Children's home in Bournemouth, Christchurch and Poole

Inadequate

There are serious and widespread failures that mean children and young people are not protected, their welfare is not safeguarded and 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 home is not effectively led and managed. Leaders and managers have failed to improve and develop the service within the timescales set at the previous inspection in July 2016. This is the fourth inspection resulting in an inadequate judgement since October 2015.  Young people are not safeguarded effectively. Senior leaders have delegated the responsibility for managing child protection concerns to staff that do not have the required expertise to undertake the role effectively. As a result, concerns are not managed in line with the ‘Working together to safeguard children (2015)’ statutory guidance.  Leaders and managers have failed to vet and recruit agency staff safely. As a result, as a result a restraint took place during the inspection which inspectors judged to be excessive, this incident is being investigated by safeguarding authorities.  Leaders and managers have failed to ensure that records of all restrictive

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The children's home provision is inadequate because:

practices contain the required information. As a consequence, they are unable to effectively monitor and evaluate the use of physical interventions.  Although new staff have been recruited, significant weaknesses in staffing the home with staff who are not sufficiently qualified, skilled and experienced continue. Young people are not receiving consistent care and support provided by a stable and experienced workforce.  Permanent staff do not receive good-quality supervision and appraisal to enable them to reflect on their practice and the needs of the young people. Neither agency staff nor temporary staff who routinely work in the houses receive supervision. This weakness was also evident at the previous inspection.  Leaders and managers fail to provide evidence of young people’s progress or lack of progress.  Despite some improvements, the monitoring, evaluation and review of the quality of care provided in the home remain ineffective. In addition, the

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The children's home provision is inadequate because:

independent visitor’s monitoring does not assist leaders and managers in driving forward improvements.  The majority of residential accommodation continues to require significant improvements to provide young people with a comfortable home to live in.

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The children's home strengths

 The range of activities provided for young people are of good quality and take into account their interests.

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The children's home strengths

 The school attendance of young people is good.

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The children's home strengths

 Staff seek young people’s input in creating plans on how they like to be cared for, how best to communicate with them, their likes and dislikes. There is also evidence of parents having input into some of these plans.

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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

6: The quality and purpose of care standard (1) The quality and purpose of care standard is that children receive care from staff who (a) understand the children’s home’s overall aims and the outcomes it seeks to achieve for children; (b) use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential. (2) In particular, the standard in paragraph (1) requires the registered person to (b) ensure that staff (iv) provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background; (vii) provide to children living in the home the physical necessities they need in order to live there comfortably; and (viii) provide to children personal items that are appropriate for their age and understanding. (Regulation 6(1)(a)(b)(2)(b)(iv)(vii)(viii)) 30/11/2016

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Requirement Due date

12: The protection of children standard (1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

(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 14/10/2016 account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (iii) have the skills to identify and act upon signs that a child is at risk of harm; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; and (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; and (e) that the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12(1)(2)(a)(i)(iii)(v)(vi)(b)(e)

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Requirement Due date

13: The leadership and management standard (1) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that (a) helps children aspire to fulfil their potential; and (b) promotes their welfare. (2) In particular, the standard in paragraph (1) requires the registered person to (a) lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home’s statement of purpose; (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child; (d) ensure that the home has sufficient staff to provide care for each child; (e) ensure that the home’s workforce provides continuity of care to each child; (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

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Requirement Due date

30/11/2016 of care provided in the home; (g) demonstrate that practice in the home is informed and improved by taking into account and acting on (ii) feedback on the experiences of children, including complaints received; and (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. In particular, this monitoring should include the action points raised in the independent visitor’s report to improve practice. (Regulation 13(1)(a)(b)(2)(a)(c)(d)(e)(f)(g)(ii)(h))

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Requirement Due date

14: The care planning standard (1) The care planning standard is that children (a) receive effectively planned care in or through the children’s home; and (b) have a positive experience of arriving at or moving on from the home. (2) In particular, the standard in paragraph (1) requires the registered person to ensure (b) that arrangements are in place to (i) ensure the effective induction of each child into the home; (ii) manage and review the placement of each child in the home; and (iii) plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements agreed with the child’s placing authority. (c) that each child’s relevant plans are followed and (f) that staff help each child to access and contribute to the records kept by the registered person in relation to the child. In particular, the records need to demonstrate the progress children are making against their individual goals.

