Children's home run by Phoenix Learning & Care Holdings Limited in North Devon

Inspection report children’s home: SC463647 1 SC463647 Registered provider: Phoenix Learning and Care Ltd 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 provide care and accommodation for up to five young people who have emotional and/or behavioural difficulties. The home is operated by a private provider that operates a number of homes in the local area.

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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’s welfare is not promoted or safeguarded.

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inadequate

Overall judgement at last inspection: Improved effectiveness

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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

 The staff are not able to safely manage the behaviour of the young people. The young people have little respect for most of the staff and regularly physically Inspection report children’s home: SC463647 2 assault the staff and each other. Some young people said that they feel unsafe living at the home. One young person was found to have a large number of bruises on their body, inflicted by the other young people as a result of ‘play fighting’. Behaviour management plans are too basic and do not give the staff strategies for managing the behaviour of the young people.  On one occasion, a 12-year-old young person was restrained by four staff for four minutes face down on the ground. One of the staff undertaking this restraint was not trained to use this hold. The hold was not one that had been risk assessed as suitable and safe to use with this young person.  Staff do not enforce rules and boundaries consistently. The young people do not

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Key findings from this inspection

respect the boundaries, as they know that responses are inconsistent. On some occasions, the young people have been rewarded for poor behaviour by being bought items or have been allowed to go on outings in order to appease them.  Leaders and managers fail to ensure that there are consistent routines in the home. Some young people regularly refuse to get out of bed in the morning to attend education.  One young person was found to be sending inappropriate photographs of themselves to strangers from their phone. The phone was confiscated. The staff have failed to help the young person to keep themselves safe with follow-up work that was put in place by their social worker six weeks ago.  The staff do not receive sufficient supervision and support. One member of staff started working at the home in January 2017 and in six months has only received two supervision sessions.  The home uses agency staff to cover staff absences. Managers accept a brief

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Key findings from this inspection

staff pro-forma from the agency, which does not detail previous experience, qualifications or whether references were obtained. It is not possible from this very brief information to determine whether the person is suitable to work in the home. On one occasion, an agency member of staff left the home during their shift due to their anxiety about the out-of-control behaviour of the young people.  Two out of the three young people in the home do not eat a healthy, balanced diet. They eat chips or takeaway meals on most days. There is no record of any vegetables or fruit being eaten at all during one week.

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Key findings from this inspection

 Incidents of young people going missing from the home have been reduced. The staff are proactive and follow young people if they do go missing. Inspection report children’s home: SC463647 3

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Inspection date Inspection type Inspection judgement

09/03/2017 Interim Improved effectiveness 07/06/2016 Full Good 14/01/2016 Interim Declined in effectiveness 04/06/2015 Full Good Inspection report children’s home: SC463647 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

Ensure that the health and well-being needs of children are met; in particular, that the young people eat healthy and balanced meals, and the purchase of takeaway meals is limited. (Regulation 10(1)(a)) 25/08/2017

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Requirement Due date

Ensure that children receive effectively planned care in the children’s home, ensure that children are admitted to the home only if their needs are in the range 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 and ensure that arrangements are in place to manage and review the placement of each child in the home;

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Requirement Due date

In particular, ensure that comprehensive behaviour management plans are in place that staff consistently follow, and placement plans both identify targets and document progress. (Regulation 14(1)(a)(2)(a)(b)(ii)) 25/08/2017

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Requirement Due date

Ensure that children are helped to develop and benefit from mutual respect and trust, an understanding of acceptable behaviour, positive responses to other children and adults;

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Requirement Due date

In particular:  that staff meet each child’s behavioural needs as set out in the child’s relevant plans;  help each child to develop and practice skills in resolving conflicts positively and without harm to anyone,  strive to gain each child’s respect and trust and  teach children that bullying is unacceptable, how to recognise incidents of bullying and how to deal with them. (Regulation 11(1)(a)(b)(c), (2)(a)(i)(iv)(viii)(xii)(xiii)) 25/08/2017 Inspection report children’s home: SC463647 5 Ensure that children are protected from harm and enabled to keep themselves safe;

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Requirement Due date

In particular, help each child to understand how to keep safe (Regulation 12(1)(2)(a)(ii)) 25/08/2017

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Requirement Due date

Ensure that restraint in relation to any child must be necessary and proportionate.

