Children's home run by Cambian Childcare Limited in Hammersmith and Fulham

Inspection report children‟s home: SC035657 1 SC035657 Registered provider: Cambian Childcare Ltd

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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 provides care and accommodation for up to seven young people who have emotional and/or behavioural difficulties. The home is owned by a private organisation.

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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

Overall judgement at last inspection: Sustained effectiveness

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Enforcement action since last inspection

None Inspection report children‟s home: SC035657 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

 Staff do not meet young people‟s needs; this compromises their safety and emotional well-being.  Young people go missing, sometimes for long periods. When they are missing, some young people get involved in criminal activity.  Care plans and risk assessments are not robust or effectively reviewed. Consequently, they do not address the changing needs of the young people.  Compatibility assessments lack detail and clarity. As a result, staff and managers do not make informed judgements about young people who come to live at the home.  Staff fail to support young people‟s health, specifically in relation to young people who misuse drugs and who smoke.  Healthcare plans do not adequately reflect the health needs of the young people. They also contain incorrect information about young people‟s medication.  As a result of poor recording the home fails to provide a factual record of young people‟s care experience.

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Key findings from this inspection

 Not all young people are achieving their full potential in education and some staff are not aware of the educational needs of each young person.  Staff are not suitably experienced or competent to meet the complex needs of young people.  Monitoring is weak. As a result, the manager does not understand the strengths and needs of the service and this limits the capacity of the home to improve.  Staff do not manage young people‟s behaviour effectively.  Parts of the home environment are unsafe. This compromises young people‟s safety.

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Key findings from this inspection

 Independence plans are individualised. Staff support young people to learn new skills which will support them into adulthood.  Staff support young people to stay in touch with their families, in line with their individual plans. Inspection report children‟s home: SC035657 3

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Inspection date Inspection type Inspection judgement

30/03/2017 Interim Sustained effectiveness 16/11/2016 Full Good 30/03/2016 Interim Sustained effectiveness 11/01/2016 Full Outstanding Inspection report children‟s home: SC035657 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

The education standard is that children make measurable progress towards achieving their education potential and are helped to do so.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure—

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Requirement Due date

that staff help each child to understand the importance and value of education, learning, training and employment; help a child who is excluded from school, or who is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as possible. (Regulation 8(1)(2)(a)(iv)(viii)) 22/09/2017

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Requirement Due date

The health and well-being standard is that children receive advice, services and support in relation to their health and well- being; and children are helped to lead healthy lifestyles. (Regulation 10(1)(b)(c)) 22/09/2017

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Requirement Due date

12: The protection of children standard*

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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: 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; help each child to understand how to keep safe; have the skills to identify and act upon signs that a child is at risk of harm; understand the roles and responsibilities in relation to protecting 22/09/2017 Inspection report children‟s home: SC035657 5 children that are assigned to them by the registered person; take effective action whenever there is a serious concern about a child‟s welfare; are familiar with, and act in accordance with, the home‟s child protection policies; 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; and that the premises used for the purposes of the home

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Requirement Due date

are designed, furnished and maintained so as to protect each child from avoidable hazards to the child‟s health. (Regulation (1)(2)(a)(i)(ii)(iii)(v)(vi)(vii)(b)(d))

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Requirement Due date

13: The leadership and management standard*

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Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads 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; understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home; use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(a)(b) and (2)(a)(f)(h)) 22/09/2017

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Requirement Due date

The care planning standard is that children receive effectively planned care in or through the children‟s home; and have a positive experience of arriving at or moving on from the home.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure: that children are admitted to the home only if their needs are within the range of needs 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. (Regulation 14(1) and (2)(a)) 22/09/2017

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children‟s home. 22/09/2017 Inspection report children‟s home: SC035657 6 In particular, the registered person must ensure that a record is kept of the administration of medicine to each child. (Regulation 23(1)(2)(c)) The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33(4)(b)) 22/09/2017

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Requirement Due date

The registered person must maintain records (“case records”) for each child which include the information and documents listed in Schedule 3 in relation to each child: Are kept up to date; and are signed and dated by the author of each entry. (Regulation 36(1)(a)(b)(c)) 22/09/2017

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation; an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious. (Regulation 40(4)(a)(b)) 22/09/2017

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Requirement Due date

*These requirements are subject of a compliance notice.

