Children's home run by Lioncare Limited in Epping Forest

Inspection report children's home: SC014234 1 SC014234 Registered provider: Lioncare Limited

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The home is run by a private organisation and is registered to provide residential care for seven children who have emotional and/or behavioural difficulties. Children may access the organisation’s school, which is registered with the Department for Education.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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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, and the care and experiences of children and young people are poor and they are not making progress.

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inadequate

Date of last inspection: 11 January 2017

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inadequate

Overall judgement at last inspection: Inadequate

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Enforcement action since last inspection

On 25 January 2017 Ofsted issued seven compliance notices. A monitoring inspection was conducted on 2 March 2017.

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Key findings from this inspection

This children’s home is inadequate because Inspection report children's home: SC014234 2  There has been a failure to address many of the weaknesses identified at a full inspection in January 2017, when the home was judged to be inadequate. The progress that was being made in March 2017 has not been sustained.

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Key findings from this inspection

 The systems for monitoring the quality of care being provided do not consistently identify where practice needs to improve.

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Key findings from this inspection

 The assessment and management of risk is poor. This increases the potential for children to come to harm.

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Key findings from this inspection

 Leaders and managers have failed to identify weaknesses in the electronic case records system. Children’s confidential information has not been kept secure.

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Key findings from this inspection

 The assessment and care planning process fails to clearly identify the needs of each child. The strategies for caring for children are weak and, as a result, children do not consistently make good progress.

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Key findings from this inspection

 Peer relationships among the children are not consistently good. The potential for bullying is not managed well and there have been occasions when children have assaulted one another.

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Key findings from this inspection

 Leaders and managers have not made provision for children to contact an advocacy service, or other external support services, in confidence.

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Key findings from this inspection

 Staff are not provided with the support needed to ensure professional development. Leaders and managers have not ensured that training is provided within the timescale specified by Ofsted after the inspection in January 2017.

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Key findings from this inspection

 Child protection concerns have not been consistently shared with the child’s placing authority.

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Key findings from this inspection

 The premises are not maintained so as to prevent avoidable hazards to children’s health and well-being.

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Key findings from this inspection

 Inspectors observed warm, nurturing interactions between staff and the children. Inspection report children's home: SC014234 3

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Inspection date Inspection type Inspection judgement

11/01/2017 Full Inadequate 11/05/2016 Full Good 26/01/2016 Interim Sustained effectiveness 10/06/2015 Full Good Inspection report children's home: SC014234 4

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet 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)(ii) protect and promote each child’s welfare.

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Requirement Due date

This is with specific reference to supporting children who may have been mistreated by care or teaching staff. 14/06/2017

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Requirement Due date

*7: The children’s views, wishes and feelings standard

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Requirement Due date

In order to meet the children’s views, wishes and feelings standard, the registered person must ensure that staff give an explanation about: (7)(2)(d)(iii) what advocacy support or services are available to the child, how the child may access that support or those services and any entitlement the child may have to independent advocacy provision.

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Requirement Due date

This is with particular reference to ensuring children may contact an advocacy service in confidence. 14/06/2017

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Requirement Due date

*11: The positive relationships standard

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Requirement Due date

In order to meet the positive relationships standard the registered person must ensure that staff: (2)(a)(xiii) have the skills to recognise incidents or indications of bullying and how to deal with them.

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Requirement Due date

Specifically how staff can prevent and address bullying in the home. 14/06/2017

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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: (2)(a)(i) 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 14/06/2017 Inspection report children's home: SC014234 5 harm to the child; (2)(d) 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.

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Requirement Due date

With specific reference to the assessment and management of risk, and maintenance of the premises. 13: The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, the registered person must: *(2)(c) ensure that staff have the experience, qualifications and skills to meet the needs of each child; (2)(e) ensure that the home’s workforce provides continuity of care to each child; (2)(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; (2)(h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

With specific reference to ensuring staff develop relevant skills, raising the standard of care and monitoring the quality of care being delivered. 14/06/2017

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Requirement Due date

In order to meet the care planning standard, ensure that children: (1)(a) receive effectively planned care in or through the children’s home.

