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

Inspection report children‟s home: SC476259 1 SC476259 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

This is a privately owned children‟s home, registered to provide care and accommodation for up to four young people. The home specialises in caring for young people who have experienced child sexual exploitation.

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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, their welfare is not promoted or safeguarded and the care and experiences of children and young people are poor.

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inadequate

Date of last inspection: 15 February 2017

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inadequate

Overall judgement at last inspection: improved effectiveness

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Enforcement action since last inspection:

None. Inspection report children‟s home: SC476259 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

 Leadership and management are inadequate. The registered manager does not recognise and provide for young people‟s complex needs. This places young people at risk of significant emotional harm.

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Key findings from this inspection

 Poor staff practice and ineffective leadership mean that young people are not safeguarded.

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Key findings from this inspection

 The registered manager has failed to follow the organisation‟s safeguarding procedures. He has not learned from safeguarding incidents.

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Key findings from this inspection

 Staff recording of safeguarding incidents is poor.

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Key findings from this inspection

 Staff failed to take effective action when they learned that a young person might go missing.

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Key findings from this inspection

 Communication with partner agencies is poor.

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Key findings from this inspection

 Staff have not made sure that young people have the support and services that they need to manage their complex emotions.

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Key findings from this inspection

 When staff use physical interventions, they do not take into account young people‟s previous traumatic experiences.

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Key findings from this inspection

 Young people experience poor relationships with each other. The registered manager took no action to respond to one young person‟s allegations of bullying.

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Key findings from this inspection

 After young people have disclosed past traumatic experiences, staff do not support them adequately.

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Key findings from this inspection

 Staff fail to update young people‟s risk management plans or behaviour support plans after significant incidents.

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Key findings from this inspection

 The registered manager‟s monitoring of this home is inadequate. He does not question or challenge poor staff practice.

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Key findings from this inspection

 Inconsistent staffing has led to young people feeling unsafe and unsettled.

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Key findings from this inspection

 Supervision sessions with staff are inadequate.

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Key findings from this inspection

 The registered manager has failed to ensure that he is meeting the aims and Inspection report children‟s home: SC476259 3 objectives of the home‟s statement of purpose.

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Inspection date Inspection type Inspection judgement

15/02/2017 Interim Improved effectiveness 09/06/2016 Full Requires improvement 16/11/2015 Full Requires improvement 14/09/2015 Full Inadequate Inspection report children‟s home: SC476259 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

In meeting the quality standards, the registered person must, and must ensure that staff, seek to secure the input and services required to meet each child‟s needs. (Regulation 5 (b)) 17/09/2017

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Requirement Due date

The quality and purpose of care standard is that the registered person ensures that staff understand and apply the home‟s statement of purpose. (Regulation 6 (1) and (2) (b) (i)) 17/09/2017

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who protect and promote each child‟s welfare and treat each child with dignity and respect. (Regulation 6 (1) and (2) (b) (ii) and (iii)) 17/09/2017

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Requirement Due date

The quality and purpose of care standard is that staff provide personalised care that meets each child‟s needs, as recorded in the child‟s relevant plans, taking account of the child‟s background, and that staff help each child to understand and manage the impact of any experience of abuse or neglect. (Regulation 6 (1) and (2) (b) (iv) and (v)) 17/09/2017

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Requirement Due date

The quality and purpose of care standard is that the registered person provides to children living in the home the physical necessities they need in order to live there comfortably, such as a well-maintained home, personalised bedrooms and a homely environment. (Regulation 6 (1) and (2) (b) (vii)) 17/09/2017

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Requirement Due date

The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on mutual respect and trust; an understanding about acceptable behaviour; and positive responses to other children and adults. (Regulation 11 (1) (a) (b) (c)) 17/09/2017

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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. 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; 17/09/2017 Inspection report children‟s home: SC476259 5 that staff help each child to understand how to keep safe. (Regulation 12 (1) and (2) (a) (i) (ii)) The protection of children standard is that children are protected from harm and enabled to keep themselves safe. In particular, the standard in paragraph (1) requires the registered person to ensure— that staff have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

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

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Requirement Due date

that staff take effective action whenever there is a serious concern about a child‟s welfare. (Regulation 12 (1) and (2) (a) (iii), (iv) and (vi*)) 17/09/2017

