Children's home run by ROC Northwest Limited in Westmorland and Furness

Inadequate

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

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The children's home provision is inadequate because:

 Poor day-to-day care arrangements fail to ensure children‟s safety and well- being. Suitable arrangements are not in place to guide staff in the management of medical care for young people.  Medication arrangements in the home require significant improvement in order to ensure that children‟s medical needs are met and their well-being effectively safeguarded.  The setting does not provide a safe, homely and welcoming environment for children. This is due to poor maintenance and poor health and safety arrangements at the home.  Following challenge of poor care practice by inspectors, safeguarding failures were compounded by records being altered by senior staff, to give false representation of action taken.  Poor training opportunities impact significantly on the ability of staff to respond to both the day-to-day needs of children and emergency situations.  Exceptionally high turnover of staff and poor staffing arrangements have

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The children's home provision is inadequate because:

significantly affected the ability of the staff in the home to deliver consistent good-quality care for children.  Poor leadership and inadequate overview of the service, alongside an inability to effectively identify and address areas of concerns, places children at risk.  Regular and good-quality supervision, as required by the home‟s policy, has not been provided for all staff.

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The children's home strengths

 Some children enjoy their time with staff with whom they have been able to develop relationships.  Young people use independent advocacy services effectively to voice their opinions, likes and dislikes.

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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

12: The protection of children standard In order to meet the protection of children standard, the registered person must ensure that: (2)(a)(vi) staff take effective action whenever there is a serious concern about a child‟s welfare; and (2)(b) 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. * 09/12/2016

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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: (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; (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; and (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. 09/12/2016

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Requirement Due date

10. The health and well-being standard In order to meet the health and well-being standard the registered person must ensure that: 09/12/2016 (1)(a) the health and well-being needs of children are met. In particular, ensure that suitable dietary management protocols and guidance are in place to support children who have weight management issues.

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Requirement Due date

6: The quality and purpose of care standard In order to meet the quality and purpose of care standard, with particular reference to providing children with a comfortable, good-quality, homely living environment, the registered provider must: (2)(c) ensure that the premises used for the purposes of the home are designed and furnished so as to— (i) meet the child's needs; and (ii) enable each child to participate in the daily life of the home. 31/12/2016

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Requirement Due date

7: The children‟s views, wishes and feelings standard (1)(c) ensure that young people receive care from staff who take their views, wishes and feelings into account in relation to matters affecting the children‟s care and welfare and their lives. 31/12/2016

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children‟s home. In particular, ensure that records of medication are accurate, that the stock held correlates with the record of medication held and that any emergency remedies are not kept beyond their expiry date. (Regulation 23 (1)) * 09/12/2016

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Requirement Due date

The registered person must ensure that the requirements of the Regulatory Reform (Fire Safety) Order 2005(1) and any regulations made under it are complied with in respect of the home. In particular, ensure that all staff who work in the home receive suitable instruction and ensure that the fire risk assessment is maintained under review to reflect changes within the home. (Regulation 25 (2)(b)). 09/12/2016

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Requirement Due date

The registered person must ensure that all employees receive appropriate supervision and undertake appropriate continuing professional development. (Regulation 33 (4)(a)(b)). 09/12/2016

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

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

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Recommendations

 The registered person should ensure that all incidents of control, discipline and restraint are subject to systems of regular scrutiny to ensure that their use is fair. In particular, ensure suitable overview of any restraint by a person independent of the incident („Guide to the children‟s homes regulations including the quality standards‟, page 46, paragraph 9.36).

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Information about this children's home

 The home is registered for up to 15 children from eight to 18 years old.  The home is run by a private company.  A company school is on-site.  The home offers care and accommodation for children who have learning disabilities, physical disabilities and associated medical needs.  An outreach service is registered separately with the Care Quality Commission.

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Recent inspection history

Inspection date Inspection type Inspection judgement 15/03/2016 Interim Improved effectiveness 20/05/2015 Full Requires improvement 05/03/2015 Interim Sustained effectiveness 25/09/2014 Full Good

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Inadequate

The key judgement area of „how well young people are helped and protected‟ is inadequate due to the shortfalls found at this inspection. In line with Ofsted‟s framework, 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 identified serious safeguarding concerns:  Poor day-to-day care arrangements fail to ensure young people‟s safety and well-being, as suitable arrangements are not in place to guide staff in the management of medical care for young people.  Arrangements for the administration of medication in the home require significant improvement in order to ensure that children‟s medical needs are met and their well-being is effectively safeguarded.  The setting does not provide a safe, homely and welcoming environment for children. This is due to poor maintenance and health and safety arrangements.