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Requirement Due date

With specific reference to assessing the needs of each child, delivering specific interventions to meet those needs and monitoring the progress each child makes. 14/06/2017

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Requirement Due date

The registered person must ensure that the privacy of children is appropriately protected. (Regulation 21(a))

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Requirement Due date

Specifically, ensure that children can bathe or shower without other children entering the room and ensure that children do not share bedrooms with staff unless this has been agreed with the placing authority or parent where appropriate. 14/06/2017

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Requirement Due date

The registered person must ensure that all employees: undertake appropriate continuing professional development; receive practice-related supervision by a person with appropriate experience. (Regulation 33(4)(a)*(b)) 14/06/2017 Inspection report children's home: SC014234 6 Specifically, ensure the professional development of staff through delivering the training specified in requirements and compliance notices issued by the regulator, and ensure that staff receive practice-based supervision with the regularity specified in the home’s statement of purpose. *The registered person must prepare and implement a policy which provides 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. (Regulation 34(2)(b))

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Requirement Due date

Specifically, ensure a referral is made to a child’s placing authority when there are concerns the child may harm another child in the home. 14/06/2017

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Requirement Due date

*Case records must be kept securely in the children’s home during the period when the child to whom the case records relate is accommodated there. (Regulation 36(2)(c))

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Requirement Due date

Specifically, ensure case records stored on electronic devices can only be accessed by authorised staff, and that managers have the capacity to undertake an audit to establish when and why electronic records have been accessed. 14/06/2017

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 Ensure there is a workforce plan which details the processes and agreed timescales for staff to achieve induction. (‘Guide to the children’s homes regulations including the quality standards’, page 53, paragraph 10.8) Specifically, when staff are promoted, ensure they have an induction plan with timescales prior to commencing their new role.

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Recommendations

 Ensure children’s case records are kept up to date and signed and dated by the author of each entry. (‘Guide to the children’s homes regulations including the quality standards’, page 62, paragraph 14.3) Specifically, ensure a record is kept of any discussion that takes place with a child’s social worker, particularly where this relates to a safeguarding concern.

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Recommendations

 Ensure each child has permission for staff to administer first aid and non- prescription medication from a person with parental responsibility for them recorded in their relevant plan. (‘Guide to the children’s homes regulations including the quality standards’, page 34, paragraph 7.14)

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Overall experiences and progress of children and young people: inadequate

Inspection report children's home: SC014234 7 A full inspection of the home was undertaken in January 2017. At this inspection significant shortfalls were identified in relation to the quality of care being provided, how children were being protected from harm and the effectiveness of leaders and managers. The home was judged inadequate. The regulator subsequently took action to ensure the home completed steps to improve the quality of the service. A monitoring inspection took place in March 2017, and it was established that the home was making progress. This progress has not been sustained and consequently the children do not consistently have a positive experience of day-to-day life in the home.

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Overall experiences and progress of children and young people: inadequate

Since the inspection in January 2017, the organisation’s service manager has taken on the responsibility for day-to-day management of the home.

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Overall experiences and progress of children and young people: inadequate

The standard of care planning is weak. Some children who have lived at the home for more than two years have not had a full assessment of their needs. This is despite them demonstrating highly challenging behaviour. The home’s plans for the children do not clearly identify what interventions will be undertaken to ensure the placing authority’s overall plan for the child will be achieved. For example, no evidence could be found of work being undertaken with children to prepare them for a move to foster care, where this was the placing authority’s goal.

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Overall experiences and progress of children and young people: inadequate

Children do not consistently receive the support they require to manage negative experiences. The inspectors found that children who may have experienced confrontational situations with teachers at the organisation’s school do not always receive the support at home that would prepare them for when they next come into contact with the teacher. A social worker expressed the view that one child may have ‘internalised the blame’ for a confrontational situation at school, where the member of staff concerned had managed the situation inappropriately.

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Overall experiences and progress of children and young people: inadequate

Since the inspection in January 2017, some progress has been made in promoting advocacy services in the home. Despite this, the home has failed to ensure that children can contact an advocate, or other support services, without having to get the permission of staff to use a telephone. This would make it unlikely that a child could seek the support of an external support agency if they had concerns or worries they could not share with the professionals working with them.

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Overall experiences and progress of children and young people: inadequate

All of the children have an educational placement, either at the organisation’s school or an external establishment. They maintain good levels of attendance at school. One child has made very good progress on creative art projects. The service manager has made representations to one child’s placing authority where there has been a long delay in securing a more appropriate school placement for the child. However, she has not made contact with the headteacher of the virtual school for looked after children to engage their support and guidance. There is no school-time activity plan for one child who is currently only engaging in education on a part-time basis.

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Overall experiences and progress of children and young people: inadequate

Generally, the health needs of children are met well. Children receive a healthy, balanced diet and have many opportunities to take part in activities that enable them to Inspection report children's home: SC014234 8 take exercise. The home does not have the required level of consent to administer non- prescribed medication for one child. The organisation provides children with access to therapeutic counselling, and some engage well with their therapists. However, it is of concern that some children are receiving counselling without there having been a comprehensive assessment of their needs. Some children also receive a service from the child and adolescent mental health service (CAMHS). In one case, the service manager has not taken prompt action to ensure the child’s CAMHS assessment report has been made available in order to guide and support staff.

