Children's home run by Marlowe Child & Family Services Limited in Tewkesbury

children and young people since the most recent full inspection

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

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children and young people since the most recent full inspection

The home has declined in effectiveness since the last inspection in June 2016. At the last inspection, seven requirements and four recommendation were made. Only one requirement, relating to young people attending and working with their therapists, is met.

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children and young people since the most recent full inspection

Leaders and managers have failed to ensure that young people living at the home are looked after by a consistent team of staff who have the necessary skills and experience to provide a good standard of care. Staff working at the home include agency staff, staff from the organisation’s other homes and the organisation’s sessional staff. This inconsistency does not enable young people to build relationships with the adults who care for them.

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children and young people since the most recent full inspection

The staffing levels detailed in the home’s statement of purpose are not maintained. In addition, there was one occasion when an agency member of staff was left alone with two young people, and another when a new, inexperienced member of staff was left in sole charge of the home and three young people.

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children and young people since the most recent full inspection

The supervision and appraisal of staff are inadequate. They are irregular and not effective at reviewing and developing staff practice. Supervision does not safeguard young people, and supervisors do not take effective action when staff express concerns about practice. New staff are not receiving supervision as stated in the home’s statement of purpose, as it is not fortnightly.

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children and young people since the most recent full inspection

When staff have been involved in significant incidents, they are not provided with a debriefing or a follow-up supervision. This leaves staff feeling unsupported by leaders and managers. When staff other than the registered manager supervise team members, there is no system in the supervision for routinely feeding back to the registered manager about performance.

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children and young people since the most recent full inspection

Team meetings are not taking place fortnightly, as stated in the home’s statement of purpose. Minutes of these meeting vary in quality from adequate to inadequate. Some record only the topic, with no discussion or outcome of the discussion and subsequent actions to be taken. There is evidence of young people and some incidents being discussed.

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children and young people since the most recent full inspection

The system in place to support staff out of hours is ineffective. Inspectors found on one occasion that, when staff rang the call manager and the registered manager for support with a significant incident, neither of them answered the phone. This resulted in a member of staff feeling unsupported and left in sole charge of three young people. This puts young people and staff at risk.

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children and young people since the most recent full inspection

Staff, including the safeguarding lead and the registered manager, are not following safeguarding procedures. This has led to delays in reporting safeguarding incidents to the local authority designated officer (LADO). There was no evidence of information of concern being shared with social workers or the LADO. Inspectors raised this and asked for the information to be shared with the relevant people. The staff member responsible for managing child protection concerns does not have the required expertise to undertake the role effectively.

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children and young people since the most recent full inspection

Impact risk assessments are carried out for young people moving into the home. These are not adhered to in practice. The staffing level falls short of what was originally determined to be necessary to provide safe care. There was no review on one young person’s file to support any changes to the original plan.

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children and young people since the most recent full inspection

Key-worker records lack details of the work undertaken with young people. This inhibits effective evaluation of the progress that young people make as a result of one-to-one work. The records also lack agreed actions or a review of how effective the agreed actions have been.

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children and young people since the most recent full inspection

Records of incidents and restraint are inadequate. They do not consistently evidence if a debriefing was held with the young person. The registered manager does not evaluate all incidents and restraint reports. This means that he has no oversight of these records and does not monitor them for patterns or trends or to improve practice. When young people are injured during a restraint, body maps are not always completed. Staff fail to make links between restraint and safeguarding. Concerns are not reported in a timely manner, either by staff on duty, the registered manager or the safeguarding lead. Neither do staff protect young people from hurting each other during incidents.

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children and young people since the most recent full inspection

Young people’s records are not well maintained. The young people’s files that detail their needs and how they wish to be cared for are falling apart. As a result, staff found it difficult to find some key information about young people when inspectors asked for records. There is no thought about how this demonstrates how this reflects on the way that the young people in their care are valued.

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children and young people since the most recent full inspection

Safer recruitment guidelines are followed. However, there is nothing in place to determine the quality of the reference verification.

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children and young people since the most recent full inspection

The registered manager’s monitoring is ineffective. A significant number of records showed no evidence of being evaluated by the registered manager. When it has taken place, it fails to identify the shortfalls as identified in this report. The monitoring report that the manager completes every six months covers all the relevant areas, but lacks effective evaluation which can then be used to develop practice.

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children and young people since the most recent full inspection

An independent visitor comes to the home regularly. They do not consistently visit when the young people are at home, so cannot gather the young people’s views. In addition, the report produced does not clearly evaluate the quality of care provided or effectively reflect the discussion had with young people and staff. This does not make the report an effective tool for developing the practice at the home. When actions are set, the registered manager does not ensure that all actions are met.

