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

Inspection report children’s home: SC457272 1 SC457272 Registered provider: Cambian Childcare Limited

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This home provides care and accommodation for up to three children who have emotional and/or behavioural difficulties. A private organisation owns and operates this home.

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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 are not protected or their welfare is not promoted or safeguarded.

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inadequate

Date of last inspection: 23 February 2017

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inadequate

Overall judgement at last inspection: declined in effectiveness

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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

 There are significant concerns regarding the matching process for children. Impact assessments do not fully assess and consider the risks in relation to all Inspection report children’s home: SC457272 2 of the children, or detail how the risks should be managed.  The staff and the manager have failed to safeguard the children effectively.  There are gaps in the fire risk assessment and weekly fire equipment checks. There is no fire risk assessment in relation to a child who was recently lighting paper in the bathroom.  Management and oversight of the significant number of incidents have been poor. Managers have failed to evidence whether they have taken action in response to significant incidents and concerns.  A restraint record for one child had not been completed three days after the incident took place.  The manager and staff have failed to review and update risk assessments effectively. This has resulted in incidents that could have potentially been

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Key findings from this inspection

avoided having a negative impact on the children involved.  The manager and the staff have failed to evidence whether they have taken action in response to significant incidents and concerns.  The missing-from-care plan for one child is out of date and refers to his previous placement in a different locality. Consequently, the staff have not had relevant and accurate information to guide them in keeping this this child safe.  The locality risk assessment does not sufficiently detail the known and concerning risks within the local area.  Some of the notifications submitted to Ofsted lack clarity and detail about the nature and seriousness of events.  The registered manager has failed to provide effective oversight of the home. Lack of professional curiosity and challenge means that serious incidents have not been followed up, and staff have not been guided in how to manage these incidents.  Managers are failing to provide staff with the training they need to meet

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Key findings from this inspection

children’s needs safely. They have not received any supervised contact training, or training in relation to self-harm or mental health.  Managers are not providing effective supervision for the staff. Supervision is not reflective and is not regular enough to provide the support that the staff need.  Managers have failed to complete a risk assessment for new staff undertaking waking night and sleep-in duties. This failure means that it is unclear whether staff are confident and competent to undertake these duties.

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Inspection date Inspection type Inspection judgement

23/02/2017 Interim Declined in effectiveness 07/07/2016 Full Good Inspection report children’s home: SC457272 3 10/02/2016 Interim Sustained effectiveness 24/09/2015 Full Requires improvement Inspection report children’s home: SC457272 4

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Statutory requirements

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

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who understand the children’s home’s overall aims and the outcomes it seeks to achieve for children and use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that the premises used for the purposes of the home are designed and furnished so as to meet the needs of each child. (Regulation 6(1)(a)(b)(2)(c)(i)) 08/12/2017

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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 are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same. (Regulation 11(2)(a)(x)) 08/12/2017

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Requirement Due date

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

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff: 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; take effective action whenever there is a serious concern about a child’s welfare; 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)(a)(i)(vi)(b))

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Requirement Due date

In particular: Ensure that all relevant information is obtained about children 08/12/2017 Inspection report children’s home: SC457272 5 prior to placement, and a full assessment of the suitability of the placement takes account of all risk factors relating to the child and the home.

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Requirement Due date

Ensure that the management team reviews and evaluates the competence of all staff who work with the children to take all appropriate action to reduce the risks of a serious incident, and to react appropriately in the event of a serious incident involving a child.

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Requirement Due date

Ensure that the management team and staff receive the appropriate training and support in order to provide safe and effective care for children that meets their individual needs.

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Requirement Due date

Ensure that all risk assessments and behaviour plans are reviewed and evaluated, and updated with any identified action taken to reduce the identified risks to children. *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.

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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; 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 the care provided in the home; use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(a)(b)(2)(c)(f)(h)) 08/12/2017

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Requirement Due date

The registered person must ensure that the requirements of the Regulatory Reform (Fire Safety) Order 2005(a) and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the home. (Regulation 25(2)(b)) 08/12/2017

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Requirement Due date

The registered person must ensure that within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes—the name of the child; details of the child’s behaviour leading to the use of the measure; the date, time and location of the use of the measure; a description of the measure and its duration; details of any methods used or steps taken to avoid the need to use the measure; the name of the person who used the measure (‘the user’), and of any other person present when the measure was used; the effectiveness and any consequences of the use of 08/12/2017 Inspection report children’s home: SC457272 6 the measure; and a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure. Ensure that, within 48 hours of the use of the measure, the registered person, or a person who is

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Requirement Due date

authorised by the registered person to do so (‘the authorised person’) has spoken to the user about the measure; and has signed the record to confirm it is accurate. (Regulation 35(3)(a)(i-vii)(b)(i)(ii)) The registered person must notify HMCI and each other relevant person without delay if an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious and when there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40(4)(b)(e)) 08/12/2017

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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

This inspection identified significant shortfalls in the way that the staff and the manager safeguard children. Serious shortfalls in the leadership and management of the home mean that safeguarding concerns for children had not been identified and acted on effectively.

