Children's Home run by Children of the Mangrove Limited in Merton

Inspection report children’s home: 1235653 1 Registered provider: Children Of The Mangrove Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The home is privately owned. The home is registered for up to four young people aged 11 to 17 with emotional and/or behavioural difficulties. The home offers a therapeutic model of care and support.

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Overall experiences and progress of

children and young people, taking into account

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requires improvement to be good

How well children and young people are helped and protected requires improvement to be good

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requires improvement to be good

The effectiveness of leaders and managers requires improvement to be good

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requires improvement to be good

The children’s home is not yet delivering good help and care for children and young people. However, there are no serious or widespread failures that result in their welfare not being safeguarded or promoted.

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requires improvement to be good

Date of last inspection: 28 February 2017

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requires improvement to be good

Overall judgement at last inspection: requires improvement

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requires improvement to be good

Enforcement action since last inspection: none Inspection report children’s home: 1235653 2

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Key findings from this inspection

This children’s home requires improvement to be good because:

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Key findings from this inspection

 Not all staff have the skills or knowledge to practice the home’s therapeutic care approach.  Some staff fail to receive vital training.  Young people’s challenging behaviour towards each other and staff continued to escalate during the summer months. One young person said that they did not feel safe.  There have been a high number of police call outs to manage young people’s behaviour in the home.  The staffing structure is still in development. Roles and responsibilities require further clarity.  Safeguarding notifications do not inform Ofsted of the outcomes and actions following serious incidents involving the young people.  Young people’s records are not complete and lack being routinely reviewed or audited.  Staff do not consistently apply the home’s house rules.  There is no planned age-appropriate independence skills training for the young people.

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Key findings from this inspection

 Leaders and managers acknowledge the home’s requirement to improve.  The recently appointed manager is actively addressing the home’s shortfalls.  Many of the requirements made at the last inspection have been met.  Young people’s incidents of challenging behaviour have significantly reduced in recent months.  There have been no safeguarding notifications and reports of the use of physical restraint during the six weeks prior to this inspection.  Young people say that they like their home.  Young people enjoy a wealth of exciting and stimulating community activities.  Parents and professionals compliment the staff’s dedication to the young people.

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Inspection date Inspection type Inspection judgement

28/02/2017 Full Requires improvement Inspection report children’s home: 1235653 3

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet the Care Standards Act 2000, Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. The registered person(s) must comply within the given timescales.

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Requirement Due date

Behaviour management policies and records The registered person must ensure that within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3) (c)) This particularly relates to ensuring that all young people receive a debrief after any use of restraint and that it is recorded on the young people’s files. 31/01/2018

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Requirement Due date

Notification of a serious event A notification made under this regulation must include details of any actions taken by the registered person as a result of the matter. (Regulation 40 (5) (iii)) 31/01/2018

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Requirement Due date

Independent person: visits and reports The independent person must produce a report about a visit (‘the independent person’s report’) which sets out, in particular, the independent person’s opinion as to whether children are effectively safeguarded and the conduct of the home promotes children’s well-being. (Regulation 44 (4) (a) (b)) 31/01/2018

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Requirement Due date

The quality and purpose of care standard In order to meet the quality and purpose of care standard, the registered person must ensure that staff— understand and apply the home’s statement of purpose and help each child to develop resilience and skills that prepare the child to return home, to live in a new placement or to live independently as an adult. (Regulation 6 (2) (b) (i) (vi)) This particularly relates to all staff training and practising the home’s therapeutic care model and the development of young people’s individualised independence skills programme. 31/01/2018

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Requirement Due date

The care planning standard The care planning standard is that children— 31/01/2018 Inspection report children’s home: 1235653 4 In particular, the standard in paragraph (1) requires the registered person to ensure that the child’s placing authority is contacted, and a review of that child’s relevant plans is requested, if— the registered person considers that the child is at risk of harm or has concerns that the care provided for the child is inadequate to meet the child’s needs. (Regulation 14 (1) (2) (e) (i)) The leadership and management standard The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that— 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)) 31/01/2018

