Children's home run by Lioncare Ltd Operating as The Lioncare Group in Epping Forest

Inspection report children’s home: SC014235 1 SC014235 Registered provider: Lioncare 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 can accommodate up to seven children and young people. The service aims to accommodate children and young people who have emotional and/or behavioural difficulties, and provides a therapeutic care approach towards meeting their needs. The home is part of an organisation which has three other residential homes and a school.

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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/or widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded and/or the care and experiences of children and young people are poor and they are not making progress.

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Inadequate

Date of last inspection: 19 October 2016

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Inadequate

Overall judgement at last inspection: Good

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Enforcement action since last inspection

None Inspection report children’s home: SC014235 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

 The standard of safeguarding practice is poor. Effective action is not consistently taken to ensure that children’s welfare is promoted and they are protected from harm.  Leaders and managers do not always take appropriate action when there are concerns about the practice of staff.  Children’s needs are not clearly identified and the plans made do not address how they will achieve permanence.  The management of allegations against staff is weak, and the processes identified in the home’s policies and procedures are not always followed.  Risk management is poor. Children’s individual risk assessments are not effective tools for protecting them from harm.  The home has failed to ensure that every child has a behaviour management plan. Staff do not always have clear guidance on how to manage challenging behaviour.  Monitoring systems do not consistently identify weaknesses and ensure that remedial action is taken.

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Key findings from this inspection

 Staff performance management does not ensure continuous professional development.  Insufficient priority is given to ensuring that the children live in a safe, physical environment.

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Key findings from this inspection

 Most staff build positive, nurturing relationships with the children and provide a good standard of day-to-day care.  Currently, all children have a school placement and attendance is good.  The physical healthcare needs of children are met well.  Children enjoy a range of stimulating activities and are provided with many opportunities to have fun.

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Inspection date Inspection type Inspection judgement

19/10/2016 Full Good Inspection report children’s home: SC014235 3 20/07/2016 Full Inadequate 30/03/2016 Interim Sustained effectiveness 10/09/2015 Full Good Inspection report children’s home: SC014235 4

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet the Care Standards Act 2000, Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. The registered person(s) must comply within the given timescales.

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Requirement Due date

6: The quality and purpose of care standard

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Requirement Due date

In order to meet the quality and purpose of care standard the registered person must ensure that staff: (2)(b)(vi) help each child to develop resilience and skills that prepare the child to return home, to live in a new placement or to live independently as an adult.

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Requirement Due date

This is with specific reference to preparing children to live in a foster placement. 01/08/2017

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Requirement Due date

In order to meet the education standard the registered person must ensure that staff: (2)(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 return to school as soon as possible.

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Requirement Due date

This is with specific reference to working in partnership with placing authorities to re-engage children who refuse to attend their educational placement. 01/08/2017

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Requirement Due date

In order to meet the positive relationships standard, the registered person must ensure that staff: (2)(a)(i) meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans.

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Requirement Due date

This is with specific reference to ensuring that staff have a clear understanding of each child’s emotional difficulties and how these can impact on their behaviour. 01/08/2017

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Requirement Due date

In order to meet the protection of children standard, the 01/08/2017 Inspection report children’s home: SC014235 5 registered person must ensure: (2)(a)(i)* that staff 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; (2)(a)(vi)* that staff take effective action whenever there is a serious concern about a child’s welfare; (2)(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.

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Requirement Due date

This is with specific reference to the assessment and management of risk, taking action to safeguard children who make allegations or are mistreated by staff, and the maintenance of the premises. 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 lead a culture in relation to the children’s home that: (1)(a) helps children aspire to fulfil their potential; (2)(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

This is with specific reference to assessing the likely impact new admissions would have on the established group of children and monitoring the quality of care being delivered. 01/08/2017

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Requirement Due date

In order to meet the care planning standard the registered person should ensure that children: (1)(a) receive effectively planned care in or through the children’s home; (2)(b)(i) ensure the effective induction of each child into the home.

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Requirement Due date

This is with specific reference to assessing the needs of each child and planning how these will be met, delivering specific interventions to meet those needs, and monitoring the progress each child makes. 01/08/2017

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Requirement Due date

After consultation with the fire and rescue authority, the registered person must take adequate precautions against the risk of fire and ensure, by means of fire drills and practices at suitable intervals, that persons working at the home and, so far as reasonably practicable, children are aware of the procedure to be followed in case of fire. (Regulation 25*(1)(a)(b)) 01/08/2017 Inspection report children’s home: SC014235 6 Specifically, ensure that the emergency evacuation plan is easily accessible so that staff, children and visitors can familiarise themselves with the plan and ensure that accurate records are kept of those taking part in fire drills. The registered person must ensure that each individual is mentally and physically fit for the purposes of the work that the individual is to perform. (Regulation 32*(3)(c))

