Children's Home run by Horizon Care and Education Group Limited in Staffordshire

Inspection report children's home: SC463852 1 SC463852 Registered provider: Horizon Care and Education Group 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 registered to provide care for three young people who have emotional and/or behavioural difficulties. The home forms part of a large social care company.

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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 young people are not protected and their welfare is not promoted or safeguarded.

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inadequate

Date of last inspection: 22 December 2016

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inadequate

Overall judgement at last inspection: Declined in effectiveness

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Enforcement action since last inspection

None. Inspection report children's home: SC463852 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

 Young people have gone missing and have exposed other young people to exploitative situations.  Staff do not manage relationships between young people in ways that prevent them from harming each other.  Staff have not worked consistently as a team. Staff have undermined one another’s work with young people. This has resulted in allegations, assaults, damage and injuries.  Managers and staff have not learned from incidents in order to protect young people from further harm.  Young people have experienced inadequate responses from staff when they have gone missing.  Placements have been made despite serious safeguarding concerns.  Young people have displayed aggressive behaviour towards staff and have not made consistent progress with this behaviour.  Young people’s transitions into and out of the home take place on a crisis basis.  Relationships and information exchange between professionals, relatives, staff

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Key findings from this inspection

and managers have failed to address young people’s risky behaviour and educational disengagement.  Some young people have not made progress in relation to their education because staff have not addressed the barriers that affect the young people’s learning.  Leaders and managers do not provide the right supportive environment for staff through effective supervision and appraisal, or through high quality induction, training and development.  The manager does not know enough detail about complaints and allegations that have happened in order to ensure that all issues are effectively dealt with.  A number of agency staff have been used, particularly in April, which has unsettled young people. There are no available records about a few of these agency staff.

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Key findings from this inspection

 The new manager and the staff team have started a reward system and a home boundaries book, which are starting to help staff manage young people better.  Since one young person has been on her own in placement, she has started to feel safe. She recently stated that she likes staff and feels that they support her and listen to her. Inspection report children's home: SC463852 3  Staff are now providing social workers with monthly reports on the young person whom they have placed.  The care manager has organised a training day for the staff team to reflect on the changes they are experiencing, and to improve on basic risk assessment, consistency of care practice, report writing and recording.  Some new staff are keen and able to provide more insightful care.

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Inspection date Inspection type Inspection judgement

22/12/2016 Interim Declined in effectiveness 11/05/2016 Full Good 02/02/2016 Interim Declined in effectiveness 24/11/2015 Full Good Inspection report children's home: SC463852 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

In order to meet the protection of children standard, the registered person must ensure—

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Requirement Due date

(2)(a) that staff— (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 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

(2)(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. 16/06/2017

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Requirement Due date

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— 16/06/2017 Inspection report children's home: SC463852 5 (2)(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

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

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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. 14: The care planning standard

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Requirement Due date

In order to meet the care planning standard, the registered person must ensure—

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Requirement Due date

(2)(a) that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose;

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Requirement Due date

(i) ensure the effective induction of each child into the home;

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Requirement Due date

(ii) manage and review the placement of each child in the home; and

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Requirement Due date

(iii) plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements agreed with the child’s placing Authority. 16/06/2017

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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—

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Requirement Due date

(v) help each child to understand and manage the impact of any experience of abuse or neglect;

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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. 16/06/2017

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Requirement Due date

8: The education standard 16/06/2017 Inspection report children's home: SC463852 6 In order to meet the education standard, the registered person must ensure— (2)(a) that staff—

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Requirement Due date

(ii) support each child’s learning and development, including helping the child to develop independent study skills and, where appropriate, helping the child to complete independent study;

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Requirement Due date

(iii) understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers;

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Requirement Due date

(iv) help each child to understand the importance and value of education, learning, training and employment. The registered person must ensure that records are kept of an allegation of abuse or neglect, and the action taken in response. (Regulation 34 (2)(d)) 16/06/2017

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Requirement Due date

The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation. (Regulation 39 (3)) 16/06/2017

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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; and have their performance and fitness to perform their roles appraised at least once every year. (Regulation 33 (4)) 16/06/2017

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Requirement Due date

The registered person must ensure that there is a record of any persons who reside or work at any time at the home, who are not mentioned in the records kept in accordance with paragraphs 1 or 2 of schedule 4. (Regulation 37 (2) schedule 4.4) 16/06/2017

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Overall experiences and progress of children and young people: inadequate

Four young people have lived here since the last inspection in December 2016. During this period, staff and the manager have not influenced their progress and experiences for the better. Three of the four young people have moved out following numerous serious incidents. One 13-year-old was moved to another home in January 2017 after 18 months living here. His plan for fostering was changed because he was not able to engage in education, regularly attacked peers and staff, and was going missing. The organisation’s clinician said in late 2016 that he was ‘re-traumatised’ by his experiences. He was moved to another of the organisation’s homes following going missing with a young person, then aged 14, who came here in December 2016. The young people Inspection report children's home: SC463852 7 allege to have engaged in a sexual activity together while missing. A young person, aged 13, was admitted to the home late at night as an emergency in March 2017. She started

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Overall experiences and progress of children and young people: inadequate

going missing within two days of arrival, always with another young person from the home. She went missing five times during her 12-day placement, and staff were unable to establish any relationship with her. The organisation served notice on her placement with immediate effect after the fifth episode, when she was missing for three days. At the time of this inspection, a third young person, aged 15, was refusing to return following going missing back to her home area. She did not make progress because staff could not manage her behaviour.