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Requirement Due date

(Regulation 14(1)(a)(b)(2)(b)(c)(f)). 30/11/2016

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Requirement Due date

19: Behaviour management and discipline. 14/10/2016 No measure of control or discipline which is excessive, unreasonable or contrary to paragraph (2) may be used in relation to any child. (Regulation 19(1))

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Requirement Due date

20: Restraint and deprivation of liberty

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Requirement Due date

No measure of control or discipline which is excessive, unreasonable or contrary to paragraph may be used in relation to any child. In particular, the staff carrying out the restraint need to be trained in the techniques they are using. (Regulation 19(1)) 14/10/2016

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Requirement Due date

21: Privacy and access The registered person must ensure that the privacy of children is appropriately protected; that children can access all appropriate areas of the children’s home’s premises; and that any limitation placed on a child’s privacy or access to any area of the home’s premises is intended to safeguard each child accommodated in the home, is necessary and proportionate, is kept under review and, if necessary, revised, and allows children as much freedom as is possible when balanced against the need to protect them and keep them safe. In particular, this applies to the use of observation holes in children’s bedroom doors and keypads on external and internal doors. (Regulation 21(1)(a)(b)(c)(i)(ii)(iii)(iv)) 31/10/2016

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Requirement Due date

25: Fire precautions After consultation with the fire and rescue authority, the registered person must take adequate precautions against the risk of fire, including the provision of suitable fire equipment in the children’s home and ensure, by means of fire drills and practices at suitable intervals, that persons working at the home and, so far as reasonably practicable, children are aware of the procedure to be followed in case of fire. This includes when children have personal evacuation plans. (Regulation 25(1)(a)(d)) 14/10/2016 32: Fitness of workers The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety. The registered person may only employ an individual to work at the children’s home, or, if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children,

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Requirement Due date

allow that individual to work at the home, if the individual satisfies the requirements in paragraph (3). The requirements are that the individual is of integrity and good character, the individual has the appropriate experience, qualification and skills for the work that the individual is to perform, and that full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. The registered person must take reasonable steps to ensure that any individual who is working at the home and who does not fall within paragraph (2)(a) and (b) is appropriately supervised while carrying out the individual’s duties. This includes the use of staff from external agencies who are caring for young people. (Regulation 32(1)(2)(a)(b)(3)(a)(b)(d)(8)) 31/10/2016

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Requirement Due date

33: Employment of staff The registered person must ensure that all employees undertake appropriate continuing professional development and receive practice-related supervision by a person with appropriate experience. (Regulation 33(4)(a)(b)) 30/11/2016

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Requirement Due date

40: Notification of a serious event The registered person must notify HMCI and each other relevant person without delay if a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation; an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; there is an allegation of abuse against the home or a person working there; a child protection enquiry involving a child is instigated or concludes; or there is any other incident relating to a child which the registered person considers to be serious. 31/10/2016 (Regulation 40(3)(a-e))

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Requirement Due date

44: Independent person: visits and reports The registered person must ensure that an independent person visits the children’s home at least once each month. When the independent person is carrying out a visit, the registered person must help the independent person, if they consent, to interview in private such of the children, their parents, relatives and persons working at the home as the independent person requires, and to inspect the premises of the home and such of the home’s records (except for a child’s case records, unless the child and the child’s placing authority consent) as the independent person requires. 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. The independent person’s report may recommend actions that the

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Requirement Due date

registered person may take in relation to the home and timescales within which the registered person must consider whether or not to take those actions. In particular, the independent person’s report needs of to be of a good quality and provide information which will aid the service in driving forward improvement. (Regulation 44(1)(2)(a)(b)(4)(a)(b)(5)) 31/10/2016

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Recommendations

To improve the quality and standards of care further, the service should take account of the following recommendation:  Records of restraint must be kept and should enable the registered person and staff to review the use of control, discipline and restraint to identify effective practice and respond promptly when any issues or trends of concern emerge. The review should provide the opportunity for amending practice to ensure that it meets the needs of each child. (‘Guide to the children’s homes regulations including the quality standards’, page 49, paragraph 9.59)

