Children's home run by Derbyshire County Council in Derbyshire Dales

Inspection report children‟s home: SC036186 1 SC036186 Registered provider: Derbyshire County Council

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

A local authority operates this children‟s home, providing care for up to eight children and young people who have learning and physical disabilities, including sensory impairment, under short-break arrangements.

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Information about this children’s home

Inspection dates: 20 to 21 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 failures that mean children and young people are not protected, and their welfare is not promoted or safeguarded.

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inadequate

Date of last inspection: 23 February 2017

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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: SC036186 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

 The physical environment is poor in many areas and has not been maintained to a satisfactory standard. Children‟s bedrooms lack the necessary measures to ensure that they are private and that the dignity of children is maintained.

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Key findings from this inspection

 Staff have used inappropriate physical intervention to manage a child‟s behaviour.

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Key findings from this inspection

 Staff do not follow the procedures designed to keep children safe. Risk assessments are incomplete, and risk management and behaviour support plans are not followed. This places children and staff at risk.

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Key findings from this inspection

 Staff and managers have failed to prevent mistakes with children‟s medication. This has led to services for children and families being suspended on two occasions, while leaders and managers assess whether the medication system is fit for purpose and safe.

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Key findings from this inspection

 Managers have not ensured that staff understand how to store documents. As a result, a safe-care plan pertaining to one child has been destroyed.

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Key findings from this inspection

 The independent person‟s visits are not sufficiently challenging in respect of safeguarding children, especially in respect of the failures in the medication system.

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Key findings from this inspection

 Leaders and managers have failed to take swift and effective action to prevent ongoing safeguarding problems. This is with specific reference to maintaining a safe medication system, ensuring that staff understand their roles and responsibilities in safeguarding children and ensuring that immediate action is taken in response to safeguarding concerns.

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Key findings from this inspection

 The home provides a crucial service in supporting children who have physical and learning disabilities. Families say overwhelmingly that they value and appreciate the care and support from staff.

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Key findings from this inspection

 Staff develop good relationships with children. They achieve this through good quality, individual key-work sessions and by treating all children as individuals, especially in respect of communication.

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Key findings from this inspection

 Arrangements for multi-agency and partnership working with other agencies are very good. Good communication and collaboration with other agencies ensure that children have the service in place that they need to make progress. Inspection report children‟s home: SC036186 3  Managers and staff value and promote children‟s education and healthcare needs. Managers and staff make good and sustained efforts to help children fulfil their developmental potential in all areas.

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Inspection date Inspection type Inspection judgement

23/02/2017 Interim Sustained effectiveness 05/10/2016 Full Outstanding 23/03/2016 Interim Sustained effectiveness 13/01/2016 Full Outstanding Inspection report children‟s home: SC036186 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 quality and purpose of care standard requires the registered person to ensure that staff-

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Requirement Due date

provide to children living in the home the physical necessities they need in order to live there comfortably; and

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Requirement Due date

ensure that the premises used for the purposes of the home are designed and furnished so as to meet the needs of each child.

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Requirement Due date

This is with particular reference to the property being in a poor state of repair in some areas. Additionally, children‟s bedrooms are not supporting the privacy and dignity needs of children. 27/10/2017

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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.

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Requirement Due date

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

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Requirement Due date

assess whether each child is at risk of harm, taking into account information in the child‟s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; and

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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 27/10/2017 Inspection report children‟s home: SC036186 5 that the effectiveness of the home‟s child protection policies is monitored regularly.

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Requirement Due date

This requirement is made in relation to staff physically restraining a child inappropriately. Staff did not follow policies and procedures designed to keep children safe. Additionally, the requirement relates to staff needing to follow risk assessments and adhere to protocols to keep children safe.

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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.

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Requirement Due date

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

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Requirement Due date

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.

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Requirement Due date

This requirement is made with reference to the significant failure of management to take effective action to address shortfalls later identified in this inspection. 27/10/2017

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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.

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Requirement Due date

In particular, the registered person must ensure that-

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Requirement Due date

a record is kept of the administration of medicine to each child.

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Requirement Due date

The registered person must maintain records (“case records”) for each child which must be kept-

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Requirement Due date

in cases not falling within sub-paragraph (a), for 75 years from the child‟s date of birth.

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Requirement Due date

The independent person must produce a report about a visit 27/10/2017 Inspection report children‟s home: SC036186 6 (“the independent person‟s report”) which sets out, in particular, the independent person‟s opinion as to whether-

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Requirement Due date

children are effectively safeguarded; and

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Requirement Due date

the conduct of the home promotes children‟s well-being.

