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

Inspection report children’s home: SC455991 1 SC455991 Registered provider: Cambian Signpost Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This service provides care and accommodation for up to four young people who have a sensory impairment, emotional or behavioural difficulties and a learning disability. This service is run by a national provider.

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Information about this children’s home

Inspection dates: 27 to 29 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/or widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded. Their care and experiences are poor and they are not making progress, or likely to make progress.

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inadequate

Date of last inspection: 13 December 2016

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inadequate

Overall judgement at last inspection: good

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Enforcement action since last inspection:

None. Inspection report children’s home: SC455991 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

 Leaders and managers have failed to ensure that all staff can communicate effectively with the young people who use British Sign Language (BSL) as their first language. This practice is not in line with the home’s statement of purpose.  Young people’s experiences have been poor. There are widespread failures that mean that children are not protected. Unsafe behaviour and bullying have become commonplace among the young people.  Leaders, managers and staff have failed to follow the child protection policy correctly in response to all allegations made by young people. In addition, leaders and managers have failed to act quickly on recommendations made by the designated officer following the outcome of a recent allegation.  Staff have not ensured that injuries sustained by a young person in relation to an allegation had been assessed by medical professionals. This serious failure resulted in the young person’s allegation being deemed unfounded by staff who

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Key findings from this inspection

were unqualified to make that judgement.  Not all staff have the skills, experience and confidence to manage young people’s behaviours. As a result, some staff fail to manage behaviour well and they do not always set consistent boundaries.  Serious incidents, including young people physically assaulting and bullying other young people, have happened. Some incidents have been out of the control of staff. At times, staff have locked themselves in the office leaving young people alone together, resulting in their negative behaviours escalating. At other times, staff have inappropriately called the police to manage some behaviours.  Leaders, managers and staff are failing to protect young people from bullying. The strategies that staff are currently using are ineffective and are not preventing these behaviours from continuing.  There is poor management oversight and monitoring of the quality of care. Incidents relating to child protection, bullying, restraint, accidents and

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Key findings from this inspection

challenging behaviour have not been closely monitored.  Leaders and managers have failed to ensure that all risk assessments and behaviour support plans include all known risks and specific strategies to reduce those risks. These include matters relating to child sexual abuse and exploitation and online bullying.  Not all young people are going to school, undertaking training or in employment. Staff are not engaging them in alternative educational activities. This lack of structure and purpose is contributing to young people’s poor behaviour.  Leaders and managers have not ensured that all staff have the required training and skills to care for young people before they work with them. This includes Inspection report children’s home: SC455991 3 being able to use BSL, protecting young people from sexual exploitation and supporting those at risk of self-harm.

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Key findings from this inspection

 Young people are provided with and enjoy good-quality social and leisure- based activities.

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Inspection date Inspection type Inspection judgement

13/12/2016 Full Good 08/03/2016 Interim Declined in effectiveness 11/08/2015 Full Good 11/03/2015 Interim Sustained effectiveness Inspection report children’s home: SC455991 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

5: Engaging with the wider system to ensure children’s needs are met

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Requirement Due date

In meeting the quality standards, the registered person must, and must ensure that staff:

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Requirement Due date

seek to involve each child’s placing authority effectively in the child’s care, in accordance with the child’s relevant plans. (Regulation 5(a))

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Requirement Due date

In particular, develop and agree robust behaviour support plans with the placing authorities and ensure that these are regularly reviewed. In addition, work with placing authorities to secure education provision for all young people. 31/10/2017

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Requirement Due date

6: The quality and purpose of care standard

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Requirement Due date

In meeting the quality and purpose of care standard children must receive care from staff who:

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Requirement Due date

understand the children’s home’s overall aims and the outcomes it seeks to achieve for children;

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Requirement Due date

ensure that the premises used to the home are designed and furnished so as to meet the needs of each child. In particular, that the home is well maintained and provides young people with a homely and welcoming environment;

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Requirement Due date

ensure that the care is delivered by a person who has the experience, knowledge and skills to deliver that care. (Regulation 6(1)(a), (2)(c), (3)(c)) 17/11/2017

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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. 17/11/2017 Inspection report children’s home: SC455991 5 In particular, the standard in paragraph (1) requires the registered person to ensure that staff:

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Requirement Due date

help a child who is excluded from school, or is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as possible; and

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Requirement Due date

promote opportunities for each child to learn informally. In particular, ensure that staff provide young people with suitable educational activities to support their learning and development while they are out of school. (Regulation 8(2)(a)(v)(viii))

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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.

