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

Inspection report children‟s home: SC068277 1 SC068277 Registered provider: Cambian Childcare Ltd Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This children‟s home is owned by a large national private provider. It is registered to provide care and accommodation for up to six children and young people who have emotional and/or behavioural difficulties.

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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 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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Enforcement action since last inspection:

The home was judged inadequate at the last full inspection on 6 June 2017. Following this inspection, a compliance notice was issued under Regulation 12(2)(a)(vi) and Regulation 8(2)(v)(x). Regulation 12(2)(a)(vi) was found not to be met at the monitoring visit of 28 June 2017. A further compliance notice was issued which detailed that staff must consistently follow young people‟s missing from home risk assessments. Both notices were deemed to be met at a monitoring visit undertaken by the compliance inspector on 20 July 2017. Inspection report children‟s home: SC068277 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

 There are serious failings in health and safety practice and risk management around fire setting and safety. This leaves young people and staff at serious risk of harm.  Staff fail to engage young people positively. As a result, young people spend most of their time out of the home. This limits the opportunity for staff to have any positive influence on their actions or progress.  Young people‟s attendance at education is poor and staff do not provide sufficient opportunity for them to learn informally when they do not attend. As a result, young people are not meeting their educational potential.  Behaviour management in the home is ineffective due to a lack of positive relationships between young people and staff, and a lack of guidance for staff to follow on how to manage each young person‟s behaviour.  The manager has failed to provide a home environment for young people that is safe and maintained to a suitable standard.

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Key findings from this inspection

 The manager and staff fail to record significant events that occur in the home, leading to lack of transparency in how staff manage such events.  The manager has failed to notify Ofsted and placing authorities of significant events. This prevents safeguarding agencies, including Ofsted, from having the necessary oversight of safeguarding incidents in the home.  The senior management team has failed to take effective action in respect of requirements made at the last inspection. Furthermore, its members do not use independent visits effectively to improve the quality of the service.  The home is staffed by an inexperienced staff team whose members do not have the skills, experience or qualifications to meet the needs of the young people they are caring for.

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Key findings from this inspection

 Staff now follow actions in young people‟s missing from home risk assessments and search for young people when they go missing. Inspection report children‟s home: SC068277 3

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Inspection date Inspection type Inspection judgement

06/06/2017 Full Inadequate 31/01/2017 Interim Declined in effectiveness 01/11/2016 Full Good 21/01/2016 Interim Sustained effectiveness Inspection report children‟s home: SC068277 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 develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate having regard to the range of needs of children for whom it is intended that the children‟s home is to provide care and accommodation. (Regulation 5(d)) 26/10/2017

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Requirement Due date

In order to meet the education standard, the registered provider must ensure that staff— promote opportunities for each child to learn informally; help each child to attend education or training, in accordance with the expectations in the child‟s relevant plans. (Regulation 8(2)(v)(x)) 26/10/2017

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Requirement Due date

The quality and purpose of care standard requires the registered person to ensure that the premises used for the purposes of the home are designed and furnished as to meet the needs of each child and enable each child to participate in the daily life of the home. (Regulation 6(2)(c)(i) and (ii)) 26/10/2017

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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— (a) mutual respect and trust; (b) an understanding about acceptable behaviour; and (c) Positive responses to other children and adults. That each child is encouraged to build and maintain positive relationships with others. (Regulation 11(2)(b)) 26/10/2017

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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 and that the premises used for 26/10/2017 Inspection report children‟s home: SC068277 5 the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child‟s health. (Regulation 12(1))

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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 promotes their welfare. (Regulation 13(1)(b)) (2) in particular, the standard in paragraph (1) requires the registered person to— ensure that the staff have the experience, qualifications and skills to meet the needs of each child; the home has sufficient staff to provide care for each child; Use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(2)(c)(h)) 26/10/2017

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Requirement Due date

The registered person must keep the statement of purpose under review and, where appropriate, revise it; and notify HMCI of any revision and send HMCI a copy of the revised statement within 28 days. (Regulation 16(3)(a)(b) 26/10/2017

