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

Inspection report children’s home: SC061952 1 SC061952 Registered provider: Marlowe Child and Family Services 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

This children’s home is registered to accommodate up to 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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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 widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded and/or 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: 6 December 2016

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inadequate

Overall judgement at last inspection: Declined in effectiveness

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Enforcement action since last inspection

Following the interim inspection in December 2016, a compliance notice was issued under Regulation 13: The leadership and management standard. A monitoring visit was carried out on 12 January 2017. That monitoring visit judged that improvements had been made to address many of the weaknesses previously identified. However, those improvements have not been sustained. Inspection report children’s home: SC061952 2

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Key findings from this inspection

This children’s home is inadequate because:

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Key findings from this inspection

 Leaders do not manage this home effectively. There is no registered manager in post and care is not provided in line with the home’s statement of purpose.

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Key findings from this inspection

 Weaknesses found at this inspection were also identified at the interim inspection in December 2016; leaders have taken insufficient action to rectify the weaknesses and to sustain improvements.

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Key findings from this inspection

 Leaders do not manage child protection concerns well. Staff have not reported all child protection concerns to the designated officer as required and they have failed to investigate other concerns robustly.

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Key findings from this inspection

 At times, staff have injured young people during restraints. Leaders have failed to link injuries that happen during restraint with safeguarding.

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Key findings from this inspection

 Leaders do not always implement safer recruitment processes rigorously.

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Key findings from this inspection

 Not all staff working with young people have the required skills, training and support from leaders to meet their needs.

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Key findings from this inspection

 Young people are not always cared for by a staff team that they know well. The staff team changes frequently, with members starting and leaving regularly. As a result, it is difficult to provide an environment where positive relationships thrive.

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Key findings from this inspection

 Young people’s records are poorly maintained; this was also a weakness at the last inspection. Staff do not have up-to-date care and support plans available to them to guide their work with young people.

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Key findings from this inspection

 Leaders have failed to provide young people with a home that is always kept clean and well maintained.

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Key findings from this inspection

 Leaders promote education well to the young people. All of the young people are engaged in full-time education. One young person is beginning a phased reintroduction to school and another has a place at a further education college. Inspection report children’s home: SC061952 3

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Inspection date Inspection type Inspection judgement

06/12/2016 Interim Declined in effectiveness 30/06/2016 Full Requires improvement 30/03/2016 Interim Sustained effectiveness 19/08/2015 Full Requires improvement Inspection report children’s home: SC061952 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

6. (1) The quality and purpose of care standard is that children receive care from staff who:

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Requirement Due date

(a) understand the children’s home’s overall aims and the outcomes it seeks to achieve for children;

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Requirement Due date

(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:

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Requirement Due date

(a) understand and apply the home’s statement of purpose;

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Requirement Due date

(i) understand and apply the home’s statement of purpose;

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Requirement Due date

(ii) protect and promote each child’s welfare;

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Requirement Due date

(iii) treat each child with dignity and respect;

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Requirement Due date

(iv) provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background;

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Requirement Due date

(vi) help each child to develop resilience and skills that prepare the child to return home, to live in a new placement or to live independently as an adult;

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Requirement Due date

(vii) provide to children living in the home the physical necessities they need in order to live there comfortably;

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Requirement Due date

(viii) provide to children personal items that are appropriate for 02/06/2017 Inspection report children’s home: SC061952 5 their age and understanding; and

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Requirement Due date

(ix) make decisions about the day-to-day arrangements for each child, in accordance with the child’s relevant plans, which give the child an appropriate degree of freedom and choice;

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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:

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Requirement Due date

(ii) enable each child to participate in the daily life of the home.

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Requirement Due date

Staff must understand and apply the statement of purpose. Staff must understand the individual needs of the young people. Staff must ensure that the premises are kept clean, tidy and well maintained.

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Requirement Due date

11: The positive relationships standard*

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Requirement Due date

11. (1) The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on:

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Requirement Due date

(b) an understanding about acceptable behaviour; and

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Requirement Due date

(c) 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:

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Requirement Due date

(i) meet each children’s behavioural and emotional needs, as set out in the child’s relevant plans;

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Requirement Due date

(ii) help each child to develop socially aware behaviour;

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Requirement Due date

(iii) encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding;

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Requirement Due date

(iv) help each child to develop and practise skills to resolve conflicts positively and without harm to anyone;

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Requirement Due date

(v) communicate to each child expectations about the child’s behaviour and ensure that the child understands those 02/06/2017 Inspection report children’s home: SC061952 6 expectations in accordance with the child’s age and understanding;

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Requirement Due date

(viii) strive to gain each child’s respect and trust;

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Requirement Due date

(ix) 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;

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Requirement Due date

(x) 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;

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Requirement Due date

(xi) de-escalate confrontations with or between children, or potentially violent behaviour by children;

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Requirement Due date

(b) that each child is encouraged to build and maintain positive relationships with others.