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Recommendation

 As outlined in 10.1 the registered person should plan staffing levels to ensure that they meet the needs of children and can respond flexibly to unexpected events or opportunities. Staffing structures should promote continuity of care from the child‟s perspective. If children complain, or give a view on how the staffing structure could be improved to promote the best care for them, appropriate action should be taken. („Guide to the children‟s homes regulations including the quality standards‟, page 54, paragraph 10.15)

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Overall experiences and progress of children and young people: inadequate

Staff and managers are inconsistent in their understanding of risk to children and in recognising children‟s vulnerabilities. Managers and senior staff have failed to take effective action in response to significant shortfalls in practice. An example of this is repeated errors in the administration of children‟s medication. Managers have implemented changes to prevent mistakes, but medication errors have continued. This places children at risk.

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Overall experiences and progress of children and young people: inadequate

During the inspection, it was recognised that children have positive experiences while attending the home for short breaks. The service also provides a much-valued service to families. However, shortfalls in safeguarding have implications for the welfare and safety of all children. This has led to the judgement of inadequate at this inspection.

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Overall experiences and progress of children and young people: inadequate

Managers and staff have not considered children‟s privacy and dignity. Children‟s rooms do not have frosted glass or blinds to safeguard their privacy. This is problematic in instances where children undress, sometimes unpredictably, and their bedroom windows face a public road. Staff and managers had not considered this as a potential risk to children. Staff had not completed any assessments in respect of the environment and designation of rooms, taking into account children‟s needs in this regard.

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Overall experiences and progress of children and young people: inadequate

Staff have a good understanding of the challenges for families and carers. The home provides a well-regarded and valued service. The views expressed by families and carers Inspection report children‟s home: SC036186 7 are overwhelmingly positive. One parent said: „I am completely relaxed, staff are “fab”, and he [child] has made great friendships. He is safe and they take him out whenever they can.‟

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Overall experiences and progress of children and young people: inadequate

Communication between staff and families is good overall. Staff communicate with families before and following short breaks, providing information and reassurance. In addition, staff provide support and guidance to families and will often provide short breaks at short notice, and/or at times of crisis. Crucially needed support, provided to families and children at the right time, can avert family breakdown.

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Overall experiences and progress of children and young people: inadequate

Children receive personalised care and support. Staff have a good, in-depth knowledge of the educational and communication needs of children. Staff regularly attend education reviews and update educational plans for children. Staff set targets for children, which correspond with those developed at school.

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Overall experiences and progress of children and young people: inadequate

Staff understand that children have individual communication needs. Staff utilise a range of communication methods, and they adapt their approach to the child. Communication is primarily through symbols and Makaton. Signs and social stories are adapted according to the child‟s needs. Consequently, staff communicate well with children and this helps to develop and maintain good relationships between children and staff.

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Overall experiences and progress of children and young people: inadequate

Staff undertake regular, individualised key-work sessions with children. An example of this is supporting children in decision-making, with some children now choosing what activity they would like to undertake with staff. Staff recognise the need for children to experience new things, and an example of this is a staff member bringing their new baby into the home for children to hold. Male members of staff have been positive role models for some boys who relate particularly well to males. These experiences and planned sessions develop good relationships between staff and children and develop children‟s confidence.

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

Managers and staff have consistently failed to ensure that the medication system is safe. There have been several medication errors since the last full inspection. These errors have resulted in children receiving out-of-date and/or incorrect medication. Poor communication about medication with families and health professionals has contributed to some of the medication errors. At the last inspection, a statutory requirement was made in response to an error in dispensing medication. Unfortunately, medication errors have continued, so this requirement remains unmet. Of further concern is an unreported medication error from March 2017. This medication error was not reported to the responsible individual, and Ofsted was not notified. The error was discovered in August 2017. Several new medication errors have occurred since this discovery. Following all medication errors, managers complete an investigation. From this, a plan to address the

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

shortfall in practice is implemented. Staff have undergone training and a new medication system has been developed. This has been overseen by managers from other services, who have provided training and support. A health and safety officer has reviewed the medication system. Despite these efforts by managers, errors continue. The service has Inspection report children‟s home: SC036186 8 been suspended by the responsible individual on two separate occasions following concerns over the safety of the medication system and consequently the safety of children. This is a clear example of failure in the administration, oversight and management of systems designed to keep children safe.

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

Staff have failed to follow safe-care plans. An example of this is an incident of inappropriate restraint of a child. This restraint, used to manage behaviour, was disproportionate and avoidable. Staff failed to follow clear guidelines on how to provide effective and safe care to the child concerned. A risk management protocol was in place to provide guidance to staff when taking the child out into the community, and detailed what needed to be in place if difficulties arose. Staff failed to follow this risk management protocol at every stage. They did not complete a risk assessment before the trip or take essential items designed to be used to de-escalate difficult situations. There was failure on the part of the manager to ensure that the staff were following procedures correctly. Following the incident, the manager did not ensure that staff recorded what happened in line with the organisation‟s policy and procedure. The

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

subsequent recording was confused, with two staff recording on one significant event report. Staff delayed completing the document, leading to delay in the child‟s allocated social worker being informed. This hampered any potential investigation by the social worker into the incident. Poor management oversight prior to and following this incident, combined with poor staff practice, gives rise to serious concerns over the ability of staff and managers to prioritise the safety and well-being of children.