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Requirement Due date

The registered person must ensure that the requirements of the Regulatory Reform (Fire Safety) Order 2005 and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the home. This is in respect of fire drills being carried out. (Regulation 25(2)(b)) 26/10/2017

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Requirement Due date

If the registered provider appoints a person to manage the home, the registered provider must, without delay, give HMCI notice of the name of the person so appointed; and the date on which the appointment takes effect. (Regulation 27(2)(a)(b)) 26/10/2017

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Requirement Due date

The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33(4)(b)) 26/10/2017

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Requirement Due date

The registered person must prepare and implement a policy (“the behaviour management policy”) which sets out how appropriate behaviour is to be promoted in the children‟s home Regulation 35(1)(a)) 26/10/2017

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Requirement Due date

The registered person must maintain records for each child which are kept up-to-date. (Regulation 36(1)(b)) 26/10/2017

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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 26/10/2017 Inspection report children‟s home: SC068277 6 child which the registered person considers to be serious; there is an allegation of abuse against the home or a person working there; a child protection enquiry involving a child is instigated; or concludes (in which case, the notification must include the outcome of the child protection enquiry); or there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40(4)(a)(b)(c)(d)(i)(ii)(e))

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Recommendations

 Any staff member who is in charge of leading a shift should have substantial relevant experience of working in a children‟s home. (‟Guide to the Children‟s homes regulations including the quality standards‟, page 54, paragraph 10.21) This is specifically in respect of an inexperienced deputy manager leading and managing shifts.

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Recommendations

 Significant changes to a looked-after child‟s care, such as a change of placement, should only take place following a statutory review of their care plan chaired by their Independent Reviewing Officer (IRO). (‟Guide to the Children‟s homes regulations including the quality standards‟, page 57, paragraph 11.10) This is with particular reference to requesting looked-after child (LAC) reviews when young people‟s care plans and placements change.

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Recommendations

 Where the registered person considers that a child is at serious risk of harm, due to their escalating violence and aggression or an increase in their risk-taking behaviour, such as being persistently missing from their placement, they must contact the local authority to request a review of the child‟s care plan. Where a review does not take place, the Registered Person must escalate this concern under regulation 5 (engaging with the wider system to ensure children‟s needs are met). (‟Guide to the Children‟s homes regulations including the quality standards‟, page 57, paragraph 11.12)

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Overall experiences and progress of children and young people: inadequate

Young people do not make progress in this home due to the systemic failures with the leadership and management arrangements, and the safeguarding practice. This means that young people do not receive the care from staff that they require to make progress and keep themselves safe.

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Overall experiences and progress of children and young people: inadequate

Transitions for young people out of the home are poor. Two young people have left the placement in an unplanned way since the last inspection, as staff were unable to meet their needs or keep them safe from harm. This resulted in short placements and further instability for young people. The manager did not escalate her request for care planning meetings to take place to consider the escalating risks and concerns about either of the Inspection report children‟s home: SC068277 7 young people‟s placements; nor has the manager requested a statutory review with one young person‟s independent reviewing officer following a change to their placement.

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Overall experiences and progress of children and young people: inadequate

Young people‟s attendance at education continues to be poor and when they are not in education there is no structure or opportunity for them to learn informally. While one young person achieved a GCSE in maths, staff do not have a clear understanding of the academic progress that young people make. The manager informed inspectors that she was „not privy‟ to the result of the other GCSE exam a young person had taken and a staff member reported that the young person had „achieved lower C in maths, but I don‟t know what else she has‟. This lack of knowledge does not provide the foundation for staff to encourage young people to meet their full educational potential. Consequently, young people‟s future employment opportunities are compromised, as they do not gain the knowledge, skills and qualifications they need in adulthood.

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Overall experiences and progress of children and young people: inadequate

The day-to-day experiences of young people living in the home are not positive. Young people spend the majority of their time out of the home. Logbooks suggest that young people get up late or stay in their rooms until lunchtime and then leave the home. One young person said that „staff do not do anything with me‟. A social worker reported that „[name of child] is not really staying in the placement a lot.‟ As a result, there is no structure and routine and young people do not invest in the home.

