Children's Home run by New Horizons (Stockport) Limited in Manchester

Inspection report children’s home: SC472680 1 SC472680 Registered provider: New Horizons (Stockport) Ltd Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The home is registered to provide care for five children who may have emotional and/or behavioural difficulties. The home is provided by a private company.

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Information about this children’s home

Inspection dates: 13 to 14 December 2017

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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 failures that mean young people are not protected or their welfare is not promoted or safeguarded.

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inadequate

Date of last inspection: 27 February 2017

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inadequate

Overall judgement at last inspection: sustained 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

 Leaders and managers admit young people to the home with insufficient information to allow them to assess whether they are able to meet young people’s needs or manage their risk-taking behaviour.  Leaders and managers do not consider the welfare of the existing group when they admit young people to the home. Inspection report children’s home: SC472680 2  Risk assessments are inaccurate and unclear. They do not support staff to minimise and manage risk-taking behaviour. Staff do not always follow risk assessments, placing young people and staff at risk of harm.  Staff do not have the training and skills to manage young people’s high levels of self-harm.  Monitoring systems are ineffective, and this has led to wide-ranging shortfalls. For example, there is insufficient managerial oversight of direct work with young people, limited checks on case recording and lack of monitoring of property damage and that it is promptly repaired.

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Key findings from this inspection

 Staff do not consistently record sanctions. This does not allow young people to understand why they are receiving the sanction or allow staff to review the effectiveness of the measure.  Staff’s recording of the use of restraint lacks essential details and there is no record of the manager’s debriefing of staff after they have used a restraint. This represents lost opportunities to evaluate and improve practice.  Staff do not ensure that young people who have disengaged from education have routines and engage in meaningful activity.  Leaders and managers have consent to use bedroom alarms at night to safeguard young people’s welfare. They are in use throughout the day, which is an unnecessary intrusion into young people’s privacy and is institutional.  Leaders and managers do not ensure that safer recruitment practice is used in the selection and vetting of staff.  Leaders and managers do not ensure that they provide Ofsted with up-to-date

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Key findings from this inspection

information in a timely manner about how the home is operating or when serious incidents occur.

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Key findings from this inspection

 Staff develop positive relationships with young people, and these allow most young people to feel a sense of security.  Some young people are making good progress from their starting points and have achieved stability.  Staff support young people to maintain or restore their relationships with their families. They communicate well with young people’s families. Inspection report children’s home: SC472680 3

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Inspection date Inspection type Inspection judgement

27/02/2017 Interim Sustained effectiveness 15/11/2016 Full Good 23/02/2016 Interim Improved effectiveness 28/07/2015 Full Requires improvement Inspection report children’s home: SC472680 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

*13: The leadership and management standard

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Requirement Due date

(1) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that – (a) helps children aspire to fulfil their potential: and (b) promotes their welfare.

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Requirement Due date

(2)In order to meet the leadership and management standard, 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 12(2)(h)) 26/01/2018

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Requirement Due date

*12: The protection of children standard

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Requirement Due date

(1)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

(2) In particular, the standard in paragraph (1) requires the registered person to ensure staff assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child. (Regulation (2)(a)(i)) 26/01/2018

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Requirement Due date

(1) In order to ensure the care planning standard is met the registered provider must ensure:- (a) children receive effectively planned care in or through the children’s home; and (b) have a positive experience of arriving at or moving on from the home. In particular, the standard in paragraph (1) requires the registered person to ensure that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose. (Regulation 14(2)(a)) 26/01/2018 Inspection report children’s home: SC472680 5 8: The education standard (1) The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff help a child who is above compulsory school age to participate in further education, training or employment and to prepare for future care, education or employment. (Regulation 8(2)(ix)) 26/01/2018

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Requirement Due date

The registered person must ensure that within 24 hours of a measure of control, discipline or restraint in relations to a child in the home, a record is made which includes the name of the child, details of the 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 and any other person present, the effectiveness of the measure and a description of any injury to the child or other person and any medical treatment administered. The registered person must ensure within 48 hours of the use of the measure the user is spoken to about the measure and the registered person signed the record to confirm it is accurate. (Regulation 35(3)(a)(b)) 26/01/2018

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Requirement Due date

The registered person may only use devices for the monitoring or surveillance of children if it is for the purpose of safeguarding and promoting the welfare of the child concerned, or other children and it is no more intrusive than necessary, having regard to the child’s need for privacy. (Regulation 24(1)(a)(d)) 26/01/2018

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Requirement Due date

The registered person may only allow an individual to work at the home if the registered provider has full and satisfactory information available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32(3)(d)) 26/01/2018

