Children's home run by Crossways Care Ltd in Tewkesbury

The effectiveness of the home and the progress and experiences of

children and young people since the most recent full inspection.

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The effectiveness of the home and the progress and experiences of

This home was judged good at the full inspection. At this interim inspection, Ofsted judges that it has declined in effectiveness .

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The effectiveness of the home and the progress and experiences of

The home is in a period of transition. The registered manager named on this report is no longer in day-to-day control of the home, because, in consultation with Ofsted, he has swapped homes with a colleague. This move took place about four weeks before the inspection.

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The effectiveness of the home and the progress and experiences of

The new interim manager is currently applying to be registered for this home. He is an experienced manager who is working towards his level 5 award in leadership and management. He has worked with the company for eight years.

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The effectiveness of the home and the progress and experiences of

Almost all the weaknesses identified during this inspection relate to the period between the full inspection on 9 June 2016 and the new manager’s arrival. This has been a challenging period in terms of responding to serious incidents, staffing matters, out-of-date documentation and both young people currently being out of education. Despite the shortfalls raised in this report, the interim manager has responded to these difficulties as they have arisen and has already made substantial improvements to documentation.

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The effectiveness of the home and the progress and experiences of

The most serious weakness in the home lies within leadership and management, where there were also deficits at the full inspection. The requirement from that inspection, to update key documents for the young people, was actioned at the time, but the learning from this was not applied after the event. Consequently, there were no further updates and this led to major deficits in paperwork right up until the time of this inspection.

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The effectiveness of the home and the progress and experiences of

For example, the young people’s risk assessment and contact planning documents provide conflicting information about the frequency of contact and whether it has to be supervised or not. There is a lack of clarity about the status of one contact, with confusing messages to staff about the level of risk that this individual may or may not present to the young person. The Regulation 44 visitor has pointed out numerous deficits in the quality of paperwork.

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The effectiveness of the home and the progress and experiences of

In spite of this scrutiny, there has been a continuing failure to update behaviour management strategies in line with some young people’s changing physical and emotional development. This has resulted in advice to staff that was outdated and counterproductive.

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The effectiveness of the home and the progress and experiences of

Staff training is completed at a basic level, but does not help staff sufficiently to meet the needs of very complex young people. Consequently, some young people’s mental health needs are not fully understood and urgently require qualified psychological assessment. These weaknesses have had serious consequences for behaviour management and have contributed to several situations where the young people and the staff were at risk of harm.

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The effectiveness of the home and the progress and experiences of

Inconsistent and insufficient staffing, with employees leaving and the introduction of new team members, has led to the young people feeling insecure, disenchanted and more likely to test out boundaries. The young people and staff say that team members are sometimes moved without warning. Their perception is that sometimes people they really like disappear from the team and go to work in other homes. This is not acceptable. When staff have to move, for professional or personal reasons, the young people must be adequately prepared and be encouraged to say goodbye to the person who has helped them through a proper ‘ending’ process.

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The effectiveness of the home and the progress and experiences of

The interim manager recognises that this has been a problem for some young people, and it has been raised in managers’ meetings. The company has, within the very recent past, allocated staff to each individual home so that there is more consistency. There appears to be no coherent rota showing which staff have been on duty in the home in recent weeks, and staff can be redeployed without any consultation with the young people. This must also make it very difficult for managers to plan their staffing from day to day.

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The effectiveness of the home and the progress and experiences of

These combined circumstances have had a major impact on the young people and have led to an increase in serious incidents. The most serious single shortfall found on this inspection concerns restraint practice, which is unsafe. A requirement and a compliance notice have been issued.

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The effectiveness of the home and the progress and experiences of

Since the previous inspection, there have been at least 29 restraints in the home, all involving one young person. At least three of these restraints involved unauthorised techniques, some of which had the potential to harm the young person by restricting his breathing.

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The effectiveness of the home and the progress and experiences of

On 6 August 2016, the young person attempted to harm the driver of the vehicle in which he was a passenger. He then attempted to drive the vehicle. During the ensuing restraint, he fell to the ground and the staff held him there. The manager identified that this was an unauthorised hold, but said that ‘given the level of danger due to the location, this was understandable and appropriate’. It might not have been necessary to hold him on the ground if there had been sufficient staff to manage a less restrictive hold.

