Children's home run by Wigan Council in Wigan

Inspection report children’s home: SC051856 1 SC051856 Registered provider: Wigan Council Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This home is registered to provide care and accommodation for up to four children with physical and/or learning disabilities. The home is operated by a local authority.

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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 and/or the care and experiences of children and young people are poor and they are not making progress.

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inadequate

Overall judgement at last inspection: not judged

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inadequate

Enforcement action since last inspection: none Inspection report children’s home: SC051856 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 staff state that they are not equipped with appropriate training, skills and experience to manage the complex needs and behaviour of the young person in placement.  Risk assessments contained significant deficiencies in ensuring the provision of safe care.  Staff are unable to assert consistent boundaries and safely de-escalate violent confrontations, and as a consequence the young person has been criminalised.  The young person was not attending education or provided with sufficient opportunities to engage in educational activity when she did not attend school.  Leaders and staff failed to notify Ofsted of a significant event. This has prevented the regulator from having sufficient oversight of a serious safeguarding incident.  The registered manager has failed to ensure that independent visits to the home take place and has not submitted a quality of care review.  The registered manager did not escalate concerns to the responsible individual

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Key findings from this inspection

about the service’s inability to provide safe care.  The children’s guide to the home was not revised and the young person did not receive a copy of the guide when she went to live in the home.  The arrangements to ensure that records are kept securely in this home are inadequate.

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Key findings from this inspection

 Staff have facilitated and supported an increased level of contact with the young person’s siblings.  The staff team has actively supported the young person to address a number of previously unmet physical healthcare needs.  The young person has accessed a range of positive activities, which have improved her social development in the community. Inspection report children’s home: SC051856 3

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Inspection date Inspection type Inspection judgement

15/05/2017 Interim Not judged 12/01/2017 Interim Not judged 27/10/2016 Interim Not judged 16/03/2016 Interim Improved effectiveness Inspection report children’s home: SC051856 4

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Statutory requirements

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

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Requirement Due date

In meeting the quality standards, the registered person must, and must ensure that staff, if the registered person considers, or staff consider, a placing authority’s or a relevant person’s performance or response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans. (Regulation 5 (c)) 29/11/2017

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Requirement Due date

The children’s views, wishes and feelings standard is that children receive care from staff who develop positive relationships with them. In particular, the standard in paragraph (1) requires the registered person to— ensure that staff regularly consult children, and seek their feedback, about the quality of the home’s care; ensure that each child has access to the home’s children’s guide, and the home’s complaints procedure, when the child’s placement in the home is agreed and throughout the child’s stay in the home; keep the children’s guide and the home’s complaints procedure under review and seek children’s comments before revising either document; ensure that an explanation is given to each child as soon as reasonably practicable after the child’s arrival about— the children’s guide; and how to make a complaint or representations in relation to the home or the care the child receives and how any such complaint

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Requirement Due date

or representations will be dealt with. (Regulation 7 (1)(a)(2)(a)(iv)(b)(ii)(c)(d)(i)(ii)) 29/11/2017

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Requirement Due date

The education standard is that children make measurable progress towards achieving their educational potential and are 29/11/2017 Inspection report children’s home: SC051856 5 helped to do so. In particular, the standard in paragraph (1) requires the registered person to ensure— that staff— help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans; help each child to understand the importance and value of education, learning, training and employment; and help a child who is excluded from school, or who 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. (Regulation 8 (1)(2)(a)(i)(iv)(viii)) The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on mutual

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Requirement Due date

respect and trust, an understanding about acceptable behaviour and positive responses to other children and adults. 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; help each child to develop socially aware behaviour by encouraging each child to take responsibility for the child’s behaviour while helping each child to develop and practise skills to resolve conflicts positively and without harm to anyone; and de-escalate confrontations with or between children, or potentially violent behaviour by children. (Regulation 11 (1)(a)(b)(c)(2)(a)(i)(ii)(iii)(iv)(xi)) 29/11/2017