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Requirement Due date

In particular, that any restraint used on a child has been risk assessed to be a safe hold for that child and that all staff are trained in the use of that hold (Regulation 20(2)) 28/07/2017

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Requirement Due date

Ensure that the home is led in a way that is consistent with the approach and ethos and delivers the outcomes as set out in the home’s statement of purpose, and ensure the staff have the experience, qualifications and skills to meet the needs of each child (Regulation 13(2)(a)(c)) 25/08/2017

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Requirement Due date

Ensure that all employees receive practice related supervision by a person with appropriate experience (Regulation 33(4)(c)) 25/08/2017

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Recommendations

 Ensure that the views of young people are taken into account when planning and undertaking their care. (‘Guide to the children’s homes regulations including the quality standards’, page 21, paragraph 4.5)

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Overall experiences and progress of children and young people: inadequate

The staff do not effectively implement routines, rules or boundaries for the young people. There are no consistent plans for structured activities, so the young people spend most of their time bullying each other or trying to take control of the home and intimidate the staff. Young people were observed by the inspector to walk around the home with tea towels, using them to flick each other or the staff. This was not challenged effectively by the staff. One young person said in response to a question ‘What could make the home better?’ that he needed ‘Better boundaries: I can punch a window out and nothing happens.’ The staff try to get one young person out of bed in the mornings to go to school, but most of the time they are unsuccessful.

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Overall experiences and progress of children and young people: inadequate

Healthy eating is not encouraged by the staff. The young people frequently visit a nearby fast-food restaurant instead of eating healthy meals. Meal records show that one young person, in one week, ate junk food for six of the seven days. Fruit is not easily available and is locked in the office, as it is feared that the young people will throw it. Inspection report children’s home: SC463647 6 Two windows of the home have egg on them where a young person had thrown eggs at the window.

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Overall experiences and progress of children and young people: inadequate

Placement plans do not clearly document the aims and targets for young people, so it is difficult to establish what progress they are making. One social worker commented that she believed that her young person was making progress with his education and was going missing less. Another social worker reported that the staff successfully support visits for the young person to see their family, some distance from the home. However, there is no written evidence that the home is responsible for these improvements.

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Overall experiences and progress of children and young people: inadequate

The young people take part in some activities in the community, such as participation in a football team, scootering, shopping and cinema, which channel their energies positively. However, the young people spend too much time in the home, resulting in boredom and disruption.

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Overall experiences and progress of children and young people: inadequate

The young people have access to local healthcare when they need it. Medication is safely stored and administered by the staff.

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Overall experiences and progress of children and young people: inadequate

Independence is encouraged, and two of the young people are shopping for themselves, and preparing and cooking their own meals. All young people said that they like their bedrooms, which are large, personalised and well equipped. Young people report that the home did look really nice, but was recently destroyed by one young person. Repairs have been swiftly undertaken and, apart from a few areas of minor damage, the home has regained a homely, well-furnished and decorated appearance.

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

The staff struggle to manage the behaviour of the young people. Ofsted has received two complaints regarding the lack of behaviour management and subsequent risk to the safety of the young people and the staff. These complaints have been investigated as key lines of enquiry during this inspection. Neighbours, staff members and the young people themselves report that, at times, the young people are out of the control of the staff, causing serious harm to each other and the staff team and extensive damage to the house. One young person said: ‘Staff don’t have control; I don’t want to be here. I don’t feel safe here.’ Behaviour management plans are too basic and do not provide sufficient strategies for the staff to use to de-escalate incidents and promote positive behaviour.

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

One young person who has recently left the home caused extensive damage in the six weeks that they were living there. A young person was bullied by two other young people living in the home and, when admitted to hospital for a medical issue, hospital staff found a large number of bruises on his body. These had all been inflicted by the other young people during what he described as ‘play fighting’. There are no documented strategies for the staff to follow to stop the bullying. No counter-bullying work has been undertaken with the young people to help them to understand the effects of bullying on others and understand the reasons why they are bullying others. One member of staff said: ‘There is a lack of consistency and mixed messages, no consistent Inspection report children’s home: SC463647 7 routines.’ A placing social worker said: ‘Boundaries are not consistent. The young people collude against the weaker staff.’

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

Incidents of restraint have been reduced, and most of the restraints used are for the minimal time and with the minimum of force. However, one very concerning restraint took place where a child was restrained face down on the ground by four members of staff. This type of restraint is potentially harmful. It was not risk assessed as being an appropriate and safe restraint for this young person. One of the members of staff undertaking the restraint was not trained in the safe use of this restraint technique.

