Children's home run by BREAK

Inspection report children’s home: 1256794 1 Registered provider: Break

p.1

Full inspection Inspected under the social care common inspection framework

p.1

Information about this children’s home

This charity-owned home is registered to accommodate up to two children who have emotional and/or behavioural difficulties.

p.1

Overall experiences and progress of

children and young people, taking into account

p.1

inadequate

How well children and young people are helped and protected inadequate

p.1

inadequate

The effectiveness of leaders and managers inadequate

p.1

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.

p.1

inadequate

Overall judgement at last inspection: Not applicable

p.1

Key findings from this inspection

This children’s home is inadequate because:

p.1

Key findings from this inspection

 Managers have failed to ensure that staff follow agreed arrangements to manage risks for a child who has a significant history of self-harm. This makes it more likely that the child will come to harm. Inspection report children’s home: 1256794 2  Managers have failed to provide enough training to ensure staff know how to manage risks for a child. Since the home opened, over one third of shifts have not had a member of staff with the relevant training.  The manager has not updated risk assessments to reflect known risks following incidents.  The staff have not received safeguarding training despite the home being open since July 2017.  The approach to behaviour management has not been consistent. This does not provide clear messages and expectations to the child.  A significant reliance on agency and temporary staff has affected the continuity of care experienced by the child.  The management monitoring arrangements have not been strong enough to

p.1

Key findings from this inspection

identify the serious weaknesses.  The staff and manager do not ensure that information from independent return interviews carried out when the child has gone missing inform risk management plans.  Managers have failed to provide the clear guidance that the staff need to provide safe and effective care. The child’s care plan is unclear. Some supervision records lack clarity.

p.2

Key findings from this inspection

 Feedback from external professionals is positive in respect of the staff members’ developing relationships with the child, and the way that the home communicates with the school.  The child has returned to education, which is real progress.  The service utilises local resources effectively to provide new leisure and socialisation opportunities for the child.

p.2

Inspection date Inspection type Inspection judgement

Not applicable Not applicable Not applicable Inspection report children’s home: 1256794 3

p.2

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.

p.3

Requirement Due date

The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on mutual trust and respect and an understanding about acceptable behaviour.

p.3

Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans. (Regulation 11(1)(a)(b)(2) (a)(i)) 02/11/2017

p.3

Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

p.3

Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure 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(1)(2) (b)) 26/10/2017

p.3

Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

p.3

Requirement Due date

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. (Regulation 12(1)(2)(a)(i)) 26/10/2017

p.3

Requirement Due date

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

p.3

Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff have the experience, qualifications and skills to meet the needs of each child. (Regulation 13(1)(a)(b)(2)(c)) 26/10/2017

p.3

Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the 26/10/2017 Inspection report children’s home: 1256794 4 children’s home that helps children to aspire to their full potential and promotes their welfare.

p.3

Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff have the experience, qualifications and skills to meet the needs of each child. (Regulation 13(1)(2)(c)) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that helps children to aspire to their full potential and promotes their welfare.

p.4

Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(2)(h)) 02/11/2017

p.4

Recommendations

 Ensure that the registered person takes account of information provided by independent return interviews when assessing risks and putting arrangements in place to protect each child. (‘Guide to the children’s homes regulations including the quality standards’, page 45, paragraph 9.30)

p.4

Recommendations

 It is good practice for a note of the content and/or outcomes of supervision sessions to be kept, and to ensure that both the person giving the supervision and staff member have a copy of the record. (‘Guide to the children’s homes regulations including the quality standards’, page 61, paragraph 13.4) In particular, ensure that records of supervisions clearly capture the discussion that takes place and any agreed actions.

p.4

Recommendations

 Ensure that information about the child is always recorded in a way that will be helpful to the child. (‘Guide to the children’s homes regulations including the quality standards’, page 62, paragraph 14.4) In particular, ensure that care plans are clearly detailed.

p.4

Overall experiences and progress of children and young people: inadequate

The quality of care provided by the home is inadequate because of significant failings resulting in the child not being sufficiently protected or safeguarded. These failings are:

p.4

Overall experiences and progress of children and young people: inadequate

 A failure to ensure that staff follow agreed arrangements to manage the known risks associated with a child who has a significant history of self-harm through Inspection report children’s home: 1256794 5 ligature. This undermines the ability of the home to keep the child safe from harm  Managers and staff are not updating risk assessments in response to incidents, to inform action needed to address known risks. Again, this is a missed opportunity to act effectively to reduce risk for the child.  Managers have failed to provide safeguarding training for staff, despite the home being open since July 2017.

p.4

Overall experiences and progress of children and young people: inadequate

Leaders and managers have not ensured that the child has consistently experienced continuity of care. Since the home opened in July 2017, there has been considerable reliance on agency staff and staff from other homes owned by the provider to cover shifts. This reliance has increased over recent weeks. A cohesive and consistent staff team has yet to develop to meet the child’s needs. This weakness is clearly recognised by leaders and managers. This shortfall has been noted as a concern by the external professionals who support the child. An external professional said, ‘They [managers] are having to move staff from other services. He [child] is getting more new staff than we want. Everyone knows he works better with consistency.’

p.5

Overall experiences and progress of children and young people: inadequate

Despite the lack of consistency in staffing, there are good relationships developing between the child and some of the staff who are supporting him. Observations during the inspection noted the child getting on well with staff, interacting positively with them and engaging in good communication. Professionals also report good developing relationships, with one stating, ‘They [staff] are very [child] focused. It’s been nice to see how the workers work with him. They model appropriate behaviour.’