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Information about this children's home

The home is registered to provide care and accommodation for up to 36 young people who have autistic spectrum disorders and associated learning difficulties. At the time of this inspection, 12 young people had full-time or term-time placements, and four young people were accessing the short-breaks service. The residential accommodation comprises six houses. One of the houses is currently not in use. Five are located on the main school site, with a sixth house located in the local town. One of the houses on the main site is used as a short-breaks service. The house located in the local town is used for older young people in order to promote their independence. The short-breaks service was not open on the days of the inspection.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

19/11/2014 Interim Sustained effectiveness

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Inadequate

Weaknesses in the leadership and quality of care of this home continue to negatively affect the experiences and progress of young people. This is the fourth inspection since October 2015 that has resulted in an overall inadequate judgement. Despite work by leaders, managers and staff, action taken has not remedied the weaknesses. The newly appointed responsible individual recognises the majority of weaknesses and told inspectors, ‘There are fundamental flaws in the service.’ Accommodation in the on-site houses remains poor and does not provide young people with a comfortable, homely place in which to live. Some parts of the on-site houses were not clean or well organised. The group manager also identified this concern when undertaking a recent monitoring exercise. She is arranging a deep clean for the houses. The layout of the houses limits the development of young people’s independence and personal choice. Keypad locks remain in use to enter and exit the houses and

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Inadequate

are on kitchen doors and some bathrooms. Two houses continue to have and use observation holes in five young people’s bedroom doors, as a strategy to monitor them. Support plans describe the use of this strategy, but leaders and managers have not identified more creative solutions to monitoring young people, in order to meet their needs. Records are not maintained about when observation holes are used, nor is there a policy to ensure that young people’s privacy and dignity are maintained. The occupational therapist has started to audit the suitability of the houses to assess whether the accommodation supports the development of young people who have autism. To date, one house has been assessed and was rated as ‘needing major improvement to provide support and opportunities for the residents’. House managers have started to action some of the recommendations from the audit and have involved young people in making some improvements in

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Inadequate

their homes. As a result, some young people have been involved in redecorating their bedrooms and purchasing new rugs and storage boxes. These changes are important and a good start, but do not tackle the underlying concerns about the environment. The off-site home provides young people with a homely, personalised environment in which to live. There has been additional work to improve the decor and personalise the space for young people in this house since the previous inspection. Young people have been involved in making these choices. Staff have reviewed the young people’s files and red and amber support plans have been updated. There are a number of documents throughout the care plan that are not dated, so it is unclear when these were written or when they should be reviewed. Staff are now starting to record young people’s progress with their individual goals. However, this recording is not consistently documented in each of the houses or

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Inadequate

with each young person. As a result, it remains challenging for managers to evidence and to evaluate how well young people are doing. A new system to measure young people’s outcomes has been implemented and is being trialled with two young people. It is too early to determine whether this system will be successful. There continues to be instability in the workforce. Leaders and managers are continuing to recruit new staff and are managing the additional vacancies through the use of temporary staff. Consequently, staffing ratios are met, but result in a large number of different adults caring for the young people. This approach does not support the needs of the young people who live in the home. All staff spoken to during the inspection raised concerns about this. It was evident that some staff know the young people well. In these cases, positive relationships and good interactions were seen. However, some other staff were not

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Inadequate

purposeful in their interactions with the young people and, at times, were observed to be ‘hovering’ and not engaging well. During the inspection, these staff members were not given enough direction or coaching from managers to improve their interactions with young people. Young people are able to take part in a range of activities both on and off site. They are supported to choose the activities they wish to take part in. On site, there is a swimming pool and several play areas. Young people are able to ride their bicycles safely around the site and use local facilities, such as the leisure centre. Staff reported that off-site activities depend on staffing levels available to support young people.