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The effectiveness of the home and the progress and experiences of

On 11 September 2016, a member of staff was alone with a young person when the latter started to cause damage to the home and threaten serious self-harm. This led to three holds being deployed. During the third hold, the young person was held for two minutes on his back on the floor, with his arms across his chest. This hold has the potential to interfere with breathing.

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The effectiveness of the home and the progress and experiences of

The independent visitor appropriately challenged the use of a supine hold and said in her report that it was far from clear why the member of staff did not let go of the young person after he went to the floor. The manager at the time responded by saying that the young person had taken himself to the floor during the second restraint, and the staff member was being kicked, so he had used the hold to keep himself safe. The manager instructed the member of staff not to use this technique in future and recommended further training for the staff member.

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The effectiveness of the home and the progress and experiences of

It should have been clear from these incidents that this young person cannot be managed safely by one member of staff working alone. Despite this, his 1:1 staffing ratio remained in place for a further three months, until this potentially dangerous shortfall in staffing was highlighted during this inspection.

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The effectiveness of the home and the progress and experiences of

On 9 November 2016, another very serious situation arose when a young person began to assault a member of staff and attempted to stab him. The member of staff had a colleague present, who was looking after the other young person, but decided to try to manage the situation alone. This placed him and the young person he was trying to restrain at risk of harm. Some of the facts in this matter are disputed and are still under investigation.

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The effectiveness of the home and the progress and experiences of

Managers have failed to adapt behaviour management techniques to accommodate the fact that this young person is now almost 15 years old, and has become a great deal stronger. Staff followed behaviour management strategies which had not been updated since the young person was 12 years old. For example, on this occasion he was offered ‘a hug’, which may have inadvertently helped to escalate the incident.

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The effectiveness of the home and the progress and experiences of

The interim manager observed that the young person had scratches and bruises to his neck after the incident. These were documented in the accident book at the time, but not on the body map which forms part of the restraint record.

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The effectiveness of the home and the progress and experiences of

The incident shows not only that the continuing failure to provide adequate staffing levels for this young person placed him and the staff at risk, but that the home’s managers have failed to convey to all staff the importance of only using authorised techniques to restrain young people. In addition, failure to document injuries sustained during restraint makes it difficult for managers to evaluate this information afterwards, and for other agencies to investigate any formal complaints or disclosures by young people.

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The effectiveness of the home and the progress and experiences of

The home’s managers have also failed to ensure that there are sufficient staff on duty at all times to manage this very troubled young person’s behaviour. The inspector was told that a professionals’ meeting, held immediately after the inspection, reviewed the incident and concluded that staffing should remain 1:1 with the other young person’s member of staff supporting. This is inappropriate, because it withdraws staff from another young person in the home and makes it impossible for that member of staff to leave the home to carry out other duties. The interim manager has since confirmed that 2:1 staffing is now in place, but this would probably not have happened if the inspector had not challenged the decision.

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The effectiveness of the home and the progress and experiences of

There have been no recorded complaints in the home since 2014. The young people feel that they are not adequately consulted, and say that there is no point in making a complaint. The interim manager has made efforts to consult with the young people, but because they feel that they were not consulted about the change of manager and staff moves, they have found it difficult to engage with him.

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The effectiveness of the home and the progress and experiences of

The young people explained that there are some other important matters that affect their lives which had not been explained to them in an accessible manner. These include some young people’s financial provision and their contact arrangements.

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The effectiveness of the home and the progress and experiences of

The home has consulted with young people in their own way, but this is not sufficiently creative in finding ways to engage the young people so that important messages are conveyed and their views are heard. The interim manager has been responsive to this and is working hard to support the young people so that they can express their views. The inspector discussed advocacy during the inspection, and both young people were encouraged to consider this.

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The effectiveness of the home and the progress and experiences of

The interim manager has initiated a programme of repair and redecoration. In the process, the cupboard that is used for storing potentially harmful chemicals had been partially dismantled. On 25 November, when the interim manager was away from the home on a training day, staff had placed all the cleaning chemicals on the window ledge in the office, where they remained for much of that day. The office door is usually open, so there is the potential for the young people to gain access to the chemical containers. By the time the inspector returned on 30 November, these had been put away in a lockable cupboard in the office.