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Overall experiences and progress of children and young people: inadequate

The complex emotional needs of the children mean they often experience difficulties in maintaining positive peer relationships. Occasionally, children have become physically aggressive, and staff have not always been able to prevent them assaulting one another. One child’s privacy has been compromised by another child entering her bedroom. The service manager was not able to identify any significant progress in terms of a reduction in challenging behaviour for two children who have lived at the home for over two years.

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Overall experiences and progress of children and young people: inadequate

During a meal shared with the children, the inspector observed warm and supportive interactions between the children and staff. The staff clearly want to provide sensitive and nurturing care that meets the needs of the children. However, their ability to achieve this is compromised by the poor standard of care planning for the children and by the failure to ensure they have the opportunity to reflect on their practice and develop the knowledge and skills required to take on a demanding role.

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How well children and young people are helped and protected: inadequate

Practice in relation to keeping children safe and protecting them from harm is weak. Managers and staff consistently fail to effectively assess the risks to each child and do not take actions to reduce the prospect of them coming to harm. Following a serious incident in which one child was harmed, the placing authority wasn’t informed and risk assessments weren’t reviewed to consider the heightened risk to that child of further harm. When one of the inspectors interviewed members of care staff, it became clear that not all staff were aware that the serious incident had occurred, and that one of the children in the home was potentially at greater risk of being harmed by her peers.

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How well children and young people are helped and protected: inadequate

The shortfalls in the standard of risk assessment and management are widespread. Prior to a recent vacation at a holiday camp, no risk assessment was undertaken in respect of the sleeping arrangements for the children. These arrangements included two children sharing bedrooms with care staff. No account was taken of known behavioural concerns. The social workers and, where appropriate, the parents of these children were not consulted about the proposed sleeping arrangements. The inspectors were informed that after the first night, the staff did not feel comfortable sleeping in the same room as the children, and alternative arrangements were made.

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How well children and young people are helped and protected: inadequate

At the last full inspection in January 2017, shortfalls were identified in some aspects of behaviour management, particularly in relation to the use of physical restraint. There has been an improvement in this area of practice. All restraint records reviewed by the Inspection report children's home: SC014234 9 inspectors at this inspection provided a full account of the events leading up to the child being restrained, the de-escalation techniques that were used and a factual description of the physical intervention. No examples of restraint being used inappropriately were identified.

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How well children and young people are helped and protected: inadequate

Not all practice relating to behaviour management has shown a similar improvement. At the full inspection in January 2017, concerns relating to children bullying one another were identified. A requirement was made to ensure staff would acquire the skills to recognise incidents and indications of bullying and how to deal with them. Since the inspection, only one member of staff has completed the organisation’s training course on this aspect of childcare practice. The inspectors could find no evidence that staff manage bullying effectively. The record of a ‘care coordinator’ session for one child states she had said that she did not know what bullying was. There is no record of how the member of staff responded. Children who are known to have been victims of bullying behaviour from their peers, and children who have demonstrated bullying behaviour, do not have the specific plans required to show how they will be supported to address the

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How well children and young people are helped and protected: inadequate

Failure to assess children’s needs and implement robust strategies to manage their behaviours has meant that children’s challenging behaviours have not reduced and in some cases they have increased in frequency and intensity.

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How well children and young people are helped and protected: inadequate

Since the inspection in January 2017, there has been some improvement in how child protection concerns are shared with other safeguarding professionals. For example, consultation with the local authority designated officer, following a child making an allegation against a member of staff, has been consistent. There has also been more frequent consultation with professionals from the local multi-agency safeguarding hub. However, practice in this area is not yet sufficiently robust. This is demonstrated by the failure to inform the social workers of the two children who became a potential risk to their peer, referred to earlier in this report. When consultation does take place with other professionals, clear written records of the decisions taken are not always kept.

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How well children and young people are helped and protected: inadequate

Leaders and managers have not given sufficient priority to ensuring that children’s sensitive and confidential information is stored securely. At the time of this inspection, staff were able to access children’s confidential case records through an application on their mobile electronic devices. This included staff’s personal mobile telephones. There was no lock-out system on the application to ensure that access to the files would be disabled after a period of inactivity. This meant there was the potential for people outside of the organisation to gain access to the children’s files which would compromise children’s confidentiality.

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How well children and young people are helped and protected: inadequate

Managers’ ability to monitor staff’s activity in children’s electronic files was insufficiently robust. Managers took action to rectify this during the inspection. It is of concern that leaders and managers within the organisation had not identified this risk to children’s safety prior to this being brought to their attention during the inspection.