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Requirement Due date

* The protection of children standard is that children are protected from harm and enabled to keep themselves safe. In particular, the standard in paragraph (1) requires the registered person to ensure— that staff assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child; and that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from 10/11/2017 Inspection report children’s home: SC051856 6 harm. (Regulation 12 (1)(2)(a)(i)(b)) * 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 aspire to fulfil their potential and promotes their welfare. 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; ensure that staff have the experience, qualifications and skills to meet the needs of each child; ensure that the home has sufficient staff to provide care for each child; ensure that the home’s workforce provides continuity of care to each child; and use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b)(2)(a)(c)(d)(e)(h)) 29/11/2017

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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 and that each child’s relevant plans are followed. (Regulation 14 (1)(a)(2)(c)) 29/11/2017

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Requirement Due date

Case records must be kept securely in the children’s home during the period when the child to whom the case records relate is accommodated there. (Regulation 36 (2)(c)) 29/11/2017

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation or a child protection enquiry involving a child is instigated or concludes (in which case, the notification must include the outcome of the child protection enquiry). (Regulation 40 (4)(a)(d)(i)(ii)) 29/11/2017

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Requirement Due date

The registered person must ensure that an independent person visits the children’s home at least once each month. 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 29/11/2017 Inspection report children’s home: SC051856 7 effectively safeguarded and the conduct of the home promotes children’s well-being. The independent person must provide a copy of the independent person’s report to HMCI. (Regulation 44 (1)(4)(a)(b)(7)(a)) The registered person must complete a review of the quality of care provided for children (‘a quality of care review’) at least once every 6 months. In order to complete a quality of care review the registered person must establish and maintain a system for monitoring reviewing and evaluating the quality of care provided for children, the feedback and opinions of children about the

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Requirement Due date

children’s home, its facilities and the quality of care they receive in it and any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children. After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (‘the quality of care review report’). The registered person must supply to HMCI a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed. (Regulation 45 (1)(2)(a)(b)(c)(3)(4)(a)) 29/11/2017

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Requirement Due date

* These requirements are subject to a compliance notice.

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Overall experiences and progress of children and young people: inadequate

The provider made a decision to complete a full refurbishment of the home after the last young people moved out of the home in October 2016. Between October 2016 and July 2017, there have been no young people living at the home. The registered manager agreed to accommodate a young person with highly complex needs and behavioural difficulties to enable the placing authority to assess her long-term care needs. The statement of purpose was amended to enable the young person to move into the home and no other placements have been considered throughout this time. However, the care that the young person has received has fallen short in being able to meet her needs or to make sufficient progress. While there have been meetings to discuss the current care arrangements, they have not addressed the young person’s emotional and behavioural needs or considered her safety. This has had a considerably negative impact on her

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Overall experiences and progress of children and young people: inadequate

overall experiences and progress. Inspection report children’s home: SC051856 8 Staff struggle to build and maintain positive relationships with the young person. Instability in the staff team has disrupted the continuity of care provided. The young person’s behaviour has escalated to the point where she has displayed violent and aggressive behaviour towards the staff and caused significant damage to the home. There was insufficient evidence to demonstrate that the young person has a say in her day-to-day care arrangements or records to demonstrate effective consultation with her about the care and support provided. This fails to demonstrate that staff are able to meet the young person’s behavioural and emotional needs, as set out in her plan. Furthermore, there was limited evidence to demonstrate that staff have worked with the young person to enable her to develop more socially acceptable behaviour in the home

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Overall experiences and progress of children and young people: inadequate

and encourage her to take responsibility for her behaviour. Staff have been unable to help her to develop the skills needed to resolve conflict positively and without causing harm to others. Staff have been unable to resolve this conflict effectively and promote positive relationships. Consequently, the young person does not live in a consistently safe, stable and nurturing environment.

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Overall experiences and progress of children and young people: inadequate

Prior to moving into the home, the young person was in full-time education. A report from a placing authority social worker stated that ‘it is felt that school gives the young person structure and she becomes anxious and lost without this’. While an educational placement was identified for the young person, she has attended once and refused to return. Staff have failed to engage her in formal educational opportunities and assert sufficient boundaries to provide the structure that the young person needs. This fails to ensure that she is supported to reach her full education potential and this could have a detrimental effect on her future life chances and economic well-being.

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Overall experiences and progress of children and young people: inadequate

The young person has considerable emotional health needs, which were reported to be having a negative impact on her behaviour and social development. A mental health practitioner who was assigned to work with the young person stated that she has ‘not been adequately involved in or invited to any of the care planning meetings’ and as a consequence, the young person has made little progress in this important aspect of her development.