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Requirement Due date

The registered provider must notify HMCI without delay of any incident relating to a child which the registered person considers to be serious. (Regulation 40(4)(e)) 26/01/2018

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Requirement Due date

The registered manager must supply a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed. The system established to monitoring, reviewing and evaluating the quality of care must provide for ascertaining and considering the opinions of parents, placing authorities and staff. (Regulation 45(4), (5)) 26/01/2018

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Requirement Due date

The registered person must keep the statement of purpose under review and notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days. (Regulation 16(3)(b)) 26/01/2018

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Requirement Due date

The registered person must maintain in the home the records in Schedule 4 and ensure that the records are kept up to date. (Regulation 37(2)(a)(b)) In particular, ensure that the rota reflects the full names of all staff who have worked at the home and that the visitor’s book is accurately maintained. 26/01/2018 Inspection report children’s home: SC472680 6 * These requirements are subject to a compliance notice.

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Recommendations

 The registered person should only accept placements for children where they are satisfied that the home can respond effectively to the child’s assessed needs as recorded in the child’s relevant plans and where they have fully considered the impact that the placement will have on the existing group of children. In particular, that the registered manager records their evaluation in an impact risk assessment. (‘Guide to the children’s homes regulations including the quality standards’, page 56, paragraph 11.4)  For children’s homes to be nurturing and supportive environments that meet the needs of their children, they will, in most cases, be homely, domestic environments. In particular, staff ensure that any graffiti is removed and that redecoration takes place in a timely manner. (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9)  Staff should be familiar with the home’s policies on record keeping and

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Recommendations

understand the importance of careful, objective, and clear recording. Information about the child must always be recorded in a way that will be helpful to the child. This is with particular reference to the clear and detailed logging of daily events. (‘Guide to the children’s homes regulations including the quality standards’), page 62, paragraph 14.4)

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Overall experiences and progress of children and young people: inadequate

Since the last inspection, two young people have joined the home. Leaders and managers did not ensure that they had sufficient information to understand their needs, risks and behaviours. They were unable to establish whether the young people joining the home were compatible with the existing group. The limited information available identified that one young person presented with significant risk taking in relation to self- harm. Staff did not have the skills, tools or training to meet the young person’s complex needs in relation to self-harm, in particular ligature management, and in relation to gender identity. It quickly became apparent that staff were unable to meet the young person’s needs and the placement ended within 48 hours following a serious incident. This does not represent effective care planning and it exposed the young person to significant harm and an additional placement move. The existing group also suffered

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Overall experiences and progress of children and young people: inadequate

harm, with one young person clearing up blood from the young person’s self-harm injuries and another struggling due to their own vulnerabilities.

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Overall experiences and progress of children and young people: inadequate

Another admission to the home involved leaders and managers admitting a young person from police custody. They admitted the young person with insufficient information regarding their risks, particularly their outstanding charges. Subsequently, leaders and managers became aware that the young person faced a significant number Inspection report children’s home: SC472680 7 of charges. The young person was frequently missing from home. Other young people living at the home were drawn into the ‘missing’ behaviour and were introduced to the young person’s criminal associates. This does not promote young people’s welfare or safety. Most young people do not engage with education or training. Three of the four young people living at the home are not receiving education or training. Young people stay awake late at night and sleep in late in the day. Staff do not support them to maintain routines and engage in educational activity through the day. This does not promote their

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Overall experiences and progress of children and young people: inadequate

learning or prepare them for independent living. One young person is being re- integrated into school and is currently attending for one hour a week. This represents progress from his starting point.

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Overall experiences and progress of children and young people: inadequate

Staff promote young people’s health. Staff develop positive relationships with local health professionals and encourage young people to engage with universal health services. Staff support some young people to attend and engage with therapeutic interventions which promote their emotional well-being.

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Overall experiences and progress of children and young people: inadequate

Staff develop positive relationships with most young people. Young people value this as they feel stable and make progress. Staff support young people to maintain and develop their family relationships, which promotes their sense of identity. One young person said: ‘Staff have helped with contact and getting me back into school… I am in touch with my family so there is no need to go missing now.’ Staff promote young people’s interests and they enjoyed a holiday in the summer.

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Overall experiences and progress of children and young people: inadequate

Staff develop positive relationships with young people’s families. They advocate for young people so that they are able to develop their family relationships, and this promotes young people’s identities. Families and professionals alike feel that the home is a welcoming environment.

