West End House & The Bungalow

Inspection report children's home: SC061045 1 SC061045 Registered provider: Dorset County Council

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Inspected under the social care common inspection framework

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Information about this children’s home

This local authority children‟s home is registered to provide care and accommodation for up to four young people who have emotional and/or behavioural difficulties. The bungalow, which is adjacent to the main house, provides flexible accommodation to support the development of young people‟s independent living skills as they grow into young adults.

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

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inadequate

Date of last inspection: 16 January 2017

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inadequate

Overall judgement at last inspection: Sustained effectiveness

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inadequate

Enforcement action since last inspection: None

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Key findings from this inspection

This children‟s home is inadequate because: Inspection report children's home: SC061045 2  Serious and widespread weaknesses have been identified that impact negatively on the safety, health and well-being of the young people living at this home.  Young people are not protected because staff managing the home do not know if the temporary staff who regularly work here are safely recruited nor if they have the required skills and training to meet the young people‟s needs effectively.  The arrangements to assess whether the home can meet young people‟s needs and whether young people can live safely together are inadequate. Poor decision- making by senior leaders has resulted in one young person coming to live here, despite managers identifying before she moved in that they would not be able to meet her needs.  The negative effect of one young person‟s behaviour has resulted in the other residents saying that they do not feel safe and that their experiences and quality

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Key findings from this inspection

of care have declined.  Leaders and managers have not ensured that each young person has a healthcare plan. This means that not all of the young people‟s health and well-being needs are met. Leaders, managers and staff have failed to ensure that young people receive urgent sexual-health intervention when required.  One young person is regularly cared for by different temporary staff. This arrangement does not ensure that staff provide stability and continuity of care and that positive relationships can develop. Fire safety is not well managed. Not all staff have completed a fire evacuation drill and staff do not reduce effectively the risk of fire-setting by one young person.  Monitoring systems for reviewing the quality of care are ineffective. The independent visitor, leaders and managers do not recognise the full extent of the weaknesses in the quality of care provided to young people in the home. In

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Key findings from this inspection

addition, the management team does not effectively monitor central records of physical interventions, sanctions and significant events. As a result, opportunities are missed to identify patterns and trends of behaviours, and to improve the quality of care.  Leaders and managers have not ensured that the Children‟s Home Regulations (England) 2015 relating to the recruitment, selection, training and supervision of staff, restraints, sanctions, complaints, record keeping and risk assessments are met.

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Key findings from this inspection

 Two young people have made good progress educationally. They have successfully finished school, and are enrolled on further education courses of their choice.  Relationships between the permanent staff and young people are positive.  The newly appointed responsible individual completed a full audit of the home prior to this inspection. She is taking appropriate action to strengthen the safeguarding arrangements and remedy the widespread weaknesses. Inspection report children's home: SC061045 3

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Inspection date Inspection type Inspection judgement

16/01/2017 Interim Sustained effectiveness 13/09/2016 Full Outstanding 16/02/2016 Interim Sustained effectiveness 22/09/2015 Full Outstanding Inspection report children's home: SC061045 4

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Statutory requirements

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

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Requirement Due date

7: The children‟s views, wishes and feelings standard

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Requirement Due date

The children‟s views, wishes and feelings standard is that children receive care from staff who: develop positive relationships with them; engage with them; and take their views, wishes and feelings into account in relation to matters affecting the children‟s care and welfare and their lives.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff:

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Requirement Due date

help each child to express their views, wishes and feelings;

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Requirement Due date

help each child to understand how the child‟s views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child;

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Requirement Due date

ensure that the views of each relevant person are taken into account, so far as reasonably practicable, before making a decision about the care or welfare of a child.

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Requirement Due date

This requirement also relates to ensuring that young people‟s views are sought following incidents, restraints and sanctions. 01/09/17

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Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff:

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Requirement Due date

assess whether each child is at risk of harm, taking into account 01/09/17 Inspection report children's home: SC061045 5 information in the child‟s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child;

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Requirement Due date

help each child to understand how to keep safe;

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Requirement Due date

have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

manage relationships between children to prevent them from harming each other;

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Requirement Due date

understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person;

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Requirement Due date

take effective action whenever there is a serious concern about a child‟s welfare; and

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Requirement Due date

ensure that the home‟s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm.