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children and young people since the most recent full inspection

Accommodation at the home is of an appropriate standard. There has been some redecoration and refurbishment since the last inspection. There remains on one young person’s bedroom window a restrictor of an institutional style which needs to be replaced.

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Information about this children’s home

This children’s home is registered to accommodate four children and young people with emotional and behavioural difficulties. It is owned by a private organisation that also operates other children’s homes and a registered school in the locality.

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Recent inspection history

Inspection date Inspection type Inspection judgement 30/06/2016 Full Requires improvement 30/03/2016 Interim Sustained 19/08/2015 Full Requires improvement 01/10/2014 Full Adequate 04/08/2014 Full Inadequate 17/02/2014 Interim Inadequate progress

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Statutory requirements

This section sets out the actions which must be taken so that the registered person(s) meets the Care Standards Act 2000, Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. The registered person(s) must comply within the given timescales.

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Requirement Due date

6: The quality and purpose of care standard

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who: (1)(a) understand the children’s homes 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.

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Requirement Due date

(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 understand and apply the home’s statement of purpose, protect and promote each child’s welfare, treat each child with dignity and respect, provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background, help each child to understand and manage the impact of any experience of abuse or neglect, provide to children living in the home the physical necessities they need in order to live there comfortably, provide to children personal items that are appropriate for their age and understanding, and 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;

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Requirement Due date

(c) ensure that the premises used for the purposes of the home are designed and furnished so as to meet the needs of each child, and ensure that any care that is arranged or provided for a child that relates to the child’s development (within the meaning of section 17(11) of the Children Act 1989) or health, and is not arranged or provided as part of the health service continued under section 1(1) of the National Health Service Act 2006(a), satisfies the conditions in paragraph (3). (Regulation 6(1)(a)(b) (2)(a)(b)(i)(ii)(iii)(iv)(v)(vii)(viii)(ix)(c)(i) (d)(i)(ii)) 06/01/2017 11: The positive relationships standard (1) The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on mutual respect and trust, an understanding about acceptable behaviour, and positive responses to other children and adults.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to ensure that staff meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans, help each child to develop socially aware behaviour, encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding, help each child to develop and practise skills to resolve conflicts positively and without harm to anyone, understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children, are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same, de-escalate confrontations with or between children, or

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Requirement Due date

potentially violent behaviour by children, understand and communicate to children that bullying is unacceptable, and have the skills to recognise incidents or indications of bullying and how to deal with them. (Regulation 11(1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(ix)(x)(xi)(xii)(xiii)) 06/01/2017

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Requirement Due date

(1) The protection of children standard is that 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 that staff 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, help each child to understand how to keep safe, have the skills to identify and act upon signs that a child is at risk of harm, manage relationships between children to prevent them from harming each other, take effective action whenever there is a serious concern about a child’s welfare, and that the home’s day-to- 06/01/2017 day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm, that the premises used for the purposes of the home are located so

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Requirement Due date

that children are effectively safeguarded, that the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child’s health. (Regulation 12(1) (2)(a)(i)(ii)(iii)(iv)(vi)(b)(c)(d))

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Requirement Due date

13: The leadership and management standard

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Requirement Due date

(1) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that helps children aspire to fulfil their potential, and promotes their welfare.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to 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, ensure that staff work as a team where appropriate, ensure that staff have the experience, qualifications and skills to meet the needs of each child, ensure that the home has sufficient staff to provide care for each child, ensure that the home’s workforce provides continuity of care to each child, 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, use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(a)(b) (2)(a)(b)(c)(d)(e)(f)(h))*

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Requirement Due date

(1) The care planning standard is that children: (a) receive effectively planned care in or through the children’s home.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to ensure: (c) that each child’s relevant plans are followed; (f) that staff help each child to access and contribute to the records kept by the registered person in relation to the child. (Regulation 14(1(a) (2)(c)(f)) 06/01/2017 16: Statement of purpose

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Requirement Due date

The registered person must compile in relation to the children’s home a statement (‘the statement of purpose’) which covers the matters listed in schedule 1.

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Requirement Due date

Subject to paragraph (6), the registered person must ensure that the home is at all times conducted in a manner which is consistent with its statement of purpose. (Regulation 16(1)(5)) 06/01/2017

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Requirement Due date

(1) The registered person must ensure that each employee completes an appropriate induction, ensure that each permanent appointment of an employee is subject to the satisfactory completion of a period of probation, and provide each employee with a job description outlining the employee’s responsibilities.

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Requirement Due date

(4) The registered person must ensure that all employees undertake appropriate continuing professional development, receive practice-related supervision by a person with appropriate experience, and have their performance and fitness to perform their roles appraised at least once every year. (Regulation 33 (1)(a)(b)(c) (4)(a)(b)(c)) 06/01/2017

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Requirement Due date

34: Policies for the protection of children

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Requirement Due date

(1) The registered person must prepare and implement a policy which is intended to safeguard children accommodated in the children’s home from abuse or neglect, and sets out the procedure to be followed in the event of an allegation of abuse or neglect.