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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

help each child to develop socially aware behaviour;

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Requirement Due date

encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding;

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Requirement Due date

help each child to develop and practice skills to resolve conflicts positively and without harm to anyone;

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Requirement Due date

communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding;

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Requirement Due date

help each child to understand, in a way that is appropriate to the child’s age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful;

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Requirement Due date

understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children;

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Requirement Due date

de-escalate confrontations with or between children, or potentially violent behaviour by children; 17/11/2017 Inspection report children’s home: SC455991 6 have the skills to recognise incidents or indications of bullying and how to deal with them;

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Requirement Due date

that each child is encouraged to build and maintain positive relationships with others. (Regulation 11(1)(a)(b)(c), (2)(a)(ii)(iii)(iv)(v)(vi)(ix)(xi)(xiii)(b))

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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:

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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, plan to reduce the risk of any harm to the child. In particular, ensure all risk assessments and behaviour support plans include the known risks such as child sexual exploitation and cyber bullying and how these are to be managed, and reduced.

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Requirement Due date

manage relationships between children to prevent them from harming each other.

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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;

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Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare; and

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Requirement Due date

are familiar with and act in accordance with, the home’s child protection policies;

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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. (Regulation 12(2)(a)(i)(v)(vi)(vii)(b)) 31/10/2017

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Requirement Due date

13: The leadership and management standard

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Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that promotes their welfare.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to: 17/11/2017 Inspection report children’s home: SC455991 7 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

Ensure that the staff have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

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. In addition, respond to recommendations made by the designated officer following the referral of an allegation, and its subsequent outcome;

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Requirement Due date

use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(b), (2)(a)(c)(f)(h))

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Requirement Due date

The care planning standard is that children receive effectively planned care in or through the children’s home

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Requirement Due date

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

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Requirement Due date

that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose. (Regulation 14(1)(a)(2)(a) 21/10/2017

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Requirement Due date

After consultation with the fire and rescue authority, the registered person must ensure, by means of fire drills and practices at suitable intervals, that persons working at the home, and so far as reasonably practicable, children are aware of the procedure to be followed in case of a fire. (Regulation 25(1)(a)) 31/10/2017

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Requirement Due date

The registered person must ensure that all employees undertake appropriate continuing professional development. In particular, that all staff receive training in understanding matters relating to child sexual exploitation, supporting young people who self-harm, and provide staff 17/11/2017 Inspection report children’s home: SC455991 8 with sufficient training in British sign language in order to communicate effectively with all young people. (Regulation 33(4)(a))

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 Ensure that when a child returns to the home after being missing from care or away from the home without permission, the responsible local authority provides an opportunity for the child to have an independent return home interview. (‘Guide to the children’s home’s regulations including the quality standards’, page 45, paragraph 9.30)

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Recommendations

 Ensure that any child who has been restrained is given the opportunity express their feelings about their experience of the restraint as soon as practicable, ideally within 24 hours of the restraint incident, taking the age of the child and circumstances of the restraint into account. (‘Guide to the children’s homes regulations including the quality standards’, page 49, paragraph 9.60)

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Recommendations

 Ensure that all staff are familiar with the home’s policies on record keeping and understand the importance of careful, objective and clear recording. (‘Guide to the children’s homes regulations including the quality standards’, page 62, paragraph 14.4)

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Overall experiences and progress of children and young people: inadequate

The young people who live at this home are deaf, and use BSL as their first language. Despite this being the specialism of the home, not all staff can communicate with them using their first language. This fundamental weakness has had a negative effect on the young people’s experiences, due to some staff failing to communicate expectations and boundaries to the young people or to build successful relationships with them.

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Overall experiences and progress of children and young people: inadequate

Young people have mixed views about their relationships with staff. One young person told the inspector that she is ‘extremely annoyed’ that some staff cannot communicate effectively with her or understand her and her needs. Therefore, she becomes verbally and physically aggressive to staff. Another young person said that she feels that staff listen to her and give her reassurance.

