Children's home run by Tumblewood Project Limited in Wiltshire

The children's home provision is inadequate because:

 Young people are not kept safe. Significant incidents, including bullying, risky behaviours and violence between young people and against staff have occurred.  Managers and staff have failed to manage young people’s behaviour effectively and protect them from harm. Young people have either witnessed or have been directly involved in incidents of violence or bullying.  Leaders and managers consistently fail to follow safeguarding procedures and repeatedly fail to inform Ofsted of all serious events as required.  The home has operated without a registered manager for 11 months.  Leaders and managers have not taken effective action to deal with all of the weaknesses identified in previous inspections.  Sanctions are not consistently applied by the staff team.  Young people do not always receive opportunities to talk about incidents and say how they feel following episodes of physical intervention.

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The children's home provision is inadequate because:

 Young people continue to move between houses because of incompatibility and concerning incidents that put themselves and each other at risk.  The home has deteriorated in terms of its cleanliness and maintenance.

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The children's home strengths

 Leaders and managers have developed some positive relationships with agencies.  Some young people are proud of their progress and educational achievements.

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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 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

11: The positive relationships standard In order to meet the positive relationships standard, the registered person must ensure that children are helped to develop, and to benefit from, relationships based on— (a) mutual respect and trust; (b) an understanding about acceptable behaviour; and (c) positive responses to other children and adults. (2) In particular, the registered person must ensure— (a) that staff— (i) meet each child's behavioural and emotional needs, as set out in the child's relevant plans; (v) communicate to each child expectations about the child's behaviour and ensure that the child understands those expectations in accordance with the child's age and understanding; (vi) help each child to understand, in a way that is appropriate according to the child's age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful; (vii) help each child to develop the understanding and skills to

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Requirement Due date

recognise or withdraw from a damaging, exploitative or harmful relationship; (x) are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same; (xi) de-escalate confrontations with or between children, or potentially violent behaviour by children; (xii) 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. 24/10/2016

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Requirement Due date

12: The protection of children standard 24/10/2016 In order to meet the protection of children standard, the registered person must ensure that children are protected from harm and enabled to keep themselves safe. In particular, the registered manager must ensure that staff— (a)(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; (ii) help each child to understand how to keep safe; (iii) have the skills to identify and act upon signs that a child is at risk of harm; (iv) manage relationships between children to prevent them from harming each other; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; (vi) take effective action whenever there is a serious concern about a child's welfare; and

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Requirement Due date

(vii) are familiar with, and act in accordance with, the home's child protection policies. In addition, reduce unnecessary police involvement in managing behaviour and criminalisation of behaviours.

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Requirement Due date

13: The leadership and management standard In order to meet the leadership and management standard, the registered person must— (1) 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. (2)(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; (f) understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home; (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. Ensure that staff are regularly supervised to ensure staff's care of young people meets their needs and ensures their safety.

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Requirement Due date

Ensure that staff investigations are fully completed. Ensure that there is a consistent and safe approach to behaviour 24/10/2016 management.

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Requirement Due date

14: The care planning standard In order to meet the care planning standard, the registered manager must ensure that young people— (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)(b) that arrangements are in place to— (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. 24/10/2016

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Requirement Due date

35: Behaviour management policies and records The registered person must ensure that within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made and within five days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(c)) 24/10/2016

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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) 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. (Regulation 40 (4) (a–e)) 15/10/2016

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Information about this children's home

This children’s home operates as a therapeutic community for a maximum of 15 girls with emotional and behavioural difficulties. The community is run by a private organisation that offers residential care alongside therapeutic intervention including counselling, play therapy and psychiatric support. Children and young people attend the on-site school.

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Recent inspection history

Inspection date Inspection type Inspection judgement 13/07/2016 Full Inadequate 22/03/2016 Interim Declined in effectiveness 02/12/2015 Full Requires improvement 19/02/2015 Interim Improved effectiveness

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Inadequate

Leaders and managers do not operate the home effectively to ensure that young people are kept safe and protected from harm. Managers do not acknowledge the severity of destructive, aggressive, bullying and risk-taking behaviours, despite incident reports that document the level of violence between the young people and assaults against staff. Children and young people are living in a chaotic and stressful environment. Although some children have made some progress within the home, overall their experiences and progress have been adversely affected as a result of poor behaviour management. Children and young people experience too many moves within the setting that negatively impacts on their ability to form and sustain positive relationships with staff and other young people. Managers fail to thoroughly risk assess young people or ensure young people’s behaviours do not impact negatively upon each other. As

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Inadequate

a result, young people are too frequently moved when their poor or anxious behaviour escalates or relationships between the young people break down. Two of the 10 young people are now resident in separate houses and living alone because of peer bullying and incidents of violence. Documentation maintained by staff does not clearly include targets for individual young people with evidence of their corresponding progress. Staff report anecdotally on the progress that individual young people make. Managers did not provide written evidence to demonstrate young people’s progress. Leaders and managers have not ensured that the home is clean and well- maintained. Some refurbishment has been undertaken since the previous inspection, including the replacement of a carpet and decorations to make the houses more homely. However, during this inspection, the home was not clean throughout. There were splinters of glass from smashed windows left on the

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Inadequate

window sill in the reception area. Windows are boarded up but new panes of glass have been ordered. Swear words were written on a wall with no evidence of attempts to remove them. There remains fire signage in parts of the home that is not typical of a domestic, family style home. Complaints from young people are now being collated and responded to. Young people have made 14 complaints over the last two months, indicating that they understand how to make a complaint. This requirement from the previous inspection is met. Some young people do very well at school and are proud of their educational achievements. Several young people are attending different clubs and activities. Staff were observed to support young people in a caring and sensitive manner and young people responded positively to them. Parents contacted by inspectors speak well of the home.