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Requirement Due date

(Regulation 12(1)(2)(a)(i)(ii)(iii)(iv)(v)(vi)(b))

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Requirement Due date

13: The leadership and management standard

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Requirement Due date

In order to meet the leadership and management standard, the registered person should enable, inspire and lead a culture in relation to the children‟s home that helps children aspire to fulfil their potential; and promotes their welfare.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to: lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home‟s statement of purpose; ensure that staff have the experience, qualifications and skills to meet the needs of each child; ensure the home‟s workforce provides continuity of care for each child; understand the effect that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home; demonstrate that practice in the home is informed and improved 01/09/17 Inspection report children's home: SC061045 6 by taking into account and acting on— feedback on the experiences of children, including complaints received; 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

(Regulation 13(1)(a)(b)(2)(a)(c)(e)(f)(g)(ii)(h))

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Requirement Due date

The registered persons must 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.

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Requirement Due date

In particular, ensure that all bank and agency staff have engaged in an evacuation drill. 01/09/17

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Requirement Due date

The registered person must ensure that the employment of any person on a temporary basis at the children‟s home does not prevent children from receiving continuity of care as is reasonable to meet their needs.

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Requirement Due date

The registered person must recruit staff using recruitment procedures that are designed to ensure children‟s safety.

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Requirement Due date

Ensure that full and satisfactory information in respect of all staff working in the home has been obtained in relation to the matters in paragraphs 1 and 2 of schedule 2.

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Requirement Due date

In particular, ensure checks are completed for all bank and agency staff and ensure all recruitment checks are accessible to the interim manager and available for review during inspection. 01/09/17

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Requirement Due date

The registered person must maintain records (“case records”) 01/09/17 Inspection report children's home: SC061045 7 for each child which include the information and documents listed in Scheduled 3 in relation to each child. The registered person must ensure that all case records are kept up to date.

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Requirement Due date

In addition, the registered person must ensure that all records are legible, accurate, detailed and factual.

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Requirement Due date

The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation.

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Requirement Due date

44 : Independent person; visits and reports

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Requirement Due date

The registered person must ensure that an independent person visits the children‟s home at least once each month. The independent person must produce a report about a visit (“the independent person‟s report”) which sets out, in particular, the independent person‟s opinion as to whether— children are effectively safeguarded; and the conduct of the home promotes children‟s well-being. The independent person must provide a copy of the independent person‟s report to HMCI. (Regulation 45(1)(4)(a)(b)(7)(a))

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Requirement Due date

In addition, ensure that copies of the report are provided to HMCI promptly after the visit. 01/09/17

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Requirement Due date

The registered person must review the appropriateness and suitability of the location of the premises used for the purpose of the children‟s home at least once in each calendar year taking into account the requirement in regulation (12)(2)(c) (the protection of children standard).

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Requirement Due date

In particular, the registered person should consider the known risks in the local community that have a potential to effect on 01/09/17 Inspection report children's home: SC061045 8 the safety and well-being of the young people living in the home.

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Overall experiences and progress of children and young people: inadequate

Senior leaders made a decision to move a young person into this home whose needs cannot be met here. Following this poor decision, the experiences and progress of all young people have deteriorated.

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Overall experiences and progress of children and young people: inadequate

Temporary staff regularly work in the home. Leaders and managers do not know if these temporary staff are safely recruited or whether they have the required skills and training to meet the young people‟s needs. This serious oversight fails to protect the young people.

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Overall experiences and progress of children and young people: inadequate

One young person is always looked after by different temporary staff. On one occasion, the young person was looked after by two male staff. This arrangement places the young person and staff at risk as it is not in line with the young person‟s care plan, risk assessment and needs. This continued use of different temporary staff restricts the ability of staff to provide the young person with continuity of care and enable positive relationships to develop.