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

Staff undertake safeguarding training. However, there are concerns that despite this training, staff lack a working knowledge of safeguarding in their day-to-day work, as required to keep children safe. Inadequate management monitoring of staff‟s safeguarding practice means that there has been a failure to identify additional areas of training and support. Managers and leaders are now actively monitoring safeguarding practice and performance.

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

Children visiting this service for short breaks do not enjoy a well-maintained and comfortable environment. The building presents as tired and worn, both externally and internally. A number of outstanding maintenance issues have been brought to the attention of managers. These issues include play equipment already deemed as not fit for purpose, but awaiting removal, damage and wear to internal doors, stained carpet, odour, screws jutting out of bedroom walls and unsuitable bathroom locks. Overall, the managers and leaders of this service have not maintained the building to a satisfactory standard.

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The effectiveness of leaders and managers: inadequate

At this time, the home does not have a registered manager in post. The post holder resigned their registration in May 2017. The organisation has since appointed a manager who is in the process of registering with Ofsted. The current manager is appropriately qualified, having the requisite management qualifications. This inspection has identified significant shortfalls in safeguarding practice and in management oversight of the service. Managers have been ineffective in quality-assuring the care provided to children, Inspection report children‟s home: SC036186 9 and in ensuring that staff are well supported and supervised. This has compromised the safety and welfare of children. Failures and shortfalls in management oversight have impaired the home‟s capacity to work to its stated aims and objectives as set out in the statement of purpose.

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The effectiveness of leaders and managers: inadequate

Children‟s records have not been stored safely. A member of staff deleted a child‟s safe- care plan. When asked for this document, staff informed the inspector that it had been „shredded‟ and that the electronic copy was no longer available. The member of staff had received training, but did not understand their responsibilities in relation to document and data management. The manager was unaware of what had happened to the document and subsequently had spent a great deal of time searching for the document, which no longer existed. This represents a shortfall in leadership and management, in not paying sufficient attention to compliance with the organisation‟s policies and procedures.

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The effectiveness of leaders and managers: inadequate

Quality assurance systems have been ineffective in alerting the manager to safeguarding concerns. An example of this is the medication error in March 2017. The independent visitor did not identify this error. This meant that the responsible individual was not alerted through the monthly report and was not able to challenge the manager over their inaction in response to the incident. The monthly reports produced by the independent person lack rigour and do not provide sufficient challenge to managers and leaders regarding safeguarding matters.

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The effectiveness of leaders and managers: inadequate

Staff report feeling well supported through the provision of regular professional supervision. Supervision meetings between members of staff and their supervisor take place monthly. The sessions focus upon children, staff training, professional development and the day-to-day running of home. Staff say that they feel listened to and describe managers as responding to any concerns or worries they may have.

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The effectiveness of leaders and managers: inadequate

Levels of staffing have decreased through staff sickness, maternity leave and a struggle to recruit night-care staff. This has resulted in the use of relief staff and day staff having to work nights to cover shifts. Recruiting suitably experienced and skilled night-care staff is a priority for the manager. This contributes to wider problems of staff sufficiency, not merely numbers of staff but matching the skills of staff to the needs of children.

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The effectiveness of leaders and managers: inadequate

Good partnership working with other agencies and professionals supports children. The children receive the support they need from health professionals, such as occupational therapists and physiotherapists. These professionals visit the home and help staff to provide good care that maximises the developmental potential of children. Staff become competent in the use of adaptations and equipment for children, tailored to the child‟s specific needs. Professionals praise the support the service provides to families. A community worker talked about the help the service provided to a school and a parent regarding helping with a child‟s sensory development: „They have helped school and mum through completing a DVD regarding sensory stimulation. This has greatly helped, and his mum very much appreciated this.‟ Staff and managers attend education and health reviews for young people and provide their views based on their knowledge and understanding of the child. This helps to

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The effectiveness of leaders and managers: inadequate

Inspection report children‟s home: SC036186 10 develop plans and secure the service that the child requires to help them progress, while also supporting the family.

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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: SC036186 11

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Children’s home details

Registered provider: Derbyshire County Council

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Children’s home details

Registered provider address: County Hall, Matlock, Derbyshire DE4 3AG

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Inspector

Phillip Morris, social care inspector Inspection report children‟s home: SC036186 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 looked children after, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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