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Requirement Due date

Young people should receive care from a staff team who they know, who know individual young people’s needs and how these are to be met. 12: The protection of children standard*

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Requirement Due date

12. (1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to ensure:

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Requirement Due date

(i) assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child;

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Requirement Due date

(ii) help each child to understand how to keep safe;

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Requirement Due date

(iii) have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

(iv) manage relationships between children to prevent them from harming each other;

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Requirement Due date

(v) understand the roles and responsibilities in relation to 02/06/2017 Inspection report children’s home: SC061952 7 protecting children that are assigned to them by the registered person;

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Requirement Due date

(vi) take effective action whenever there is a serious concern about a child’s welfare; and

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Requirement Due date

(vii) are familiar with, and act in accordance with, the home’s child protection policies;

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Requirement Due date

(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;

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Requirement Due date

(c) that the premises used for the purposes of the home are located so that children are safeguarded effectively;

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Requirement Due date

(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; and

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Requirement Due date

(e) that the effectiveness of the home’s child protection policies is monitored regularly.

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Requirement Due date

Staff must have a working knowledge of safeguarding procedures and ensure that child protection concerns are managed effectively.

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Requirement Due date

13: The leadership and management standard*

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Requirement Due date

13. (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:

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Requirement Due date

(a) helps children aspire to fulfil their potential; and

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to:

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Requirement Due date

(a) 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;

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Requirement Due date

(b) ensure that staff work as a team where appropriate;

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Requirement Due date

(c) ensure that staff have the experience, qualifications and 02/06/2017 Inspection report children’s home: SC061952 8 skills to meet the needs of each child;

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Requirement Due date

(d) ensure that the home has sufficient staff to provide care for each child;

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Requirement Due date

(e) ensure that the home’s workforce provides continuity of care to each child;

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Requirement Due date

(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;

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Requirement Due date

(g) demonstrate that practice in the home is informed and improved by taking into account and acting on:

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Requirement Due date

(i) research and developments in relation to the ways in which the needs of children are best met; and

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Requirement Due date

(ii) feedback on the experiences of children, including complaints received; and

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Requirement Due date

(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

Leaders and managers must ensure that monitoring systems are effective and that they are used to highlight weakness and areas for development to improve practice. In addition, leaders and managers need to ensure that the staff caring for the young people are sufficient in number and have the skills and knowledge to meet the needs of the young people placed.

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Requirement Due date

14. (1) The care planning standard is that children:

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Requirement Due date

(a) receive effectively planned care in or through the children’s home; and

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Requirement Due date

(b) have a positive experience of arriving at or moving on from the home.

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Requirement Due date

In particular, care plans need to be current and identify how young people’s needs will be met. In addition, staff need to have a good understanding of these plans and consistently implement them. 02/06/2017

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Requirement Due date

16: Statement of purpose 02/06/2017 Inspection report children’s home: SC061952 9 16. (1) 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

(2) The registered person must provide a copy of the statement of purpose to HMCI.

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Requirement Due date

(a) keep the statement of purpose under review, and where appropriate, revise it; and

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Requirement Due date

(b) notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision.

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Requirement Due date

(4) If a home has a website, the registered person must ensure that a copy of the statement of purpose is published on that website unless the registered person considers that such publication would prejudice the welfare of children in the home.

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Requirement Due date

(5) 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.

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Requirement Due date

19. (1) No measure of control or discipline which is excessive, unreasonable or contrary to paragraph (2) may be used in relation to any child. 02/06/2017

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Requirement Due date

25. (1) After consultation with the fire and rescue authority, the registered person must:

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Requirement Due date

(c) make arrangements for persons working at the home to receive suitable training in fire prevention; and

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Requirement Due date

(d) 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 case of fire. 02/06/2017

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Requirement Due date

32. (1) The registered person must recruit staff using 02/06/2017 Inspection report children’s home: SC061952 10 recruitment procedures that are designed to ensure children’s safety.

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Requirement Due date

(a) employ an individual to work at the children’s home; or

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Requirement Due date

(b) if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children, allow that individual to work at the home,

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Requirement Due date

If the individual satisfies the requirements in paragraph (3).

