Children's home run by Cambian Autism Services Limited in Hammersmith and Fulham

inspection

Two compliance notices were served on 30 September 2016, following a second inspection of the school which found it to be inadequate. A monitoring visit, conducted on 27 October 2016, established that the compliance notices were met.

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Inadequate

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

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The children’s home’s provision is inadequate because:

 This is the home’s third inadequate judgement. There has been a repeated failure to meet the requirements set out following previous inspections.  Leaders and managers do not have sufficient skills or experience to lead the home in the absence of the registered manager.  Insufficient, and in some cases inexperienced, staff and a lack of consistency in the quality of care provided to children mean that children and young people are not always properly protected. Incidents have occurred when children and young people have been left unsupervised or left in the care of staff who do not have the skills and training to meet their needs effectively.  Leaders and managers do not provide staff with regular and effective supervision. Supervision records do not demonstrate that leaders and managers challenge and respond appropriately to the staff team’s poor practice.  Leaders and managers have failed to respond effectively to all child

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The children’s home’s provision is inadequate because:

protection concerns. When they have responded, they have failed to conclude investigations swiftly or effectively. The designated safeguarding lead did not follow the child protection procedure on three occasions.  Young people in one of the homes are not aware of what action to take in the event of a fire because staff have failed to carry out appropriate fire practice procedures with them.

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The children’s home’s strengths

 Leaders and managers have developed a multidisciplinary team to include occupational therapists, speech and language therapists and psychologists to ensure that children’s needs are responded to more effectively.

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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

In order to meet the quality and purpose of care standard, the registered person must ensure that staff: (2)(b)(iii) treat each child with dignity and respect. In particular, ensure that bathroom and bedroom doors are closed when staff are supporting children and young people with their personal care needs. 16/02/2017

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Requirement Due date

12: The protection of children standard *

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Requirement Due date

In order to meet the protection of children standard the registered person must ensure that staff: (2)(a)(iii) have the skills to identify and act upon signs that a child is at risk of harm; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; (vi) take effective action whenever there is a serious concern about a child’s welfare; (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. In particular, ensure that leaders and managers take swift action to protect children and young people from harm and that investigations into safeguarding concerns are conducted in a robust and timely manner to protect children. Leaders and managers must ensure that care plans are updated to include new information about risk and child protection issues. Leaders and

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Requirement Due date

managers must ensure that children are not left unsupervised. Staff must know where the ligature cutters are located. 16/02/2017

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Requirement Due date

13: The leadership and management standard *

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Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads a culture that: (a) lead and manage the home in a way that is consistent with 16/02/2017 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 to 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; (h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. In particular, ensure that leaders and managers have effective

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Requirement Due date

monitoring systems in place to protect children and young people. Leaders and managers must ensure that there are sufficient staff with the skills and required experience to care for each child and that children get consistency of care, including when agency staff are used. 19: Behaviour management and discipline

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Requirement Due date

The following measures may not be used to discipline any child; (a) any punishment involving the consumption or deprivation of food (Regulation 19 (2)(b)) In particular, food must not be removed from children as a behaviour management strategy. 16/02/2017

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Requirement Due date

The registered person must ensure that children are provided at all reasonable times with access to the following facilities which they may use without reference to persons working in the home: (3)(a) a telephone on which to make and receive telephone calls in private (Regulation 22 (3)(a)) In particular, leaders and managers must ensure that children’s access to a telephone is not restricted to manage behaviour. 16/02/2017

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Requirement Due date

The registered person must: ensure, by means of fire drills and practices at suitable intervals, that persons working at the home and, so far as reasonably practicable, children are aware of the procedure to be followed in 16/02/2017 case of a fire (Regulation 25 (1)(d)) In particular, ensure that a fire drill takes place immediately in the new home recently opened. 33: Employment of staff

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Requirement Due date

The registered persons must ensure that all employees receive practice-related supervision by a person with appropriate experience (Regulation 33 (4)(b)) In particular, ensure that leaders and managers use supervision to monitor staff performance, challenge poor practice and protect children and young people from harm. 01/03/2017

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Requirement Due date

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 (3)) In particular, ensure that leaders and managers implement an effective system to record complaints from children and make a distinction between a complaint and a child protection concern. 01/03/2017

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Requirement Due date

* These requirements are subject to statutory requirement notice.

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Information about this children’s home

This national private organisation provides care and accommodation for children and young people with autistic spectrum disorder and learning disabilities. It operates as a residential special school which also provides accommodation for students requiring 52 weeks boarding and is therefore registered as a children’s home for 40 placements.