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Overall experiences and progress of children and young people: inadequate

Staff do not develop positive relationships with young people that can be used to influence young people‟s behaviour. As a result, staff have little influence over young people and their actions. This means that young people are left to their own devices with no consistent and effective guidance and boundaries in place. This has had a negative impact on the progress that young people make in this home.

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Overall experiences and progress of children and young people: inadequate

The home environment does not encourage young people to want to remain or stay in the home. Although young people choose to spend time in their bedrooms, these rooms are insufficient in providing young people with a warm and welcoming space. For example, young people‟s bedroom furniture is broken, such as their wardrobes and drawers, graffiti is evident on some young people‟s walls, and fire damage, where some young people have attempted to set fire to their walls, is apparent. Furthermore, laminated flooring in one bedroom was observed to have lifted, causing a trip hazard and another bedroom floor was observed to be stained. This theme is maintained throughout the upstairs of the home as the stair carpet and hall carpet are heavily stained. This does not provide a warm and homely environment where young people want to spend time. This was validated by one young person, who commented that the home was „trampy‟.

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

There are a number of significant shortfalls in the health and safety arrangements of the home that compromise the safety of young people, staff and visitors to the home. Safeguarding practices and procedures, and the leadership and management arrangements within the home, are also ineffective at keeping young people safe. This has had a detrimental impact on the welfare and safety of young people living in the Inspection report children‟s home: SC068277 8 home.

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

Risk management in the home is poor. Individual risk assessments lack sufficient detail about specific actions that staff should take to reduce the risk of harm, for example in respect of fire setting, which is an identified risk for some young people in the home. There are no clear strategies to reduce the fire risk in the home and actions identified in young people‟s management plans to reduce this risk, such as room searches and young people handing in their lighters at night, are not carried out by staff. Furthermore, there is no evidence to demonstrate what work the staff are undertaking with young people to reduce these particular behaviours, and there is no evidence of the manager working with the wider agencies, such as the fire service or youth offending teams, to look at fire prevention to reduce these risks. Staff spoken with during the inspection confirmed that young people continue to smoke in their rooms. One member of staff said that „All the

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

young people smoke. They are not allowed to smoke in the home but they will stand at the door. We ask them to move, but they won‟t. We ask for lighters but we can‟t take them off them, they just refuse.‟ This poor risk management practice and general apathy from staff to challenge these behaviours appropriately with young people places everyone in the home at significant risk of harm.

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

The safety of staff and young people is further compromised due to poor health and safety practice within this home. A number of shortfalls that had been identified within the home‟s own health and safety audits have still not been adequately addressed, despite these issues being raised in July 2017. For example, young people‟s bedroom fire doors do not close properly, some smoke seals need to be replaced, and curtains and blinds and the electrical cupboard need to be made fire-retardant. These shortfalls had been identified by the manager but she has not taken action to ensure that they are addressed. Furthermore, weekly fire checks are not systematically conducted and visitors to the home are not informed of the fire procedures to be followed in the event of an emergency. All of these shortfalls leave young people and staff and visitors to this home at risk of harm.

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

There have been incidents when young people have returned to the home under the influence of alcohol. Staff do not record how they have monitored young people during these times. This means that it is not possible to establish what actions staff are taking and whether staff are following young people‟s plans. This does not ensure that staff are taking action to reduce the risk of harm to young people and maintain young people‟s safety at these critical times. Staff do not work effectively with other agencies and communication with professionals is poor. One social worker reported that staff, „don‟t communicate with us very well; I don‟t hear from Fraser Street now. I have given up chasing them for missing reports and there has been quite a few of them.‟ This does not ensure a multi-agency approach in reducing known risks for young people.

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

Missing from home practice has improved. Staff now follow young people when they go missing and there are now two waking night staff on shift to ensure that this happens. There are key-work sessions on case files detailing work that has been undertaken with Inspection report children‟s home: SC068277 9 young people on the risks of going missing from home; however, this work is not effective as missing from home incidents are not decreasing for some young people.

