Children's Home run by Progress Children’s Services Ltd in Sandwell

Inspection report children’s home: SC437486 1 SC437486 Registered provider: Progress Children’s Services Full inspection Inspected under the social care common inspection framework

p.1

Information about this children’s home

This service offers short breaks for up to five children and young people. The service is available to children and young people who have a learning disability, a physical disability and/or sensory impairment. This service is managed by an independent provider that operates other social care services.

p.1

Information about this children’s home

Inspection dates: 31 October to 1 November 2017

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 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: sustained effectiveness

p.1

inadequate

Enforcement action since last inspection: none Inspection report children’s home: SC437486 2

p.1

Key findings from this inspection

This children’s home is inadequate because:

p.2

Key findings from this inspection

 Poor staff judgement and ineffective leadership mean that young people are not safeguarded effectively.  Staff do not adequately review the compatibility of new young people with those already attending the home for short breaks.  Staff fail to adequately assess and manage risk. This puts young people and others at risk of significant harm.  Management oversight of the service is ineffective.  Staff do not give young people their prescribed medication as required.  Staff do not safely store cleaning substances and potentially hazardous domestic appliances.

p.2

Key findings from this inspection

 Young people enjoy positive relationships with staff.  Young people are positive about coming to stay for their short break.  Staff support young people to make some good progress from their starting points.

p.2

Inspection date Inspection type Inspection judgement

14/03/2017 Interim Sustained effectiveness 02/08/2016 Full Good 14/03/2016 Interim Sustained effectiveness 01/12/2015 Full Good Inspection report children’s home: SC437486 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 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; that staff have the skills to identify and act upon signs that a child is at risk of harm; and that the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child’s health. (Regulation 12(1) (2)(a)(i)(iii)(d)) 06/12/2017

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 promotes children’s welfare. 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)(b)(2)(h)) 06/12/2017

p.3

Requirement Due date

The care planning standard is that children receive effectively planned care in or through the children’s home. (Regulation 14 (1)(a)) 06/12/2017

p.3

Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. (Regulation 23(1)) 06/12/2017 Inspection report children’s home: SC437486 4

p.3

Overall experiences and progress of children and young people: inadequate

Staff and managers have failed to adequately assess and manage risk. This failure has had a detrimental impact on young people’s safety, well-being and experiences.

p.4

Overall experiences and progress of children and young people: inadequate

Care planning shortfalls mean that managers and staff do not adequately review the compatibility of new young people with those already attending the home for short breaks. The registered manager and staff have not followed previously well-established admissions and matching procedures. This has led to one young person visiting the home for tea prior to the completion of an initial assessment. As a result, one young person came to the home and was placed alongside younger and more vulnerable young people without appropriate safeguards being put in place. This compromised young people’s safety and welfare.

p.4

Overall experiences and progress of children and young people: inadequate

Records used at the time of this young person’s admission were not kept up to date and contained inaccuracies. Furthermore, the registered manager had not reviewed the records to identify this shortfall and so did not take prompt action to address this. Only when a serious incident occurred, relating to a young person, did managers review their admissions procedures. Managers have taken steps to review the admissions procedures and to revise the records that they use. These records and processes now link to young people’s risk assessments and evaluate a young person’s compatibility with other young people.

p.4

Overall experiences and progress of children and young people: inadequate

Young people’s care plans have not always contained sufficient detail about how staff should care for and support young people. For example, staff have not consistently reviewed young people’s behaviour support plans. These documents do not adequately outline how staff should respond if a young person is likely to cause harm to others. The registered manager has not always routinely audited files and reviewed staff practice. This has led to inconsistencies in the quality of care provided to young people and has placed young people and others at risk of serious harm.

p.4

Overall experiences and progress of children and young people: inadequate

Managers have now recognised this shortfall in care planning. All files have been audited recently and young people’s plans revised. These plans now provide sufficient information about how to care for each young person. The implementation of these revised plans is in its infancy. However, young people do not contribute to their short- break care plan. Managers are working on a simplified, child-friendly version of the plan. When introduced, this is designed to promote young people’s contribution to and ownership of their short-break plan.

p.4

Overall experiences and progress of children and young people: inadequate

Young people participate in a range of activities. Most young people enjoy these activities. Participation in leisure activities gives young people the chance to have fun and to try new experiences. The home itself has a sensory room and an outdoor trampoline on which young people enjoy playing. Young people make trips with staff to the local park, the bowling alley and the cinema. Staff have taken some young people on mini holidays to a seaside caravan park. Inspection report children’s home: SC437486 5 However, planning for these activities has been poor. The staff have not adequately risk assessed activities to take account of young people’s individual needs. Furthermore, staff have not considered the potential impact of young people’s behaviour on others. Because of these failings, staff have not always provided young people with tailored support so that young people can enjoy the activities safely. This omission has resulted

p.4

Overall experiences and progress of children and young people: inadequate

in a serious incident. Although managers took immediate steps to review what had happened, the incident has had a significant impact on young people’s safety and welfare. Risk management training is now being rolled out to staff, which is helping them to consider a wide variety of factors when planning an activity.