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

One young person had their mobile phone confiscated when it was found that they were sending inappropriate images of themselves and had befriended numerous people on social media who were not known to them. The social worker requested work on e- safety to be undertaken with this young person to help them to understand the risks of social media and sending inappropriate images. The toolkit to facilitate this work was sent to the home by the social worker six weeks prior to the inspection, but the work has not yet started. This means that the young person is not equipped with the understanding and knowledge that they need to keep themselves safe. Also, the phone was returned to the young person by a member of staff due to the young person’s persistent demands for their phone to be returned, leaving the young person at risk.

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

Recruitment records for permanent staff demonstrate that comprehensive checks are undertaken to assess the suitability of staff to work in the home. However, comprehensive checks are not undertaken for agency members of staff working in the home. Managers accept a very brief pro-forma that only details a person’s right to work in the UK and that they have a clear police check. This information does not provide enough detail to enable the manager to determine that the person has the skills and experience necessary to work in the home. One agency member of staff recently left the home while on duty due to concern about their own safety.

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

Safeguarding concerns are referred to the appropriate authority and are followed up. The manager takes swift disciplinary action if there are any concerns about the conduct of a member of staff.

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

Incidents of young people going missing from home have been reduced. The staff have clear guidance on what action to take, should a young person be missing. The staff actively follow young people if they go missing and persistently contact them on their mobile phones until they return.

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The effectiveness of leaders and managers: inadequate

The registered manager is qualified to level 5 in leadership and management, and is very experienced. The manager and staff have been overwhelmed and exhausted by the extreme behaviour of one young person in particular, who was placed in the home for six weeks. The manager did not ensure that the placing authority provided sufficient information to make a properly informed decision about whether staff were able to meet their care needs. Two young people were admitted to the home within two weeks of Inspection report children’s home: SC463647 8 each other. The other young people had been living in the home for over a year and were reasonably settled. The staff team is inexperienced, and only two of the 14 staff members are qualified to a suitable level in childcare. Managers did not fully consider the impact of two new young people being admitted in a short space of time on all the young people living in the home and on a largely inexperienced staff team. This poor

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The effectiveness of leaders and managers: inadequate

decision making is a serious shortfall. It has had a negative impact on the behaviour and safety of the young people and the morale of the staff team.

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The effectiveness of leaders and managers: inadequate

Neighbours have made repeated complaints to the home about noise and the disruptive behaviour of the young people. The manager is in communication with the neighbours, but they are not satisfied that action is being taken to address their concerns. Complaints are logged and dealt with in line with the home’s complaints procedure, but the manager does not document whether the complainants are satisfied with the outcome of their complaint.

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The effectiveness of leaders and managers: inadequate

The manager fails to ensure that the mainly inexperienced staff team receives sufficient supervision and support. Team meetings do take place, but meeting notes detail that these are information-giving events rather than a reflective discussion about how best to care for the young people and keep them safe. The staff report that they are not regularly supervised. One member of staff started work at the home in January 2017 and has had only two supervision sessions when, as a new starter, they should receive supervision every two weeks as documented in the home’s supervision procedures. This lack of direction and supervision has led to staff being unclear about their role. For example, one young person reports that he is trying to give up smoking but, when out on activities, the staff smoke around him. He also reports that staff smoke just outside the back door of the house and leave their cigarette butts in the garden. This was

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The effectiveness of leaders and managers: inadequate

observed to be accurate by the inspector.

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The effectiveness of leaders and managers: inadequate

The manager does not ensure that the staff are clear about what they are trying to achieve with the young people and how this will be done. The young people report that staff give them mixed messages and are inconsistent. There is a lack of shared ownership about practice in the home. For example, some staff report that the young people are rewarded for poor behaviour by the manager, and that this action undermines them when they have been assaulted by the young person earlier that day.

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The effectiveness of leaders and managers: inadequate

An independent visitor makes monthly visits to the home. His reports are comprehensive and thorough, and have highlighted the recent difficulties and shortfalls in the home. He sets actions that the manager must address. It is noted that six of the actions detailed in April 2017 had not been completed by the time of his return visit in May 2017.

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The effectiveness of leaders and managers: inadequate

Case records and monitoring systems have not been updated or reviewed recently due to the staff and manager ‘firefighting’ the behaviour of the young people in the home. The manager is aware of the shortfalls in the home, and acknowledges and understands why the quality of care has declined. Inspection report children’s home: SC463647 9

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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: SC463647 10

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Children’s home details

Registered provider: Phoenix Learning and Care Ltd

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Children’s home details

Registered provider address: Rolle Quay, Barnstaple EX31 1JE

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Children’s home details

Responsible individual: Stephen Nicholson

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Inspector(s)

Tina Maddison, social care inspector Inspection report children’s home: SC463647 11 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for 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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