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Requirement Due date

The leadership and management standard is that the registered person leads and manages 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 and that they ensure that staff have the experience, qualifications and skills to meet the needs of each child. (Regulation 13 (1) and (2) (a) (c)) 17/09/2017

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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 ensures that the home has sufficient staff to provide care for each child; that the home‟s workforce provides continuity of care to each child; and that the registered person understands 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. (Regulation 13 (1) and (2) (d) (e) (f)) 17/09/2017

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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 ensures that the registered person uses monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1) and (2) (h*)) 17/09/2017

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Requirement Due date

The care planning standard is that children have a positive experience of arriving at or moving on from the home. (Regulation 14 (1) (b)) 17/09/2017

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Requirement Due date

A person may only manage a children‟s home if, having regard to the size of the home, its statement of purpose, and the number and needs (including any needs arising from any disability) of the children, the person has the appropriate experience, qualification and skills to manage the home 17/09/2017 Inspection report children‟s home: SC476259 6 effectively and lead the care of children. (Regulation 28 (1) (b) (i)) 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. (Regulation 36 (1) (a)) 17/09/2017

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Requirement Due date

* These requirements are subject to a compliance notice.

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Overall experiences and progress of children and young people: inadequate

Young people do not make progress. The registered manager relies on the young people wanting to engage with their therapeutic programmes rather than on the staff using their skills, experience and knowledge to help young people engage. Staff do not provide individualised care to young people which meets their emotional needs or keeps them safe. For example, on one occasion, staff allowed a young person to use a mobile phone without this being agreed by the placing authority or risk-assessed. This is a clear breach of the home‟s statement of purpose.

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Overall experiences and progress of children and young people: inadequate

Young people‟s plans are not personalised and are not updated after significant incidents have happened. The plans do not take into account young people‟s previous traumatic experiences. This is particularly significant in relation to the use of physical interventions, settling at night and young people‟s self-harm. Staff do not have enough guidance on how to provide nurturing, sensitive care to young people that allows them to develop positive relationships, or that supports young people to make progress. On one occasion, a young person who was new to the home told staff that she felt scared in her bedroom and would like to leave her bedroom door open. Despite the fears of the young person, staff would only allow her to keep her bedroom door open for 10 minutes. Staff have failed to provide good-quality care to young people.

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Overall experiences and progress of children and young people: inadequate

Individual key-working sessions are poor. After young people have disclosed significant information about their experiences, staff do not ensure that they receive follow-up support. Staff do not seek to secure the support or services that young people need to help them make progress, such as mental health support. When a young person has refused a service, staff do not persevere and try to support them to access the support that they need. When young people report difficulties sleeping, staff do not provide them with support or strategies to manage this. After incidents when young people self-harm, staff do not talk to young people about the reasons for their behaviours or try to find ways of preventing future occurrences. Despite the home‟s statement of purpose citing that the home specialises in providing care for young people who have experienced child sexual exploitation, staff do not undertake regular key-working sessions about this.

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Overall experiences and progress of children and young people: inadequate

Inspection report children‟s home: SC476259 7 Young people do not feel that staff listen to them. They told the inspector that they had poor relationships with the staff team. When young people have raised complaints about staff practice, the registered manager has failed to rigorously investigate the concerns. The registered manager has failed to ensure that young people receive feedback after they have made a complaint. This has led to one young person feeling distrustful of staff and saying, „I won‟t say anything to anyone anymore. They keep saying I am doing so well, but that is because I won‟t talk to them about anything I‟m thinking or how I am feeling.‟

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Overall experiences and progress of children and young people: inadequate

Young people have had poor and unsafe experiences while living at this home. There is a culture of disbelief about bullying concerns, demonstrated by the behaviour and practices of the registered manager and staff. One young person told staff that they were experiencing poor relationships with other young people and that they were being bullied. The young person discussed the emotional impact of receiving physical and verbal aggression from her peer with staff. However, the registered manager dismissed the young person‟s concerns, and neither the staff nor the registered manager took any action to resolve, mediate or improve peer relationships in the home. On one occasion, another young person attempted to mediate after an incident of bullying and aggression between young people. Staff lack control during some incidents and do not assert protective boundaries. Young people have felt unsafe in their own home.

