 There are serious and persistent failures by the home’s managers to identify and act on weaknesses in how the home is run. Specifically, managers have failed to act upon hazards to health and safety. Managers have also failed to ensure that young people’s risk assessments are kept updated.  The registered manager has failed to notify Ofsted of at least two serious incidents.  Although some progress has been made, the home’s managers have failed to take action to deal with all the deficits in the quality of the environment, some of which were first identified at the full inspection 12 weeks ago.  Managers have failed to ensure consistent and effective staff recording practice. Specifically, they have not ensured that there is an effective system to record serious incidents. The young people’s key working and other records have not been completed in a timely and appropriate manner, and these records are not always accessible to all the staff on duty.

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The children’s home provision is inadequate because:

 It was a challenge for staff and senior managers to locate some documents during the inspection and, in particular, the accident book was missing. The registered manager was on leave, yet there should be systems in place that can be accessed by others in her absence.  The home relies on the continuing high level of use of casual, and sometimes agency, personnel. Some casual staff do not know to whom they are accountable, because there is lack of clarity about reporting lines.  On the day of the inspection, managers had no accessible system in place to monitor staff training. In addition, they had not provided appropriate supervision and training for casual staff to provide them with essential skills.  Managers have failed to ensure that, when young people go missing, they receive a ‘return home’ visit from their social worker or an independent person within the timescales specified in the statutory guidance. A protocol

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The children’s home provision is inadequate because:

has now been put in place, but it is not being operated effectively.

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The children’s home strengths

 The team of permanent staff, all hold a relevant qualification at level 3. The team is ethnically diverse, and represents a range of ages and genders.  Some young people have flourished in the home. Outcomes for them have improved, because there have been only two residents in recent weeks, and the atmosphere has been relatively settled and calm.  Some of the young people continue to attend college and are making good progress. They continue to receive support to have strong cultural links with their own ethnic community, while integrating well into life in this country.  The external appearance of the front of the home has improved. The heavy- duty rails at the sides of the path have been dismantled and removed. The area has been grassed over so that the home blends in with other properties in the street.  The bedroom of a previous resident has been refurbished and redecorated to a good standard, ready for a new admission. The room is bright and

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The children’s home strengths

cheerful, with attractive artwork and a child-friendly theme.  One young person has a life-story book, which has been prepared by a member of staff in their own time. This book reflects the young person’s national culture and traditions, and has clearly been undertaken with great care and commitment.  Permanent members of staff work well to help the young people with their independence skills. Some staff have set up a cookery club to help the young people to learn to prepare home-cooked, wholesome food. The quality of care provided to some individual young people has helped them to make difficult transitions and to progress towards independence.  There is a residential services improvement programme in place which has involved the staff and the young people. The recommendations arising from this piece of work have been submitted to senior leaders.

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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 ‘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

6: The quality and purpose of care standard

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Requirement Due date

In order to meet the quality and purpose of care standard, with particular reference to the removal of institutional features and upgrading the quality of the accommodation to promote a homely, comfortable, domestic environment, including refurbishing the young people’s bathroom, replacing water- damaged doors, taking action to resolve the problem with condensation in the laundry cupboard, replacing damaged carpet and providing domestic-style tables or desks in the bedrooms, the registered person must— (2)(c)(i) ensure that the premises used for the purposes of the home are designed and furnished so as to meet the needs of each child. 31/10/2016

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Requirement Due date

In order to meet the protection of children standard, with particular reference to updating young people’s risk assessments when there is a change in circumstances; ensuring that food is stored correctly to prevent spoilage and potential harm to health, and that sharp objects and other obvious hazards are removed from the home promptly, the registered person must— 12.—(1) ensure 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; (vi) take effective action whenever there is a serious concern about a child’s welfare. 31/10/2016 33: Employment of staff

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Requirement Due date

33(4) The registered person must— (b) ensure that all employees receive practice-related supervision by a person with appropriate experience.

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Requirement Due date

In particular, ensure that staff, including casual staff, receive regular, effective and well-recorded supervision appropriate to their level of experience. (Regulation 33(4)(b)) 31/10/2016

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Requirement Due date

40(4) 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; or (ii) concludes (in which case, the notification must include the outcome of the child protection enquiry); or (e) there is any other incident relating to a child which the registered person considers to be serious. (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; and (iii) any actions taken by the registered person as a result of the

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Requirement Due date

matter; (b) must be made or confirmed in writing. (Regulation 40(4)) 31/10/2016

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Requirement Due date

{an asterisk is added in the table above where Compliance = ‘Y’} * 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 recommendations:

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Recommendations

 Ensure the children’s home seeks as far as possible to maintain a domestic rather than ‘institutional’ impression. In particular, this relates to the exterior presentation and interior decoration of the home. (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9)