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Overall experiences and progress of children and young people: inadequate

Sleeping-in arrangements for staff at the adjoining bungalow are inadequate. The second member of staff who stays overnight sleeps on a mattress in the young person‟s main lounge. The mattress remains in the lounge during the day. This has a negative effect on a young person‟s daily living experience.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers have not fully considered the significance of the known vulnerabilities and high-risk behaviours of one young person. As a result, staff have been unable to prevent significant incidents from happening. Incidents have included assaults on staff and fire-setting in the local park. Staff are not provided with the correct instruction or guidance on how to manage these incidents because in-house risk assessments are of poor quality and the placing authority‟s risk assessments have not been reviewed. Two young people say that they fear for their safety and that they are upset by seeing members of staff who they care about being assaulted.

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Overall experiences and progress of children and young people: inadequate

Staff sometimes work hard to encourage young people to make safe choices and to keep themselves safe. However, at times some young people have been missing from the home and have spent time with friends in the local area or at parties consuming alcohol and misusing illegal substances. Staff failed to respond appropriately to a disclosure made by a young person. This meant that the young person did not receive the healthcare and emotional support they needed. Staff have not used one-to-one sessions Inspection report children's home: SC061045 9 to explore if the young person is at risk of exploitation or to provide advice and guidance on making safer choices and keeping safe.

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Overall experiences and progress of children and young people: inadequate

The help provided to young people to develop socially acceptable behaviour is not effective. Sanctions for unacceptable behaviour are, in the main, financial rather than restorative. On two occasions, a young person who was sick in the car was fined the cost of cleaning the car. Leaders and managers failed to explore the reasons why the young person was sick and determine whether the sanction was reasonable or proportionate.

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

Young people are not protected from harm because leaders and managers have failed to obtain critical information that temporary staff who regularly work in the home have been safely recruited. The interim manager does not have access to the recruitment records for two newly appointed permanent staff. As a result, she does not know if they are safe to work with the young people.

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

Risk assessments, care plans and behaviour management records are not well maintained. Not all known risks are identified in the home‟s risk assessments and two local authority documents used to assess and manage the risks of child sexual exploitation have not been reviewed. Leaders and managers have failed to rectify these weaknesses. Strategies that help staff to manage high-risk behaviours are not clearly documented and young people do not have health care plans. As a result, not all of the young people‟s needs are met and young people continue to self-harm, go missing from the home, assault members of staff and frequently display heightened levels of anxiety.

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

Not all staff demonstrate an effective understanding of fire safety. Temporary staff have not engaged in a fire evacuation. Staff did not ensure that a young person who has a known history of fire-setting was provided with an opportunity to practise the fire evacuation procedures as soon as they moved in. The same young person has recently set a fire in a local park resulting in the emergency services being called. The young person‟s care plan states that lighters should be handed in to staff. In practice, this is not happening and the young person has unrestricted access to tobacco and a lighter. During the inspection, the young person was observed to use the lighter to burn plastic wire clips on the exterior of the home. Staff do not challenge or prevent this unsafe behaviour.

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

Sanctions for unwanted behaviour do not provide young people with opportunities to consider the effect that their behaviour has on themselves and others. As a result, staff do not always manage young people‟s challenging behaviour effectively. Consequently, their challenging behaviour increases and has a negative effect on other young people living at the home.

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

Leaders and managers do not keep detailed records of the action that they have taken in response to complaints made by young people. As a result, there are not always records Inspection report children's home: SC061045 10 which show that complaints have been acknowledged, investigated or that a satisfactory resolution has been is found.

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

Physical intervention is only used as a last resort and incidents where is it used are infrequent. However, since the last inspection leaders and managers have failed to monitor the records when physical intervention has been used. They have not assessed if the actions taken by staff are proportionate and effective, and young people have not been spoken to following these interventions. This has resulted in their experiences not being understood and used to inform future practice.