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Requirement Due date

Specifically, assess whether workers suffering from an illness are fit to perform their role in such a way as to promote the safety and well-being of the children. 01/08/2017

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Requirement Due date

The registered person must operate a disciplinary procedure which provides for the suspension from work if necessary in the interests of the safety or welfare of children and provides that the failure on the part of an employee to report an incident of abuse, or suspected abuse, whether past or present, in relation to a child to the appropriate person is a ground on which disciplinary proceedings may be instituted; ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33*(2)(a)(b), (4)(b))

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Requirement Due date

This is with specific reference to considering the need suspend a member of staff who is being investigated as the result of poor practice and allegations made, and to providing staff supervision with the regularity specified in the home’s statement of purpose. 01/08/2017

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Requirement Due date

* These requirements are the subject of a compliance notice.

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Recommendations

 Ensure that the home works in close partnership with all those who play a role in protecting and caring for the child. (‘Guide to the children’s homes regulations including the quality standards’, page 11, paragraph 2.3) Specifically, when two therapists are working with a child at the same time, take steps to promote communication between both professionals.

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Recommendations

 Ensure that staff can access appropriate facilities and resources to meet their training needs. (‘Guide to the children’s homes regulations including the quality standards’, page 53, paragraph 10.11) Specifically, review whether the current training available in relation to child sexual exploitation provides staff with the knowledge and skills to help them to prevent children being exploited.

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Recommendations

 Ensure staff understand the importance of careful, objective, and clear recording. (‘Guide to the children’s homes regulations including the quality standards’, page 62, paragraph 14.4) Specifically, ensure that records are signed and dated by the author, and that Inspection report children’s home: SC014235 7 they provide clear and accurate accounts of the circumstances they are reporting on.

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Overall experiences and progress of children and young people: inadequate

The planning process for admitting new children to the home is poor. Leaders and managers do not consistently adopt a child-centred approach to decision making about who comes to live at the home.

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Overall experiences and progress of children and young people: inadequate

Children do not make enough progress against the terms of their placing authority’s plans for long-term fostering. This is attributable to a lack of detailed care planning. Some children have lived at the home for nearly two years, but there is no evidence to suggest that the care and interventions provided by the home are sufficient to prepare them to move to a foster placement. Over time, most children do learn the skills they need to regulate their behaviours more effectively, but they are not always able to use them and their progress is stalled.

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Overall experiences and progress of children and young people: inadequate

Children generally build positive relationships with staff, and the inspectors observed nurturing interactions which were sensitive to the children’s day-to-day care needs. Staff speak affectionately of the children, and they have developed caring routines to help the children settle at night. However, one serious incident occurred when a member of staff acted aggressively towards a child, indicating that positive relationships are not consistently maintained. Social workers spoken to during this inspection expressed mixed opinions on the quality of care being delivered. One social worker stated that the physical care being delivered was 'exemplary'. However, another referred to staff expressing negative attitudes towards children, and felt that the home did not provide the therapeutic approach to caring for children that it claimed to.

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Overall experiences and progress of children and young people: inadequate

Most children have educational placements and good school attendance. However, staff and managers failed to address the deterioration in one child's attendance. One child had good school attendance rates prior to living at the home, but this fell to zero attendance while living at the home. Although the registered manager clearly made efforts to engage education professionals in resolving this issue, the child’s social worker felt that staff initially expressed reluctance to cooperate with the placing authority's plan to provide home tutoring.

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Overall experiences and progress of children and young people: inadequate

The health needs of children are understood and appropriate actions taken. One member of staff spoken to during the inspection had a clear understanding of the complex health needs of one child, and had communicated effectively with health professionals to ensure that all necessary appointments were made. However, the records relating to this child’s health needs were disorganised, and did not reflect the information the member of staff had in relation to how the child’s health needs would be met. Medication errors are quickly identified, and investigations are undertaken to Inspection report children’s home: SC014235 8 establish how these occurred in order to prevent reoccurrence.

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Overall experiences and progress of children and young people: inadequate

All children have access to a play therapist, and they generally engage positively in the sessions they attend. However, the registered manager did not display enough knowledge of the specific areas of work for these sessions. In addition, she had not ensured effective liaison between different therapists. For example, for one child she did not know how the play therapy was contributing towards the child’s preparation for fostering. One child is currently receiving short-term therapeutic work in school to support her to build positive peer relationships. During this time, the child is still receiving the play therapy provided by the organisation. The registered manager had not ensured that the two therapists communicated so that they would both be aware of the issues presented by the child.

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Overall experiences and progress of children and young people: inadequate

The home provides children with a range of stimulating activities to develop their interests and have fun. One child spoke enthusiastically to the inspectors about a recent holiday. On the first day of this inspection, the children were attending a party at another of the provider’s homes. They all enjoyed the event, and one child described it as an ‘awesome’ experience.