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Overall experiences and progress of children and young people: inadequate

One young person, aged 12, has lived here for two years now. She has made little progress since the last inspection. She is no longer likely to move on to foster care, as originally planned. She has experienced inconsistent care and has been exposed to many unsafe situations. A member of staff said that the other young people here ‘have made a lasting impression to a negative extent on her.’ Her social worker said, ‘She has not made the progress she should’ve done. Ideally I would like her to go fostering but she has now become at risk of child sexual exploitation (CSE) and last time she went missing she did so on her own.’

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Overall experiences and progress of children and young people: inadequate

Some young people make inadequate progress in their education and learning. Only one young person attends school. This young person has missed school sessions on three occasions because she has refused to go or has been too tired after going missing late into the night. She said on one occasion, ‘If [other young person] does not go to school, I’m not.’ Three young people have not attended education and have refused to engage in a routine of learning at the home. Staff have not worked as a team or found ways to overcome the barriers to learning that are entrenched for these young people. Staff have not provided effective support or found ways of engaging and motivating young people. In addition, the manager and staff have not provided an assessment of educational need, as requested as part of one young person’s care plan.

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Overall experiences and progress of children and young people: inadequate

The needs of young people who live far from home are inadequately met. Young people do not feel at home and do not want to develop relationships with staff. Staff do not work creatively together to make a positive impact on young people’s lives. Staff have not worked with young people’s relatives and social workers to overcome deep-seated safety and communication issues arising from young people’s experiences of abuse and neglect. As a result, young people run away, run back to family and are at ongoing risk. One young person’s social worker said, ‘I was assured that there would be work done with [young person] on CSE but the relaying of information has been poor. I have not had access to records about incidents; ‘missing’; or the quality of the contact with relatives and the money and cigarettes being exchanged. Staff are not well briefed and are not writing up reports on what happens at contact.’ Overall, young people do not

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Overall experiences and progress of children and young people: inadequate

make progress and social workers seek other placements, including secure accommodation.

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Overall experiences and progress of children and young people: inadequate

Young people have experienced excessive change and confusion in their relationships with staff. This is because staff have not been confident in one another and have undermined each other. Some staff compete to have the ‘best’ relationships with young Inspection report children's home: SC463852 8 people and frequently take them out on a one-to-one basis. Staff have been inconsistent about the boundaries of care practice that they should all use.

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Overall experiences and progress of children and young people: inadequate

Young people have enjoyed some good experiences over the last four months. For example, one young person regularly attends girl guides and has some friends there. Another young person spent some quality time at local stables and enjoyed working with the horses, including having riding lessons. Staff have engaged young people quite often in cooking activities and in playing board games. They have taken young people to local places of interest to develop their learning about history. A member of staff said that the remaining young person ‘feels happier now her older female peer is not here. She also feels happier now that she has been assured that money will not be taken out of her pocket money in relation to the ‘alleged’ damage to [member of staff] car.’ This young person wrote on a home questionnaire that she likes staff and feels that they support her and listen to her.

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

The risks to young people are not understand by staff. Young people are admitted to the home with insufficient information about their presenting risks. When information about risks becomes known, staff and the manager have not done enough to minimise these risks. This means that young people who have lived at the home have not become increasingly safe. Young people have become more sexualised and have been introduced to ways of making unsafe sexual relationships through misuse of social media and going missing. All three young people living at the home in February had experienced unsafe situations while missing. Staff have not managed situations effectively, and have not given young people clear and consistent help and protection. As a result, young people have continued to be unsafe until placements have ended.

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

Staff and the manager’s planning and responses to young people going missing have been inadequate. They do not take the risks seriously enough. For example, in consultation with a social worker, staff decided to allow a young person aged 14 more free time ‘as a test’ to see if they would use the time to make suitable friends. Staff did not amend the plan when the test failed and the young person was out until the early hours. The young person was returned by police under the influence of alcohol and it emerged she had placed herself at risk of harm during this time.

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

Staff have not taken enough account of obvious signs that young people are planning to go missing, such as: young people dressing provocatively; young people taking photos to circulate on social media; and grooming and bullying behaviour between young people. Staff monitor and observe these signs but continue to follow a response that allows free time, even when young people are adopting increasingly dangerous missing behaviour. This means that young people also go missing further afield to large cities, and are missing for longer. Young people have also learned to hide one another, and manage to elude police and staff in their home areas. The new manager said that there were 23 missing incidents in the six months to 31 March. Twelve of these pertained to one young person. Police said that they recorded 30 missing incidents for the same young person. Police said, ‘Action taken by this organisation isn’t working. They are not

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

Inspection report children's home: SC463852 9 learning from the previous missing incidents. We are yet to see risk assessments detailing how the setting is keeping [young person] safe.’