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Recommendations

 Ensure that a record of supervision is kept for staff, including the manager. The record should provide evidence that supervision is being delivered in line with regulation 33(4)(b). (‘Guide to the children’s homes regulations including the quality standards’, page 61, paragraph 13.3)

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Recommendations

 Ensure that when a child is found, they are offered an independent return interview. Independent return interviews provide an opportunity to uncover information that can help protect children from the risk of going missing again, from risks they may have been exposed to while missing or from risk factors in their home. The interview should be carried out within 72 hours of the child returning to their home or care setting. This should be an in-depth interview and is normally best carried out by an independent person (i.e. someone not involved in caring for the child) who is trained to carry out these interviews and is able to follow up any actions that emerge. (Statutory guidance on children who run away or go missing from home or care (January 2014), paragraphs 31 and 32)

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Information about this children’s home

This local authority children’s home is registered for up to five children and young people, irrespective of gender, who may have emotional and behavioural difficulties. The responsible individual has agreed to a temporary restriction to four young people until works to the home have been completed. The home’s remit is to take short-term and emergency admissions.

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Inspection date Inspection type Inspection judgement

30/06/2016 Full Inadequate 23/03/2016 Interim Sustained effectiveness 21/10/2015 Full Requires improvement 19/02/2015 Interim Sustained effectiveness

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Inadequate

The home remains inadequate, because the experiences and outcomes for the young people have been negatively affected by major shortfalls in safeguarding, leadership and management. These include hazards to health and safety, and a lack of rigour in management monitoring.

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Inadequate

Managers have failed to extrapolate learning from the first inspection to this one. New problems found on this occasion suggest that, while individual issues raised at the first full inspection have triggered some action, this has been neither sustained nor reliably applied to new challenges. This means that the ‘bigger picture’ has been missed. The home still lacks aspiration, and fails to meet a number of quality standards and regulations.

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Inadequate

Four requirements and three recommendations have been repeated, and an additional requirement has been made under Regulation 40. A new compliance notice has been issued under the leadership and management quality standard.

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Inadequate

The registered manager was on leave during the inspection, so has not had the opportunity to respond to the shortfalls found. There were ineffective deputising arrangements in place, because a number of key documents could not be located in her absence. Some management monitoring material was produced during and after the inspection, but this relied on hard work on the part of an acting team leader who came to the home to support the inspection process.

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Inadequate

By the end of the inspection, there was a new training matrix in place and some of the training deficits for casual staff were in hand, but the team had still not, despite their best efforts, been able to locate the missing accident book. Because the home has failed to notify at least two serious incidents to Ofsted, it is clear that these matters are not always recorded and escalated appropriately. This means that the regulator is not always provided with accurate and up-to-date information required tobe confident that young people are suitably safeguarded.

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Inadequate

Although relationships between staff and the young people are positive, there is insufficient evidence that effective key working is taking place. The last key-worker meeting recorded on one young person’s file was three months ago, on 21 June. Key-working records may be stored on the computer, but if this is the case, they are not accessible to all the staff and young people in the home. Placement plans are not kept updated as required. Some log book entries have not been filled in. No consequences have been recorded in response to recent serious damage to the home, apart from one young person being charged £1 to replace a broken mug. At best, this is poor recording and, at worst, it indicates that there is no clear behaviour management strategy.

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Inadequate

There are now only two young people in the home. Apart from a small number of recorded incidents, the atmosphere is calmer and more settled. It is a positive that the registered manager has resisted new admissions when she identified that the home could not meet the young people’s needs. There have been some improvements to the young people’s quality of life. Both appear to be relatively settled, at present, and they get along together.

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Inadequate

The young people confirmed that they been offered their own door keys to their bedrooms. One young person chose not to have a key, and the other does have a key but does not use it. He said that the reason that this is no longer necessary is that he trusts other people in the home, now. This is a very positive comment and reflects a major change in the atmosphere in the home.

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Inadequate

The young people are consulted about plans for the home. One young person came on a tour of the home with the inspector and staff, and put forward some ideas. The residential services improvement plan has now been submitted to senior leaders, but no decision has yet been made about the future development of the home.

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Inadequate

Activities during the college holiday period have been varied, and it is clear that staff have worked hard to engage young people and find them interesting things to do. The young people enjoyed zip wiring, trips to London and Thorpe Park, bowling, film nights, walks and visits to local attractions. The staff should be commended for this, because young people in their later teens are not always easy to persuade to engage in activities outside their own peer group.

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Inadequate

One young person continues to progress well in his education and has entered the second year of a college course. This young person is currently gaining experience through observation at a friend’s barber’s shop to help him to decide on a future career.