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Overall experiences and progress of children and young people: inadequate

The home is in a poor state of repair. It lacks warmth and does not feel homely. Furniture is of a poor standard and the walls, doors and carpets are stained and damaged. Young people‟s bedrooms lack personalisation. One young person has requested on several occasions for her bedroom and its furniture to be changed. However, this has not happened. This does not promote young people‟s emotional well- being or encourage them to invest in their placements.

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Overall experiences and progress of children and young people: inadequate

Young people do not always have a positive experience when they move from the home. One young person was moved after she seriously assaulted another young person. During this period, the provider continued to support this young person. However, she had to stay in several different temporary accommodations and was cared for by eight different adults prior to moving to another home. The young person did not know all of the staff who cared for her during this period.

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

Young people are not safe in this home. Their welfare is not promoted. The registered manager has failed to take effective action when young people have been placed at risk by poor staff practice. For example, staff allowed a young person to use a mobile phone to contact an unsafe adult. Another member of staff gave a young person a cigarette. The registered manager did not report these incidents to the safeguarding team, the designated officer or the young people‟s placing authorities. He has not thoroughly investigated incidents of poor staff practice or other incidents when young people have raised potential safeguarding concerns. Records of safeguarding concerns are poor, and sometimes lack detail about what action, if any, has been taken. Inspection report children‟s home: SC476259 8 Staff do not put into practice young people‟s risk management plans or the organisation‟s safeguarding procedures. For example, after one young person made

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

significant attempts to self-harm, staff failed to seek advice from the on-call manager or seek any specialist input, such as support from a mental health professional. After young people have self-harmed, staff have not completed any checks on them through the night to reassure the young people and assure themselves of the young people‟s safety. On one occasion, a young person (who has a history of harming herself) had obtained a screwdriver, which she handed to staff. However, staff failed to follow the organisation‟s procedures and complete a room search to identify whether there were any other objects that the young person could use to harm herself. In addition, the registered manager failed to carry out an investigation into how the young person obtained a screwdriver. Staff do not carry out any key-working sessions with young people after incidents of self-harm in order to try to prevent future occurrences. The registered

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

manager fails to make sure that learning is identified after these significant incidents. Risk management plans are not updated and staff do not ensure that they keep sharp objects safely stored away. This does not support young people‟s safety in the home.

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

Young people‟s safety and welfare have been compromised because of ineffective responses to serious incidents. After young people have barricaded themselves in rooms, the registered manager has failed to make sure that their risk management plans are updated. In addition, he has not implemented a policy outlining what actions staff should take in these situations. On some occasions, staff have made decisions and taken action without assessing clearly the potential implications. For example, staff kicked open a bedroom door when there were young people behind the door without first attempting to de-escalate the situation. On another occasion, staff restrained a young person in their bedroom, on their bed. Staff failed to assess the potential physical and emotional impact that their actions could have on the young people. The registered manager did not challenge staff practice or question their decision-making. This seriously

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

compromises young people‟s feelings of safety.

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

Staff do not understand the impact that young people‟s past experiences have on their emotional well-being and behaviours. Restraints have caused significant distress to some young people, reminding them of previous abusive experiences. Despite this, staff continue to use restraints without consistently attempting other methods of de- escalation or different holds. Young people have witnessed their peers being restrained and this has caused them emotional distress. These actions also do not protect young people‟s dignity. A young person said: „Staff don‟t try to make sure we don‟t see what‟s happening with the other young people in the house, so when one of them is kicking off and screaming, they don‟t take me out or take me to play a game or nothing. I hate seeing her being restrained. When she screams for them to get off, then they should, so I say that they should get off her as she has said she will stop.‟

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

Physical intervention records are poor. They do not detail the actions that staff take to de-escalate situations. One physical intervention document refers to a member of staff „pushing‟ a young person‟s head away due to her attempting to bite him. This is not a recognised means of physical intervention. The registered manager failed to investigate this appropriately. Inspection report children‟s home: SC476259 9 Staff do not take appropriate preventative steps to protect young people who are at risk of child sexual exploitation. On one occasion, staff failed to report overhearing a young person telling her peer that she had accessed the internet and had arranged to be collected from the home by unknown males. Staff did not report this significant information to the police or the local authority. This placed young people and staff at risk.

