Children's home run by Crossways Care Ltd in Tewkesbury

Inspection report children’s home: SC443079 1 SC443079 Registered provider: Crossways Care 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 children’s home was registered in March 2012 to provide care and accommodation for up to three young people, irrespective of gender, who may have emotional and/or behavioural difficulties. The home is run by a care company that runs several other children’s homes and a small, specialised school in the area. In 2013, the company was purchased by a larger national organisation, but it retains its local corporate identity.

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Information about this children’s home

Inspection dates: 12 to 13 September 2017

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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 and they are not making progress.

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inadequate

Overall judgement at last inspection: inadequate

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Key findings from this inspection

Inspection report children’s home: SC443079 2 This children’s home is inadequate because:

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Key findings from this inspection

 On at least four occasions, members of staff have not supervised the young people adequately. On each occasion, young people have placed themselves in situations that had the potential to be fatal. One young person has been hospitalised and criminalised because of this failing.

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Key findings from this inspection

 While not being supervised, a young person took a gun and knives from a neighbour’s unlocked shed and threatened staff and the other young person with them. The organisation has failed to fully investigate this incident and records are both inaccurate and inconsistent.

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Key findings from this inspection

 The registered manager cannot provide evidence that the staff and young people received support following this serious safeguarding incident.

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Key findings from this inspection

 The registered manager failed to perform subsequent monitoring checks of the neighbour’s shed. As a result, during the course of this inspection, inspectors found a gun, knives, lighter fuel, petrol, matches and other potentially dangerous tools within easy access of the young people.

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Key findings from this inspection

 The registered manager has failed to ensure that one young person is engaged with meaningful learning opportunities.

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Key findings from this inspection

 There is no evidence of an assessment of deprivation of liberty in respect of the young person who is currently living in the home, despite restrictive practices that bring her liberty into question.

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Key findings from this inspection

 Improvements to the home’s furnishings and decorations mean that young people live in a well-kept and comfortable home.

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Key findings from this inspection

 Senior leaders have made changes to the staff team recently. As a result, members of the staff team are beginning to work well together and are keen to improve the outcomes of the young people.

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Inspection date Inspection type Inspection judgement

23/05/2017 Full Inadequate 15/11/2016 Interim Declined in effectiveness 13/05/2016 Full Good 11/02/2016 Interim Sustained effectiveness Inspection report children’s home: SC443079 3

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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 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. 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; 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)(2)(a)(c)(f)(h))

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Requirement Due date

*The quality and purpose of care standard

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who understand the children’s home’s overall aims and the outcomes it seeks to achieve for children; use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential. In particular, the standard in paragraph (1) requires the registered person to understand and apply the home’s statement of purpose; ensure that staff understand and apply the home’s statement of purpose; protect and promote each child’s welfare; make decisions about the day-to-day arrangements for each child, in accordance with the child’s relevant plans, which give the child an appropriate degree of freedom and choice. The conditions are that the care meets the child’s needs; that the care is delivered by a person who has the experience, knowledge and skills to deliver that care; and is under the supervision of a person who is

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Requirement Due date

25/10/2017 Inspection report children’s home: SC443079 4 appropriately skilled and qualified to supervise that care. (Regulation 6(1)(a)(b)(2)(b)(ii)(ix)(3)(b)(c)(i)(ii))

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Requirement Due date

The health and well-being standard is that children are helped to lead healthy lifestyles. In particular, the standard in paragraph (1) requires the registered person to ensure that staff help each child to achieve the health and well-being outcomes that are recorded in the child’s relevant plans. (Regulation 10(1)(c)(2)(a)(i)) 25/10/2017

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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 an understanding about acceptable behaviour. In particular, the standard in paragraph (1) requires the registered person to ensure that staff meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans; help each child to develop and practise skills to resolve conflicts positively and without harm to anyone. (Regulation 11(1)(b)(2)(a)(iv)) 25/10/2017

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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; 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 children that are assigned to them by the registered person; 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; that the premises used for the purposes of the home are located so that children are effectively safeguarded. (Regulation 12(1)(2)(a)(i)(ii)(iii)(v)(b)(c))

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Requirement Due date

The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so. In particular, the standard in paragraph (1) 25/10/2017 Inspection report children’s home: SC443079 5 requires the registered person to ensure that staff help each child to understand the importance and value of education, learning, training and employment; promote opportunities for each child to learn informally and help each child who is above compulsory school age to participate in further education, training or employment and to prepare for future care, education or employment. (Regulation 8(1)(2)(a)(iv)(v)(ix))

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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

The registered manager cannot evidence that the young person currently living in the home has made progress in key areas since the last inspection. The care given to the young person is nurturing and appropriate, confirming that staff know and understand the young person. However, some of the staff team, including the registered manager, do not demonstrate sufficient understanding of the mental health needs and associated behaviours of the young person. For example, the young person is at times restricting her eating and not eating a balanced diet. Staff do not demonstrate an understanding of the potential correlation between the young person’s mental health, history of self-harm and restrictive behaviours. There is no evidence of specific training or advice being given to staff about how to identify these important trends. The staff team failed to prevent two young people from placing themselves at risk and from harming themselves. Staff

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Overall experiences and progress of children and young people: inadequate

members confirm that the training they have received on self-harm and mental health has not equipped them with the knowledge and skills necessary to support the young people.