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

The manager has completed a locality risk assessment. Although detailed in parts, this document requires improvement. The manager has failed to consider whether there is an increased risk to the young people when they go missing, because of limited street lighting. In addition, the manager does not know if there is a potential risk from farming machinery, livestock and events that occur in the local area.

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

Young people sometimes go missing from this home. Staff actively search for the young people and communicate well with other agencies to identify the whereabouts of the young people. Missing-from-home protocols have recently been implemented and agreed with the police. These protocols provide staff with clear guidance on the actions to take so the young person can be located and returned to the home without delay.

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The effectiveness of leaders and managers: inadequate

The home is not led nor managed effectively. Leaders and managers do not provide care to young people in line with the principles described in the statement of purpose. The document states that young people will be loved, happy and healthy and kept safe from harm. It states that there will be „careful selection and vetting of all staff and volunteers‟ and that „staff will receive four-weekly formal and recorded supervision‟. Weaknesses have been identified in all of these areas.

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The effectiveness of leaders and managers: inadequate

Leaders and managers made a poor decision in admitting a young person into the home. Prior to the young person‟s arrival, the interim manager completed an assessment to evaluate whether the young person‟s needs could be met safely alongside the current group of young people. The interim manager identified that the risks to the existing young people would be too high and that the required level of staffing to keep all young people safe would be too difficult to maintain. However, the interim manager was overruled, the young person moved into the home and the identified risks have occurred. Leaders, managers and staff said that they feel overwhelmed and exhausted by trying to meet the young person‟s high-risk needs.

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The effectiveness of leaders and managers: inadequate

Staff do not receive good support to enable them to fulfil their role successfully. In order to provide the numbers of staff required to meet the needs of all of the young people, staff regularly work in excess of their commissioned hours. Staff do not receive regular practice-related supervision or the opportunity to reflect on their practice following significant incidents. Inspection report children's home: SC061045 11 The current staffing arrangements are poor and have had a negative effect on the quality of care provided to young people. Temporary staff regularly work in the home and one young person is not provided with stability, and is not cared for by staff whom they know well.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not know if all of the staff who work with young people have the necessary skills, training and experience to meet their needs. Leaders are unable to confirm that all staff have received training in protecting young people from sexual exploitation and self-harm. Both of these areas are high risk for the young people. Not all staff have completed basic mandatory training or received updates at the intervals specified by the provider.

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The effectiveness of leaders and managers: inadequate

The monitoring of the quality of care provided in the home is inadequate. Records relating to the care of young people and the running of the home are not well maintained. Records, including the home‟s log book and those relating to physical interventions, sanctions, complaints, incidents and weekly overviews lack critical information and on occasion are illegible. Leaders and managers do not monitor these records effectively, and are therefore unable to identify possible trends and patterns in young people‟s behaviour or identify if they are at risk of harm. Leaders and managers have failed to identify that external monitoring of the quality of care has not taken place within the timescales required by the regulations.

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The effectiveness of leaders and managers: inadequate

A registered manager is in post, but he is not currently working at the home. The deputy manager, supported by the newly appointed responsible individual, is currently responsible for the day-to-day running of the home. More work is needed to strengthen the management arrangements, provide effective leadership and secure improvements.

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The effectiveness of leaders and managers: inadequate

Prior to this inspection, the responsible individual had completed an audit of the home‟s operation and function. She is aware that the manager has not monitored the quality of care and records effectively, that support plans are not in place, that supervision does not take place frequently and that untrained staff administer medication. The responsible individual has taken some immediate actions to address these weaknesses and she is in discussions with senior leaders in the local authority to review the purpose and function of this home.

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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. Inspection report children's home: SC061045 12 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

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Information about this inspection

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: SC061045 13

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Children’s home details

Registered provider address: County Hall, Colliton Park, Dorchester, Dorset DT1 1XJ

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Inspector

Sharron Escott: social care inspector Inspection report children's home: SC061045 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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Inspector

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Inspector

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Inspector

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