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Overall experiences and progress of children and young people: inadequate

Although staff provide most children with stability and the opportunity to address some of their emotional and behavioural difficulties, practice in the home sometimes fails to ensure their safety, frequently fails to identify their specific needs, or plans effectively for their future.

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

The standard of practice relating to the protection of children is weak. Staff do not consistently act in accordance with the home’s child protection policy, and consequently effective action is not always taken when there are concerns for a child’s welfare. The inspectors examined documents relating to an incident in March 2017, when a member of staff acted in a threatening manner towards a child during the late evening. Following this incident, the member of staff was permitted to carry on with his waking night-time duties while other staff slept in at the home. Two members of staff failed to report this matter to the registered manager at the first opportunity, and no written record was made following the incident. The child subsequently made allegations, later judged to be unsubstantiated, that he had been physically assaulted by the member of staff as well as being threatened.

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

The internal investigation into this incident was poor. Not all of the staff involved were asked to provide written statements, and no record was kept of the conversation that the registered manager had with the child. The member of staff was not suspended from duty while the investigation was undertaken. In conversation with the registered manager, the inspectors were concerned that she minimised the seriousness of these events. The account she gave of the incident was not consistent with the written report. The management of this incident does not reflect a home where the safety and well- being of children is prioritised. Inspection report children’s home: SC014235 9 The assessment and management of risk does not consistently identify clear strategies for reducing the potential for children coming to harm. For example, a child’s risk assessment in relation to sexually harmful behaviour did not contain any strategies for

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

reducing the risk and/or to prevent other children from coming to harm. The control measures in place stated, ‘This can be addressed in a sensitive manner should it occur.’ This is not a preventative measure. The risk assessment made no reference to the level of supervision the child would require to ensure that other children were not exposed to potentially sexually harmful behaviour.

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

Records do not demonstrate that staff know when and how children are accessing the internet. Risk assessments pertaining to the safe use of the internet do not always specify effective strategies for helping children to stay safe.

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

Management monitoring and oversight of some incidents is poor. The independent visitor's monitoring report for March 2017 makes reference to a child being 'highly aroused' and in some 'distress' after accessing a website. The report states that the child later disclosed, 'the code words young people used to engage in sexual activity, intimating that she had witnessed something'. The registered manager was not able to give a full account of this incident and the outcomes of the actions taken in response.

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

There have been no incidents when children have gone missing from the home since the last inspection in October 2016. However, the guidance given to staff on how to respond to a missing episode is not good enough and is not consistently followed. In one child’s ‘missing’ risk assessment, it states that the child should be reported to the police immediately if he goes missing. However, the guidance given to staff on a notice in the office states that children should be reported missing if they have not been seen for one hour. Given the age and vulnerabilities of the children in this home, it would be inappropriate to wait for an hour before reporting them missing.

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

Positive behaviour is not consistently promoted in the home, and effective de-escalation techniques are not always used. The behaviour management plans do not contain sufficient detail regarding the strategies for responding to challenging behaviour. Records indicate that in one case, staff were clearly seeking guidance on how to manage a child's escalating violence and aggression, but a revised behaviour management plan was not produced in a timely manner. This increased the potential for the child to receive inconsistent responses when demonstrating challenging behaviour. A social worker commented, 'Staff could see the triggers [for challenging behaviour], but they could not address these, and situations escalated to the point of violence.' The social worker further commented that as a result the child was, 'Restrained far too often.' There have been 87 physical restraints of children since 20 October 2016.

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

The home is not sufficiently well maintained in terms of quickly identifying and rectifying health and safety hazards. In one child’s bedroom a full length mirror was found to be insecurely attached to the wall, and in another a large screw was protruding from the window frame. Further concerns were identified in respect of fire safety precautions. The emergency evacuation plan is not displayed in a prominent position, and the fire drill records do not identify which staff or children have taken part in drills. There are Inspection report children’s home: SC014235 10 discrepancies in the records of how many people have taken part in fire drills. These two issues were the subject of a requirement made in October 2016, and they have not been addressed effectively. Some staff spoken to during the inspection did not have a clear understanding of the emergency evacuation procedure, as described by the registered

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

The inspectors observed sensitive and nurturing relationships between the staff and children, and it is clear that the children feel relaxed in the company of staff. This ensures that children have the opportunity to share any worries or concerns they may have with a trusted adult. However, the shortfalls identified at this inspection indicate that effective action is not consistently taken when risks to a child’s well-being are known to managers and staff.

