Children's home run by Horizon Care Limited in Cannock Chase

Inspection report for children’s home - monitoring visit: SC374939 1 SC374939

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Information about this children’s home

This is a children’s home for three young people who have emotional and/or behavioural difficulties. It is owned and operated by a private company.

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This monitoring visit

During the full inspection visit to the home on 23 and 24 May 2017, Michelle Edge, social care regulatory inspector found that safeguarding practice in this home was not sufficiently robust and that the arrangements for safeguarding young people were inadequate. A large number of failings were identified including: a lack of effective action taken by managers and staff in response to serious safeguarding concerns, leaving young people at risk of harm; young people’s needs had not been met across aspects of their welfare, including their health and education. The practice of recording and administration of medication was unsafe. There was also a lack of required education and health documents to inform practice. Furthermore, behaviour management practices in relation to restraint were unsafe and the registered manager and staff had failed to identify, minimise and manage all known risks to young people. These practices failed to protect young people from the risk

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This monitoring visit

of harm. The children’s home was judged inadequate. As a result, twelve requirements were made. Four of the requirements are subject to compliance notices, which were issued on 26 May 2017. On 1 June 2017, Michelle Edge, social care regulatory inspector completed an unannounced monitoring visit. The purpose of this monitoring visit was to assess the progress made by the home to ensure that there were effective safeguarding practices in place. The inspector was shown the daily logbook. On 26 May 2017, the following detail was recorded. Young person (1) had been out of the home with friends. He contacted the home at 20.35pm, from the train station, and requested a lift home from staff. He was informed that, ‘Staff were doing a test and it is getting timed, therefore no lift could be provided.’ The young person again contacted the home at 21.30pm and requested a lift. However, staff informed him to make his own way

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This monitoring visit

home. At both 22.20pm and 22.40pm, staff contacted the young person to check on Inspection report for children’s home - monitoring visit: SC374939 2 his whereabouts. The record states ‘(initials of young person) says he is on his way home.’ On his arrival at the home at 23.10pm, staff recorded that the young person appeared to be under the influence of cannabis. It is recorded that the young person then goes to his bedroom at 23.15pm and a staff member takes him a drink. At 23.40pm, it is then recorded ‘all quiet staff to bed’. There is no further information to show what, if any, actions were taken by the staff on duty to safeguard the young person, including seeking medical advice or undertaking any further welfare checks throughout the night. Furthermore, both staff failed to report this information to their colleagues during the handover the next day, and there was no evidence of any concerns recorded in the young

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This monitoring visit

person’s daily information sheets or risk assessments. Staff’s lack of response to potential safeguarding concerns, and their failure to complete the necessary checks to ensure that the young person was safe and well during the night, have significant implications for the young person’s safety and does not demonstrate safe practice in the home. The inspector brought this information to the attention of the regional manager, senior care worker, placing authority team manager and the staff member on shift. They all reported that no one had made them aware of this information. Staff had failed to raise these potential safeguarding concerns directly with the home’s current management team or the local authority social worker. This failure to pass on important information highlights poor communication and does not ensure that appropriate action was taken swiftly to identify, minimise and assess the current

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This monitoring visit

risks. The failure to safeguard the young person potentially placed them at risk. Since the last inspection, a new format had been implemented to record medication for young people. However, the inspector found failings in the new system. There were further errors in the recording of the administration of medication, which means staff have repeatedly failed to demonstrate that young people’s medication has been administered in line with their prescription. Staff also failed to follow the companies’ own medication procedures and policies. This has compromised the welfare and safety of young people. Ofsted have the following concerns:  Risks to the safety and well-being of young people are not being identified, assessed or managed effectively.  At the first inspection, the registered manager and staff have failed to follow safeguarding procedures when concerns about a young person’s welfare have been identified. At this monitoring visit, significant shortfalls were repeated,

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This monitoring visit

thus demonstrating a failure to adequately safeguard the young person.  There have been continued failures in the safe administration and recording of medication.  Behaviour management plans and risk assessments are not yet robust and neither are they effectively reviewed to address the changing needs of the young people. Inspection report for children’s home - monitoring visit: SC374939 3  There continues to be a lack of effective leadership and management oversight, which has led to serious incidents not being identified and managed.  The current young person living at the home is not being adequately safeguarded or protected from harm. As a result, it is Ofsted’s view that it is unsafe at this time to admit any other young people to the home. A restriction notice was issued. This period of restriction is for three months and relates to the time required to achieve the improvements required to ensure that young people receive safe, effective care that meets their needs and

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This monitoring visit

helps them to progress. Further monitoring visits will be completed to monitor the four compliance notices and requirements issued at the full inspection and are set out below.