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Recommendation

 When a child returns to the home after being missing from care or away from the home without permission, the responsible authority must provide an opportunity for the child to have an independent return home interview. Homes should take account of information provided by such interviews when assessing risks and putting arrangements in place to protect each child. („Guide to the children‟s homes regulations including the quality standards‟, page 45, paragraph 9.30) Inspection report children‟s home: SC035657 7

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Overall experiences and progress of children and young people: inadequate

Young people live in an unstable environment. Several changes in staff have led to inconsistent care. As a result, staff do not meet young people‟s individual needs consistently. Staff are not fully aware of their roles and responsibilities in relation to protecting young people. This does not protect young people from harm.

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Overall experiences and progress of children and young people: inadequate

Managers do not make well-considered decisions when new young people move to the home. Compatibility risk assessments lack detail and evaluation. As a result, the registered manager offered a placement to a new young person without identifying and assessing their full range of needs. Furthermore, he failed to consider the needs of the young people already living in the home. Poor care planning and admission processes have placed young people at risk. For example, young people quickly influenced each other; some went missing and engaged in criminal behaviour. Staff failed to manage young people‟s needs and risks and consequently their placements ended earlier than expected. The manager‟s failure to assess the needs of each young person prior to admission has resulted in additional disruption for them.

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Overall experiences and progress of children and young people: inadequate

Young people‟s educational progress varies. Some young people engage well with their learning and make good progress. However, other young people do not. Furthermore, some young people‟s education plans contain inaccurate information. The manager does not consistently share information with staff and update records when things change. As a result, staff do not know enough about young people‟s education plans and needs. This leads to confusion and means that young people do not receive tailored support. This compromises young people‟s learning and may affect their life chances in the future.

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Overall experiences and progress of children and young people: inadequate

Staff support young people to register with all primary healthcare services. However, healthcare plans lack detail and are not up to date. For example, one young person‟s plan contained information about medication that was no longer relevant. Furthermore, information provided by the child and adolescent mental health services (CAMHS) was not included in the young person‟s healthcare plan. This does not ensure that staff have a clear overview of all young people‟s health needs.

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Overall experiences and progress of children and young people: inadequate

Young people smoke and misuse drugs. Staff do not always discourage young people. For example, during the inspection, the inspector observed young people smoking cigarettes at the front door without challenge from staff. Staff do not effectively support young people to understand the dangers of smoking or misusing drugs and the impact that this may have on their health and well-being.

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Overall experiences and progress of children and young people: inadequate

Staff help young people to prepare for their next steps. They tailor independence plans to suit each young person. Staff have introduced new documentation, which includes useful information about budgeting, cooking and household tasks. Staff also work with young people to educate them about how to get a tenancy and about paying rent. As a result, young people are able to prepare for their transition into adulthood. Inspection report children‟s home: SC035657 8 Staff promote family contact for young people, when it is appropriate to do so. They make sure that this is positive and safe. Consequently, young people keep in touch with people who are important to them.

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

Safeguarding practice in this home is not sufficiently robust and does not promote the safety and welfare of young people. Managers and staff do not fully consider risks or learn from events that happen. For example, on one occasion an unknown male attended the home and threatened young people and staff. Staff report that this was likely to be linked to young people accumulating drug debts. Although staff contacted the police, the staff did not update risk assessments following this incident. Managers and staff did not consider other potential risks or safety factors that related to the individual young person, other young people living at the home and staff. As a result, the manager cannot be assured that all staff fully understand the risks and the strategies in place for managing these risks.

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

Managers and staff do not respond effectively to incidents of bullying. They do not investigate incidents thoroughly or develop clear strategies for preventing any reoccurrence. This does not keep young people safe. Furthermore, this means that managers and staff do not act in accordance with the home‟s statement of purpose, which states, „Where a bullying incident or claim occurs it is thoroughly documented and investigated by staff. The staff members work hard to ensure that a suitable consequence is delivered and the right support is put in place to help the bully and their victim explore why it happened and how to avoid it happening again.‟

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

Missing-from-care episodes have increased. Some young people go missing for a number of days at a time. When young people go missing, the staff follow their internal procedures and inform the relevant people. However, records show a lack of evaluation; this does not assist staff in identifying any further strategies for preventing further missing episodes. When young people return to the home after being missing from care, they do not always have a meeting with somebody independent. As a result, young people do not have the opportunity to talk with someone unconnected with the home about why they went missing and what happened while they were away from the home. This does not promote the safety and well-being of the young person. It is a missed opportunity for learning for the staff.