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Inadequate

Safeguarding practices are ineffective. Senior leaders have not ensured that staff responsible for managing child protection concerns have the required expertise or support to undertake the role effectively. As a result, child protection concerns have not been managed in line with statutory guidance. Two allegations were investigated prior to them being reported to the local area designated officer. Ofsted was not notified of these serious incidents as required by the children’s homes regulations (2015). The internal investigations were of poor quality and failed to identify evident discrepancies in the concerns. In addition, senior leaders have advised staff to refer all safeguarding incidents to the local authority designated officer, regardless of whether the concerns relate to adults working with children. This practice is not in line with ‘Working together to safeguard children (2015)’. Behaviour management systems remain ineffective. There have been 41 physical

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Inadequate

interventions since the previous inspection in July 2016. A number of staff have been injured during these incidents. Leaders and managers, in partnership with a placing authority, employed agency nurses to provide care for a young person as it was determined that internal staff could not meet his complex needs. Leaders and managers failed to ensure this young person’s safety, as they did not gather information on the physical intervention training that these staff have received. Furthermore, leaders and manager did not ensure that restraint techniques that the agency staff used on the young person were in line with the home’s policies. Records of physical intervention for one young person are inadequate, as staff do not comprehensively record what happened and how. This was particularly concerning as this young person was held by agency staff in a ground hold. Records are not effectively monitored by managers. As a result, information is not

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Inadequate

gathered to effectively improve or change practices to meet young people’s behavioural needs. In addition, medical checks are not routinely carried out on young people who have been restrained. Some young people who have moved houses since the previous inspection have still not taken part in a fire evacuation drill. This was a requirement at the previous full inspection. This failure could place young people at risk. Young people’s fire evacuation plans have been updated since the previous inspection to reflect their house move. During the inspection, medication was not managed safely. An incident occurred in which a member of staff directed another member of staff to administer medication that they had not witnessed being dispensed. Action was taken during the inspection to deal with this unsafe practice. At the time of the inspection, the behaviour support team had started to work with the care team to develop staff skills in managing behaviour. As a result, the

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Inadequate

behaviour team has attended care team meetings and is beginning to model good practice. In addition, young people’s behaviour support plans are being reviewed together. A system of sharing information and plans between the education and care teams has also recently begun, to provide consistent practice to young people. It is not possible to evaluate the impact of this work yet as they are recent developments. Young people’s individual risk assessments have recently been reviewed. These documents reflect the level of risk and ways in which staff will reduce it. There is a lack of evidence that all staff working with the young people have read these assessments, as the sign-off sheets for staff to complete after they have read the plans are incomplete.

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Inadequate

The school was last inspected during 19 to 21 July 2016, when it was judged inadequate in all areas. A monitoring visit took place on 23 August 2016. At that visit, the new group manager had commenced her role and there was a new responsible individual in post. The responsible individual and group manager have started to evaluate the quality of provision and, as a result, demonstrate a stronger understanding of the strengths and weaknesses of the home. An action plan to tackle some of the weaknesses already identified in the service has been implemented, and senior staff have kept Ofsted informed of their development. However, there has been insufficient progress, since the previous inspection, to improve the service. Seven of the 10 requirements and the recommendation issued at the previous inspection have not been met. The house managers lack experience to undertake their roles successfully. House managers are starting to receive supervision and

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Inadequate

direction from the new group manager, and there are longer-term plans in place to develop their roles further. Uncertainty in the workforce continues. Since the previous inspection, eight members of the care staff have left the organisation. There have been 10 new staff employed, but significant staff vacancies remain in two of the houses. These gaps are still being covered by temporary staff and staff working overtime. In one house, there was evidence of 40 different staff members working in the house in one month. This is double the number of adults required. As a result, young people are not provided with the certainty of who will care for them or the stability they need. Staff are still not receiving good-quality supervision or annual appraisals. In addition, temporary staff who undertake regular work in the home are still not receiving supervision. This weakness means that their work with the young people is not

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Inadequate

reviewed and they are not helped to develop. This weakness was evident at the previous inspection, and insufficient action has been taken to rectify it. Since the previous inspection, the independent visitor has changed. The monitoring by the visitor does not assist the staff in driving forward necessary improvements. In addition, one house did not have a visit in August 2016. The house manager’s monitoring of each of the homes has improved, but it still lacks evaluation of the impact of the improvement work. The lack of this evaluation means that trends and patterns are not identified and cannot then be used to develop practice. The group manager is working with the house managers to improve the quality of this monitoring.

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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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