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The effectiveness of the home and the progress and experiences of

Both of the young people are struggling with their education at the moment, and find mainstream education very difficult to sustain. Neither are attending school or college. This is not due to any shortcomings on the part of the home or the managers, who have worked hard to achieve educational provision to help the young people to sustain this.

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The effectiveness of the home and the progress and experiences of

Other shortfalls in leadership and management include the home having inadequate protection in place against data loss. When the home was the victim of a ransomware attack, all the computer documents were lost because the company had failed to ensure that these were backed up. The manager now has an external hard drive for this purpose, but the consequence is that all the electronic copies of the home’s photographs of the young people who have lived there over the years were lost.

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The effectiveness of the home and the progress and experiences of

Two recommendations have been made with regard to the previous manager not updating the home’s statement of purpose for five months, and describing it inaccurately. The present manager redrafted this before the inspection, so no requirement has been made. The second recommendation has been made with regard to stencils on the walls of the lounge which are supposedly wise sayings, but for a vulnerable young person, are likely to appear insensitive. The interim manager is consulting with the young people about the style of decoration that they would prefer.

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The effectiveness of the home and the progress and experiences of

Some other shortfalls were identified which were actioned during the inspection, so no requirements have been made. These include some Regulation 44 reports not being sent to Ofsted as required, and a minor deficit in the statement of purpose.

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Information about this children's home

This independent children’s home is registered to provide care and accommodation for up to two children and young people, irrespective of gender, who may have emotional and/or behavioural difficulties. The home is operated by a national provider of specialist services for children and adults with complex needs.

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Recent inspection history

Inspection date Inspection type Inspection judgement 09/06/2016 Full Good 10/03/2016 Interim Sustained effectiveness 03/12/2015 Full Good 10/02/2015 Full Adequate

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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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6: The quality and purpose of care standard

In order to meet the quality and purpose of care standard, with particular reference to:  prompt provision of accurate, up-to-date placement plans, contact plans and risk assessments for young people;  ensuring that the home is able to meet each young person's needs; and  ensuring that there is clarity and fairness in relation to young people's contact arrangements the registered person must ensure that: 6.—(1) The 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— (a) understand and apply the home's statement of purpose; (b) ensure that staff— (i) understand and apply the home's statement of purpose; (ii) protect and promote each child's welfare;

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6: The quality and purpose of care standard

(iii) treat each child with dignity and respect; (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; (v) help each child to understand and manage the impact of any experience of abuse or neglect; and (ix) make decisions about the day-to-day arrangements for each child, in accordance with the child's relevant plans, which give the child an appropriate degree of freedom and choice. 13/01/2017

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7: The children's views, wishes and feelings standard

In order to meet the children's views, wishes and feelings standard, with particular reference to finding creative ways to engage with the young people so that they feel that their views have been heard, the registered person must ensure that: 7.—(1) Children receive care from staff who— (a) develop positive relationships with them; (b) engage with them; and (c) take their views, wishes and feelings into account in relation to matters affecting the children's care and welfare and their lives. (2) In particular, the standard in paragraph (1) requires the registered person to— (a) ensure that staff— (i) ascertain and consider each child's views, wishes and feelings, and balance these against what they judge to be in the child's best interests when making decisions about the child's care and welfare; (ii) help each child to express views, wishes and feelings; (iii) help each child to understand how the child's views, wishes

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7: The children's views, wishes and feelings standard

and feelings have been taken into account and give the child reasons for decisions in relation to the child; (iv) regularly consult children, and seek their feedback, about the quality of the home's care; (b) ensure that each child— (i) is enabled to provide feedback to, and raise issues with, a relevant person about the support and services that the child receives; (ii) has access to the home's children's guide, and the home's complaints procedure, when the child's placement in the home is agreed and throughout the child's stay in the home; and (iii) is given appropriate advocacy support; (c) keep the children's guide and the home's complaints procedure under review and seek children's comments before revising either document; (d) ensure that an explanation is given to each child as soon as reasonably practicable after the child's arrival about— (iii) what advocacy support or services are available to the child,

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7: The children's views, wishes and feelings standard

how the child may access that support or those services and any entitlement the child may have to independent advocacy 13/01/2017 provision; and (e) ensure that the views of each relevant person are taken into account, so far as reasonably practicable, before making a decision about the care or welfare of a child.

