Children's Home run by Witherslack Group Limited in Lancashire

Inadequate

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

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The children’s home provision is inadequate because:

 Disproportionate, unnecessary and unsafe restraint practice leaves young people at risk of harm.  Ineffective de-escalation strategies do not safeguard young people.  A number of staff failed to recognise and report potential safeguarding concerns.  Inaccurate recording of significant events compromises young people’s safety and welfare.  Managers fail to carry out debriefs with all those involved in or witness to incidents of restraint. This means that staff and young people do not always have the opportunity to reflect on what has happened and to give their views.  Poor restraint practice undermines the development of positive relationships between staff and young people, which are based on mutual respect and trust.  One behaviour support plan does not take account of a young person having asthma. This does not promote his safety and well-being.  Not all young people feel safe, are able to talk to staff about their worries

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The children’s home provision is inadequate because:

and feel confident that they will be listened to.  Some consequences make young people feel uncomfortable, for example close supervision.  Ineffective monitoring fails to ensure that all aspects of care are delivered in a way that keeps each child safe and protected from harm.  Staff supervision is not always targeted to meet the individual needs of staff, and the quality of some supervision records is poor.  Managers fail to lead the home in a way that is consistent with the approach and ethos set out in the home’s statement of purpose.  Young people do not fully understand the electronic surveillance system used at night because it has not been explained well enough to them.

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The children’s home strengths

 Young people make progress with their education. They enjoy increased attendance and improved attainment levels.  Young people make progress from their starting points in different aspects of their development. For example, some young people develop independence skills, and others present less challenging behaviour over time.  Some young people achieve excellent outcomes. For example, two young people have recently moved on from the home on turning 18. One has just started university, and the other is working full time.  Staff prepare young people well for their next steps and, consequently, most young people make a successful transition to independence.  Staff fully support young people to maintain contact with their families. As a result, young people stay in touch with people who are important to them.  Staff help young people to understand difficult aspects of their care plan, when it may not be possible to act on their wishes and when action is taken

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Statutory requirements

This section sets out the actions which must be taken so that the registered person(s) meet(s) 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

7: The children’s views, wishes and feelings standard In order to meet the wishes and feelings standard, children must receive care from staff who: (1)(c) take their views, wishes and feelings into account in relation to matters affecting the children’s care and welfare and their lives. (Regulation 7(1)(c)) 09/12/2016

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Requirement Due date

11: The positive relationships standard In order to meet the positive relationship standard, the registered person must ensure that: (1) 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)(a)(xi) staff de-escalate confrontations with or between children, or potentially violent behaviour by children. (Regulation 11(1)(a)(b)(c)(2)(xi)) 09/12/2016

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Requirement Due date

12: The protection of children standard In order to meet the protection of children standard, the registered person must ensure: (2)(a) that staff (i) assess whether each child is at risk of harm, taking into account information in the child's relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered 09/12/2016 person;* (vii) are familiar with, and act in accordance with, the home’s child protection policies.* (Regulation 12(2)(a)(i)(v)(vii))

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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 (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; (c) ensure that staff have the experience, qualifications and skills to meet the needs of each child, specifically in relation to all aspects of behaviour management; (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(b)(2)(a)(c)(h)) 09/12/2016

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Requirement Due date

19: Behaviour management and discipline Ensure that no measure of control or discipline, which is excessive or unreasonable, is used in relation to any child. (Regulation 19(1)) 09/12/2016

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Requirement Due date

20: Restraint and deprivation of liberty Ensure that restraint in relation to a child is necessary and proportionate.* (Regulation 20(2)) 09/12/2016

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Requirement Due date

35: Behaviour management policies and records Ensure that within 48 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, the registered person, or a person who is authorised by the registered person to do so (‘the authorised person’): (i) has spoken to the user about the measure; and (ii) has signed the record to confirm it is accurate; and (c) within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they 09/12/2016 have spoken to the child about the measure. (Regulation 35(b)(i)(ii)(c))