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Overall experiences and progress of children and young people: inadequate

A high number of worrying incidents have been reported. Ineffectual or no follow-up has led to poor experiences for children. Due to the consistent verbal and unwanted physical behaviours of some children over a significant period of time, other children do not have positive experiences. Those children have not had their emotional well-being needs met and they have not felt safe. One child left the home in an unplanned way due to the staff team’s inability to manage his behaviours and keep him safe. Another child said, ‘He [child] would not stop when I told him to. I’m glad he is gone’. Insufficient supervision, training and support for staff means that the staff have not been able to manage children’s behaviour, or the impact of incidents on children living at the home.

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Overall experiences and progress of children and young people: inadequate

There are significant concerns regarding the matching process for children. Impact assessments do not fully assess and consider the risks in relation to all of the children. Nor do they consider whether the staff have the skills and training to meet the children’s individual needs.

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Overall experiences and progress of children and young people: inadequate

Managers have failed to ensure that there is a thorough matching assessment prior to the children arriving at the home, and there are concerns that crucial information is missing. Children placed at the home are vulnerable, and exposed to unacceptable risks. Three children who are at risk of using weapons and knives were all placed together. In addition to this, one child who presented with high-risk behaviours, with the potential to Inspection report children’s home: SC457272 7 pose a significant risk to others, was moved to the home very quickly with poor planning. The manager advised that she was unaware of all of the information prior to the placement, despite the child moving from a home within the same organisation. Consequently, other children have been affected by these behaviours.

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Overall experiences and progress of children and young people: inadequate

Direct work with the children is taking place. However, many of the records of this work are too brief. These sessions primarily report on incidents rather than detailing the content of planned work with the child. Therefore, it is difficult to see any meaningful work and the progress made. During these sessions, children may share concerns with a staff member. For example, one child talked of his fears of a gang of local young people trying to find and hurt him. There is no record of follow-up action detailing if appropriate safeguarding steps were put in place and if the information shared. This does not support the child to develop confidence that they are listened to and their concerns are acted on.

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Overall experiences and progress of children and young people: inadequate

It was clear at the start of the inspection that not enough is being done to keep the home in an acceptable condition. There were bags and boxes of rubbish and a mattress by the bins in the garden. There were remains of apples thrown at the bedroom window. The children had written their names on their bedroom doors. The walls in the dining room were poorly painted and there was a rip in the sofa. There was no television in the lounge because a child had broken it. The manager said that she is gradually replacing items as there had been a lot of damage to the home. Ornaments and crockery items were broken. Not enough is done to provide the children with a homely environment as equipment is regularly damaged. This discourages children from taking pride in their surroundings or from taking care of their home. The children have been exposed to high levels of violence in and damage to their home, over a sustained period.

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Overall experiences and progress of children and young people: inadequate

Due to the short time that the two currently accommodated children have lived at the home, they are not yet attending school. However, applications for local schools are being progressed by the registered manager. A social worker, whose child has recently moved into the home, spoke positively of his experiences of the home so far. He said, ‘He [my child] is forming relationships. I am really impressed so far. We are looking at a school. The manager is sorting this, with good pastoral support.’

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Overall experiences and progress of children and young people: inadequate

Two children have successfully moved on from the home. One child is living independently and the other child has returned to the care of her family. One child said, ‘The home is good.’ This demonstrates that some children have moved from the home in a planned way.

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

Failure to ensure that safety checks and assessments are in place puts children in potential danger. There are gaps in the fire assessment and weekly fire equipment checks. The forms used are inconsistent and lack clarity as to what is being checked. The manager advised that the staff are using the wrong forms to record this information. There is no fire risk assessment in relation to a child who was recently lighting paper in Inspection report children’s home: SC457272 8 the bathroom. The manager said, ‘I have not done this, I will be honest’.

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

The staff physically intervene when required in order to safeguard and protect the children and others around them. Due to high-level behaviours at the home over the past few months, physical intervention has been used more frequently. A restraint record for one child was not completed, three days after the incident. The manager advised that this was due to a staff member being off work for several days. This is an unacceptable delay. Failure to record physical interventions promptly means a lack of transparency about the nature of the restraint, and if it was appropriate. The absence of the record means that the views of the child are not captured, and means that it is unclear if they have had the opportunity of a debrief about the incident.

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

The manager and the staff have failed to regularly review and update risk assessments. This has resulted in incidents that could have potentially been avoided having a negative impact on the children involved. A high number of incidents were reported for one child. Each incident highlighted escalating risks and concerns. Almost every day and evening during this child’s placement he had been involved in a high-level incident. There is no evidence that the staff took effective action, or that known risks had been added to risk assessments and reduction strategies put in place. The home has failed to protect the children.