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

Staff have followed young people and tried to reason with them at the rail station or along the roads, but young people have still gone missing with strangers or got onto trains. On two occasions, staff have used restraint to prevent immediate danger to younger peers from going out. These measures have prevented some incidents of going missing. However, staff and the manager do not review each episode of going missing with sufficient rigour or skill. They have not successfully engaged with young people to help them talk about what happens to them while they are missing. Without protective, nurturing relationships, young people have refused to return, or notice on the placement has been necessary.

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

One young person remains in long-term placement after two years. The organisation’s clinician noted in a consultation in early February that ‘[Young person] has been switching suddenly from engagement to inappropriate behaviours; she has been going missing on a number of occasions, for long periods and extending into the night. Also, when using the iPad with an agency staff member, she managed to download files with explicit sexual content. We discussed the importance of following agreed risk assessments and not shying away from putting limits down to protect her.’ This young person has not experienced consistent protection in subsequent months. A record of her being missing in April said that she ‘mirrored her older peer’s behaviour and had applied make-up and straightened her hair.’ This young person has been inadequately safeguarded and her welfare has not been promoted. Her plan to move to foster care

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

this year has had to be changed because she copies the behaviour of other young people who have now gone. Her social worker said, ‘We are not looking for a foster placement because of her behaviour – she has to stop running off and assaulting staff.’

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

Young people do not always feel safe in placement because staff do not practise consistently and with sufficient skill. Young people have attacked staff and said that staff have hurt them. Allegations about staff’s behaviour management practice continue, but staff and the manager do not follow the home’s child protection policies properly. For example, one member of staff was recently suspended for what the local authority designated officer (LADO) described as ‘threatening and aggressive practice that was not consistent with that of a professional carer.’ This incident was not whistle-blown until ten days after the event, and the member of staff continued to work in that time. The member of staff recorded the incident herself and implemented a fine to a young person for some damage that no one had witnessed. The manager’s debrief did not identify the poor practice and did not seek the young person’s view. This was despite the manager’s

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

prior concerns about the member of staff’s practice.

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The effectiveness of leaders and managers: inadequate

Staff and young people have experienced considerable change and inadequate management of the home in the four months since the last inspection. The registered manager left following a few periods of absence. Various managers oversaw the home during January and February until the new manager began in mid-February. A new Inspection report children's home: SC463852 10 registered individual has been supporting the manager for approximately one month. This means that young people have not experienced the ‘period of stability and respite to reflect on their difficulties and make future plans based on a comprehensive assessment of their social, emotional/behavioural, physical and educational needs and a dynamic care plan’ that is promised in the home’s statement of purpose.

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The effectiveness of leaders and managers: inadequate

The new manager has a staff group that do not work as a team. He plans to address major issues within the team, but has been hindered by not having adequate records of complaints and allegations to appraise himself quickly. Staff still feel unsupported and vulnerable. A member of staff said, ‘I have had supervision six weeks ago. The last one before that was in December, but there is no record of that.’ Some staff records contain no appraisal documentation or development planning. Staff have been moved to work in other homes then returned, but there is no record of the reasons for this or any personal development. Consequently, managers have not addressed staff practice through effective supervision and appraisal.

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The effectiveness of leaders and managers: inadequate

The new manager has not got indexed records of all complaints and allegations that have occurred since the last inspection. Complaints and allegations records are not cross-referenced. There are no logs of the recordings pertaining to each one, or logs of the actions taken on them. This means that the manager cannot tell if all the relevant documents are there, and what action needs to be taken next. Allegations and complaints about staff take excessively long to investigate and conclude. Staff feel vulnerable and do not know where they stand following allegations and complaints. The manager has not reviewed complaints and allegations with sufficient rigour and therefore cannot help staff to continuously improve their practice.

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The effectiveness of leaders and managers: inadequate

Despite inadequacies in leadership since the last inspection, the new manager is determined to bring about improvement. He is ensuring that staff provide social workers with monthly reports on the young person who remains in placement. He has organised a training day for the staff team to reflect on the changes they are experiencing and to improve on basic risk assessment, consistency of care practice, report writing and recording. He has booked staff onto the organisation’s training in therapeutic care practice. He has stressed to staff the importance of using the strategies and advice given by the organisation’s clinician in everyday practice with young people. He has also asked the police to run a training day with the staff to increase their understanding of the risks faced by young people around child sexual exploitation and internet safety. The new manager is capitalising on the strengths of new staff members who are helping other

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The effectiveness of leaders and managers: inadequate

staff to improve their practice. He has also been delegated greater authority over placement decisions. He says that he will take better account of the location’s risks to inform his placement decisions moving forward.

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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 differences 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 Inspection report children's home: SC463852 11 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: SC463852 12

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Children’s home details

Registered provider: Horizon Care and Education Group Limited

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Children’s home details

Registered provider address: Venture House, Unit 12, Prospect Business Park, Longford Road, Cannock WS11 0LG

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Inspector

Rachel Britten, social care inspector Inspection report children's home: SC463852 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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Inspector

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Inspector

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Inspector

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