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Requirement Due date

(a) the individual is of integrity and good character;

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Requirement Due date

(b) the individual has the appropriate experience, qualification and skills for the work that the individual is to perform;

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Requirement Due date

(c) the individual is mentally and physically fit for the purposes of the work that the individual is to perform; and

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Requirement Due date

(d) full and satisfactory information is available in relations to the individual in respect of each of the matters in Schedule 2.

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Requirement Due date

33. (4) The registered person must ensure that all employees:

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Requirement Due date

(a) undertake appropriate continuing professional development;

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Requirement Due date

(b) receive practice-related supervision by a person with appropriate experience.

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Requirement Due date

The registered person must ensure that this provision also includes staff employed from an external agency. 02/06/2017

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Requirement Due date

35: Behaviour management policies and records

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Requirement Due date

(3) The registered person must ensure that: (a) within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes:

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Requirement Due date

(iv) a description of the measure and its duration; 02/06/2017 Inspection report children’s home: SC061952 11 (v) details of any methods used or steps taken to avoid the need to use the measure;

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Requirement Due date

(vii) a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure;

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Requirement Due date

(b) 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:

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Requirement Due date

(i) has spoken to the user about the measure; and

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Requirement Due date

(ii) has signed the record to confirm it is accurate; and

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Requirement Due date

(c) within 5 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.

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Requirement Due date

36. (1) The registered person must maintain records (‘case records’) for each child which: (a) include the information and documents listed in Schedule 3 in relation to each child; (b) are kept up to date. 02/06/2017

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Requirement Due date

38. The registered person must ensure that the following items, which may be kept in electronic form, are kept in an accessible manner: (h) records of the use of measures of control, discipline or restraint; (i) children’s case records; (j) other records.

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Requirement Due date

In particular, young people’s files must be well maintained and ensure that staff have access to the up-to-date records. 02/06/2017

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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. 02/06/2017 Inspection report children’s home: SC061952 12

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Recommendations

 Ensure that the children’s home is a nurturing and supportive environment that meets the needs of the children in a homely and domestic setting. Children’s homes must comply with relevant health and safety legislations; however, in doing so, homes should seek as far as possible to maintain a domestic rather than ‘institutional’ impression. (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9)

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Overall experiences and progress of children and young people: inadequate

Young people do not live in a clean or welcoming environment. The property lacks a homely feel; it is untidy and uncared for. The initial impression for those visiting the home is not good; the front door is damaged with chips and dents; cobwebs and dirty marks are on the walls and ceilings; and, in one young person’s bedroom, there is a heavily stained carpet. The television in the lounge does not work because there is no aerial. Young people’s bedrooms are untidy, with items strewn over the floor, indicating that staff fail to help them to keep their rooms in good order.

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Overall experiences and progress of children and young people: inadequate

Young people are subject to restrictive practices in this home. Staff on duty are unable to provide any explanation as to why young people’s freedom is restricted and young people’s care planning documents contain no reference as to why restrictions are in place. Windows in the lounge and young people’s rooms cannot be opened. Two young people’s bedroom windows have bars across them to prevent them from opening. Restrictive practice was also raised as a concern at the interim inspection in December 2016 and no action has been taken in response. Staff routinely remove personal items such as toiletries from young people. These items are locked away without staff being able to explain why these items have been removed or how the team intends to work with young people to enable them to use these items independently.

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Overall experiences and progress of children and young people: inadequate

At times, staff sleeping-in arrangements have a negative impact on young people’s daily living experiences. When a third member of staff stays overnight, they sleep on an air bed in the young people’s main lounge. This arrangement limits young people’s ability to move freely around the communal areas of their home.

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Overall experiences and progress of children and young people: inadequate

At times during March 2017 and May 2017, between 12 and 16 different members of staff were scheduled to work at the home, limiting the opportunity for staff and young people to develop positive and nurturing relationships. This weakness was identified at previous inspections. Inspection report children’s home: SC061952 13

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

Safeguarding is inadequate. The team’s understanding, approach and responses to safeguarding concerns are weak. The staff team lacks clarity about when to make a referral to the designated officer and the team fails to report safeguarding concerns to the organisation’s designated safeguarding lead. Staff do not always make the link between injuries received during a restraint and safeguarding. Staff do not always recognise that complaints or concerns voiced by young people may constitute a safeguarding concern.

