Children's Home run by Blue Mountain Homes Ltd in Derbyshire

Inspection report children’s home: SC464759 1 SC464759 Registered provider: Blue Mountain Homes Ltd

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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 privately owned and provides care to children and young people who have emotional and/or behavioural difficulties (EBD).

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Overall experiences and progress of

children and young people, taking into account

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requires improvement to be good

How well children and young people are helped and protected requires improvement to be good

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requires improvement to be good

The effectiveness of leaders and managers inadequate

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requires improvement to be good

The children’s home is not yet delivering good help and care for children and young people. However, there are no serious or widespread failures that result in their welfare not being safeguarded or promoted.

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requires improvement to be good

Date of last inspection: 6 September 2016

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requires improvement to be good

Overall judgement at last inspection: Requires improvement

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Enforcement action since last inspection

None Inspection report children’s home: SC464759 2

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Key findings from this inspection

This children’s home requires improvement to be good because

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Key findings from this inspection

 Young people are making some good progress, but this is hindered by poor leadership and management.  Staff are not supported and led effectively in their role. There are several new staff who are new to childcare and who have not been supervised appropriately.  Where there has been a medication error, lessons have not been learned and the management team has not fully investigated or spoken to the staff concerned about how they could improve their practice.  There are some gaps in staff training, for example in understanding radicalisation, drug and alcohol misuse and dealing with self-harm.  The new acting manager has not read the home’s statement of purpose. This document has not been updated since 2015 with relevant changes about the staff team.  The registered manager has not undertaken checks and monitoring in line with the regulations, allowing shortfalls in practice to drift.  The organisation has arranged for an independent person to visit the home and

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Key findings from this inspection

there has been thorough scrutiny of practice. However, some issues are repeated over a number of visits, showing that action is not swiftly taken when shortfalls arise.  Several key documents are missing from young people’s files, such as personal education plans, review minutes and important health information.  While the home has met two requirements set at the last inspection, three recommendations are not met. These are in relation to records and previous educational information, which cannot be found on young people’s files. The recommendation about staff supervision made at the last inspection has now been escalated to a requirement.

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Key findings from this inspection

 Young people are making some good progress despite shortfalls raised.  The impact of the shortfalls on young people is minimal to date.  There are some developing areas of good practice, such as risk reduction through comprehensive risk assessment and implementation.  The safety of young people is improving. Young people are going missing less often and have less incidents of self-harm.  A new acting manager is leading the home while the registered manager is on a period of leave. She has made positive changes to the rota to ensure that staff competence is evenly spread out over each shift. Inspection report children’s home: SC464759 3  The acting manager is fully aware of the shortfalls in leadership and management and has made good progress in starting improvements in the short time she has been at the home. This has minimised the impact of the shortfalls on young people.

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Inspection date Inspection type Inspection judgement

06/09/2016 Full Requires improvement 12/07/2016 Full Inadequate 21/03/2016 Interim Sustained effectiveness 13/10/2015 Full Good Inspection report children’s home: SC464759 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

13. The leadership and management standard (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— (a) helps children aspire to fulfil their potential; and (b) promotes their welfare. 31 May 2017

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Requirement Due date

13. The leadership and management standard (2) In particular, the standard in paragraph (1) requires the registered person to— (c) ensure that staff have the experience, qualifications and skills to meet the needs of 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. 31 May 2017

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Requirement Due date

Must keep the statement of purpose under review and, where appropriate, revise it. (Regulation 16(3)(a)) 31 May 2017

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Requirement Due date

Ensure that the registered person makes arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. (Regulation 23(1)) 31 May 2017

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Requirement Due date

Ensure that the person managing a children’s home has the appropriate qualification and has, by the relevant date, achieved the Level 5 Diploma or equivalent. (Regulation 28 (2)(c)(i)) 31 May 2017

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Requirement Due date

Ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33(4)(b)) 31 May 2017

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Requirement Due date

Ensure that the registered person maintains records (‘case records’) for each child, which include all the documents in relation to schedule 3 in relation to each child. This is in 31 May 2017 Inspection report children’s home: SC464759 5 particular reference to the outcome of medical investigations, education and healthcare plans, school reports and the result of any review of the placing authorities’ plan for the care of the child. (Regulation 36, Schedule 3) The registered person must establish a system for monitoring, reviewing and evaluating the quality of care provided for children. (Regulation 45(2)(a)) 31 May 2017

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Recommendations

 Staff should be familiar with the home’s policies on record keeping and understand the importance of careful clear and objective recording. (‘Guide to the children’s homes regulations including the quality standards’, page 62, point 14.4)  Ensure that staff have the knowledge and skills to understand each child’s education and training targets and their next steps for learning. This is in relation to obtaining relevant personal education plans and previous information about young people’s past achievements. (‘Guide to the children’s homes regulations including the quality standards’, page 27, paragraph 5.11)  Any child who has been restrained should be given the opportunity to express their feelings about their experience of the restraint as soon as practicable, ideally within 24 hours of the restraint incident. (‘Guide to the children’s homes regulations including the quality standards’, page 49, paragraph 9.60)