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

Behaviour management plans, placement plans and risk assessments do not accurately reflect or address the needs of young people. Staff do not understand young people‟s risks and needs nor do they know how to respond to these effectively. This does not adequately protect young people.

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

Young people do not benefit from clear and consistent boundaries or effective behaviour management strategies. One staff member said, „Sometimes one staff member will do one thing and another will do something else. We should make sure we all give the Inspection report children‟s home: SC035657 9 young people the same support.‟ This lack of consistency means that young people do not learn to modify their behaviour.

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

The home has sustained significant damage and is showing significant signs of wear and tear. This includes broken spindles on the staircase, boarded up windows, stained carpets and damaged furniture. Managers do not ensure that repairs are carried out quickly. This creates hazards for young people and staff. As a result, the home is not a safe and comfortable environment for the young people living there.

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

The recording of medication is not robust. For example, one young person‟s prescribed medication dosage has increased. However, the medication records show two different dosages. Amendments made to the records made them unclear. This has the potential to cause confusion to all staff and increases the risk of errors when they administer medication. In addition, staff are not always clear about why the young person requires medication. This does not show that staff handle, administer and record medication safely. This has the potential to have serious consequences for the young person.

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The effectiveness of leaders and managers: inadequate

The manager commenced in his post in February 2017 and has submitted an application for registration with Ofsted. Soon after the manager started, the deputy manager and four other staff left the home. Although recruitment to these posts is now complete, this level of sudden staff turnover created some instability. For example, it affected the ability of the staff to work cohesively and young people did not receive consistent care. The admission at the same time of young people who displayed complex and challenging behaviour created further difficulties because the staff were ill prepared and not suitably experienced.

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The effectiveness of leaders and managers: inadequate

The home‟s statement of purpose states that the ethos of the home is, „To ensure that looked after children are provided with the help, care and support needed for them to thrive.‟ However, a number of placements have ended due to the staff‟s inability to keep young people safe and support their progress. This is another example of the home failing to operate within its own statement of purpose.

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The effectiveness of leaders and managers: inadequate

Managers and staff do not keep good records. For example, although the manager says that staff carry out key-work sessions with young people, there is no recorded evidence of these having taken place. The manager acknowledges the shortfalls in recording and he has tasked the deputy manager with reviewing the recording systems and updating young people‟s individual placement plans. However, due to staff shortages, the deputy manager has been working on shift. As a result, this review has yet to take place and aspects of recording remain poor.

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The effectiveness of leaders and managers: inadequate

This inspection identified gaps in staff training. Only four staff hold the relevant level 4 qualification in caring for children and young people. New staff have completed induction training, which includes safeguarding. However, some staff were unable to show a strong understanding of safeguarding practice. For example, two members of staff Inspection report children‟s home: SC035657 10 spoken to are not aware of „Working Together to Safeguard Children‟, and staff have not all completed training on child sexual exploitation. This does not demonstrate that the induction process and training are enabling staff to develop a basic knowledge of the home‟s safeguarding practices and the relevant guidance that all staff need to understand.

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The effectiveness of leaders and managers: inadequate

Staff have not consistently received supervision. Team leaders who provide staff supervision have not received the relevant training. Consequently, they are not fully equipped to carry out this role. As a result, staff do not receive the appropriate support and guidance to help them to develop their practice. Furthermore, staff, including the manager, do not always receive a record of supervision.

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The effectiveness of leaders and managers: inadequate

The manager has failed to use monitoring and review systems to make continuous improvements in the quality of care provided in the home. Due to the shortfall in monitoring, the manager has been unable to identify and address gaps within young people‟s records. Furthermore, it does not allow the manager to track young people‟s progress easily.

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The effectiveness of leaders and managers: inadequate

The manager does not notify Ofsted promptly when significant events occur. Notifications do not always contain enough information. For example, it is not always clear what action staff have taken to minimise the risks identified and prevent reoccurrence. This does not allow the regulator to have a clear overview of all safeguarding incidents, and is in breach of the Children‟s Homes (England) regulations 2015. Inspection report children‟s home: SC035657 11

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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: SC035657 12

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Children’s home details

Registered provider: Cambian Childcare Ltd

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Children’s home details

Registered provider address: Cambian Group, 4th Floor, Waterfront Building, Chancellors Road, Hammersmith Embankment, London W6 9RU

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Inspector

Sarah Oldham: social care inspector Inspection report children‟s home: SC035657 13 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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