Serendipity Family Assessment Centre

Inspection report for residential family centre: Serendipity Family Assessment Centre 1 Serendipity Family Assessment Centre Serendipity (Devon) Ltd Serendipity, 24 Victoria Road, EXMOUTH, Devon EX8 1DW Inspected under the social care common inspection framework

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Information about this residential family centre

This residential family centre provides parenting assessments for up to six families. The families are accommodated in two houses which are a very short distance apart. Parents must be at least 16 years old, and the service will accept children up to 10 years old.

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Overall experiences and progress of

children and parents, taking into account inadequate

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Overall experiences and progress of

How well children and parents are helped and protected inadequate

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Overall experiences and progress of

The effectiveness of leaders and managers inadequate

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Overall experiences and progress of

There are serious and widespread failures that mean children and parents are not protected or their welfare is not promoted or safeguarded and the care and experiences of children and parents are poor.

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Overall experiences and progress of

Date of previous inspection: 23 January 2014

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Overall experiences and progress of

Overall judgement at last inspection: good

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Enforcement action since last inspection

None Inspection report for residential family centre: Serendipity Family Assessment Centre 2

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Key findings from this inspection

This residential family centre is inadequate because:

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Key findings from this inspection

 The staff do not intervene promptly to ensure the safety and welfare of children. Leaders and managers fail to provide the staff with clearly documented plans and strategies that detail how, and at what point, staff must intervene to keep children safe.

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Key findings from this inspection

 Leaders and managers admit families to the service before undertaking a comprehensive assessment of risk. The effect that a newly-admitted family will have on existing residents is not fully considered.

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Key findings from this inspection

 Individual risk assessments that are in place for families fail to give the staff clear guidance on how to manage and control identified risks.

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Key findings from this inspection

 Leaders and managers employ agency staff as the lone worker awake during the night in one house. This lone worker monitors up to three families all night through closed circuit television (CCTV). The agency members of staff often lack the experience necessary to undertake this role. If the lone worker has to attend to one family during the night, there is not a member of staff observing the other families as required. This shortfall compromises the safety of children and families.

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Key findings from this inspection

 Families do not always realise the extent of the assessor’s concerns until they read the court report. Feedback to some families does not always identify concerns. Consequently, they do not have the opportunity to challenge, or improve how they care for their child.

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Key findings from this inspection

 Placement plans that were scrutinised by inspectors during the inspection did not set clear targets, monitor progress, or detail and document a clear exit plan.

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Key findings from this inspection

 Families do not always have individualised parenting assessments. Families are admitted to the service before essential information is received from the placing authority, and therefore a generalised parenting assessment is undertaken.

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Key findings from this inspection

 Placing authorities are not kept informed of significant safeguarding incidents. On one occasion a decision was made by managers to remove a child from the care of their parents following incidents of domestic violence. The placing social worker was not made aware of this action and so was unable to take steps to safeguard the child.

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Key findings from this inspection

 Management oversight of the residential family centre is poor. Systems for monitoring and improving the quality of the service are not in place, and are not informed by feedback from families and professionals. A development plan is not in place to provide evidence that managers understand the strengths and weaknesses of the service, and how they intend to deal with identified shortfalls. Inspection report for residential family centre: Serendipity Family Assessment Centre 3 The residential family centre’s strengths:

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Key findings from this inspection

 The residential family centre offers families a homely environment that is well maintained, decorated and furnished.

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Key findings from this inspection

 Parents report that the staff are supportive and helpful.

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Key findings from this inspection

 Parents who have a learning disability and/or difficulty receive final reports in a format that they are able to understand, such as one involving the use of pictures and symbols.

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Key findings from this inspection

 The children’s guide to the family centre is suitable for children. It is informative and makes good use of pictures that help children to understand why and where they will be staying at the residential family centre. Inspection report for residential family centre: Serendipity Family Assessment Centre 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, Residential Family Centre Regulations 2002 and the national minimum standards. The registered person(s) must comply within the given timescales.