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improvement to be good

Young people’s files are not up to date and it is not easy to see a clear picture about what action the home should be taking and has taken, to ensure that each area of need is met. For example, young people’s ‘Looked After Children’ review notes, personal education plans and information about previous attainment at school are missing. Also, when a young person had a significant health issue, there was no information recorded about the outcome. Young people could be at risk if their health conditions are not being properly addressed or recorded for future reference. The arrangements for the administration and recording of medication are not fully effective. Some medicines have not been appropriately signed for as given by staff. The day before the inspection, one young person should have been given their prescribed controlled drug. However, there was no record of this, or of two other occasions in the

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improvement to be good

same month. For one of the occasions, the acting manager was able to establish that the young person had received their medication, but that it had not been recorded. On another occasion, appropriate medical attention was sought and staff did the right thing in informing their manager straight away. However, there was a lack of proper investigation and lessons learned were not fully identified to secure improvement, hence Inspection report children’s home: SC464759 6 continuing problems with the procedure. Young people have all made some good progress. All young people appeared happy and relaxed in their placement. All young people spoken with said that they felt happy and safe. One young person said, ‘I have enjoyed being here and feel happy’, demonstrating that they are having a positive experience. All young people are in either education or employment. Staff are encouraging and active in supporting young people when problems occur. One young person talked about

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improvement to be good

issues in a previous education placement and about where staff have supported them to change direction effectively. Another young person is pleased that staff are supporting them with a chosen career for when they leave education. One social worker reflected on some very positive work on one young person’s education, saying, ‘This is the longest they have been in school, I am stunned.’ There is some paperwork missing in young people’s files in relation to education. For some young people, their learning journey cannot be established. As a result of this, staff will not know about their previous achievements and difficulties in order to maximise progress. There are some very positive relationships between staff and young people, although young people do report that they get on better with some staff than others. Young people can identify staff who they say care about them, helping them to develop their

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improvement to be good

self-esteem and sense of belonging. There is always someone for young people to talk to about their problems and worries. Staff spend quality time with young people, particularly following significant events or safeguarding issues. Young people engage well with staff, feel able to trust them, and regularly and positively reflect on their own behaviour. Since the last inspection, some young people have presented with some serious self- harm issues. However, all young people in placement are getting the help they need. This has led to a reduction of such behaviours. Drug and alcohol issues are reported by young people to be less of a problem than before. One young person, who felt that this was a big problem before, reported that this was ‘better’ and said they now felt ‘happy’ at the home. Some of the staff team have not been trained in how to assist young people with self-harm issues, or drinking and drug misuse, although young people have

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improvement to be good

made improvements in this area. Training should be urgently organised to minimise any impact on young people in the future. A lot of time and effort goes into supporting young people in maintaining, and further developing, contacts with people who are important in their life. Young people are listened to and staff work well with placing authorities to secure improvements. This means that young people maintain positive relationships with family for when they move out of care. A young person who has left since the last inspection, had a turbulent time at the home, without a positive ending. Although staff believe that some of her photos were given to her social worker, it is not clear whether she has seen these, and staff cannot demonstrate, therefore, that she has positive momentums of the home to reflect on, and remember that the staff cared for her. Inspection report children’s home: SC464759 7

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improvement to be good

More recently, one-to-one sessions have been effective in helping to reduce risky behaviours such as going missing, but this has only been in the last few weeks. Progress with behaviours, such as going missing, had been allowed to drift until then and the improvements need to be bedded in to ensure that the momentum of progress continues. However, all young people are now making significant progress. The new acting manager is keen to build on recent progress, and there has been very positive multidisciplinary working on this to safeguard young people more effectively in the last few weeks. The police are in agreement that things have started to improve. However, they feel that there has been a lack of experience and understanding from staff about when to report young people who are missing until very recently, with an over-reliance on the police service. Some procedures which are designed to keep young people and staff safe have started

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improvement to be good

to slip. During a recent incident, a staff member found themselves in a position where they were in the community with a young person and needed assistance from colleagues. However, the staff member did not have the home’s mobile phone or the telephone number of the home to summon assistance, despite this being the home’s policy. This put the staff member and young person at risk. Staff are getting more training all the time, and there are some areas that have been particularly helpful to assist staff to meet the complex needs of young people. However, some basic training for staff on self-harm, how to support young people with drugs and alcohol issues, and how to pick up signs and what to do if young people are at risk of radicalisation, is missing. Since the last inspection, there was a turbulent period during which some young people displayed some very challenging behaviours. However, more recently the home has