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Requirement Due date

Statement of purpose The registered person must compile in relation to the children’s home a statement of purpose which covers matters listed in Schedule 1. The registered person must keep the statement of purpose under review and, where appropriate, revise it and notify HMCI of any revisions and send to HMCI a copy of the revised statement within 28 days of revision. (Regulation 16 (1) (3) (a) (b)) 31/01/2018

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Requirement Due date

Children’s case records The registered person must maintain records (‘case records’) for each child which— are kept up to date and signed and dated by the author of each entry. (Regulation 36 (1) (b) (c)) 31/01/2018

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Recommendations

 The children’s guide should help children to understand how they can access advocacy support. (‘Guide to the children’s homes regulations including the quality standards’, page 24, paragraph 4.22)  Expectations of standards of behaviour should be high for all staff and children in the home. These standards should be clear and unambiguous. (‘Guide to the children’s homes regulations including the quality standards’, page 39, paragraph 8.11.) In particular, staff must apply house rules consistently with all young people.  At least one person on duty at any given time in a children’s home must have a Inspection report children’s home: 1235653 5 suitable first aid qualification (Regulation (2) (a)). (‘Guide to the children’s homes regulations including the quality standards’, page 35, paragraph 7.13.) In particular, the first aider must be clearly identified on shift rotas.  When a child returns to the home after being missing from care or away from the

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Recommendations

home without permission, the responsible local authority must provide an opportunity for the child to have an independent return home interview. Homes should take account of the information provided by such 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.) In particular, the staff must ensure that all young people’s return home interview records are sent to the home.  The registered person is responsible for ensuring that all staff consistently follow the home’s policies and procedures for the benefit of the children in the home’s care. (‘Guide to the children’s homes regulations including the quality standards’, page 54, paragraph 10.20.) In particular, all staff should understand the home’s room search policy.

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improvement to be good

Since the last inspection, the home has experienced an unplanned change of manager. The newly appointed manager is actively taking steps to address the shortfalls identified in the home. However, young people’s positive experiences and progress in the home continue to be inconsistent.

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improvement to be good

The young people’s guide outlines the home’s rules. Bedtimes and curfew times, alongside sanctions as a result of criminal damage or assaults on staff, are clearly set out. A young person said, ‘They are good rules and fair sanctions.’ However, staff’s application of house rules is not consistent. For example, a daily summary records one young person up after bedtime, cooking and playing cards with staff until 1.00am. This is contrary to the house rules. A young person said that staff, ‘Need to start sticking to the rules.’ Another young person said, ‘I understand the rules very differently from the staff on duty.’ As a result, young people are confused.

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improvement to be good

Young people’s pre-placement impact risk assessments are now in place. Staff accurately assess young people’s needs to ensure that their individual needs can be met and are appropriately matched with the young people already living in the home. However, because of previous ineffective pre-placement impact risk assessments, a young person’s continued placement in the home with escalating challenging behaviours has negatively affected the other young people in the home. A parent said, ‘(X) finds it hard to cope with the other young people’s behaviour.’ The police described the high number of police call outs to the home to support staff during incidents of assault and property damage as ‘unacceptable’. Inspection report children’s home: 1235653 6 Leaders and managers have recognised the disruption in the home and the placing authority concerned received notice from the home of the young person’s placement

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improvement to be good

breakdown. Nevertheless, the young person remained in the home for three more months. Disruption and negative behaviour continued. Staff’s de-escalation techniques were not effective and young people were unsettled. A young person said that she did not feel safe and wanted the young person to leave the home. Leaders and managers did not effectively challenge the placing authority and the young person’s transition to alternative accommodation drifted. In addition, staff did not prioritise all of the young people’s emotional stability and security.

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improvement to be good

All young people are registered with a doctor, dentist and optician. Staff effectively support young people to attend their appointments. Prescribed medication is kept secure and relevant records are accurate. When young people refuse their prescribed medication, staff coordinate with the appropriate professionals for advice and support. A designated first aider is available during every shift. However, while the shift handover book records the designated first aider, the staff rota does not. This raises the risk of staff’s confusion should first aid be required.

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improvement to be good

The new manager is addressing the gaps in young people’s case records. This includes improved assessment records in young people’s files. Behaviour management plans, risk assessments, health plans, weekly placement reports, daily living plans and key-worker records now provide staff with young people’s essential information. However, staff do not consistently complete or update these records. In addition, managers do not audit young people’s files on a regular basis. This means that staff do not always have a complete and accurate record of the young people’s changing care needs.