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Requirement Due date

Ensure that wherever there is a conflict between the interests of the members of the family, the welfare of the child must be treated as paramount. (Regulation 10(4)) 28/07/2017

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Requirement Due date

Ensure that whenever practicable, the wishes and feelings of residents are taken in to account when making decisions concerning their health and welfare, or the manner in which they are treated. In particular, that residents meetings regularly take place and residents’ views are incorporated in the quality monitoring processes. (Regulation 10(2)) 28/07/2017

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Requirement Due date

Ensure that proper provision is promoted and put in place regarding the health and welfare of residents. In particular, that any complex health needs are clearly documented in plans together with the actions staff need to take to address and meet these identified health needs. (Regulation 10(1)(a)) 28/07/2017

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Requirement Due date

Ensure that the child protection policy is implemented through clear guidance and documentation in placement plans and safeguards children accommodated in the residential family centre from abuse and neglect. In particular, that clear guidance is given to staff so they clearly understand their safeguarding responsibilities when observing a parent and child and it is made clear to them when they must intervene to safeguard a child from physical or emotional harm. (Regulation 12(1)(a)) 14/07/2017

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Requirement Due date

Ensure that before providing a family with accommodation in the residential family centre, or if that is not reasonably practicable, as soon as possible thereafter, draw up in consultation with the placing authority a written plan setting out in particular, an assessment of risks which a resident at the residential family centre may present to their own health, safety and welfare or that of other residents or staff at the centre. In particular, ensure that effective control measures to address the identified risks are documented in this plan. Also, that an impact risk assessment is undertaken to ensure that it is safe for the family to move in with the centre’s other residents. It must inform the level of supervision necessary 28/07/2017 Inspection report for residential family centre: Serendipity Family Assessment Centre 5 for the parent and be kept under review. (Regulation 13(1)(c) Ensure that the aims, objectives and intended outcomes of

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Requirement Due date

the placement are documented in the placement plan. In particular, training, assistance, assessment, supervision and protection to be provided at the centre regarding how the child’s welfare will be promoted. The plan must set out the level of supervision required and how this will change in time dependent on progress. (Regulation 13(1)(b)) 28/07/2017 *

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Requirement Due date

Ensure that an assessment or monitoring of parents’ capacity to respond to children’s needs and to safeguard their welfare is monitored or assessed by a suitably qualified person in accordance with the requirements of this regulation. (Regulation 13A(1)) 28/07/2017

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Requirement Due date

The registered person shall not employ a person to work at the residential family centre unless that person is fit to work at a residential family centre. In particular, that the suitability of agency staff is checked and evidenced in the recruitment files. (Regulation 16(1)(a)(3)(a)(b)(c)(d)) 28/07/2017

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Requirement Due date

Ensure that all persons employed by the registered person receive appropriate supervision and appraisal from a suitably qualified person. (Regulation 17(5)) 28/07/2017

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Requirement Due date

Ensure that all complaints made under the complaints procedure are fully investigated. (Regulation 20(2)) 28/07/2017

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Requirement Due date

Ensure there is a clear and effective policy on the use of surveillance in parenting assessments and its use is no more intrusive than necessary and how legitimate privacy will be protected and how residents will be protected from potential abuse of such measures. (Regulation 21(2)(b)) 28/07/2017

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Requirement Due date

Ensure that a system is established and maintained for reviewing at appropriate intervals and improving the quality of care provided at the residential family centre and that a copy of the report is provided to HMCI. (Regulation 23(1)(a)(b)) 28/07/2017

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Requirement Due date

Ensure that the registered individual visits the residential family centre at least once a month and that a written report on the conduct of the residential family centre is prepared. In addition, that the report is supplied to HMCI. (Regulation 25 ((1)(2)(5)(a)) 28/07/2017

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Requirement Due date

Ensure that if any of the events listed in column 1 of the table in schedule 5 takes place, the registered person, without delay, notifies Ofsted and the placing authority. (Regulation 26(1)) 28/07/2017

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Requirement Due date

Ensure that records are clear, up-to-date and kept in the form of a register containing the information detailed in Schedule 4. (Regulation 19(3)) 28/07/2017 Inspection report for residential family centre: Serendipity Family Assessment Centre 6 * These requirements are subject of a compliance notice.