p.5

Overall experiences and progress of children and young people: inadequate

The home is being refurbished and staff ensure that all work is completed prior to the young people returning from school. Although young people cannot personalise their bedrooms due to the nature of the service, they are able to choose which bedroom they have when they come to stay for their short break. Each young person also has a box in which they store their own toys and photographs. When young people come to stay for their short break, staff put these personal items into the bedroom of the young person’s choice in time for their arrival. This helps young people to have some familiar things around them. However, despite this attention to detail, one bedroom contained a broken wardrobe that could not be used safely. The broken hinges on the wardrobe are sharp and this poses a risk to young people using the room. A radiator cover in the room was also broken. Although these issues were on the maintenance list, repairs had not been

p.5

Overall experiences and progress of children and young people: inadequate

carried out promptly. This has the potential to compromise young people’s safety. Furthermore, broken furniture detracts from the otherwise welcoming and homely environment.

p.5

Overall experiences and progress of children and young people: inadequate

Staff develop positive relationships with parents and external agencies, ensuring that all relevant information is shared. Social workers spoken to as part of this inspection gave positive feedback about both the level of care offered and the good communication between the staff and themselves.

p.5

Overall experiences and progress of children and young people: inadequate

Despite the concerns raised as part of this inspection, young people make some progress in key areas. Staff agree targets with young people’s parents, social workers and teachers. Social workers and parents report that staff help young people to become increasingly independent. For one young person, his ability to communicate effectively has improved. His key worker has supported and promoted the young person’s use of Makaton both on his short break and with his parents. This helps him to express himself and his views. Another young person is now able to make his own drink and dress himself, which is a considerable development from his starting point.

p.5

Overall experiences and progress of children and young people: inadequate

Key-working sessions provide young people with the opportunity to express their wishes and feelings. In the last two months, the managers have prioritised this area of work. Staff now record consistently their sessions with young people. Because of improved consultation with young people, young people are able to choose their meals and their activities. They also influence the development of the home. For example, young people have recently asked staff if the sensory room can be updated and this work is currently being planned. Inspection report children’s home: SC437486 6 Families are welcomed into the home and a ‘family fun day’ was held during the summer. At the event, a care leaver commissioned by the provider consulted with young people and their families about their experience of short breaks. Young people were positive about their experiences. Parents also spoke positively about the staff and their

p.5

Overall experiences and progress of children and young people: inadequate

children’s experiences. This view was confirmed on inspection. One parent told the inspector, ‘[My daughter] has settled really well. Staff are warm and friendly and if there are any problems, they always check out with me straight away. I could not ask for more.’

p.6

Overall experiences and progress of children and young people: inadequate

The registered manager responds to complaints effectively. Parents are confident that any concerns will be taken seriously and addressed. There have been two complaints received since the last inspection. Both of these have been resolved appropriately.

p.6

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

Staff and managers have failed to adequately assess and manage risk, leaving young people at risk of significant harm. This failure resulted in a serious incident when a young person was on an activity with staff members. The incident compromised significantly the welfare of the young person and that of other young people. A police investigation is ongoing and the organisation has commissioned an independent review.

p.6

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

Staff fail to review and update risk assessments in a timely way. The absence of up-to- date risk assessments and accompanying safety plans for all children means that staff do not have an understanding of their roles and responsibilities to keep young people safe. Staff do not follow young people’s risk management plans. For example, one young person’s risk assessment stated that he should not use the computer except to complete schoolwork. However, an entry in his behaviour support record cites a time when staff had allowed the young person to use the computer despite his risk assessment. This subsequently led to an incident of challenging behaviour.

p.6

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

Management oversight of young people’s safety and well-being has been poor. For some months, there had been no effective system to make sure that staff had read and understood risk management plans. This shortfall is now being addressed. New risk assessment and management reviews have been introduced to improve accountability of staff, and risk assessments are shared with young people’s social workers. However, the failure to manage risk consistently well has not provided a good enough standard of protection to young people.

p.6

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

Many young people require medication and some have complex medication regimens. The home has procedures for the staff to record medication being brought into and taken out of the home. However, on two occasions, staff had not followed these procedures, resulting in one young person requiring a hospital visit. Although medication is always administered by two staff, both evening and morning staff involved in this incident failed to follow the home’s procedures. A lack of staff vigilance and care resulted in a young person needing to go to hospital. This was avoidable and compromised a young person’s well-being. All staff have since received refresher training and a simplified step-by-step guide has Inspection report children’s home: SC437486 7 been added to the medication recording chart for staff to follow. All staff have completed first aid training. Additionally, staff receive competency assessments, observed by

p.6

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

registered nurses, when young people require specialist interventions such as percutaneous endoscopic gastrostomy (PEG) feeding.

p.7

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

Cleaning products and domestic appliances are not stored safely in line with the home’s procedures. For example, at the time of the inspection, cleaning products were stored in an open kitchen cupboard and an iron left on a kitchen shelf. This lack of attention to safety leaves young people at risk.