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improvement to be good

All young people living in the home are engaged in education or training. Staff also support young people to access off-site extra-curricular educational activities. Foreign languages, singing and drama are currently popular. When young people are not in education, staff successfully challenge placing authorities for school placements. A young person praised staff for supporting him to access a catering apprenticeship. However, a young person wanting to move from an apprenticeship and return to college was unclear why this had not happened. The young person said, ‘Staff do not tell me.’

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improvement to be good

Young people do not benefit from individualised support to help them learn independent living skills. Setting the dining table, unpacking the shopping, tidying bedrooms and laundry days provide all the young people with informal opportunities to develop some skills. However, no formal targets are set and progress is not measured. The new manager is developing a young people’s independence training skills programme. This is not yet in place. A member of staff agreed, ‘We need to develop this.’

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improvement to be good

Young people have individual weekly planners. Young people know in advance what appointments, key-working sessions, clubs and activities are scheduled. This helps young people to plan their week and develop a routine.

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improvement to be good

Young people are successfully encouraged to attend their weekly house meeting. Young people are consulted and put forward their ideas for future menu plans and group Inspection report children’s home: 1235653 7 activities. The exciting group activities include zorbing, paint balling and kayaking. Young people also request new games for the games room and budgets to personalise their bedrooms. Staff action the young people’s requests. A young person was very proud of her new hearts and stars lights. This encourages the young people’s sense of identity and ownership.

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improvement to be good

Young people have the opportunity to visit before coming to live in the home. A young person’s guide and detailed induction list provides young people with information about the home. This helps them to understand what care and support staff provide. However, the young person’s guide does not provide young people with details of independent advocacy services.

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improvement to be good

The large, five-bedroomed home provides a clean, bright and well-decorated environment. The new manager and staff actively promote a home from home atmosphere. A parent said, ‘Staff are lovely.’ A social worker added, ‘The young people and staff enjoy good banter.’

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improvement to be good

The approach to keeping young people safe lacks robustness. Individualised risk assessments are now in place for each young person. Staff successfully identify young people’s vulnerabilities to sexual exploitation, going missing and self-harm. Triggers that may influence a young person’s negative behaviour/s are known by staff, with actions to minimise risk put in place. With staff’s effective support, a young person’s episodes of going missing have significantly reduced as have a young person’s self-harming behaviours. A parent said, ‘Staff have worked really closely with (X) and now she is more confident.’ When appropriate, staff make referrals to specialist support services. A support services worker said, ‘Staff know (X’s) needs very well and communication is very good.’ However, despite these improvements, staff fail to consistently update any changes to risks. This means that young people’s individual vulnerabilities are not

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improvement to be good

accurately recorded. This runs the risk of insufficient safeguards being in place.

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improvement to be good

Young people are successfully encouraged to input into their own behaviour management plans. Young people help staff to understand ‘their triggers’, ‘their signs’ and ‘what makes it worse’. This is effective. During the six weeks preceding this inspection, there have been no reported incidents of challenging behaviour. A young person said, ‘If I am struggling, staff will sit and talk with me. This helps me.’

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improvement to be good

There have been no episodes of physical restraint during the six weeks preceding this inspection. When physical restraint is used, staff appropriately record the incident. However, following such incidents, the record of staff’s discussion and debrief with the young people is sometimes missing. This means that young people are not offered the opportunity to reflect on the incident or any impact on their emotional welfare.

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improvement to be good

When young people go missing from the home, staff inform the appropriate authorities. In addition, staff maintain telephone contact with the young people. The new manager Inspection report children’s home: 1235653 8 and staff team plan to meet with the local police missing person coordinator to further develop their ‘missing from home’ reporting procedures. After going missing from home episodes, young people attend return home interviews. This service is provided by the young people’s placing authorities and independent agencies. However, staff do not receive a record of these interviews. This means that staff do not have an opportunity to analyse young people’s going missing behaviour, assess risk and put arrangements in place to protect the young people in the community.