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Overall experiences and progress of children and young people: inadequate

When the young person moved into the home, the registered manager had not revised the children’s guide to reflect the current changes in the children’s home, including the new care arrangements. The young person had not been provided with a copy of the guide to enable her to have an understanding of the home and how staff would support her in all areas of her life. The registered manager was aware that this had not been completed in a timely manner. This is a breach of the Children’s Homes Regulations 2015.

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Overall experiences and progress of children and young people: inadequate

Despite the significant shortfalls, staff have worked hard to ensure that the young person’s physical health needs are met. She has joined a slimming club and has had a healthcare assessment and attended appointments to review her medication. Staff have provided opportunities for the young person to access community resources and activities. She has been on day trips to Blackpool and shopping. The young person has also enjoyed increased contact with her siblings, which the staff facilitated. Inspection report children’s home: SC051856 9

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

The young person living at the home has a history of highly challenging behaviour, which has escalated significantly since living at the home. This has resulted in serious assaults on staff and significant damage to the home. Consequently, the police have been called to the home on a number of occasions. There have been 28 notifications of significant and serious events made to Ofsted since the young person was placed at the home. Most of the notifications detailed police involvement and some had resulted in the young person being taken into custody. One police officer said, ‘What is clear is that staff at the care home struggle to be able to deal adequately with [name of young person].’

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

A deprivation of liberty order was applied for and granted prior to the young person being placed at the home. This gave the staff the ability to implement high levels of supervision and monitoring to ensure that the young person could be cared for safely. However, the registered manager and staff did not implement the strategies outlined, which included physical intervention to protect the young person and others from harm. On one occasion, staff did implement a method of restraint successfully. However, when this was reviewed by the registered manager, she deemed the risk of harm to staff from implementing those strategies as too high and requested that the staff refer the concerns to the police if situations arise.

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

The young person has been missing from home on 13 occasions. Staff have followed her and records demonstrated that staff had attempted to return her home. Staff had followed the missing from home protocol and reported the young person as missing to the police. Return interviews were completed. However, following one of the episodes of going missing, the police instigated a section 47 enquiry. The registered manager failed to notify Ofsted of this significant incident. This does not allow the regulator to have a clear overview of all safeguarding incidents, and is in breach of the Children’s Homes Regulations 2015.

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

Risk assessments relating to the young person contained significant deficiencies in ensuring the provision of safe care. The risk levels identified were not fully or accurately assessed or revised when new information and risks were evident. Staff have been unable to de-escalate the young person’s behaviour on many occasions. Despite the existence of a court order allowing the deprivation of the young person’s liberty to prevent harm to the young person, the terms of the order have not been incorporated in the young person’s care planning or risk assessment documents. The measures sanctioned by the court to maintain the safety and welfare of the young person have not been utilised in the delivery of care to the young person to mitigate risk of harm.

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

During the visit, the registered manager and staff informed the inspector that they do not have the skills or experience to manage and respond to the challenging and complex needs of the young person; this is despite the provider ensuring that all staff have attended mandatory training in physical intervention and behaviour management. The registered manager advised staff not to place themselves at risk, which meant that they Inspection report children’s home: SC051856 10 were unable to implement the strategies they were taught in the training sessions or use the measures agreed in the deprivation of liberty order. The measures were applied for in order to protect the young person. Consequently, this places the young person accommodated and staff at risk of harm.

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

Furthermore, the registered manager had advised staff to withdraw from the home to an area outside of the building when the young person was displaying difficult and challenging behaviour. While this may reduce the risk of harm to staff, it did not reduce the risk of harm to the young person who had known risk-taking behaviours that included fire-starting and self-harm. This also contradicts the required levels of supervision to provide safe care. Another measure taken to reduce the likelihood of incidents was to ensure that the office remains locked and not accessed by staff when the young person is in the home. When the inspector arrived, staff and the young person were situated in the office. Staff were not following the strategies agreed to reduce risk.

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

A child and adolescent mental health practitioner told the inspector that she had raised a formal safeguarding concern about the high risk of harm posed to both the young person and staff and had not received an adequate response. She was unaware of any action taken as a result. This fails to demonstrate that all professionals involved in the welfare and safety of the young person are kept fully informed, involved and updated.