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Requirement Due date

* 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:  Ensure that staff meet children’s basic day-to-day needs and physical necessities in the way that a good parent would. This is specifically in relation to supporting young people to maintain their bedrooms to a good standard. (‘The guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.7)  Ensure that any home using closed-circuit television (CCTV) or other monitoring equipment has a written policy describing how this will support the safeguarding and well-being of those living and working in the home, in accordance with regulation 24. In particular, the type of monitoring equipment should be explained and understood by young people. (‘The guide to the children’s homes regulations including the quality standards’, page 16, paragraph 3.16)  Ensure that the registered person has systems in place so that all staff, including

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Recommendations

the manager, receive supervision of their practice from an appropriately qualified and experienced professional, which allows them to reflect on their practice and the needs of the children assigned to their care. In particular, the frequency of supervision targeted to meet the individual needs of staff should be of sufficient quality and appropriate records kept. (‘The guide to the children’s home’s regulations including the quality standards’, page 61, paragraph 13.2)

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Information about this children’s home

This children’s home is registered to provide care and accommodation for seven children who have learning difficulties, as well as children who have emotional and behavioural difficulties. The home is operated by a private provider.

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Recent inspection history

Inspection date Inspection type Inspection judgement

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Recent inspection history

5/02/2016 Interim Improved effectiveness

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Recent inspection history

10/03/2015 Interim Sustained effectiveness

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Inadequate

The key judgement area of ‘how well young people are helped and protected’ is inadequate, due to the shortfalls identified at this inspection. In line with Ofsted frameworks, once this area is judged to be inadequate, the ‘overall experiences and progress of children and young people’ is also judged as inadequate. This inspection found serious safeguarding concerns including:  Incidents of disproportionate and unnecessary restraint compromise the safety and well-being of young people.  A failure by staff to recognise poor restraint practice and report it demonstrates that they do not fully understand their roles and responsibilities in protecting young people.  Inaccurate recording of significant incidents undermines transparency and the safe care of young people. Young people’s experiences of living in this home vary. Most young people can identify some staff that they like and with whom they can develop some good

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Inadequate

relationships. However, for those who experience poor restraint practice this undermines the development of positive relationships between staff and young people that are based on mutual respect and trust. One young person explained to the inspector that they felt unable to tell anyone about an alleged incident because ‘no-one listens and staff just stick up for one another’. Consequently, not all young people feel safe or are confident in talking to staff about matters affecting their care. Failing to create a safe environment significantly impacts on young people’s sense of security and well-being. Inconsistent behaviour management means that not all young people receive appropriate help and support to manage their own difficulties through positive relationships with staff. Furthermore, they fail to receive care from people who are good role models and show them acceptable ways of behaving. This impacts on

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Inadequate

young people’s ability to understand what is expected of them and to learn better ways of managing their feelings and behaviour. Not all young people’s bedrooms are kept in a reasonable state. This demonstrates a lack of care and attention. For example, the inspector found piles of clothes not put away, and they were subsequently crumpled up on windowsills, on the top of drawers and on the floor. Furthermore, one shower cubicle was mouldy. Thus, insufficient support is provided to young people to help them to look after their things, respect their rooms, and ensure that their space is clean and tidy. Some young people enjoy a range of activities, including scouts, ice-skating, swimming and going to concerts, and they participate in holidays tailored to meet their individual needs. Other young people said that there is not enough activity money and this means that there is not always enough for them to do. The

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Inadequate

registered manager and responsible individual are currently looking into this, to ensure that there is sufficient money to support all young people’s interests and needs. Four out of five young people’s statutory health assessments are outstanding and are not yet scheduled. Thus, staff fail to promote all aspects of young people’s health. However, the inspector identified some good practice. For example, when a young person first arrived at the home with an inhaler, there was no mention of asthma in his pre-placement information. Staff made sure that he went to the doctor for a review. In doing this, they ensured that he received medical help so that he could manage his asthma safely, and staff support him with this. Furthermore, staff refer young people to child and adolescent mental health services when necessary. This has resulted in a young person being diagnosed with a condition he is now treated for. This improves their concentration and learning