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improvement to be good

Young people know how to complain. Young people have made two allegations against staff since the last inspection. Allegations are referred to the designated officer as required. Staff do not tolerate bullying between young people in the home. A young person reported being subject to discriminatory language from another young person. Staff acknowledged and recorded the incident. Staff are quick to resolve complaints between the young people. Reparation and apologies between the young people are effective. However, young people do not receive the manager’s final outcome letter. As a result, there is no record of the resolution of the complaint.

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improvement to be good

Young people benefit from weekly key-work sessions. Staff plan well for these sessions. Discussions include sexual health, the risk of sexual exploitation, bullying and social media. This helps young people to stay safe.

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improvement to be good

Robust staff recruitment procedures are in place. The new manager conducts appropriate checks on all staff before they start work at the home. This helps to prevent unsuitable persons from working with the young people. All safety equipment is present in the home and regular compliance checks are carried out. Fire drills are undertaken with the young people present. This ensures that young people are familiar with the actions required should an emergency occur.

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The effectiveness of leaders and managers: requires improvement to be good

The newly appointed manager is actively progressing the requirements set at the last inspection. The new manager has a wealth of residential children’s homes experience. She is in the process of submitting her application for registered manager to Ofsted.

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The effectiveness of leaders and managers: requires improvement to be good

Leaders and managers recognise the shortfalls in the home’s provision and are committed to addressing the concerns raised at this inspection. The enthusiastic new manager reports that since her appointment, ‘Systems and paperwork have changed, but these need to be used consistently by all staff.’ Staff spoken to during the inspection complimented the new manager’s professionalism and commitment to the young people. A member of staff added, ‘I like the passion here.’

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The effectiveness of leaders and managers: requires improvement to be good

Staff training is not comprehensive. Not all staff have the skills to provide young people with the therapeutic care approach as identified in the home’s statement of purpose. A specialist psychologist provides the fortnightly staff team meeting with therapeutic support and advice. Three members of staff have specialist knowledge in different therapeutic approaches. However, a clear therapeutic care approach for vulnerable young people with complex needs is not embedded in staff’s practice. Therefore, there is Inspection report children’s home: 1235653 9 no cohesive approach to young people’s care.

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The effectiveness of leaders and managers: requires improvement to be good

The new manager has scheduled specialist staff training. This will enhance staff skills and their ability to provide bespoke care to young people in the home. Specialist training will include ‘creating a therapeutic environment’, ‘engaging young people’, ‘crisis intervention’ and ‘managing challenging behaviours’. A member of staff said, ‘We have a therapeutic approach, but I am not sure we all have the therapeutic skills.’ A director of the company agreed that ‘this is a work in progress’. The home’s statement of purpose continues to need revision.

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The effectiveness of leaders and managers: requires improvement to be good

Not all staff understand the home’s policies and procedures. For example, during the inspection, a member of staff was unsure of the home’s bedroom search policy. This results in inconsistent practice and young people being unsure of their rights and responsibilities.

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The effectiveness of leaders and managers: requires improvement to be good

To improve the service, leaders and managers are revising the staffing structure and staffing roles and responsibilities. A recruitment drive is underway. New staff receive a detailed six-month induction. All mandatory staff training is thorough and includes first aid, safeguarding young people, fire safety and restraint training.

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The effectiveness of leaders and managers: requires improvement to be good

The independent visitor’s monthly reports are comprehensive and provide a detailed overview of the home’s progress in addressing regulatory requirements. However, the independent visitor fails to consistently provide an opinion of whether young people are effectively safeguarded and the young people’s well-being is promoted.

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The effectiveness of leaders and managers: requires improvement to be good

Managers and staff provide good-quality written reports for statutory meetings. Regular communication between staff and care professionals enhances young people’s care. An education professional said, ‘Staff keep track of young people’s education and progress and communicate with me when there are any concerns.’

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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 Inspection report children’s home: 1235653 10 children’s homes regulations including the quality standards’. Inspection report children’s home: 1235653 11

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Children’s home details

Registered provider: Children Of The Mangrove Limited

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Children’s home details

Registered provider address: 101 Henchman Street, London W12 0BN

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Inspector

Victoria Jones: social care inspector Inspection report children’s home: 1235653 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 after children, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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