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improvement to be good

settled down and the three young people now in placement are all becoming increasingly safe. Young people’s own views are that they are safe and feel safe. Restraints are only used when necessary and to safeguard young people. Staff are trained and know how to carry out the home’s chosen method effectively and safely. Young people agree that restraints are only ever used as a last resort. However, young people are not routinely asked about what they feel about why and how the measure was used. Their opinion is lost and opportunities are missed to quality assure staff’s practice for further improvement. There is, however, always an opportunity for young people to reflect on their behaviours and they start to learn about acceptable behaviour. Young people do get the help they need from outside agencies, such as community mental health services and local organisations. All young people in placement are making

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improvement to be good

positive progress with their behaviour. One social worker was extremely positive about work on behaviour management, saying that staff have turned her around. In addition, one young person commented very positively, saying that staff ‘have helped to calm me down’. Young people spoke of personal strategies learned to self-regulate their behaviour better. This improvement will equip young people now and in later life to Inspection report children’s home: SC464759 8 better manage their emotions and behaviour. Staff are well versed in the homes and local policies on safeguarding young people. They always ask for and receive assistance from managers when there is a safeguarding issue. Relevant agencies, such as social workers, the local designated officer and the police are contacted about safeguarding concerns, including the risk of harm, risk of radicalisation and bullying, when needed. The designated officer is satisfied with the

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improvement to be good

home’s joint working with them since the last inspection and he reports that senior managers are working well with him. The implementation of health and safety procedures has ensured that the home remains a safe place in which to live and work. There are appropriate arrangements for fire protection. However, staff have been unaware that a form exists to record the effectiveness of drills and who has been involved. Opportunities have been missed to further protect young people against the risk of fire. Arrangements for the recruitment of new staff during this difficult period have been good, ensuring that young people remain safe and protected from unsuitable adults.

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The effectiveness of leaders and managers: inadequate

There are several failures in meeting the regulations in this area. The leadership and management has been poor in this home. While this does not appear to have led to an unsafe service, young people’s progress has been hindered because of a lack of good leadership. Since the last inspection, four staff have left the home because of the severity of young people’s behaviour and a lack of support and direction from managers. Morale was reported to be low following the last inspection. However, staff are confident that this has more recently started to change. The registered manager has been on a period of extended leave for three weeks and a new acting manager has been in the position. Staff feel more supported under the new management arrangements and the direction of travel is positive. Young people are also feeling that the leadership in the home is more positive. Shortfalls in leadership and management have been widespread. In particular, the new

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The effectiveness of leaders and managers: inadequate

staff team has not been supported or trained effectively. The staff’s practice has not been robustly monitored and they have not had formal opportunities to discuss their progress or concerns. Given that many of the new staff are not only new to the company but new to childcare, this lack of support and direction could easily negatively impact on young people’s safety and progress if not put right. Where mistakes are made, the manager’s actions have not been effective in securing improvements. For example, where there has been a recent medication error, lessons learned from this cannot be seen, thus leading to further problems and a procedure that is becoming unsafe. The home’s statement of purpose has not been updated for 19 months. This means that it does not fully reflect the competence and quality of the staff team, which is still only just emerging. This could give a false impression to parents, placing authorities and

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The effectiveness of leaders and managers: inadequate

young people about the current quality of the staff team. Inspection report children’s home: SC464759 9 The registered manager has not yet completed the required level of training in line with the regulations. Neither has he met a key regulation about monitoring the quality of care in the home. Where monthly audits are required, there has been no monitoring activity for several months. There is the potential for young people not to make progress, and possibly regress, because of a lack of monitoring and being able to understand where they are at. Where the company has arranged for an independent visitor to visit the home once a month, these visits have been thorough and have identified shortfalls. However, there is a pattern of shortfalls being repeated, showing that action has not been taken to address shortfalls as they arise. There is an overall picture of a lack of direction, which could very easily impact on young people’s progress if not put right.

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The effectiveness of leaders and managers: inadequate

Two recommendations from the last inspection are met and, in particular, there has been improvement to the room search policy. Three recommendations are not met and issues remain regarding documentation. One recommendation about staff supervision has been escalated to a requirement because it is not met from the last inspection. The home’s procedure for assessing new admissions has not been followed. For the most recently admitted young person, there is no evidence of a full assessment to ensure that their needs could be met and that the mix of young people would be appropriate or safe. Staff and current management do agree, however, that the decision was a safe one and that the young person is making progress. There is the potential for a bad decision and for young people’s progress to be negatively impacted if this is not put right. Such decisions are instrumental in keeping young people safe, protected and

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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: SC464759 10

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Children’s home details

Registered provider: Blue Mountain Homes Ltd

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Children’s home details

Registered provider address: Flat 17, Leeland Mansions, Leeland Road, London W13 9HE

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Children’s home details

Responsible individual: Pradeep Manaktala

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Inspector(s)

Caroline Brailsford, Social Care Regulatory Inspector Inspection report children’s home: SC464759 11 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 children looked after, safeguarding and child protection.

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Inspector(s)

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Inspector(s)

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Inspector(s)

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