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Recent inspection history

Inspection date Inspection type Inspection judgement 24/05/2017 Full Inadequate 07/02/2017 Interim Sustained effectiveness 11/08/2016 Full Requires improvement 04/02/2016 Interim Improved effectiveness Inspection report for children’s home - monitoring visit: SC374939 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

7: The children's views, wishes and feelings standard 7. (1)The children’s views, wishes and feelings standard is that children receive care from staff who— (c) take their views, wishes and feelings into account in relation to matters affecting the children’s care and welfare and their lives. In particular, providing feedback on any issues or concerns raised by children in their group meetings. 25/06/2017

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Requirement Due date

8: The education standard * 8. (1) The education standard is that children make measurable progress towards achieving their education potential and are helped to do so. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that staff— (iv) help each child to understand the importance and value of education, learning, training and employment; (viii) help a child who is excluded from school, or who is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as possible; (ix) help each child who is above compulsory school age to participate in further education, training or employment and to prepare for future care, education or employment. 25/06/2017

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Requirement Due date

10: The health and well-being standard 10 (1) the health and well-being standard is that— (2) in particular, the standard in paragraph (1) requires the registered person to ensure— 2 (a) that staff help each child to: 25/06/2017 Inspection report for children’s home - monitoring visit: SC374939 5 (i) achieve the health and well-being outcomes that are recorded in the child’ s relevant plans; and (c) that each child has access to such dental, medical, nursing, psychiatric and psychological advice, and other services as the child may require. In particular, actively ensure that children receive dental treatment and assessment without delay. 12: The protection of children standard* 12. (1) The protection of children standard is that children are protected from harm and enabled to keep themselves safe. (2) In particular, the standard in paragraph (1) requires the registered person to ensure— (a) that staff— (i) assess whether each child is at risk of harm, taking into

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Requirement Due date

account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; (ii) help each child to understand how to keep safe; (iii) have the skills to identify and act on signs that a child is at risk of harm; (v) understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; (vi) take effective action whenever there is a serious concern about a child’s welfare; (vii) are familiar with, and act in accordance with, the home’s child protection policies; (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; (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. 25/06/2017

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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. 25/06/2017 Inspection report for children’s home - monitoring visit: SC374939 6 (2) In particular, the standard in paragraph (1) requires the registered person to— (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; (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.

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Requirement Due date

16: Statement of purpose 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, in particular includes the number of children for whom it is intended that accommodation is to be provided. (Regulation 16(1)) 25/06/2017

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Requirement Due date

23: Medicines * The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. (Regulation 23(1)(2)(c)) In particular, the registered person must ensure that a record is kept of the administration of medicine to each child. 25/03/2017

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Requirement Due date

33: Employment of staff The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33(4)(b)) 25/06/2017

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Requirement Due date

35: Behaviour management policies and records (2) The registered person must keep the behaviour management policy under review and, where appropriate, revise it. (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— (i) the name of the child; (ii) details of the child’s behaviour leading to the use of the measure; (iii) the date, time and location of the use of the measure; 25/06/2017 Inspection report for children’s home - monitoring visit: SC374939 7 (iv) a description of the measure and its duration; (v) details of any methods used or steps taken to avoid the need to use the measure; (vi) the name of the person who used the measure (‘the user’), and of any other person present when the measure was used; (vii) the effectiveness and any consequences of the use of the measure; and

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Requirement Due date

(viii) a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure; (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 (‘the authorised person’)— (i) has spoken to the user about the measure; and (ii) has signed the record to confirm it is accurate; and (c) within five 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. (Regulation 35(2)(3)(a)(b)(c)) 37: Other records The registered person must— (a) maintain in the home the records in schedule 4; and (b) ensure that the records are kept up to date. In particular, this relates to staff rosters. (Regulation 37(2)(a)(b)) 25/06/2017

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Requirement Due date

40: Notification of a serious event The registered person must notify HMCI and each other relevant person without delay if: (4)(a) a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation; (b) an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; (c) there is an allegation of abuse against the home or a person working there; (d) a child protection enquiry involving a child— 25/06/2017 Inspection report for children’s home - monitoring visit: SC374939 8 (i) is instigated; or (ii) concludes (in which case, the notification must include the outcome of the child protection enquiry); or (e) there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40(4)(a)(b)(c)(d)(i)(ii)(e)) 44: Independent person: visits and reports The independent person must produce a report about a visit

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Requirement Due date

(‘the independent person’s report’) which sets out, in particular, the independent person’s opinion as to whether children are effectively safeguarded; and the conduct of the home promotes children’s well-being. (Regulation 44(4)(a)(b)) 25/06/2017

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Requirement Due date

*These requirements are subject of a compliance notice.

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Information about this inspection

The purpose of this visit was to monitor the action taken and the progress made by the children’s home since its last Ofsted inspection.

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Information about this inspection

This inspection was carried out under the Care Standards Act 2000. Inspection report for children’s home - monitoring visit: SC374939 9

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Children’s home details

Registered provider: Horizon Care Limited

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Children’s home details

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

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Inspector

Michelle Edge, social care inspector Inspection report for children’s home - monitoring visit: SC374939 10 to 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

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Inspector

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Inspector

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