p.7

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

The use of physical intervention is infrequent but when it is used, it is mainly to guide young people away from situations. This shows that staff can manage challenges and de-escalate behaviour. All incidents are evaluated and staff use a range of communication methods to effectively debrief young people. This enables staff and young people to learn from incidents of physical intervention.

p.7

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

The registered manager’s recruitment and vetting process helps to reduce the likelihood of unsuitable individuals being employed to work with young people. Safer recruitment practice protects young people from people who may pose a risk of harm to them.

p.7

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

The home has personal emergency evacuation plans for young people in the event of a fire. Those sampled were specific to the individual’s needs and abilities. Fire drills are practised periodically and, on admission, each young person is taught to know what to do if there is a fire. Young people with mobility difficulties have clear manual handling risk assessments to ensure that they are moved safely.

p.7

The effectiveness of leaders and managers: inadequate

The registered manager has been in post since September 2012 and holds a level 5 diploma in leadership and management for residential childcare.

p.7

The effectiveness of leaders and managers: inadequate

Since the last inspection, management capacity within the home has been significantly compromised. The experienced deputy left the home and the registered manager has additional responsibilities, including for a community-based service and for the development of a new home. The organisation put into place contingency arrangements and two experienced seniors took over the deputy manager’s responsibilities. However, this was insufficient. The senior residential staff did not have the necessary skills and experience to take on this role. With the manager not fully focused on the day-to-day running of the home, this led to a dip in the quality of care provided to young people. A lack of effective oversight contributed to significant failings, which seriously undermined young people’s safety and welfare.

p.7

The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to keep young people safe. A serious incident occurred in the community, which is being investigated by the police. Care planning procedures have not been followed and young people’s compatibility with other young people has not been fully assessed. Managers and staff have not effectively evaluated and managed the risk that some Inspection report children’s home: SC437486 8 young people may pose to others in the home and in the community. These failures have left young people vulnerable to the risk of harm. Management oversight and monitoring have been poor. Consequently, the registered manager has not promptly identified areas of weakness and taken preventative steps to reduce risk. These failings have compromised young people’s progress and safety.

p.7

The effectiveness of leaders and managers: inadequate

The registered manager has now submitted to Ofsted his application to cancel his registration for this service. A new manager has been appointed. She began work in late August so that there could be an effective handover with the current registered manager. Together, the registered manager and the incoming manager have taken responsibility for addressing the shortfalls identified and they have developed a comprehensive action plan. They are working through this comprehensive action plan and this is beginning to bring about improvement in the quality of care and protection afforded to young people. In addition, three new team leader posts have been created to replace the deputy manager role. These new team leaders will be responsible for shift leadership. Improvements to the quality of care are in their infancy and need time to become established in practice.

p.8

The effectiveness of leaders and managers: inadequate

The registered manager reviews the quality of care every six months. When reviewing the quality of care, the manager seeks the views of parents, partner agencies and young people to inform the development of the service. This was a shortfall raised at the last inspection and has now been addressed.

p.8

The effectiveness of leaders and managers: inadequate

The home has a stable staff team and this provides continuity for young people. Most staff members hold a level 3 diploma in residential childcare. Three staff members are enrolled and studying on the level 3 course. Two out of the three staff members are due to complete within timescale and the manager has extended the timeframe for completion for one staff member on health grounds.

p.8

The effectiveness of leaders and managers: inadequate

Staff receive regular supervision and say that they feel supported. However, communication between staff at daily handover meetings is ineffective. Shift planning does not include how staff plan to work with young people so that they can achieve care planning targets and resolve the challenges that young people present on a day-to-day basis. The new manager has recently introduced new shift planning responsibilities for team leaders to address this shortfall. The new manager will oversee team leaders to ensure that the arrangements for day-to-day care of young people are effective and safe.

p.8

The effectiveness of leaders and managers: inadequate

Staff report that they have access to high levels of training. Records viewed on inspection support this. Training for some medical procedures is detailed and individualised to young people’s specific needs. Staff involve the community children’s nurse to support them in their learning. Staff access online training in addition to face- to-face training and the staff have been trained in Makaton, epilepsy trauma and attachment to enhance their skills and knowledge. The new manager keeps an up-to- date training matrix so that she can monitor staff training and identify when refresher training is due. Inspection report children’s home: SC437486 9 Managers and staff promote and develop effective partnerships. Communication between staff, young people and their families, social workers and other professionals is good. Following the recent serious incident, a senior manager notified all placing authorities and shared the home’s action plan. Because of this collaboration, there is a

p.8

The effectiveness of leaders and managers: inadequate

clear, coordinated approach to meeting young people’s needs.

p.9

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.9

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: SC437486 10

p.9

Children’s home details

Registered provider: Progress Children’s Services

p.10

Children’s home details

Registered provider address: Progress Children’s Services Limited, Progress House, 127 Millfields Road, Wolverhampton WV4 6JG

p.10

Inspector

Anne Daly: social care inspector Inspection report children’s home: SC437486 11 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.

p.10

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 http://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.11

Inspector

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

p.11

Inspector

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

p.11