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Inadequate

 Following challenge of poor care practice by inspectors, safeguarding failures were compounded by records being altered by senior staff, to give false representation of action taken.  Poor care practice in managing the health needs of young people has placed one young person at significant risk. This young person showed signs of being unwell for four days. He had been unable to attended school because he was ill. Staff did not seek medical advice or attention at any time during the four days that the young person was ill. Despite the young person‟s poor health, staff drove him for two and a half hours to an appointment where his health continued to deteriorate throughout the day. Staff record his condition as unresponsive, yet they still did not access medical advice. Staff chose to drive an additional two and a half hour journey back to the home. After a further two hours, staff rang the NHS helpline for advice. Staff

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Inadequate

informed the helpline that the young person was unresponsive to pain stimulus, the helpline called an ambulance and the young person was admitted into hospital. This continued significant lack of appropriate care by staff for the young person placed him at significant risk of harm. Medication stocks at the home could not be explained accurately by staff. Staff have consistently made errors in the administration of medication. For example, inspectors noted that medications that should have been administered every three days had been given twice daily instead. Some medication had been signed for as given, but stocks of available medication showed that these records were incorrect. In addition, the host local authority has recently investigated a complaint regarding the administration of medication at the home. This was upheld. On at least two occasions, the home had failed to give the required medication to a young person.

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Inadequate

Emergency remedy medication for young people with epilepsy had expired in August 2016, despite regular weekly audits by the senior management team. While this medication has not been given, the potential of significant harm is high and demonstrates that internal quality audits by management are poor and ineffective. Medical equipment that had been used to administer medication was poorly maintained, as staff had not cleaned the equipment in line with health and safety procedures. In addition, storage facilities for medication that require refrigeration are inappropriate. The temperature of the fridge has not been tested to ensure that medications are stored at a safe temperature. Incorrect storage facilities could compromise the effects of the medication on young people once administered. Consequently, medication arrangements in the home are inadequate and require significant improvement in order to ensure that children‟s medical needs are met

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Inadequate

and their well-being is effectively safeguarded. Following a recent strategy meeting held by the host authority, the responsible individual informed the strategy meeting that she was in the process of recruiting a nurse. The strategy meeting placed a deadline on this to be actioned. The nurse would oversee the medical needs of young people and safe administration of medication. Suitable candidates were being interviewed during the inspection. Dietary protocols and management plans are not in place to guide staff about how to respond to young people who may refuse food or when to administer a prescribed food supplement. For example, staff were unable to explain when to offer food supplements to specific children. During the inspection, one young person was observed to eat minimal amounts of food, yet food supplements were not offered to the child by staff. This lack of poor care regarding children‟s basic

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Inadequate

needs significantly affects their physical and emotional well-being. Following challenge of poor care practice by inspectors, safeguarding failures were compounded by records being altered by senior staff, to give false representation regarding the ill health of a child by writing he had attended education. Furthermore, a recent strategy meeting raised concerns about anonymous information that „staff members have been asked to lie by management‟. A written incident report states that a telephone discussion was held with a nurse at the GP surgery, but when inspectors contacted the surgery, they confirmed that they did not have a record of this discussion taking place. This lack of honesty compromises Ofsted‟s and other agencies ability to conduct their duties in safeguarding young people. Once senior managers were informed of this poor practice, it was promptly acted on and an investigation was initiated. However, it raises concern about the

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Inadequate

quality of monitoring at the home that these serious shortfalls were not identified prior to the inspection. Frequent changes to the staff team have had a negative impact on the children and young people. 36 members of staff and two managers have left the home since it was inspected in May 2015. One parent commented that „there‟s a high staff turnover, which has a big impact on (child)‟. A manager said, „I won‟t lie, it has been hard, especially in summer months, I was here every day. Staff leaving and a high turnover leads to low morale.‟ As a result, staff have not had the opportunity to establish relationships with the children and young people. The environment is unpredictable with changing personnel who, on occasion, offer inconsistent behaviour management and care. One staff member described it as „chaotic‟. This has potentially affected young people‟s ability to manage their own conflicts and

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Inadequate

emotional well-being. The home is a spacious, two-story detached property with 15 large decorated bedrooms and a living space. Staff, managers and the senior management team stated several times, „This is not a home, it‟s an institution.‟ This is in stark contrast to the home‟s statement of purpose that states, „The home is very warm, comforting and inviting.‟ There is damage to some of the fixtures and fittings of the building, such as stained flooring and a broken shower. Two family members complained about a lack of light bulbs in each of their child‟s bedroom. One commented, „ The light bulb within the bedroom did not work for approximately four weeks. Staff had to use the torch on their own personal mobile phone to check if (name) was OK during the night.‟ This continued poor management and oversight means that staff do not have the sufficient resources to adequately monitor the welfare of children in their care.