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Recent inspection history

Inspection date Inspection type Inspection judgement 27/10/2017 Monitoring visit N/A 20/09/2016 Full Inadequate 01/08/2016 Monitoring visit N/A 20/06/2016 Full Inadequate 26/01/2016 Interim Improved effectiveness 18/05/2015 Full Good

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Inadequate

This is the third consecutive inadequate judgement for this children’s home. The weaknesses identified at this inspection have a negative impact on the overall experiences of the children and young people living in this home. Leaders and managers have failed to implement fully the changes that they have previously put in place to rectify the weaknesses identified at earlier inspections. Some staff have started to wear uniforms again, which detracts from the homely environment and ethos they are trying to create. There is poor hygiene in one of the homes as staff still do not routinely encourage children and young people to wash their hands before they eat their meals. In the same home, for some of the children and young people, staff did not provide any structure or purposeful activities before dinner, which caused an unnecessary anxiety about the mealtime. There is a lack of organisation around the planning of shifts and identifying which

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Inadequate

member of staff is leading the team. As a result, staff without sufficient experience have worked together with insufficient management direction or support. Staff are not ensuring that the privacy and dignity of children and young people are respected. Staff were seen to be helping children and young people with their personal care needs with bathroom doors left wide open. Staff are of the view that it is company policy that doors need to be kept open for safeguarding purposes. Leaders and managers have failed to challenge this poor practice. Care plans are in place for each child and young person, and leaders and managers have conducted a review of these plans. When there has been a child protection concern, information is not readily available in the care planning documentation. As a consequence, staff do not have the relevant information they need to know how to keep children and young people safe. Despite this significant weakness the

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Inadequate

overall quality of care plans is much improved. There is a full-time school nurse to coordinate the health arrangements for children and young people. Access to health services is good. The school nurse has increased her overall scrutiny of the administration of medication and the audit tools used to monitor practices to reduce the number of medication errors. Staff can only administer medication if they have completed medication training. There are a few examples of good practice across all of the individual homes. Positive interactions and engagement were seen between some of the staff and children and young people. Some staff have a soft and nurturing manner, which provides children and young people with comfort, affection and tactile play. There is a variety of activities on offer to children and young people across the homes. Some children and young people are well integrated into their local community and often visit the local town and join in group activities such as the

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Inadequate

boy’s brigade, guides and running clubs. Children and young people have the opportunity to express their views in house meetings. Staff use symbols and photographs for some children and young people to ensure that they have an opportunity to have their say about the running of the home. From these meetings children and young people plan meals and activities and can determine the decor of the homes. They also have the option to raise any concerns that they may have. Parents and social work professionals report that children and young people make progress here. One parent states, ‘It is the most settled my child has ever been’, while another says, ‘They can now sit down and eat a meal with everyone.’ Staff have worked hard with the children and young people to improve the quality of the houses to make them more homely. Children’s and young people’s bedrooms are individualised. The decor in the homes is of better quality. There are

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Inadequate

photographs on the wall of the children and lots of soft furnishings and calm colours to make it feel like a home.

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Inadequate

There continue to be widespread failures in safeguarding the children and young people living in the home. The designated safeguarding lead has a strong ethos and clear expectations about safeguarding practice. However, this is yet to be fully implemented. The approach to reporting and investigating concerns remains poor. Care staff are showing a better understanding of the child protection procedure. Since the previous inspection in September 2016, they have reported 98 safeguarding concerns to the designated safeguarding lead. This is a significant increase in reporting. Predominantly, when a safeguarding concern arises about staff, they are removed from the premises and the designated officer for the local authority is informed. In some cases, there is swift action to instigate the disciplinary process and suspend staff. However, on three occasions, inspectors found a failure to follow this process, which left staff continuing to care for children

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Inadequate

and young people when concerns had been raised about their practice. Staff have reported safeguarding concerns which evidence that children and young people have been left at risk of neglect. Serious incidents have occurred, including a failure to meet the basic care needs of children and failure to provide sufficient staff to ensure good quality nurturing care. The designated safeguarding lead takes appropriate action to instigate investigations of these concerns. However, senior managers do not conduct these investigations rigorously or in a timely manner. There is no outcome yet to investigations that were started over two months ago. Leaders and managers have failed to ensure that young people in one of the homes are aware of what to do in the event of a fire. Fire drills and practices are not routinely undertaken to ensure that children and young people are aware of the fire evacuation procedure.

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Inadequate

All children and young people have a behaviour support plan and risk assessment in place that is individual to them. Leaders and managers have placed further scrutiny on incident and restraint records by implementing a daily meeting to monitor these records. In addition, a member of staff has been appointed as a full- time behaviour support coordinator to provide support to staff and analyse incidents. Staff report that this is a positive appointment and find the support beneficial to improving care for children and young people. Some staff have received training to support young people at risk of harm from tying items around their neck, but this does not include new staff or staff who are currently caring for children with this assessed risk. Staff did not know the location of the tools used to remove the tied items (ligature cutters). The cutters were stored in a locked cabinet in the main reception area that staff did not have access