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The effectiveness of leaders and managers: inadequate

The registered manager has been in post for nearly sixteen months. She is currently studying for the level 5 diploma in leadership and management for residential childcare. Since the inspection in October 2016, eight members of staff have left the home and seven staff have joined.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not consistently ensure that the needs of children in the home are fully assessed and that effective plans are developed to meet the identified needs of children. The home’s statement of purpose specifies that a baseline assessment of need will be completed within 12 weeks of a child’s admission. This target is not always met. In May 2017, one child’s placement broke down five months after he was admitted. At this time, the baseline assessment of need had not been completed. Care plans are not effectively reviewed and amended to reflect children’s changing circumstances. Inspectors examined one child’s care plan and identified that it had not been updated to reflect the decisions taken at the child’s statutory looked after child review.

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The effectiveness of leaders and managers: inadequate

Managerial oversight of the home does not drive forward positive outcomes for the children. The placing authority’s long-term plans for all the children currently living in the home are for them to move to a foster placement. However, the inspectors found no evidence in the children’s care plans to demonstrate that staff were actively working to ensure that these plans were achieved. The care and management plans used within the home do not specify the work and tasks that staff need to undertake with children to prepare them for a move to foster care. Neither do they record the progress children are making to help them make the move to foster care. Leaders and managers are not enabling children to find permanence in their lives.

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The effectiveness of leaders and managers: inadequate

The admissions process is weak. The inspectors examined the referral information received from one placing authority, and cross-referenced this with the home’s assessment of the likely impact of the child being admitted. The home’s assessment failed to analyse the information provided by the placing authority and to take into account how the child’s needs and behaviours would affect the group of children already living in the home. The child was admitted and this led to a period of instability for all of the children. Inspection report children’s home: SC014235 11 When new admissions arrive, the process for ensuring that they have a successful induction to the home is poor. The inspectors examined the admissions conference document for a child who was admitted to the home in December 2016. The conference failed to identify all of the child’s priority needs and did not result in a provisional care plan being developed, or establish the focus for key-work sessions with the child.

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The effectiveness of leaders and managers: inadequate

Recently, a child was admitted from one of the provider’s other homes. Although the challenging behaviours of this child were well known, this did not result in an effective plan to address how certain staff might react if these behaviours were displayed.

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The effectiveness of leaders and managers: inadequate

The systems for monitoring the quality of care being provided fail to identify weaknesses in practice. The registered manager’s monitoring of serious incidents does not consistently recognise how the failure to develop individual behaviour management plans for children hampers more positive outcomes. It also became apparent during this inspection that the registered manager does not always use the independent visitor’s monitoring reports as a tool for improving practice.

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The effectiveness of leaders and managers: inadequate

Leaders and managers are inconsistent in ensuring that staff performance is monitored and staff are given the opportunity for professional development. Although all staff spoken to during the inspection said that they feel well supported by the registered manager, one new member of staff had not received formal supervision since starting two and half months ago. This is despite a requirement being made to address the regularity of supervision issued in October 2016.

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The effectiveness of leaders and managers: inadequate

In October 2016 the regulator also made a requirement in respect of assessing whether staff suffering from an illness are fit to perform their role in such a way as to promote the safety and well-being of children. At this inspection, the inspectors identified a member of staff who is currently experiencing poor health and is receiving treatment. The registered manager confirmed that no assessment had been undertaken in respect of the staff member’s ability to undertake duties in the home. This is despite the fact that concerns around poor practice have been identified on three occasions.

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The effectiveness of leaders and managers: inadequate

Leaders and managers’ response to poor performance is ineffectual. They do not properly follow the home’s policies and procedures, such as when following-up on allegations made against staff for failing to report safeguarding concerns. Neither do they ensure that staff have refresher training to address identified gaps in knowledge and practice.

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The effectiveness of leaders and managers: inadequate

Staff spoke positively about some of the training available, for example protective behaviours training, that they had recently undertaken. However, some of the training provided is at a basic level. Staff complete a one-hour online course in relation to understanding and addressing child sexual exploitation. Currently, one child at the home is assessed to be at high risk of sexual exploitation. A member of staff spoken to during the inspection did not demonstrate a suitable level of knowledge in this area.

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The effectiveness of leaders and managers: inadequate

Case records examined by the inspectors did not consistently demonstrate that a high standard of record keeping is maintained. Some incident reports did not have the name Inspection report children’s home: SC014235 12 or signature of the author, and dates and times when actions are taken are not always recorded accurately. Monitoring undertaken by the registered manager has not consistently identified the discrepancies found in some incident reports.

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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 who 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: SC014235 13

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Children’s home details

Registered provider address: Lioncare Ltd, 186 Forest Road, Loughton, Essex IG10 1EG

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Inspectors

Stephen Collett, social care inspector Teri Peck, regulatory inspection manager Inspection report children’s home: SC014235 14 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for children looked after, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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