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

The registered manager had taken steps to analyse the incidents of verbal and physical aggression. She concluded that the incidents are frequent, intense and perpetrated against all staff with a greater propensity towards males. During the inspection, she recognised that the levels of risk to both the young person and staff are unacceptably high and that there is a significant risk of harm. However, she had not raised her concerns directly with the responsible individual.

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The effectiveness of leaders and managers: inadequate

The leadership and management arrangements in the home are inadequate. The registered manager has failed to demonstrate that she is leading and managing the home in a manner that is consistent with the aims outlined in the statement of purpose and which ensures that the care being delivered meets the needs and promotes the safety and welfare of the young person at the home.

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The effectiveness of leaders and managers: inadequate

The registered manager reported that the staff team is not a cohesive team and does not have a consistent approach to providing care for young people. This is because the registered manager stated that the team comprised of two separate teams that had different styles of working and some team members lacked the experience and knowledge to minimise risk and deal effectively with the young person’s behaviour. In total, the registered manager said that 19 staff have left or moved to other departments following an organisational restructure. Nine staff members have transferred from another home. The registered manager had not raised her concerns directly to the responsible individual and no further training was planned to increase the skills, knowledge and understanding of the staff team. Inspection report children’s home: SC051856 11 Due to the complex needs of the young person accommodated at the home and their

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The effectiveness of leaders and managers: inadequate

unpredictable behaviour, the provider had agreed to increase the staffing ratio in the home to 4:1 staffing. However, the registered manager and staff openly told the inspector that there were difficulties in meeting the agreed ratio of staffing in order to provide safe care for the young person. When the inspector arrived, the staffing ratio was unmet. This fails to demonstrate that there are sufficient staff to meet the young person’s needs and, in particular, to safely support the emotional and behavioural needs of the young person.

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The effectiveness of leaders and managers: inadequate

Supervision minutes reviewed during the inspection demonstrated that staff were feeling unable to manage the young person’s behaviour and their own emotional coping mechanisms were significantly diminished. One member of staff told the inspector that he felt ‘unable to cope with the young person’s heightened behaviours’ and felt that he and other team members were ‘under the constant threat of assault’. Another staff member described the team as being ‘very down at the moment’. She said, ‘We are losing people. Two staff [members] have handed in their notice and three are off sick.’ In the placing authority care plan and an assessment completed by a consultant forensic psychiatrist, it clearly stated that staff will require enhanced levels of supervision with clinical input. While staff have received supervision from the registered manager, they have not benefited from clinical supervision and enhanced support. This has contributed

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The effectiveness of leaders and managers: inadequate

to the ‘burnout and staff resignations’ that were predicted and recorded in the psychiatrist’s assessment in September 2017. All of which have resulted in deficiencies in the continuity of care provided to the young person.

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The effectiveness of leaders and managers: inadequate

There have been no reports submitted to Ofsted from an independent person since August 2016. The registered manager stated that the independent visitor was unable to gain access to the home on at least two occasions in recent months, but she had failed to ensure that the visitor returned and submitted a report to Ofsted as required in the Children’s Homes Regulations 2015. The registered manager has not completed or submitted a quality of care review during the same period. The lack of external independent scrutiny and review of the quality of care provided has not given the regulator the ability to have oversight of events and the impact on the young person at the home.

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The effectiveness of leaders and managers: inadequate

The registered manager and staff have stated that due to their inability to access the office when the young person is at home, record keeping practice has been significantly hampered. Most of the records are being held at a nearby office. This is a breach of regulation, as records must be stored securely in the home. In addition, the registered manager acknowledged that it was likely that some recordable incidents had not been completed. This fails to demonstrate a clear record of all incidents and does not enable the registered manager to maintain a clear overview of all concerns. Inspection report children’s home: SC051856 12

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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: SC051856 13

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Children’s home details

Registered Provider : Wigan Metropolitan Borough Council

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Children’s home details

Registered provider address: Wigan Metropolitan Borough Council, Town Hall, Library Street, Wigan WN1 1YN

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Inspector

Nicola Thomas: social care inspector Inspection report children’s home: SC051856 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

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Inspector

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Inspector

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