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

The culture of this home is one of minimising young people‟s views, complaints and experiences. The registered manager and staff do not always believe young people. After young people have reported being bullied, having poor peer relationships and feeling unsafe, the registered manager has taken no action to support them. The registered manager reinforces the view that young people do not tell the truth and that young people‟s attempts to self-harm are not serious attempts to hurt themselves. This places young people at risk.

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

The registered manager fails to understand the importance of clear, concise documentation of safeguarding incidents and professional challenge. Instead, the registered manager relies on „knowing‟ staff. This culture is unprofessional and does not keep young people safe.

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The effectiveness of leaders and managers: inadequate

The registered manager has been in post since November 2015. He is suitably qualified. There have been significant staffing issues in the home which have led to an increased use of agency staff. The home has 11 members of staff, eight of whom are suitably qualified. Ten members of staff have a valid first-aid certificate. Staff lack training in child sexual exploitation, despite this home being described as a specialised child sexual exploitation service. This lack of knowledge and understanding of child sexual exploitation is evident in the poor management of complex safeguarding situations. For example, staff have not ensured that they have offered ongoing support to young people (throughout the night if necessary) after they have tried to harm themselves or after they have disclosed traumatic and painful memories to staff. The registered manager has failed to question staff about their lack of nurturing of young people.

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The effectiveness of leaders and managers: inadequate

Management oversight is particularly poor. The registered manager has not questioned staff practice after inappropriate restraints, when staff have kicked doors open or when staff have not followed safeguarding procedures. The registered manager has reviewed poorly recorded documents without challenge or question. He is dismissive of the need for what he described as a „confetti of paperwork‟ or the need for staff to document the work that they do or accurately record the actions that they take when young people are distressed. He has failed to satisfy himself that his staff team is providing good-quality care to young people. Consequently, he has failed the young people in his care.

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The effectiveness of leaders and managers: inadequate

This home lacks strong, visible management. It is disorganised and, at times, staff have been chaotic in the way that they have managed situations. Staff lack direction from the registered manager. Boundaries are inconsistent. A young person said, „It‟s not very Inspection report children‟s home: SC476259 10 organised here and needs to be better organised as staff say different things all the time and don‟t know what the rules are… it‟s confusing.‟

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The effectiveness of leaders and managers: inadequate

The registered manager has not challenged staff when they have not followed young people‟s risk management plans or the organisation‟s policies or procedures. The registered manager has failed to adhere to the company‟s safeguarding procedures and has not reported safeguarding concerns to the designated officer. Communication with partner agencies and placing authorities is poor. For example, when a young person was given access to a mobile phone, this was not reported to the placing authority, despite the young person contacting an unsafe person.

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The effectiveness of leaders and managers: inadequate

Supervision sessions with staff are poor. They are not carried out regularly and they are not in-depth. The registered manager does not promote a culture of learning from safeguarding incidents or reflecting on practice. Some new staff have not had the fortnightly supervision required by the organisation‟s own policy. New members of staff have been placed in potentially difficult situations. This includes working alone with a young person in temporary accommodation before the staff members‟ mandatory training had been completed. This does not safeguard staff or support young people‟s emotional well-being.

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The effectiveness of leaders and managers: inadequate

The registered manager and staff do not reflect on safeguarding incidents or young people‟s views, wishes and feelings. When young people raise issues with the registered manager, he does not investigate the allegations properly and he does not feed back to young people. The registered manager fails to see the significance or importance of investigating young people‟s concerns and allegations. This has had a negative impact on young people‟s relationships with and their engagement with staff. The registered manager minimises incidents of self-harm, stating that on one occasion it was an example of a young person „spouting off‟. The registered manager does not provide staff with rigorous management oversight that is child-focused. His response to young people‟s emotional needs is poor and demonstrates a concerning lack of skill and knowledge.

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The effectiveness of leaders and managers: inadequate

The registered manager acknowledges that there have been staff shortages. The frequent use of agency staff has had a negative impact on some young people‟s emotional well-being and their feelings of safety. Little action has been taken to mitigate the impact of this, despite the clinical team highlighting it as a concern to the registered manager. One young person was supported in a temporary placement by staff whom they did not know. Some of these staff were temporary staff employed through an agency or staff who worked in a different home. As a result, the registered manager failed to make sure that the young person‟s emotional needs were met. Inspection report children‟s home: SC476259 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 differences 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: SC476259 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

Hannah Bates, social care inspector Inspection report children‟s home: SC476259 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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