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Recommendations

 Ensure parents are supported to learn to develop skills, emotional resilience and self-esteem to help prepare them to care safely for their children and promote their welfare. In particular, ensure that assessments focus on events that may impact on parenting and attachment. (NMS 3.3) Inspection report for residential family centre: Serendipity Family Assessment Centre 7

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Overall experiences and progress of children and parents: inadequate

Placement planning is poor. Risks that are identified on admission by the placing social worker are not translated into clear strategies for how staff are to safely manage these risks. Plans do not identify progress against specific areas, or what the families need to work on to improve their parenting. They also contain little detail about how and when the family will exit the centre. The plans do not contain guidance for staff on how best to work with parents who have a learning disability and/or difficulty. One parent has an identified learning disability that has significant implications for their ability to learn parenting skills. While final reports are in a format that helps this parent understand, no clear method of how best to work with them on a day-to-day basis has been identified.

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Overall experiences and progress of children and parents: inadequate

Staff told a parent about a mistake they made when parenting their child 10 days after the incident happened. It was very difficult for them to understand their mistake so long after the incident as a result of their learning disability

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Overall experiences and progress of children and parents: inadequate

Assessments of parenting are conducted in line with statutory guidance but are not sufficiently individualised. Sometimes managers fail to obtain information from placing authorities, meaning that it is not always possible for staff to produce an individualised assessment plan. Consequently, parents who have previously acquired and established skills such as making up a bottle are made to participate again in these sessions as part of a generic assessment process. One parent said, ‘I have had four previous children, so know how to do a bottle, but still have to go to classes which is boring.’

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Overall experiences and progress of children and parents: inadequate

Assessments lack focus on attachment between the parent and child. The focus of assessments is on whether parents have practical parenting skills, such as feeding and changing their child. The parents’ own parenting history, which may influence their ability to parent their own child, is not explored as part of the assessment. A parent’s capacity to change is not fully explored and evaluated. This shortfall means that placing authorities are not clear about whether a further assessment would be appropriate, or whether the parent lacks the capacity to improve their parenting skills and safely care for their child.

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Overall experiences and progress of children and parents: inadequate

The staff are not always open and honest when giving feedback to parents. Placing authorities report that feedback does not address all identified concerns for fear of upsetting the parents and causing them distress, particularly early in the assessment. One social worker said, ‘The family centre is over-optimistic, too dogmatic in giving parents every opportunity and not putting the child first.’ Parents have an over- optimistic view of how the assessment is going, and only learn of concerns in the final report, when it is too late for them to challenge or have an opportunity to improve. Inspection report for residential family centre: Serendipity Family Assessment Centre 8 Assessments do not provide evidence of how parents are involved in the assessment process, and how they are able to challenge if they do not feel they are being fairly represented. Parents do not read the daily logs or have an opportunity to disagree if

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Overall experiences and progress of children and parents: inadequate

they have an alternative view. One parent reported that they were disappointed that the report did not reflect the feedback they had received from the staff. For example, in the court report a concern was raised about their level of tidiness, which was not brought up with them by the staff.

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Overall experiences and progress of children and parents: inadequate

Parents and placing authorities report that families are able to make a request to the staff about when they want an observation session to take place. This approach does not give a realistic picture of parenting skills as parents have the opportunity to present themselves for assessment only when things are going well. The assessment staff finish work at 5pm, and consequently no parenting assessments take place after this time. This means that during settling time at the end of the day, when babies are tired, parents’ skills to manage this situation are not being assessed.

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Overall experiences and progress of children and parents: inadequate

Individual and group sessions for families take place on topics such as sun safety, contraception and child development. One session on personal hygiene is entitled ‘Some of your bits ain’t nice’. Such a title is not appropriate to use with vulnerable families. These sessions are generic and not individually tailored in line with individual development plans.

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Overall experiences and progress of children and parents: inadequate

Managers do not ensure that the health care needs of families are clearly identified in plans. One very young baby has potentially life-threatening health problems. These are not clearly documented, together with the essential responses from staff required to keep the baby safe. All core staff are trained in paediatric first aid, but not all of the agency staff are trained in this topic. There is an emergency protocol in place that can be referred to by the staff, but it does not offer clear guidance for staff in the event of an emergency.