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Inadequate

Leaders, managers and staff fail to keep young people safe. Significant incidents which include peer bullying, violence between children and violence against staff have occurred. Managers and staff have been unable to effectively intervene to ensure that young people are kept safe. This led to an incident where young people barricaded the main gate and two other young people severely threatened and bullied another child resulting in her attending hospital. Two young people later damaged a young person’s bedroom, including destroying precious items, to the point of it becoming uninhabitable. This included smashing the window and breaking down the door while the young person was in the bedroom. Staff failed to stop this violent behaviour. The home’s incident reports record that the young person said, ‘I need to leave. I’m not safe here.’ The young person then had to leave the children’s home with a member of staff, returning later in the evening when it was safe to do

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Inadequate

so. Staff have failed to clean and repair the damaged ground floor bedroom that is easily visible when walking past. This damage serves as a reminder for the young person and others of the incident that occurred. Two other young people have broken windows at different times, to a frequency that led to managers being confused as to which windows had been broken and when. The homes incident reports record that a young person was found walking on the roof tops and was only persuaded to come down by another young person. When one young person witnessed another young person assaulting staff, the home’s incident report states that she said, ‘I can’t take it anymore. I hate it. It’s too much.’ There are numerous incident reports that document violence between the young people and assaults against staff, demonstrating that staff have lost control of the situation. The reports indicate that young people are living in a chaotic and

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Inadequate

stressful environment. Since the previous monitoring visit on 17 August 2016, the police have been called to manage young people’s behaviour on four occasions. On one of these occasions, a member of the public called the police because they were so concerned. A young person was running in and out of traffic and a staff member used a non-accredited hold to prevent the young person from pushing them into the traffic. Both the young person and another child who witnessed the incident were distressed. On another occasion, a young person crossed a railway track and walked on a road, resulting in cars swerving to avoid her, necessitating a staff member to make an emergency call to the police. As a result, staff are not protecting young people from harm. Some staff do not feel safe in some situations and do not feel supported by managers. In particular, they feel unsafe when the most vulnerable young people

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Inadequate

become stressed or anxious which then impacts negatively on the other young people. Staff do not feel confident that they are supported to reinforce boundaries and records show that sanctions are not consistently applied. Managers and staff do not follow up safeguarding allegations made by young people in accordance with safeguarding procedures. The head of programme and care and the newly appointed manager were not aware of which outstanding allegations needed to be dealt with. As a result, managers cannot be sure if young people are safe. A fourth consecutive requirement is now made in relation to the protection of children standard. Physical intervention is used as a last resort. Staff now restrain young people less, for a minimal time and with minimal force. This is an improvement following on from a previous compliance notice. However, young people are not always spoken to about the restraint and this weakness was raised at a previous inspection on 2

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Inadequate

December 2015. As a result, young people are not given an opportunity to understand why they were restrained, say how they feel and helped to restore relationships. Leaders and managers failed to ensure that fire drills have taken place in the daytime since 15 June 2016 and night-time since 16 May 2016. Since these times, three young people live in a different house and three staff members have started employment and have not practised a fire evacuation drill. Managers have not ensured that a young person’s current medication needs are updated in the relevant documentation. Side effects of medication for one young person are not documented for staff to clearly see when administering medication.

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Inadequate

The home has operated without a registered manager for 11 months. During this period, three people have been in the management post. The first manager applied to become a registered manager but subsequently withdrew her application. The third manager has now been in post for one week. Instability within the management team has caused confusion and concern among staff and young people. Leaders and managers have demonstrated a lack of capacity to make and sustain improvements in all areas required by legislation. They have failed to consistently meet requirements and make any significant progress. Five out of the six requirements made at this inspection are repeat requirements from at least one or more of the previous three inspections in the last 10 months. The previous manager received one formal supervision from his manager during his two and a half month period of employment. The supervision did not identify or

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Inadequate

record any concerns. However, the head of programme and care did have concerns about the manager’s practice, such as not providing regular supervision to staff. These concerns were not raised or dealt with. The head of programme did not establish with the previous manager which significant child protection enquiries and allegations were outstanding. The head of care was unable to identify outstanding issues, deal with them in his absence or pass them on. Therefore, the new manager did not have a proper handover from the head of programme and care to equip her with the information needed to carry out her role effectively. In the last three inspections, a requirement has been made in relation to notification of serious events. A fourth consecutive requirement is now made as managers continue to fail to notify Ofsted of all significant incidents. An independent visitor comes to the home monthly to assist managers in their

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Inadequate

scrutiny of the quality of care. Reports from the independent visitor have highlighted shortfalls for managers to address. Reports have been provided to Ofsted. As a result, this notification is now met. Leaders, managers and staff generally have a positive relationship with other agencies. Although two social care representatives have commented on concerns about communication with the home, other social workers have praised the home and staff, not raising any concern about the young people that they are responsible for.

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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 looked after children is safeguarded and promoted. Minimum requirements are in place. However, the children's home is not yet delivering good protection, help and care for children and young people. A children's home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

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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 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 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

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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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