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Overall experiences and progress of children and young people: inadequate

Since the last inspection, staff have repeatedly failed to follow risk assessments and, as a result, have failed to protect the young people from self-harming and challenging behaviours.

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Overall experiences and progress of children and young people: inadequate

Care plans and weekly activity plans are in place and are up to date, but lack specific detail and actions to ensure that the young person accesses meaningful learning opportunities. Insufficient challenge and advocacy by the registered manager on behalf of this young person has resulted in a delay in identifying a college placement or training opportunity. As a result, the young person is currently not in receipt of any form of education, training or employment.

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Overall experiences and progress of children and young people: inadequate

In contrast, one young person who has moved on since the last inspection to another home in the company is now making good progress. Reports indicate a significant reduction in his challenging behaviours, and 100% school attendance.

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Overall experiences and progress of children and young people: inadequate

Young people are supported by staff to visit their families. One young person is now able Inspection report children’s home: SC443079 6 to enjoy safe and positive time with family members. Unfortunately, in the two years this young person has lived in the home, she has not been able to form any meaningful and sustained friendships with a peer group. The young person does not have friends she can meet and socialise with. The young person is staffed on a 2:1 basis at all times. There are no clear strategies in place for reducing this staffing ratio and supporting the young person’s integration into society. There is no evidence of an assessment of deprivation of liberty in respect of the young person who is currently living in the home, despite arrangements that bring her liberty into question.

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

Since the last inspection, a number of serious incidents have taken place. A failure to follow risk assessments and adequately supervise young people has resulted in both young people being placed in significant danger. Despite both young people being staffed on a 2:1 basis, staff failed to supervise one young person. During this time, the young person accessed the neighbour’s unlocked shed, took a number of knives and an air rifle, and used them to threaten staff and another young person.

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

Leaders and managers have failed to take responsibility following this very serious incident and have not taken steps to reduce the risk of young people accessing these weapons. During the course of the inspection, the inspectors identified that they could access the neighbour’s shed with ease. The shed still contains weapons and flammable liquids.

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

There have been four incidents when staff have failed to fully assess environments and situations safely. As a result, a young person was able to ingest bleach cleaning fluids and swallow a small amount of cable, resulting in hospital admission. Staff have failed to prevent incidents from occurring even though young people receive high levels of staff supervision.

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

The registered manager has failed to consider items and areas in the home that remain a risk for a young person who has previously used ligatures to harm herself. Despite a risk assessment that highlights a risk of the young person using ligatures to self-harm, the young person can access rope and cord in the house.

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

The registered manager and staff do not have the skills to identify potential risks to young people. The manager’s strategy has been to use staffing arrangements that are restrictive.

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

One young person who was assessed as a risk of running away has subsequently moved on from the home. However, window restrictors and plastic window coverings have not been removed. They are not needed for the young person who is currently living in the home, and create both an institutional and restrictive environment. Inspection report children’s home: SC443079 7

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to improve outcomes and ensure the safety of young people.

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The effectiveness of leaders and managers: inadequate

There have been a high number of very serious and potentially fatal incidents for two young people. One young person has been supported by the registered manager to move smoothly and safely to another home provided by the company. However, this was not before they were able to place themselves, the other young person and staff in a potentially fatal situation.

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The effectiveness of leaders and managers: inadequate

Senior leaders failed to identify a number of inaccuracies in reports compiled by staff and the registered manager relating to this incident. An investigation into this incident was carried out by the area manager. The investigation failed to identify these inaccuracies and determine how the threat could be reduced in the future.

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The effectiveness of leaders and managers: inadequate

The registered manager has updated risk assessments since the last full inspection. However, the registered manager has failed to assess accurately the level of risk presented by the behaviour of the young person currently living in the home. In particular, the registered manager assessed the young person as being a medium risk for self-harm, despite recent incidents when the young person ingested inappropriate substances.

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The effectiveness of leaders and managers: inadequate

The registered manager does ensure that key-worker sessions, meetings with child and adolescent mental health services (CAMHS) professionals and team meetings take place regularly. However, there is no record of whether these sessions have addressed the incident when a young person threatened others with a gun.

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The effectiveness of leaders and managers: inadequate

The registered manager was unable to provide the inspector with a comprehensive understanding of the work that the young person and CAMHS are engaging in, or provide records of discussions between herself and the CAMHS professional. The inspector found no evidence of any progress being made as a result of this direct work. Neither the manager nor the staff are able to support this work as they are unaware of what it is aiming to achieve.

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The effectiveness of leaders and managers: inadequate

Management monitoring and reviewing is failing to identify inconsistencies, inaccuracies and shortfalls in records. As a result, investigations and the review of incidents are incomplete, flawed and fail to identify what has been learned.

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Information about this inspection

Inspectors 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 Inspection report children’s home: SC443079 8 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: SC443079 9

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Children’s home details

Registered provider address: Unit B2, Elmbridge Court, Cheltenham Road East, Gloucester, Gloucestershire GL3 1JZ

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Children’s home details

Responsible individual: Christine Cameron

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Inspector(s)

Linda Bond, social care inspector Inspection report children’s home: SC443079 10 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

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Inspector(s)

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Inspector(s)

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Inspector(s)

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