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

Children, on occasion, go missing from the home. The staff actively look for the children and contact the police. However, the missing-from-care plan for one child is out of date and refers to his previous placement in a different locality. As a result, the staff were not provided with the information that they needed. The manager confirmed during the inspection that the missing-from-care plan from the child’s previous placement was still being used.

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

The locality risk assessment does not sufficiently detail the known risks in the local area. Vital information is missing in relation to local crime hotspots and the potential risks to children. The staff and the manager do not consistently follow up information obtained from incidents outside the home, and therefore this information is not added to the locality assessment. The assessment states that the children must not be taken to a local lake. On two occasions, it is recorded that staff took children to this lake. Failure to act in accordance with risk assessments, and the manager’s failure to ensure that staff understand the risks, puts children in danger.

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

The staff undertake room searches when needed. One child had weapons and there were allegations of illegal substances in his room. This room search record could not be located during the inspection, although the manager confirmed that it should be available. This poor recording fails to provide an accurate picture of events or capture the views of the child, or if any items were located. This makes it difficult to see whether any risk is being managed effectively.

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

Some of the notifications submitted to Ofsted lack clarity and detail about the nature and seriousness of events. For example, one notification did not include information about cannabis use or the specific serious nature of an assault by one child on another child. Inspection report children’s home: SC457272 9 This does not provide Ofsted with a current and accurate view of incidents at the home.

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The effectiveness of leaders and managers: inadequate

The manager is suitably qualified and experienced and holds a level 4 diploma in leadership and management. Several staff members are well established in their roles. Some of the staff are new starters who are in their probation period, or who have recently completed their probation.

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The effectiveness of leaders and managers: inadequate

Poorly managed family contact resulted in risk of harm to a child. The records of this incident are unclear, as are the guidelines as to the level of supervision required for this contact. The manager failed to follow up the concerns with the staff, or to take action to prevent future occurrences. Further exploration of the incident only took place when it was raised during the inspection. In addition, the staff have not received any supervised- contact training. This leaves the children vulnerable and at risk, as the staff are not confident or skilled enough to challenge when needed. It is also of concern that information regarding this contact was not passed to the placing authority in a timely way.

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The effectiveness of leaders and managers: inadequate

The staff have had no specific training in relation to self-harm or mental health. This is despite the admission of two children in recent months who display self-harming behaviours. One child was self-harming so significantly that the manager felt that the staff could no longer keep her safe and the placement was ended after a very short time. The staff are not equipped with the knowledge to manage children’s needs and behaviour effectively on a daily basis. This undermines their capacity to give children the help and protection they need.

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The effectiveness of leaders and managers: inadequate

The staff have access to a psychologist who is employed by the organisation. One child had specific needs and high-risk behaviours; however, the psychologist was not able to undertake the specialist work with this child because he had not received the training that he needed to do so. The organisation was not equipped to meet this child’s needs, and the support was not in place for him when he needed it.

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The effectiveness of leaders and managers: inadequate

Although the staff receive supervision, it is not reflective or regular enough. This is significant because relatively new staff members are not accessing the support that they need. Two of the new staff have no residential experience prior to working at the home. Managers have failed to give them the guidance and oversight that they need to work with the challenges presented in their roles.

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The effectiveness of leaders and managers: inadequate

There is no audit trail in supervision records to show how the manager has dealt with safeguarding issues. This does not provide a clear record of accountability. In addition, an induction workbook is incomplete for one staff member. There is no record of the achievements and progress for this staff member or further learning needs. Managers are not ensuring that new staff receive an effective induction when they start work at the home. As a result, staff are not suitably equipped with the information and skills needed to fulfil their roles working with vulnerable children. A risk assessment for new staff who undertake waking night or sleep-in duties is Inspection report children’s home: SC457272 10 incomplete. The risk assessment does not evidence if the staff member is ready to undertake the waking night or sleep-in duty, or if they are confident to do so. There is no confirmation that the staff have the knowledge to safeguard themselves or the

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The effectiveness of leaders and managers: inadequate

children in relation to fire safety or other procedural matters.

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The effectiveness of leaders and managers: inadequate

Leaders and manager have failed to monitor the home effectively. The shortfalls identified during this inspection were not known to the manager or the responsible individual. Their failure to understand the strengths and weaknesses of the home means that they are not identifying or addressing shortfalls. This has a negative impact on children’s experiences at the home and the outcomes that they are able to achieve.

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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: SC457272 11

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Children’s home details

Registered provider: Cambian Childcare Limited

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Children’s home details

Registered provider address: Cambian Group, 4th Floor Waterfront Building, Chancellors Road, Hammersmith Embankment, London W6 9RU

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Inspector

Debbie Young, social care inspector Inspection report children’s home: SC457272 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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