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

Behaviour management plans are not individualised and do not contain detailed actions that staff need to take if a young person displays challenging behaviour. Staff do not follow actions identified in young people‟s behaviour management plans and as a result, young people do not receive support to manage their behaviour effectively.

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

Systems and processes in place to protect young people are inefficient. This is because recording of significant events in the home is poor. There is no clear recording system for significant events, which means that the manager does not have sufficient oversight of significant events. There have been two incidents where a young person has assaulted staff. The manager could not provide a detailed written account for inspectors of these incidents. For one incident, the only record is contained in a key-work session dated 24 July 2017, which refers to staff members „intervening‟, but no detail about what this intervention was. This is not safe practice for young people or staff.

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

There is a lack of transparency in safeguarding practice. The inspectors identified a number of significant incidents that the manager has failed to notify to Ofsted, or placing local authorities, such as the fire-starting incident on 15 August 2017, a complaint by young people on 9 August 2017 and an incident involving a young person in the local community .

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The effectiveness of leaders and managers: inadequate

Leadership and management of the home are inadequate. The responsible individual has been responsible for this home since 27 April 2017. She has not demonstrated an effective approach in supporting the managers to address the shortfalls that have been raised during previous inspections and independent visitor reports to effect positive and sustained change. For example, the requirements raised during the last full inspection, in particular, regards to leadership and management have still not been addressed adequately. Consequently, young people do not benefit from positive experiences and improved outcomes because of living in this home.

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The effectiveness of leaders and managers: inadequate

The manager‟s position has been vacant since 2 March 2017. There have been four managers in post this year. The current manager has been in post since 17 July 2017 and has not yet submitted an application to register with Ofsted. As a result, there has been a lack of consistent management oversight. This has meant that there has been no effective action taken to address the requirements made at the last full inspection. There has also been a failure to demonstrate any effective action to sustain improvement since the interim inspection took place on 31 January 2017. The current manager was unable to produce a clear plan to show how she intends to take effective action to improve the quality of the service for young people despite initially informing the inspectors that she had done this.

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The effectiveness of leaders and managers: inadequate

Staff still do not have the necessary experience, qualifications and skills to meet the needs of young people. The deputy manager, who has worked in children‟s services since September 2016, has been recently recruited to her role. She has yet to undertake Inspection report children‟s home: SC068277 10 the required childcare qualification and has no other management or leadership qualifications or experience to fulfil this role. One of the new staff recruited has had no previous experience of working with young people. Out of the 11 staff, only the manager is suitably qualified for the role. No other staff members have the required level 3 childcare qualification. This means that young people are being looked after by staff without the relevant qualifications and experience. This, in conjunction with the poor risk management in the home, means that young people are at risk of harm, as the staff do not have the necessary skills and experience to meet the complex needs of the young

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The effectiveness of leaders and managers: inadequate

Due to changes in management, not all staff have received regular supervision and new staff do not receive fortnightly supervision as detailed in the statement of purpose. A requirement was made in respect of this on 31 January 2017, 6 June 2017 and 11 September 2017, demonstrating a lack of progress in this area. This means that new staff who have little experience are not supported adequately in their roles, or monitored effectively to ensure that their practice is safe and appropriate. The manager does not use monitoring and review systems to make continuous improvements to the quality of care. Actions identified in the independent visitor‟s reports are not acted upon. For example, supervision was an action identified in the independent visitor‟s reports dated 8 June 2017, 3 July 2017 and 2 August 2017. The statement of purpose does not reflect the qualifications of the staff team accurately, nor are revisions sent to commissioners and Ofsted as required. Consequently, parents,

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The effectiveness of leaders and managers: inadequate

commissioners and the regulatory bodies cannot be assured that young people are being cared for by a staff team that has the skills, knowledge and qualifications to care for young people well.

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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, 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: SC068277 11

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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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Inspectors

Sarah Billett and Janine Shortman-Thomas, social care inspectors Inspection report children‟s home: SC068277 12 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children‟s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children‟s services, and inspects services for children looked after, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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