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Inadequate

to. Action was taken during the inspection to rectify this weakness. Sanctions are not generally used and there is a much-improved focus on praise and rewards for positive behaviour. However, in one isolated incident a staff member removed a young person’s dinner during a mealtime as a response to managing difficult behaviour. In one house, staff have continued to restrict the use of the telephone so that children and young people cannot access it without staff supervision. Staff have used a restrictive action rather than developing effective strategies to manage the behaviour around appropriate use of the telephone. On two occasions, incident records show that the staff team’s responses to a young person escalated the young person’s anxieties, which then resulted in a restraint being used. Staff failed to recognise the negative impact that their responses would have on the young person. This has been a continued weakness from previous

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Inadequate

inspections. While there is a significant decrease in the number of restraints from the previous inspections, it is clear that more needs to be done to prevent such interventions being used. Following a restraint occurring, all children and young people are offered an opportunity to communicate with staff about how they felt about the incident. The speech and language therapist has devised a ‘de-brief pack’ for each young person to provide a more individualised approach and ensure that staff can support children and young people to express their feelings about the use of restraints. Leaders and managers have successfully recruited to the therapy team, which will provide children and young people with increased opportunities for therapeutic support and intervention as required in their care plans. There is now a speech and language therapist, a clinical psychologist, a psychology assistant, an occupational

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Inadequate

therapist and a full-time school nurse. This multi-disciplinary team attends monitoring meetings and team meetings to ensure that their skills are widely used.

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Inadequate

The previous registered manager has resigned from their post. Following the inadequate inspection in September 2016, an experienced interim registered manager was appointed to fill this vacancy in the short-term. This arrangement came to an end on 25 November 2016 and the deputy manager took on the acting registered manager’s role. The acting registered manager is working towards a qualification in leadership and management. Leaders and managers have failed to implement change quickly enough to ensure that children and young people receive a good quality of care and protection. The requirements set at this inspection are repeat requirements from previous inspections in June 2016 and September 2016. Leaders and managers have written a comprehensive action plan to remedy the weaknesses. However, they do not provide the stability and skill required to facilitate the improvements. There have been three registered managers in the past four years.

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Inadequate

There is a large number of staff vacancies. This has been a persistent weakness since the home was registered. Leaders and managers are failing to recruit and retain skilled and experienced staff. Eight staff have been recruited since the previous full inspection. However, eight staff have also left in the same period. Leaders and managers use internal temporary staff and external staff from an agency to cover any shortfalls in the staffing complement. Not all agency staff have the necessary skills and training to meet the needs of children and young people. Despite this lack of training, agency staff are still directed by managers to care for some of the children and young people who have the most complex needs. Staff shortages have led to children being left at risk as a result of poor staff management. Incidents have occurred when staff have not been allocated to support children. On one occasion, some staff on the night shift refused a

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Inadequate

management request to move homes to bridge a shortage in staffing. This decision placed the children and young people at risk, resulting in one child consuming paint and others being left unsupervised. Children and young people do not have an opportunity to build meaningful and purposeful relationships with staff because of the number of staff changes and vacancies. Staff do not receive regular and effective supervision. This includes new staff who are in their induction and probationary period. Leaders and managers whose role it is to supervise staff do not have sufficient understanding to challenge staff about their poor practice. As a result, some child protection concerns have gone unchallenged and staff have not received clear direction about how they should support children in future. The system to record and analyse complaints is ineffective. The central complaints log only records complaints from parents. Complaints from children are mixed in

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Inadequate

with child protection records. As a result, leaders and managers are unable to identify patterns and trends of complaints effectively. Leaders and managers have improved their monitoring systems since the previous inspection, including completing a review of the quality of care. Senior leadership meetings now take place regularly to scrutinise the quality of care further in relation to behaviour management and incidents. Despite this action, leaders and managers continue to fail to identify shortfalls in practice, supervision and the adequacy and capability of staff.

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What the inspection judgements mean

The experiences and progress of children and young people are at the centre of the inspection. Inspectors will use their professional judgement to determine the weight and significance of their findings in this respect. The judgements included in the report are made against ‘Inspection of children’s homes: framework for inspection’.

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What the inspection judgements mean

An outstanding children’s home provides highly effective services that contribute to significantly improved outcomes for children and young people who need help and protection and care. Their progress exceeds expectations and is sustained over time. A good children’s home provides effective services that help, protect and care for children and young people and have their welfare safeguarded and promoted. In a children’s home that requires improvement , there are no widespread or serious failures that create or leave children being harmed or at risk of harm. The welfare of children looked after is safeguarded and promoted. Minimum requirements are in place. However, the children’s home is not yet delivering good protection, help and care for children and young people. A children’s home that is inadequate is providing services where there are widespread or serious failures that create or leave children and young people being

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What the inspection judgements mean

harmed or at risk of harm or 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, work- based learning and skills training, adult and community learning, and education and training in prisons and other secure establishments. It inspects services for children looked after 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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