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Inadequate

capacity in school. All young people make progress educationally, and this is relative to their starting points. For example, a young person who was previously out of education for several months achieved 98% attendance in the first half term at his new school. One young person is currently working beyond expectations as he approaches his GCSEs, and another young person’s learning comprehension has increased by five years and four months in just one year. These examples demonstrate that staff support young people’s learning and, as a result, young people make some exceptional progress that is likely to improve their future life chances. Staff support young people well in their transitions to adulthood. Young people develop good independence skills and, as a result, they are well prepared emotionally and practically for their next steps. Two young people recently moved on from the home on reaching adulthood. One has started university, and the other

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Inadequate

is working full time and living independently. This demonstrates that some young people achieve excellent outcomes, and this is attributable to the good aspects of care that they have received. When appropriate, young people benefit from contact with their families or people who are important to them. Staff work hard to develop positive relationships with birth families, and young people benefit from seeing staff and families working well together. Staff sensitively manage complex contact arrangements in line with young people’s individual plans. Staff help young people to understand difficult aspects of their care plans, when it may not be possible to act on their wishes and when action is taken that is in their best interests. For example, one young person receives good support to enable him to express his views. Effective communication with his social worker, independent reviewing officer and advocate means that he receives help to understand his

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Inadequate

Safeguarding practice is poor and fails to protect young people and keep them safe from harm. Two young people reported concerns to the inspector about restraint practice. One said, ‘Restraint isn’t right’, and both made allegations that staff use inappropriate restraint techniques. As a result, not all young people always feel safe. The inspector examined incident records and CCTV recording, which highlight disproportionate, unnecessary and unsafe restraint practice that places young people at risk of harm. This seriously compromises young people’s safety and well- being. Members of staff involved in or witness to incidents of restraint inaccurately record events, and this undermines young people’s safety. Staff fail to recognise and report incidents of restraint that are not carried out in strict accordance with legislation. As a result, staff do not fully understand and fulfil their roles and responsibilities when it comes to protecting children and do not follow the home’s

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Inadequate

child protection policy or safeguarding procedures. Furthermore, as a result of inaccurate recordings, Ofsted lacks confidence and assurance that young people living in the home are being protected from harm. Managers fail to carry out debriefs with all those involved in or witness to incidents of restraint. This means that staff and young people do not always have the opportunity to reflect on what happened and express their views with someone independent of the incident. Ineffective de-escalation strategies employed by staff lead to incidents of restraint, which could be avoided. This places young people at risk of harm. Furthermore, it fails to equip young people with the skills to regulate their behaviour at times of difficulty, and this compromises their welfare. Young people receive a number of consequences for the same incident, and staff use the same consequence repeatedly. This raises questions about the

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Inadequate

proportionality and effectiveness of consequences. Young people dislike the imposition of ‘close supervision’, which involves increased support from staff and home-based activities for specific periods. Young people describe how staff follow them around, and one young person likened this to being ‘stalked’. A member of staff indicated that young people spend more time in their bedrooms during periods of close supervision in order to get some peace. It may well be that close supervision of young people is required in order to keep them safe, but it should not be carried out in a manner that makes young people feel uncomfortable. Young people’s perception of this consequence is compromising their experience of living in the home. Not all behaviour support plans account for young people’s individual needs. For example, one fails to incorporate strategies to safely manage a young person’s asthma, should physical intervention be required. As a result, staff fail to clearly

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Inadequate

identify and assess associated risks, and this has the potential to impact negatively on a young person’s health and safety. An electronic surveillance system operates at night, to further safeguard young people. At least one young person does not understand that CCTV takes photo images and so does not fully understand its use. This demonstrates that staff do not adequately explain to young people all of the strategies in place that are designed to keep them safe. Young people rarely go missing, and there have been just eight episodes since February 2016. When they do go missing, staff make efforts to locate them and ensure their safe return. Each child has a missing-from-home risk assessment that identifies their individual vulnerabilities and needs. Staff share information with the police and maintain good links with the missing-from-home coordinator. This good practice helps to minimise and manage risks relating to incidents of young people

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Inadequate

going missing. Staff work hard to minimise risks relating to sexually harmful behaviour. When necessary, young people receive a specialist assessment, which informs their risk management plans. Because staff follow these plans, they help to protect young people and those around them from harm. Managers promptly refer safeguarding concerns to the designated officer and placing authority social workers. Once senior managers became aware of the poor restraint practice within the home, this was promptly acted on. Immediate steps were taken during the inspection to safeguard young people, and an investigation was initiated.