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

Staff use physical restraint to manage young people’s behaviour. On several occasions, young people have received injuries while being physically restrained by staff. Some young people who have been hurt during restraint have made complaints about this. The safeguarding lead for the organisation was not aware of all of the injuries that had occurred during restraints.

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

Staff do not complete records of restraints and incidents comprehensively. Inspectors found that some records of restraints and incidents were missing. Restraint records fail to demonstrate reflection or an understanding of the young people’s behaviours. In addition, young people are not always provided with an opportunity to talk about an incident or what happened when they have been physically restrained.

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

Procedures to maintain fire safety are inadequate. Staff do not carry out fire drills regularly. A member of staff stated that they had never taken part in a fire drill. The organisation carried out its own fire safety audit and identified this shortfall. However, leaders have not put an action plan in place to rectify this weakness.

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

Leaders do not always follow safer recruitment practices. Leaders and managers have failed to assess or mitigate the potential risks when employing staff with previous convictions.

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

The staff team does not always help young people to manage their behaviour positively. Sanctions are punitive and often involve the loss of the hobbies and activities that young people enjoy and that support their self-esteem. This approach is against the home’s behaviour management policy which states, ‘It is essential such privileges are not withdrawn if they are intrinsically valuable.’ The staff team misses the opportunity to build and develop their engagement with the young people through the activities that young people willingly engage in and value. In addition, the success of the sanctions given in terms of improving young people’s behaviour is not known because managers do not always monitor the records to assess the effectiveness of actions taken by the staff team.

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The effectiveness of leaders and managers: inadequate

The home is not led or managed effectively. Two senior managers have direct responsibility for the home but there is no registered manager in post. Leaders do not provide care in line with the home’s statement of purpose. The home has a poor Inspection report children’s home: SC061952 14 inspection history; leaders and managers have not secured an overall judgement of ‘good’ since 2013. Inspectors have identified similar weaknesses at previous inspections; for example, in 2014, the home was judged to be inadequate and requirements were raised in relation to staffing, management of child protection concerns linked to the use of restraint, the statement of purpose, complaint practices, maintenance of records and notifications. Despite previous compliance action being taken and initial improvements made, leaders have not been able to sustain improvements.

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The effectiveness of leaders and managers: inadequate

Leaders’ monitoring of the quality of care provided in the home is inadequate. Leaders and managers have not identified all of the weaknesses in the home’s performance, and, as a result, they have failed to take effective action. External monitoring of the home is ineffective; the independent visitor failed to identify the weaknesses found at this inspection.

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The effectiveness of leaders and managers: inadequate

Staffing arrangements are inadequate. Leaders and managers have not ensured that sufficient numbers of staff have the required expertise to meet the young people’s needs effectively. A member of staff employed by an agency works alone with young people without having undertaken safeguarding training. In addition, staff who have not been trained in supporting young people who self-harm care for them regularly. At times, staff who are in their probation period are in charge of shifts. At other times, no experienced member of staff is on duty. These deficiencies place young people at risk of harm.

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The effectiveness of leaders and managers: inadequate

Staff employed by an agency work regularly at times for long periods and on their own with young people. These staff are not provided with practice-related supervision by managers of the home. As a result, leaders and managers are unable to appraise effectively the workers’ performance and suitability to undertake their roles. Staff employed by the home receive regular supervision and appraisal; findings from these reviews link to probationary assessments.

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The effectiveness of leaders and managers: inadequate

Records are poorly maintained and stored. Staff supporting young people could not find important documents that are intended to help them to provide effective care. Support plans are out of date, some are missing and some are incomplete. Some staff demonstrate a poor understanding of young people’s needs.

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The effectiveness of leaders and managers: inadequate

Records do not provide clear evidence of young people’s progress. A young person who is due to move from the home shortly does not have a plan in place to support this move.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not ensured that all notifiable events are reported to Ofsted as required.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not taken effective action to meet all of the requirements made at the last inspection. Weaknesses in the staffing arrangements, in the management of child protection concerns and in the maintenance of records found at this inspection were also identified in December 2016. Inspection report children’s home: SC061952 15

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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 whom 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: SC061952 16

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Children’s home details

Registered provider: Marlowe Child & Family Services Limited

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Children’s home details

Registered provider address: Staverton Court, Staverton, Cheltenham, Gloucestershire GL51 0UX

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Inspectors

Wendy Anderson, social care inspector Nicola Lownds, social care inspector Inspection report children’s home: SC061952 17 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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Inspectors

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Inspectors

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Inspectors

T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: http://www.gov.uk/ofsted

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