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Inadequate

The young people now participate in a cookery club, led by a member of staff who has encouraged them to try new home-cooked food rather than relying on ready meals and processed foods. This has been successful and, although both young people eat a number of their meals outside the home and their intake is difficult to monitor, those meals taken in the home are much improved.

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Inadequate

The young people continue to receive sensitive support to follow their own cultural heritage. Halal meat is provided, and one young person is free to visit his place of worship whenever he wishes to and to maintain links with his own community.

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Inadequate

Relationships between the staff and the young people are good. The staff team is skilled and experienced in working with young people who are approaching independence, and both of the young people appear happy and settled, even though they know that they will soon have to move on. They have their own space in the kitchen and are learning how to cook and take care of themselves. Staff cook a roast dinner each Sunday, which the young people enjoy.

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Inadequate

The home is inadequate in this outcome area and overall, because there has been a failure to identify and act upon hazards to health and safety. In addition, there are continuing shortfalls in the quality of the environment.

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Inadequate

Despite a previous requirement about risk assessments for the young people, which should have triggered a rigorous review of these documents, these are not always updated when there is a significant change in risk. In addition, there is no coherent or reliable system for recording serious incidents and, consequently, no trigger to prompt managers to notify relevant matters to Ofsted. As a result, at least two serious incidents have not been notified to the regulatory body. Two requirements have been made.

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Inadequate

The appearance of some areas of the home does not demonstrate any sense of ownership or pride. However, some of the staff have used their own initiative to redecorate and bring their flair for interior design to the programme of improvement. This is shown in the quality of the decor in the three bedrooms that have been completed.

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Inadequate

Shards of broken glass, wedged in a damaged photograph frame, had been left on the landing where the young people could access them. The inspector had to ask for this frame to be removed to a safe place. The fire-damaged carpet on the landing was due to be replaced, but this has been put on hold pending a decision about structural work to one of the bedrooms. This work has not yet been agreed by senior leaders, so the whole process has stalled.

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Inadequate

The young people’s bathroom has damage to tiles and the door closure, and the shower rail and curtain have been pulled down. The door is dirty and requires either replacement or redecoration. The separate wet room’s door is peeling, because it has been damaged by moisture. In addition, there is damp and mould in the small laundry cupboard in the kitchen, likely to be due to poor ventilation. This requires a qualified person to survey and carry out remedial work, and this may involve relocation of the laundry facilities.

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Inadequate

One of the cupboard doors downstairs has a prison-style steel plate riveted onto it to house the lock. All the young people’s bedrooms have thick, wooden built-in benches that cannot be moved, instead of a table or desk. These features are highly institutional in appearance and have no place in a children’s home that is not part of the secure estate.

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Inadequate

There is an old mattress outside on the patio, which is unsightly and unhygienic. Although the appearance of the front of the building has been improved by removing the rails at either side of the pathway, the side and rear of the building still do not provide a homely, attractive space for the young people to enjoy. There are staff who are keen gardeners, but the garden is underdeveloped, because there has been no project leadership to guide improvement.

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Inadequate

Food is not always stored correctly. Although food in the fridge was covered and labelled, two large bags of potatoes, which should be stored in a cool, dark and dry place, had been left on a kitchen worktop. Many of the potatoes were going green, indicating high levels of potentially toxic glycoalkaloids. When the inspector pointed this out, the deputy manager discarded the potatoes, but this should have been identified and actioned before the inspection.

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Inadequate

On the positive side, the number of serious incidents and going missing from home have reduced since the first full inspection. This is due to some young people moving on from the home and, more recently, to court-imposed restrictions which limit their movements at certain times of the day. The home has introduced a protocol to guide staff when each young person goes missing. This includes provision for a return-home interview, but the registered manager has still not ensured that the independent person designated to conduct this actually visits the home. Staff ask the young person whether they wish to be visited. This leaves a loophole in the system, and it is theoretically possible for young people not to be consulted. They should receive a visit from the independent person, and only then should a refusal to see the visitor be accepted. The recommendation has been repeated. There have been no child protection concerns in relation to the home since the last

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Inadequate

full inspection, and no referrals to the local authority designated officer. Staff continue to receive regularly updated training in physical intervention. There have been no restraints or complaints since the last full inspection. Judgement grade

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Inadequate

The impact and effectiveness of leaders and managers are inadequate because, although some action has been taken to respond to the requirements made at the last full inspection, new shortfalls have been found that should have been identified through the home’s own internal and external monitoring processes. Deficits in management monitoring include an apparent lack of any system to track staff training and monitor the quality of written records. Failure to monitor and improve the quality of the environment has been described above.