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Inadequate

The manager was registered with Ofsted in June 2014 as part of this home’s registration process. She has recently completed the level 5 diploma in leadership and management, so is appropriately qualified. Poor management oversight fails to protect young people from harm. Monitoring systems are in place but they are not sufficiently robust because information is not scrutinised. As a result, managers fail to identify shortfalls in behaviour management and safeguarding practice. This means that leaders and managers miss opportunities to listen to, understand and act upon young people’s experiences. A lack of attention to detail results in other areas requiring improvement being overlooked by managers. For example, they have not identified that health assessments remain outstanding and that some personal education plans are missing. Furthermore, they have not recognised that a young person’s care plan contains out-of-date information. Ineffective monitoring means that managers do

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Inadequate

not prioritise young people’s safety and correctly identify areas for development. Leaders and managers do not learn from significant events that occur. For example, a young person sustained a significant injury during a restraint. This was investigated and found to have occurred accidentally. Some learning was identified: that staff need to take account of environmental factors, such as avoiding confined spaces, when entering into restraint situations. However, managers failed to disseminate this learning to staff. Thus, they have not used learning opportunities to improve young people’s safety and well-being. The statement of purpose contains the following information:  ‘Young people are at the centre of the work we do in trying to provide the most positive residential experiences possible. These are based on the core values of mutual respect and good parenting, respectful to the values of privacy, dignity, independence, choice, rights and fulfilment.’

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Inadequate

 ‘Processes are in place for the staff to ensure that they undertake their duties and ascertain the safety, health and well-being of the young people in the home at all times.’  ‘Team teach is an approach that promotes the least intrusive positive handling strategy, and a continuum of gradual and graded techniques, with an emphasis on verbal and non-verbal de-escalation strategies being used and exhausted before positive handling strategies are utilised … The home’s manager regularly monitors the use of physical intervention to effectively analyse trends and patterns to provide learning opportunities for staff and young people to seek to avoid the use of physical intervention wherever possible.’ Given the shortfalls identified during this inspection, managers are failing to lead the home in a way that is consistent with the approach and ethos set out in the home’s statement of purpose. This means that the registered person is not fully

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Inadequate

promoting and protecting young people’s welfare. Although staff say that they generally feel well supported, the frequency and quality of supervision for some staff does not meet their individual needs. The quality of supervision records is variable, and some records are missing. Furthermore, the registered manager has had three different supervisors since the interim inspection. This has now been rectified, but it demonstrates a lack of consistent support. Supervision practice does not, therefore, ensure and monitor standards in care practice for vulnerable young people. Staff access a range of training and development opportunities and they complete mandatory and specialist courses. Despite this, training is not always effective. For example, although leaders and managers responsible for supervising staff have all completed relevant training, the quality of supervision is variable. Furthermore, although all staff receive restraint training twice a year, this has failed to ensure

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Inadequate

that staff respond appropriately and safely to young people’s challenging behaviour. Ineffective training does not equip staff with the skills, knowledge and understanding to meet the needs of young people. Managers are able to demonstrate that children and young people make good progress. Most young people achieve positive outcomes. For example, one young person recognises the improvements that she has made in her behaviour and acknowledges that staff have helped her to turn her life around. A virtual school representative commented on the ‘fantastic progress’ made by a young person, and an independent reviewing officer reflected on how a young person has ‘clear plans for the future and has matured’. External professionals reported good communication from the home and positive working relationships. Collaborative working supports young people’s progress. Seven requirements and three recommendations have been raised as a result of

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Inadequate

this inspection. Two requirements are subject to compliance action. This is to ensure that failings are addressed to maintain young people’s safety and well- being.

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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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