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Inadequate

Black paper covers the windows to protect the dignity of young people but this means that young people cannot look out of the window. Furthermore, security arrangements, such as intrusively padlocked doors, create an institutional feel. These issues are not conducive to a homely, welcoming environment for children. The garden pathway to the frequently used play area is overgrown with holly bushes and is littered with broken crockery and underwear. The responsible individual called the garden team during the inspection to cut the bushes back. The children and young people enjoy long walks along the river, walking in the park or on the beach, trips to trampolining centres, visits to a swimming pool and for one young person a short-break holiday, all of which provide young people with social experiences. However, staffing arrangements and poor management of daily routines and structure prevent staff from being responsive to children‟s needs or

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Inadequate

completing planned activities. For example, staff had planned to take young people swimming, but then forgot to bring in their own swimming costumes. Children who live in this home can struggle to understand change, which can trigger incidents of aggressive or violent behaviour. Another example was a planned Indian theme day, where a lack of effective planning resulted in missed opportunities to explore the numerous temples and mosques in the area. Instead, young people ate an Indian meal together. Staff demonstrated their lack of skill and confidence when communicating with children. Inspectors had to prompt staff that a young person was signing for „more‟ when eating her lunch. Staff had failed to understand or notice the young person who was clearly expressing their view. In addition, a communication aid was not used to communicate effectively with a child. Inspectors observed that some staff did not understand how children might communicate their feelings through their

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Inadequate

behaviour, especially where the child has a disability that means they cannot communicate verbally. For example, staff were seen screaming at young people to stop doing something. There is an on-site school where most of the children and young people receive education arranged by the placing authority. This also provides an environment that staff can access to offer children and young people planned learning activities outside of the school timetable. Regular, well-planned arrangements ensure that children and young people are able to maintain frequent contact with their families. One parent commented, „The majority of staff are friendly and approachable. The home is very accommodating and flexible when we have twice-weekly contact with our child.‟ There is an independent advocate who meets with young people to help and encourage them to share their views. There is a complaints process that the advocate shares with them.

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Inadequate

There are a number of safeguarding concerns, which have the potential to place children and young people at significant risk. For example, poor day-to-day care arrangements at the home fail to promote and meet the physical and psychological health needs of children and young people. Furthermore, medication arrangements place children at risk of harm through potential medication errors. One member of staff said, „I feel we could be doing a lot more to support the young people in terms of health and well-being.‟ Behaviour management strategies are not always making a positive difference and while children may individually present as calmer than they did pre-placement, they continue to present heightened behaviours frequently, which challenge the skills of staff as well as their resilience. One member of staff feels that this is due to poor training. They commented, „The training could be improved. In the last 12 months

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Inadequate

we have had “team teach” refresher. The trainer who was delivering the training made us do some exercises during the training which weren‟t relevant. The trainer works for our company and I was very disappointed as this just isn't relevant.‟ Another staff member said, „I feel that “team teach” is great in theory but in a practical sense it is inadequate for the level of aggression displayed by some of our service users.‟ Arrangements for the review and monitoring of restraints by the manager are poor, which undermines the ability for reflection and contribution to meeting the ongoing and changing needs of children and young people. For example, individuals involved in the restraint of young people also conduct the debrief with young people after the event. Comments in the record book state that on the majority of occasions, young people did not wish to discuss this matter in a key worker session. This arrangement fails to provide children with an opportunity to discuss if

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Inadequate

they had any concerns around the appropriateness of the physical intervention with a staff member separate from the incident. Improvements to health and safety within the building are required to ensure that staff are protected and can call for assistance should it be required at night-time. Equipment to call on each other is deficient. Consequently, staff have to rely on shouting to each other up the stairs. Similarly, monitors used to observe if a young person is having a seizure at night, loose signal easily rendering them useless to safeguard children. Staff are also not provided with the necessary equipment to protect them from bodily fluids, for example gloves, aprons and waste disposal bags. This puts both staff and children at risk of cross infection. Fire safety arrangements are not sufficiently robust. For example, should the staff need to leave the premises via the fire doors into the garden, the gates are