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Requirement Due date

(2) The procedure to be followed in the event of an allegation of abuse or neglect must, in particular, provide for liaison and cooperation with any local authority which are, or may be, making a child protection enquiry in relation to a child accommodated in the home, provide for the prompt referral of an allegation about current or ongoing abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the home is located, provide for the prompt referral of an allegation about past abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the alleged abuse or neglect occurred, provide for records to be kept of an 06/01/2017 allegation of abuse or neglect, and the action taken in response, describe the measures which may be necessary to protect children following an allegation of abuse or neglect,

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Requirement Due date

and describe how and to whom staff are to report, without delay, any concern about abuse or neglect of a child.

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Requirement Due date

(6) The registered person must keep under review and, as necessary, revise the home’s child protection policies. (Regulation 34(1)(a)(b) (2)(a)(b)(c)(d)(e)(f) (6)) 35: Behaviour management policies and records

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Requirement Due date

(3) The registered person must ensure that within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes the effectiveness and any consequences of the use of the measure, and within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (‘the authorised person’) has spoken to the user about the measure, and has signed the record to confirm it is accurate, within five days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35(3)(a)(vii)(b)(i)(ii)(c)) 06/01/2017

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Requirement Due date

(1) Subject to paragraph (6), the registered person must establish a procedure for considering complaints made by or on behalf of children.

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Requirement Due date

(2) In particular, the procedure must provide that no person who is the subject of a complaint takes any part in its consideration or investigation, except at the informal resolution stage if the registered person considers it appropriate.

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Requirement Due date

(3) The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation. (Regulation 39(1) (2) (3))

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Requirement Due date

In particular, the record needs to state if the complainant is satisfied with the outcome of the investigation or not. 44: Independent person: visits and reports

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Requirement Due date

(1) The registered person must ensure that an independent 06/01/2017 person visits the children’s home at least once each month.

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Requirement Due date

(2) When the independent person is carrying out a visit, the registered person must help the independent person if they consent, to interview in private such of the children, their parents, relatives and persons working at the home as the independent person requires; and to inspect the premises of the home and such of the home’s records (except for a child’s case records, unless the child and the child’s placing authority consent) as the independent person requires.

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Requirement Due date

(3) A visit by the independent person to the home may be unannounced.

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Requirement Due date

(4) The independent person must produce a report about a visit (‘the independent person’s report’) which sets out, in particular, the independent person’s opinion as to whether children are effectively safeguarded; and the conduct of the home promotes children’s well-being. (Regulation 44(1) (2)(a)(b) (3) (4)(a)(b))

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Requirement Due date

In particular, the independent visitor should visit the home when the young people are there. The independent visitors report should contain more information and evaluation of the quality of care the the young people receive and the young people’s views. 45: Review of quality of care

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Requirement Due date

(1) The registered person must complete a review of the quality of care provided for children (‘a quality of care review’) at least once every six months.

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Requirement Due date

(2) In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating the quality of care provided for children; the feedback and opinions of children about the children’s home, its facilities and the quality of care they receive in it; and any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children.

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Requirement Due date

(3) After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (‘the quality of 06/01/2017 care review report’). (Regulation 45(1) (2(a)(b)(c) (3))

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Requirement Due date

In particular, this report needs to contain more evaluation which can then be used to develop practices within the home.

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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 recommendation(s):  Ensure that the children’s home is a nurturing and supportive environment that meets the needs of the children. It will, in most cases, be a homely, domestic environment. (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9) In particular, repairs should be addressed swiftly, health and safety equipment should, where possible, not be of an institutionalised standard.  As set out in regulations 31–33, the registered person is responsible for maintaining good employment practice. (‘Guide to the children’s homes regulations including the quality standards’, page 61, paragraph 13.1) In particular, the records of staff interviews should include an explanation of the scoring system used to decide whether to employ. Also, records of internal investigations in light of safeguarding concerns need be either

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Recommendations

included in safeguarding files or information in safeguarding files should identified where this is stored.  Staff should be familiar with the home’s policies on record keeping and understand the importance of careful, objective and clear recording. Staff should record information on individual children in a non-stigmatising way that distinguishes between fact, opinion and third-party information. Information about the child must always be recorded in a way that will be helpful to the child. (‘Guide to the children’s homes regulations including the quality standards’, page 62, paragraph 14.4) In particular, key-worker records should reflect more detail of the discussions that take place.

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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 0300 123 4234, or email enquiries@ofsted.gov.uk .

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Information about this inspection

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Information about this inspection

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Information about this inspection

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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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