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Overall experiences and progress of children and parents: inadequate

The quality of final assessment reports is mixed. Two reports scrutinised reached clear recommendations and were well evidenced with a good use of examples. Other reports focus on practical parenting skills rather than issues of emotional bonds between child and parent, or attachment. These reports do not have a clear recommendation, lack analysis and are descriptive rather than evaluative. These reports were not clear about the recommendations that the residential family centre was making to the court.

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Overall experiences and progress of children and parents: inadequate

Arrangements for the storage and administration of medication are strong. Independence is promoted through families being encouraged by staff to manage their own medication, if this is assessed as safe.

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Overall experiences and progress of children and parents: inadequate

No unnecessary restrictions are placed on relatives visiting the families at the residential family centre. Some of the families are placed a long way from home in what is a stressful and testing situation. They value a visit from family and friends. Families report that visits are welcomed, and some families enjoy visits from relatives on a weekly basis. Inspection report for residential family centre: Serendipity Family Assessment Centre 9 A strength of this residential family centre is the relationships that parents form with the staff. Families report that the permanent staff are friendly and help them feel comfortable. One resident wrote in a feedback form, ‘I will be grateful to the residential family centre for the rest of my life.’ Another parent commented, ‘Staff are supportive and helpful.’

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How well children and parents are helped and protected: inadequate

The staff fail to intervene promptly when a child is experiencing emotional and physical harm as a result of unsafe parenting. On four occasions the staff failed to intervene in a timely manner. In one incident, a parent was roughly handling their baby. This was observed by staff on CCTV for 20 minutes, but the staff failed to intervene. The staff member recorded: ‘It is clear the mother hurt the baby and had not responded to the baby’s distress.’ A placing authority commissioner raised concerns that the staff do not immediately intervene and model appropriate and safe parenting when a concern is identified.

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How well children and parents are helped and protected: inadequate

Comprehensive impact risk assessments are not carried out with families prior to them being admitted to the family centre. Families with a history of violence are admitted without a risk assessment. They share areas of the house with other families, which puts all families at risk. The staff do not have clear and informed risk assessments directing them on how to safely manage identified risks.

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How well children and parents are helped and protected: inadequate

Individual risk assessments for parents are not in place. As a result, the staff do not fully understand risks and how to manage them. For example, a parent who had previously harmed themselves and attempted suicide was admitted to the service. The staff do not have guidance on what action to take should the parent self-harm or try to commit suicide. A baby has a very serious and complex health condition but there is no risk assessment of their condition, details of likely complications and how these should be safely managed.

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How well children and parents are helped and protected: inadequate

Placement plans and risk assessments do not clearly document the level of supervision that all families should receive, as agreed with the placing authority. At night, one member of staff remains awake and is responsible for monitoring the CCTV that is observing three families. In the last month, in one house, this has regularly been an agency member of staff. An additional member of staff is sleeping in the house. Agreements with placing authorities state that some of the families must be observed at all times of the day and night. If the one waking member of staff takes a break or attends to one family then the others are not being observed, as the sleeping members of staff report that they are rarely woken. The waking member of staff does then rewind the CCTV. However, it would be too late for the staff to intervene if a child was being harmed. Inspection report for residential family centre: Serendipity Family Assessment Centre 10

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How well children and parents are helped and protected: inadequate

Agency staff are employed at the residential family centre. Managers rely on information supplied to them about the staff on a brief pro forma from the agency. Managers do not undertake their own checks to ensure that these staff are suitably qualified and experienced to work in the residential family centre. The agency staff often work alone. They are employed in a role observing vulnerable families and children. Managers do not verify that they have the skills and experience to hold this level of responsibility. Parents report that they are given mixed messages by agency staff who observe them without giving any feedback, which makes parents uncomfortable. One parent said, ‘These people (meaning agency staff) aren’t clear on what they should be doing, it’s like they don’t know what to do.’

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How well children and parents are helped and protected: inadequate

The parents sign a consent form to say that they understand the use of surveillance through CCTV cameras in the residential family centre. All families spoken to stated that they did understand why there needed to be cameras on at all times. Cameras are directed at parents’ beds, which compromises their privacy and dignity. Privacy screens are available for staff to use if necessary to obscure their view of what is on the cameras. The staff were unclear when these should be used as there is no policy or procedure in place.