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Inadequate

padlocked therefore blocking their exit from the site. Night staff state that they do not have clear guidance on how to evacuate the home effectively in the event of an emergency. Recruitment procedures are sufficiently robust to ensure that children and young people are fully safeguarded from unsuitable people gaining employment within the home. The manager is able to evidence that most staff have undertaken suitable training in safeguarding, medication, epilepsy management and how to protect children from child sexual exploitation. This inspection has identified that despite receiving this training it has not assisted staff to care for children appropriately. The responsible individual acknowledges that the current training does not support staff to manage risk effectively and robustly or to protect children and young people and has therefore developed an action plan to address this shortfall.

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Inadequate

There have been changes to the management arrangements at the home since the last inspection. The registered manager of two years left the home in June 2016. The home successfully recruited a replacement manager who subsequently resigned in October 2016 without being registered with Ofsted. The organisation has since recruited and appointed another manager who commenced work in the home on 31 October 2016. They have yet to submit an application for registration with Ofsted. This proposed manager has significant experience of working with children and young people with a learning disability in residential care and has previous management experience of looking after a large home. She has provided Ofsted with an action plan on how she plans to address the shortfalls identified at this inspection. Because of the changes outlined above, the management and leadership of the home is ineffective. The manager and provider have not been able to deliver the

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Inadequate

caring experience to children as set out in the home‟s statement of purpose. There have been changes to the staff team, which has had a major impact on the ability of the home to deliver good-quality care. One staff member cited the reason he was leaving was because of „continual staff turnover and low staffing levels‟. Another staff member said, „More experienced, stronger and better qualified staff are needed.‟ In the last 18 months, the home has employed 61 new staff and 36 staff have left, including two managers. Of the 38 staff that are employed on a permanent basis, 20 are qualified to diploma 3 level. 18 staff are currently undertaking the qualification and hope to qualify between March 2017 and September 2018. A number of staff have been employed to work within the home on a casual basis, many of whom stay for just a few weeks. This has significantly undermined the ability of the home to deliver a positive experience for children, in

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Inadequate

addition to rendering it almost impossible to deliver suitable training and supervision to staff. The host authority recently received anonymous information alleging that children are not always provided with their required and assessed level of staffing support. They alleged that a number of the children who access the home on a 2:1 basis do not receive this recommended level of support. The only children that do access the correct level of support are the children that have verbal communication. The complainant claimed that management are fully aware of the shortfall, despite continuing to charge the local authority for 2:1 support. The allegations were investigated by the responsible individual who found that managerial oversight and monitoring of staffing arrangements were poor. During the inspection, all young people were observed to have the correct levels of staffing. The home‟s statement of purpose states that the age range of the home is for

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Inadequate

children aged eight to 18 years with autism, learning, physical and associated emotional and/or behavioural difficulties. The children and young people are emotionally fragile and display significantly challenging and harmful behaviour. They require an experienced staff team that has the knowledge and understanding of complex learning disabilities and who have the skills to manage presenting behaviours. The staff team members are not consistent, nor are they always suitably qualified or competent to deliver a high-quality service to meet the needs of the very vulnerable children and young people in placement. Individual line management supervision records fail to demonstrate that staff receive competent and effective individual supervision. This shortfall, in conjunction with the poor arrangements for staff training, has the potential to significantly impact on staff‟s ability to respond to both the day-to-day care needs of children

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Inadequate

and young people and emergencies. The proposed manager works in partnership with parents and local authorities. However, this has not yet effectively addressed the concerns that some families have about aspects of the service. This lack of oversight of care practice undermines young people‟s safety and well-being. The responsible individual accepts serious failings in leadership and management. The newly appointed manager has high aspirations for the home and some staff members are individually motivated to deliver a good service to children and young people. Nevertheless, currently, the oversight, leadership and management of the home are poor and as a result, children and young people are not effectively safeguarded. The significant shortfalls identified at this inspection permeate throughout the service. The manager and provider had an awareness of some of these issues prior to the inspection and have developed an action plan to address

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Inadequate

them. This includes the employment of a nurse and investment in the property and its staff. However, due to the recent timescales linked to the action plan, the impact of this cannot yet be measured.

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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

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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