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12: The protection of children standard

In order to meet the protection of children standard, with particular reference to ensuring that potentially harmful chemicals are kept out of the young people's reach at all times, the registered person must ensure that: 12.—(1) Children are protected from harm and enabled to keep themselves safe. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that staff— (i) assess whether each child is at risk of harm, taking into account information in the child's relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; and (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. 13/01/2017

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13: The leadership and management standard

In order to meet the leadership and management standard, with particular reference to ensuring that:  management monitoring and other management tasks are completed promptly;  that the home's key documents are kept up to date;  that there are sufficient staff on duty to ensure that young people who cannot be managed safely by one person have the necessary support that they need to keep them and others safe;  that there is continuity of care and that key staff are not moved without consulting with the young people; and  that staff do not come to work in the home unless they have sufficient training and experience to work with the young people who are resident 13/01/2017 the registered person must ensure that: 13 (2)(b) the staff work as a team where appropriate; (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

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13: The leadership and management standard

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 of care provided in the home; (g) demonstrate that practice in the home is informed and improved by taking into account and acting on— (i) research and developments in relation to the ways in which the needs of children are best met; and (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.

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20: Restraint and deprivation of liberty*

20 (2) Restraint in relation to a child must be necessary and proportionate. In particular, ensure that:  only authorised techniques are used to restrain young people;  that young people are not held on the ground, handled by the neck, or in any other way that potentially interferes with breathing;  that any injuries sustained by the child are fully recorded at the time on all the relevant documents;  that the behaviour management plan for each young person takes into account and is responsive to changes in their physical and emotional development; and  that staff do not become involved in physical intervention when alone, or when they cannot safely manage with the support available. (Regulation 20 (2)) 13/01/2017

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35: Behaviour management policies and records

35.—(1) The registered person must prepare and implement a policy (‘the behaviour management policy’) which sets out— (a) how appropriate behaviour is to be promoted in the children's home; and (b) the measures of control, discipline and restraint which may be used in relation to children in the home. (2) The registered person must keep the behaviour management policy under review and, where appropriate, revise it. (3) The registered person must ensure that— (a) 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 which includes— (i) the name of the child; (ii) details of the child's behaviour leading to the use of the measure; (iii) the date, time and location of the use of the measure; (iv) a description of the measure and its duration; (v) details of any methods used or steps taken to avoid the need to use the measure; (vi) the name of the person who used the measure (‘the user’),

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35: Behaviour management policies and records

and of any other person present when the measure was used; (vii) the effectiveness and any consequences of the use of the measure; and (viii) a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure. In particular, ensure that the details of each physical intervention are recorded in full within 24 hours of the incident, that details of physical injuries to any young person are recorded on the body map as well as in the accident book and revise young people's behaviour management plans as their needs change. (Regulation 35 (1), (2) and (3)(a)) 13/01/2017

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35: Behaviour management policies and records

* These requirements are subject to a 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 the information set out in the statement of purpose is an essential part of the process of agreement between the registered person and placing authority to demonstrate that the placement in that home is the right one for that child, and that the home will be able to respond effectively to the child’s assessed needs. In particular, ensure that the company’s website displays the current statement of purpose which accurately reflects the home and staffing arrangements, and that this document complies with the Children’s Homes Regulations 2015. (‘Guide to the children’s homes regulations including the quality standards’, April 2015, paragraph 3.6)  Ensure that children’s homes are nurturing and supportive environments that meet the needs of their children, and that they are homely, domestic

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Recommendations

environments. Children’s homes must comply with relevant health and safety legislations (alarms, food hygiene etc). However, in doing so, homes should seek as far as possible to maintain a domestic rather than ‘institutional’ impression. In particular, remove inappropriate stencilled messages from the home’s communal areas, which have not been chosen by the young people and which do not support their emotional life. (‘Guide to the children’s homes regulations including the quality standards’, April 2015, paragraph 3.9)

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What the inspection judgements mean

At the interim inspection we make a judgement on whether the home has improved in effectiveness, sustained effectiveness, or declined in effectiveness since the previous full inspection. This is in line with the ‘Inspection of children's homes: framework for inspection’.

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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 focused on the effectiveness of the home and the progress and experiences of children and young people since the most recent full inspection.

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Information about this inspection

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 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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