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How well children and parents are helped and protected: inadequate

Safeguarding information is not always shared with the placing authority. On one occasion a baby was removed from the care of the parents by the staff due to concerns regarding domestic violence between the parents. This information is relevant and important to inform decisions made by the placing authorities, but it was not passed to the placing social worker by the staff.

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How well children and parents are helped and protected: inadequate

The physical environment of the residential family centre is safe. Parents report that they feel safe living there. Regular checks of electrical appliances and fire prevention equipment take place, and parents know what action to take if there is a fire.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not have a monitoring system in place that identifies the strengths and shortfalls of the service. There is no development plan for the service that deals with identified shortfalls and how leaders and managers will develop and improve the residential family centre.

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The effectiveness of leaders and managers: inadequate

The last three monthly quality monitoring reports, which are written by the registered individual, have not been sent to Ofsted as required by the regulations.

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The effectiveness of leaders and managers: inadequate

Leaders and managers fail to notify Ofsted about serious incidents at the residential family centre as required by the regulations. On three occasions, three different children were admitted to hospital in an emergency and managers did not notify Ofsted.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not compile and keep at the residential family centre a Inspection report for residential family centre: Serendipity Family Assessment Centre 11 register containing information and details about families, as detailed in Schedule 4 of the regulations.

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The effectiveness of leaders and managers: inadequate

Families report that residents’ meetings are a useful forum for expressing their views, but these meetings do not take place regularly. The families and professionals are offered a feedback form when families complete their assessment, but this feedback is not incorporated into any quality monitoring system in order to improve the quality of care provided at the service.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not have a clear understanding of the progress that children and parents are making as plans do not document targets that are regularly monitored and updated.

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The effectiveness of leaders and managers: inadequate

The management of complaints is inconsistent. Families spoken with stated that they know how to make a complaint. When a complaint is dealt with, parents are given the outcome. However, it is not documented whether parents are satisfied with the outcome of the complaint. On other occasions, families report that they complain but the staff do not always respond. One resident complained that their window was broken and would not open. This was not promptly resolved even though the weather was very hot and there was a small baby in the room at risk of over-heating. Another family made a complaint to a member of staff about an agency worker. This complaint has not been investigated or looked into, although senior staff were aware of the existence of this complaint.

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The effectiveness of leaders and managers: inadequate

The staff report that they feel well trained, supported and supervised. Inspectors repeatedly requested the staff supervision records, but these could not be produced by managers. The registered manager is not a qualified social worker. She undertakes clinical supervision with the assessing social workers who undertake court work. This means that these members of staff do not receive supervision from a suitably qualified person.

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The effectiveness of leaders and managers: inadequate

The core permanent staff team has been employed at the service for a number of years, and is experienced and appropriately qualified. Staff team members report that the training programme is informative and relevant. The training matrix provides evidence that managers arrange for suitable training when necessary to meet the needs of families, such as recent training regarding understanding autism.

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The effectiveness of leaders and managers: inadequate

The staff team reports that they find managers supportive, and that they can seek additional support following any particularly stressful or emotional situation. One member of staff said, ‘The team are amazing and supportive.’

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Information about this inspection

Inspection report for residential family centre: Serendipity Family Assessment Centre 12 Inspectors have looked closely at the experiences and progress of children and parents. Inspectors considered the quality of work and the differences made to the lives of children and parents. They watched how professional staff work with children and parents and each other and discussed the effectiveness of help and care provided. Wherever possible, they talked to children and parents. In addition, the inspectors have tried to understand what the residential family centre knows about how well it is performing, how well it is doing and what difference it is making for the children and parents 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 Residential Family Centre Regulations 2002 and the national minimum standards. Inspection report for residential family centre: Serendipity Family Assessment Centre 13

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Residential family centre details

Registered provider: Serendipity (Devon) Ltd

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Residential family centre details

Registered provider address: Serendipity, 24 Victoria Road, EXMOUTH, Devon EX8 1DW

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Residential family centre details

Email address: serendipitydevon@btinternet.com

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Inspector(s)

Ms Maddison, social care inspector Ms Canto, social care inspector Inspection report for residential family centre: Serendipity Family Assessment Centre 14 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 looked after children, 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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