p.5

Overall experiences and progress of children and young people: inadequate

The child is beginning to make progress in the placement. Recently, there has been an improvement in his behaviour and a significant reduction in serious incidents. The child has also recently enrolled with an education provider. The education provider spoke positively about the relationship that they have with the manager of the home. The education staff member said, ‘The transition has been really good. The communication has been amazing. We are always back and forth for the reviewing progress. She [the manager] answers quickly, and this is really helpful.’ A social worker reflected, ‘This is a huge step up.’

p.5

Overall experiences and progress of children and young people: inadequate

The staff are alert to other opportunities for the child to develop his independence skills. The staff balance this with the need to avoid increasing pressure on or anxiety for the child as he settles at the home.

p.5

Overall experiences and progress of children and young people: inadequate

The staff work with the child to understand his views. They involve him in key decision- making processes at the home. The child has recently taken part in interviewing applicants who want to work at the home. This inclusive approach conveys the message that the child’s views are important and that the staff are keen to act upon them.

p.5

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

The help and protection offered to the child is inadequate as there are serious failures that leave the child at risk of harm. Inspection report children’s home: 1256794 6 The child has a lengthy history of self-harm and suicide attempts via the use of a ligature. A ligature risk assessment is in place. Despite the level of risk clearly identified, over one third of shifts have not included a member of staff who is ligature trained. This presents a very clear risk with potentially fatal consequences for the child, particularly as some of the staff do not know how to respond to a ligature incident. While the provider had recognised the general issues around the inconsistency and instability of the staff team, this underlying high risk had not been identified.

p.5

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

Leaders’ and managers’ approaches to risk management are not strong enough. There have been a number of serious incidents at the home. One of these incidents involved the child threatening to burn down the house. The incident form notes that burned material was found during this incident. This was enough to indicate that the risk was real. However, the child’s risk assessment does not consider this risk. The document does not fully assess risks arising from known behaviour, and the staff have no guidance on managing or responding to future occurrences.

p.6

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

There was a lack of consistent boundaries in place for the child following his arrival. The lack of a stable staff team has led to inconsistencies in managing the child’s behaviour. Although this has recently improved, there have been times when inconsistent responses to situations have resulted in difficult behaviours.

p.6

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

When the child has gone missing from the home, the staff have looked for him. A police officer said, ‘There have been no concerns about the way in which the home has managed concerns.’ However, the home neither received nor requested copies of any return interviews. Failure to do so means that the staff are not provided with all of the relevant information that they need to inform individual risk assessments and potentially inform the location risk assessment.

p.6

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

There has been a recent improvement in the child’s behaviour. This has coincided with a clearer plan for staffing at the home. While it is too early to say that this is a sustained improvement, it is positive. A professional said, ‘[The child] is an incredibly complicated young person. They [staff] are doing a great job under the circumstances. Everything we are seeing now we expected.’

p.6

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

Managers follow safe recruitment practice. Agency staff checks are completed. Appropriate checks are sought regarding staff who cover shifts and who are currently employed in other homes run by the provider. This avoids complacency and reduces the potential for unsuitable people to gain employment.

p.6

The effectiveness of leaders and managers: inadequate

Some of the serious shortfalls identified during this inspection were not known to leaders or managers. Although there was some awareness of the issues, this awareness has not led to sufficient professional curiosity about the potential effect of the shortcomings. This has contributed to the ineffective safeguarding and protection of the child in placement. Inspection report children’s home: 1256794 7 The manager has been registered since July 2017. She has a management qualification but does not hold a level 5 qualification in residential childcare. There has been insufficient management capacity to give the oversight, supervision and training needed to enable the staff to provide effective care and keep the child safe. Management capacity reduced following the absence of the deputy manager shortly after the home opened. Despite being a new service with a new manager looking after a child who has complex needs, the service was subsequently without a full management team until very

p.6

The effectiveness of leaders and managers: inadequate

recently, when an experienced senior staff member from a neighbouring home joined the team as an acting deputy manager. The acting deputy manager brings considerable experience and authority in relation to residential childcare, and offers much needed support for the registered manager.

p.7

The effectiveness of leaders and managers: inadequate

Staffing shortages have led to the manager covering shifts, which has reduced the scope for her to fulfil managerial tasks effectively. The staffing difficulties mean that staff have been working on shift for long periods and have had limited opportunities to complete office-based tasks. As a result, the quality of some records is variable and there has been a lack of timely updates to others.

p.7

The effectiveness of leaders and managers: inadequate

At the time of the inspection, the child’s case file was not up to date. There was no up- to-date local authority care plan or safety plan on the child’s file. These plans were later located by the manager and added to the file. The home’s own care plan is weak. It provides only a general overview of who the child is. At the point of inspection, the plan included no information about the child’s ethnicity or race. The plan refers to what the child wants to achieve but offers no clarity about how this will happen. This does not provide the staff with the comprehensive guidance that they need to care for the child safely and effectively.

p.7

The effectiveness of leaders and managers: inadequate

The manager has ensured that supervisions take place regularly despite the staffing difficulties. However, the records of these supervision sessions vary significantly in quality. Handwritten records offer little clarity of the discussion that took place, and they do not consistently identify actions to take forward. This does not provide staff with the feedback or guidance that they need to develop in their role.

p.7

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.

p.7

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 Inspection report children’s home: 1256794 8 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: 1256794 9

p.7

Children’s home details

Registered provider address: Break, Spar Road, Norwich NR6 6BX

p.9

Inspector

Ashley Hinson, social care inspector Inspection report children’s home: 1256794 10 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for children looked after, safeguarding and child protection.

p.9

Inspector

If you would like a copy of this document in a different format, such as large print or Braille, please telephone 0300 123 1231, or email enquiries@ofsted.gov.uk . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

p.10

Inspector

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

p.10

Inspector

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

p.10