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Overall experiences and progress of children and young people: inadequate

Although young people say that they feel safe living at the home, they are not currently being kept safe, and some young people’s experiences have been poor. A young person who has lived at the home for over a year has been negatively affected by the behaviours of young people who have recently moved in. Incidents of unsafe behaviour, bullying and physical aggression have become commonplace among the young people, and have escalated significantly since the last inspection. Inspection report children’s home: SC455991 9 Leaders and managers assess young people’s needs before they move in. However, some of these assessments are weak. For example, during an assessment period when one young person was visiting the home and having an overnight stay, all young people joined in high-risk behaviours. Leaders and managers had made the decision for the young person to move into the home without ensuring that there were sufficient staff

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Overall experiences and progress of children and young people: inadequate

with the required skills and experience to meet the young person’s needs.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers fail to ensure that education provision is always agreed prior to young people moving to the home. At the time of this inspection, two young people were not receiving any formal education. Staff had failed to provide these young people with suitable structured activities to promote their educational development. During the inspection, these two young people remained in bed until the early afternoon. The lack of structure, routine and stimulating daytime activities has contributed to poor behaviour.

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Overall experiences and progress of children and young people: inadequate

While young people’s day-to-day medical needs are addressed well, staff do not always ensure that young people who report injuries as part of an allegation are routinely provided with medical attention.

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Overall experiences and progress of children and young people: inadequate

Young people are positive about the activities that they take part in. Some young people have recently enjoyed a holiday. One young person was particularly positive about recent activities that she had tried, including ice skating, bike riding and playing football.

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

Leaders, managers and staff have failed to respond effectively to serious child protection concerns. They have not followed the organisation’s safeguarding policy in relation to the management of allegations. Staff failed to inform the company’s safeguarding lead about an allegation within the specific timeframe described in the policy, and they did not record injuries to a young person on a body map. In addition, not all staff demonstrate a good understanding of safeguarding procedures. An investigation into an allegation of physical injury deemed it unfounded without ensuring that the young person had been seen by a medical professional.

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

Some investigations into allegations made about staff are not undertaken quickly. One remains incomplete, despite the incident happening in August 2017. In addition, leaders and managers have failed to act quickly upon recommendations made by the designated officer in response to another allegation.

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

Since the last inspection, there have been a number of changes in the staff team. As a result, some staff do not have the experience, skills or confidence to manage and support young people’s behaviours effectively. The acting manager recognises this weakness and said: ‘Of late, we have seen an increase in significant events and police involvement; things have been unsettled.’

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

Behaviour support plans do not explicitly describe the actions that staff should take to prevent and respond to difficult behaviours. For example, it is not clear how staff should Inspection report children’s home: SC455991 10 respond to self-harming, exploitative or sexually harmful behaviours. A behaviour support plan states that staff should ‘monitor’ young people’s internet and mobile phone use, yet this strategy is not preventing online exploitation and cyber bullying from happening.

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

Staff do not all set the same boundaries for young people’s behaviour. This leads to a lack of consistency in the delivery of young people’s care and support. Some staff and young people state that the response to behaviours differs depending on which staff are working, and that this is due to their level of experience and confidence. During this inspection, a member of staff did not follow a young person’s agreed behaviour support plan in relation to the use of the home’s internet. As a result, the young person responded negatively and assaulted a member of staff.

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

At times, young people’s behaviours have been out of staff’s control, and resulted in aggression and injuries to staff and each other. At times, staff have locked themselves in the office, leaving young people alone together with negative behaviour continuing. Some incident records describe young people ‘chasing staff around the garden’. At other times, staff have called the police to help them to manage young people’s behaviours. A team manager from a placing authority commented that, if there had been closer partnership working when the young person first moved to the home, an effective behaviour support plan could have been developed jointly.

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

Bullying is commonplace and staff have not taken sufficient action to prevent it from continuing. Some young people use the internet and social media to bully each other. On occasions, a young person has sexually exploited another young person. Incident records do not always show what action staff take in response to bullying. In addition, leaders and managers have failed to oversee and monitor bullying incidents effectively in order to learn lessons and to take action to prevent them.

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

Leaders and managers have failed to ensure that all risk assessments and behaviour support plans include all known risks and specific strategies to reduce those risks. These include matters relating to child sexual exploitation, using social media and cyber bullying.