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Inadequate

Staff training was reviewed on this inspection. All the core team members have received essential training to equip them to do the job, and all hold a qualification at level 3. They have not yet had more specialised training to help them to meet individual young people’s needs, for example against child sexual exploitation and self-harm or on autistic spectrum disorder. Training to counter child sexual exploitation and self-harm has been booked to take place in the near future. Some casual staff team members report not having received the most basic training in food hygiene, first aid, health and safety and fire awareness. Most have received training in safeguarding, but one person on shift during the inspection had not been updated in this area for approximately five years. Child protection training had been booked for several members of the casual staff team last year, but they were unable to attend.

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Inadequate

At the start of this inspection, there was no completed list to show the training completed by the permanent or casual staff, and where the deficits are. The training matrix could not be located, so the acting team leader constructed one for the permanent staff using a template from the home for which she is also registered manager. After the inspection, the team leaders produced a second spreadsheet showing when the casual staff had received, or were booked to attend, child protection training. All other course dates, for example for first aid and food hygiene, were blank. Communication is a problem in this home. The managers’ failure to ensure consistent and robust case file recording has already been described. A number of records are no longer being printed off and filed. The casual staff do not have a log-in to the home’s computerised records. This means that they have to rely on colleagues to give them access or to tell them what has happened since they were

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Inadequate

last on shift. This is not a reliable system.

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Inadequate

Team meetings have not been held regularly since November 2015. There have been team ‘away days’ and other special meetings which have been useful, but there was no new programme of dates for the coming months until this shortfall was highlighted during the inspection. The staffing situation is unchanged since the previous inspection. There are still two staff on most shifts, and a permanent post has been advertised to fill the position left by a member of staff who has moved on. Two staff who were on long- term sickness absence are now back at work. The reduction of numbers of young people in the home to two has had a positive impact, and staff say that the situation has improved. However, the home still relies heavily on casual and, on occasion, agency staff to support the shifts. Progress on the requirements and recommendations from the previous full inspection has been variable. The shortfalls found at this inspection have led to a

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Inadequate

new requirement being made under regulation 40 and four requirements being repeated. Although there are now regular supervision meetings planned and taking place for the permanent team members, casual staff do not receive regular supervision. One of the team leaders said that if casual staff work regularly in one particular home, the registered manager of that service is responsible for ensuring that they receive supervision. This has not happened, and one casual staff member could only recall receiving one supervision this year. The requirement made under regulation 33 has been repeated, as has the recommendation to improve supervision recording, because this still lacks clarity and detail.

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Inadequate

The requirement under the quality and purpose of care standard to improve the quality of the environment has now been repeated for the third time. Safeguarding and management shortfalls have resulted in repeated requirements under the protection of children and leadership and management quality standards.

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Inadequate

Four requirements made at the first full inspection are now met, or are no longer relevant. These relate to the need to review the statement of purpose and to ensure that there are fire drills at recommended intervals. A minor amendment was made to the statement of purpose during the inspection to provide the correct information about the frequency of fire drills. The requirement regarding privacy and access for the young people to all parts of the home has been met. The requirement made at the last inspection regarding a member of staff who did not have a certificate of good conduct has not been repeated, because this person has now left the home. Four of the seven previous recommendations have been met. These were in relation to the mix of young people in the home, their free access to all communal areas of the home, the quality of their diet and establishing a protocol for when they go missing. Three recommendations have been repeated.

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Inadequate

There are some areas that could not be inspected in full, on this occasion. The deputy manager said that the manager has reviewed the system for recording complaints, but there have been no complaints since the last inspection, so the new system has not yet been implemented. The home has not accepted any new admissions since the last inspection, and so neither has the managers’ ability to match young people been fully tested. There is now a compatibility risk assessment process in place and this has been effective, in that managers have decided not to accept several potential placements. This shows that managers now have more confidence in asserting their views in order to ensure an appropriate mix of young people. The responsible individual has led the residential services improvement project to identify and resolve areas for development in this home and the local authority’s other children’s homes. The project has progressed, in that it has now been

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Inadequate

completed and submitted to senior leaders for a decision, but the outcome is not yet known.

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Inadequate

The staff spoken to remain very committed to their work. They are pleased to have been consulted about the local authority’s plans and can see that there have been improvements to the service in some areas. The staff team remains very diverse, enthusiastic, experienced and well qualified in terms of members’ level 3 awards. Some staff are highly motivated and have completed work in their own time that should be part of their paid remit. Others have come into work to fill in gaps between shifts to avoid letting the young people down.

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Inadequate

The home now needs to build on its strengths, while monitoring and acting on any new weaknesses that arise. These changes need to be secured while the home is relatively stable and before the admission of any young people in crisis.

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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’. 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

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What the inspection judgements mean

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 harmed or at risk of harm or 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 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

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Information about this inspection

Homes (England) Regulations 2015 and ‘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 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 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

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

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