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How well children and young people are helped and protected: inadequate

At the inspection in January 2017, inspectors identified a number of serious health and Inspection report children's home: SC014234 10 safety hazards that resulted from poor maintenance of the premises. On 3 March 2017 a monitoring inspection was undertaken, and significant improvements had been made. However, at this inspection it became evident that this improvement had not been sustained. On two occasions inspectors observed a fire door propped open with a chair. The inspectors were informed that the door was propped open because the fire safety mechanism was broken. Two light switches were seen to be hanging from the wall on an upstairs landing, with the electrical wiring exposed. Vertical struts were missing from a handrail on two internal staircases.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not demonstrated they have been able sustain improvement over time. Progress in complying with the notices set following the inadequate inspection, as seen at the monitoring inspection in March 2017, have not been sustained. An allegation against a member of staff was not properly dealt with; planned training has not been delivered; and children cannot access an advocacy service in confidence.

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The effectiveness of leaders and managers: inadequate

In January 2017, the registered manager gave notice of her intention to end her employment at the home. Her final day of employment was on the last day of this inspection. Since the home received an inadequate judgement at the full inspection in January 2017, the organisation’s service manager has assumed day-to-day managerial responsibility for the home. Although senior managers have made some attempts to recruit a new manager, no significant progress had been made when this inspection took place. The children were aware that the service manager would not be in the post permanently; the inspectors were informed that the uncertainty about who would manage the home in the future was causing some anxiety among the group. Three staff have left the home since the inspection in January 2017, and this has contributed to a sense of instability for the children. The home currently has sufficient numbers of staff to

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The effectiveness of leaders and managers: inadequate

care for the number of children resident. However, more staff would need to be recruited if new children were to be admitted.

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The effectiveness of leaders and managers: inadequate

Since the last inspection in January 2017, managers have reviewed and amended systems for monitoring the quality of care. These changes are not yet embedded in practice. Although the service manager has ensured there is managerial oversight following all serious incidents, the monitoring of practice sometimes fails to provide an effective evaluation of the quality of staff practice. The inspectors could find no evidence that thematic monitoring takes place. For example, no analysis had been undertaken of the common triggers and events that have resulted in a number of restraints involving one child. Systems for monitoring the quality of care are not identifying opportunities for developing practice.

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The effectiveness of leaders and managers: inadequate

At the time of this inspection, five out of the nine staff employed at the home had not yet completed refresher training on the assessment and management of risk, which was included in the compliance notices issued following the inspection where the home was judged inadequate. The inspectors were informed on 2 March 2017 that further staff training on the assessment and management of risk – and on the home’s child Inspection report children's home: SC014234 11 protection procedures, childcare legislation and reporting allegations made against staff – would be completed by 11 April 2017. This was not achieved. In addition, the home’s new deputy manager was not able to attend training that was delivered on the notification of serious events. Consequently, managers and staff have not had the opportunity to update their skills and knowledge on these key areas of practice.

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The effectiveness of leaders and managers: inadequate

The staff do not receive an adequate level of support from leaders and managers to ensure they can perform their role effectively. One member of staff had been promoted to the role of deputy manager on 1 April 2017. At the time of this inspection he did not have an induction plan or a clear understanding of the responsibilities assigned to his new role. Staff do not receive supervision with the regularity outlined in the home’s statement of purpose. One member of staff who has no previous experience of working with vulnerable children began working at the home in January 2017. At the time of this inspection she had only received two formal supervision sessions. According to the statement of purpose, she should have received four or five at this stage in her employment.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not ensure that that the children’s ‘placement plans and treatment programmes’ comprehensively identify each child’s needs. These plans lack clearly defined strategies for ensuring children’s needs are met. There is inconsistent recording of the progress children are making. This is indicative of a home that fails to have high expectations and aspirations for the children. For some children, the failure to fully assess need and implement effective interventions has led to more frequent and severe challenging behaviour. The poor standard of leadership and management in the home has resulted in a failure to consistently take action to reduce the known risks for each child.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people. Inspectors considered the quality of work and the difference made to the lives of children and young people. They watched how professional staff work with children and young people and each other and discussed the effectiveness of help and care provided. Wherever possible, they talked to children and 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.

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Information about this inspection

Using the ‘Social care common inspection framework’, this inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, 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’. Inspection report children's home: SC014234 12

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Children’s home details

Registered provider address: Lioncare Ltd, 186 Forest Road, Loughton, Essex, IG10 1EG

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Inspectors

Stephen Collett: social care inspector Teri Peck: regulatory inspection manager Inspection report children's home: SC014234 13 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, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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