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

Restraint has been used as a last resort to manage young people’s behaviours. However, staff have failed to seek young people’s views following the use of restraint. In addition, leaders and managers have failed to regularly evaluate its use or to look for trends and patterns.

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

Since the last inspection, there has been one incident of a young person going missing from the home. Staff followed the agreed protocols to ensure the young person’s prompt and safe return to the home. However, the young person has not received an independent return home interview, therefore staff are unable to understand fully the reasons why the young person ran away.

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

Leaders and managers ensure that there are regular checks on the home’s utility services. However, not all staff have practised the fire evacuation drill. As a result, new Inspection report children’s home: SC455991 11 staff have not been trained in fire evacuation procedures, potentially placing young people at risk of harm.

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

Young people say that they feel safe at the home and that they can speak to staff if they have any worries or concerns.

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The effectiveness of leaders and managers: inadequate

The registered manager is currently on maternity leave, and the deputy is managing the home.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not have an accurate or comprehensive understanding of the home’s strengths and weaknesses. They do not actively or regularly monitor the quality of care. Incidents relating to child protection, bullying, restraint, accidents and challenging behaviour have not been carefully monitored or evaluated, and leaders and managers do not understand the detrimental effects that the incidents have on the young people’s experiences.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to ensure that the aims described in the statement of purpose are met. The home accommodates young people who are deaf and use BSL to communicate. The statement of purpose says that ‘This home is a full signing environment’. Since the last inspection, there have been a number of changes in the staff team and not all staff have completed BSL level 1 training. Consequently, some staff do not have a sufficient level of communication skills to engage with all young people effectively.

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The effectiveness of leaders and managers: inadequate

The responsible individual told the inspector that dates have been arranged to provide staff with further training. Nonetheless the statement of purpose says, ‘The home will promote the use of interpreters and interpreting services for all young people when there is a need’. Despite the fact that not all staff are able to communicate with young people, this provision has not been arranged.

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The effectiveness of leaders and managers: inadequate

Leaders and managers ensure that staff receive basic mandatory training. However, not all staff have undertaken specialist training to help them to meet the young people’s current needs. This includes training in supporting young people who self-harm and in protecting children from sexual exploitation.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to ensure that the home is maintained, furnished and presented to a good standard throughout. The home lacks soft furnishings and fittings that typically provide a welcoming and homely environment. The deputy manager is aware that some carpets need replacing, yet has failed to take prompt action to rectify this weakness. Some areas of the home have been damaged due to young people’s recent poor behaviours, and some graffiti was not removed until this was highlighted during this inspection.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have ensured that all appropriate agencies and authorities have been informed of serious incidents at the home. However, the quality of the notifications Inspection report children’s home: SC455991 12 that they have sent to Ofsted is too variable, and they have not always described the incidents clearly or concisely.

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The effectiveness of leaders and managers: inadequate

Placing authorities are generally very positive in relation to the communication that they have with leaders, managers and staff. A team manager from one placing authority said: ‘The staff have communicated well, and they have raised issues and concerns. The placement is vulnerable, and they have made us aware.’

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The effectiveness of leaders and managers: inadequate

Leaders and managers ensure that there is an effective staff recruitment and selection process. There have not been any recorded complaints since the last inspection.

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The effectiveness of leaders and managers: inadequate

The two recommendations that were made at the last inspection have been met.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people. Inspectors considered the quality of work and the difference made to the lives of children and young people. They watched how professional staff work with children and young people and each other and discussed the effectiveness of help and care provided. Wherever possible, they talked to children and young people and their families. In addition, the inspectors have tried to understand what the children’s home knows about how well it is performing, how well it is doing and what difference it is making for the children and young people whom it is trying to help, protect and look after.

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Information about this inspection

Using the ‘Social care common inspection framework’, this inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with the Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. Inspection report children’s home: SC455991 13

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Children’s home details

Registered provider: Cambian Signpost Limited

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Children’s home details

Registered provider address: 4th floor, Waterfront Building, Chancellor’s Road, Hammersmith Embankment, London W6 9RU

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Inspector(s)

David Kidner, social care inspector Inspection report children’s home: SC455991 14 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)

T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: http://www.gov.uk/ofsted

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