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

Leaders, managers and staff do not effectively identify risk-taking behaviour or develop risk assessments to inform staff on how to minimise presenting risks. Risk assessments are not up to date and, as a result, young people are at risk of and suffer harm. For example, staff do not remove items which pose a risk to young people who are at risk of self-harming, as advised by the child and adolescent mental health service (CAMHS). Staff do not update risk assessments to reflect the current position in relation to young people’s offending behaviour or share this information with all young people’s placing authorities. This does not safeguard young people.

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

Staff do not consistently follow risk assessments which describe how to minimise risks. For example, when a risk assessment describes that staff should not be on their own with a young person, staff continue to take young people out alone or with another young person present. This does not safeguard young people or staff. Risk assessments addressing young people’s substance misuse are very vague regarding what presenting behaviour staff should respond to and how staff should respond. For example, the risk assessment regarding substance misuse details that staff should ‘be vigilant’ and contact Inspection report children’s home: SC472680 8 NHS Direct. The assessment is unclear regarding what actions by staff are necessary when they observe that a young person is under the influence of substances.

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

Staff know what to do and follow young people’s missing from home protocols by attempting to contact young people and their family. Staff report young people missing to the police. However, they do not always search for them. The incidence of ‘missing’ behaviour was reduced when one young person received a custodial sentence and left the home. Staff develop positive relationships with specialist police officers and the youth offending service to support young people who have offended. They do not ensure that the youth offending service shares specialist risk assessments with them in order to provide consistent support and management of risk-taking behaviour.

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

Staff support young people to develop strategies to manage their behaviour. Some young people report feeling that staff support has been influential in helping them to keep themselves safe. Staff do not consistently record the sanctions given to young people. This does not support young people to understand the purpose of this method of control or the duration. It is not useful to sanction young people by putting them on ‘supervised spends’ when the young people are transitioning to semi-independent living within a few weeks. This does not support them to develop their independence or prepare them for adult life. Staff use physical intervention infrequently. Managerial overview fails to identify that there these records are insufficiently clear or detailed, including when young people are restrained into a supine position. The manager does not record that staff have an opportunity to discuss their involvement in using physical

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

intervention. This represents lost opportunities to improve practice and provide support to staff in these emotionally challenging incidents.

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

Staff conduct room searches appropriately when they are concerned that young people have items in their bedrooms which may pose a risk to their welfare. Young people can identify a trusted adult whom they can discuss concerns with. Staff understand how to manage allegations and the manager refers matters to the designated officer appropriately, resulting in prompt investigation. Young people who make allegations feel well supported by their staff team. Bedroom door alarms are in use in the home to alert staff when young people leave their bedrooms at night. Staff ensure that risk assessments are in place regarding the use of bedroom door alarms and the local authority has provided consent. However, the alarms are in use continually, which is contrary to the consent provided, is an intrusion into young people’s privacy and is not reflective of a homely environment.

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

The manager and staff do not notify Ofsted in a timely manner when serious events occur at the home, and at times they do not notify Ofsted at all. This prevents the regulator from being able to monitor patterns and trends in serious events.

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

There is a lack of robust management oversight of recruitment practice. For example, gaps in employment are going unnoticed and references are not being verified. This places young people potentially at risk of unsuitable people working at the home. Such deficits result in a lack of assurance that the necessary safeguards are in place to support and protect children and young people. Inspection report children’s home: SC472680 9

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The effectiveness of leaders and managers: inadequate

The manager has been in post for less than two months, although for two years she was the deputy at the home. She has suitable qualifications and the experience to manage the home, but is not registered with Ofsted. The manager has not made child-centred decisions about a young person coming to live at the home. She has accepted a young person in an emergency without considering the impact of her behaviour on the existing group or whether her placement was compatible with her needs and behaviour. The manager did not consider if staff have the necessary skills, tools and training to meet her needs. For example, the young person is highly vulnerable and uses ligatures, but staff have not all received ligature training and there is no ligature hook at the home. This places the young person and other young people at risk of harm.

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The effectiveness of leaders and managers: inadequate

The manager has begun to consider monitoring and reviewing systems. However, new monitoring procedures are in their infancy and a number of practice shortfalls remain. For example, staff case recording, including within the daily log, is not always clear, the revised statement of purpose has not been sent to Ofsted, and graffiti on a young person’s bedroom wall, which has been there for some months, has not been addressed. Leaders and managers do not know the strengths and weaknesses of the home, and believe that key working is a strength when, in fact, staff are not completing frequent and regular key-work sessions with all young people, including those who are most vulnerable.

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The effectiveness of leaders and managers: inadequate

Staff report that the manager provides the right support through formal and informal supervision. There have been significant staff changes, including the registered manager leaving and delays in recruiting to vacancies. These have led to a period of significant change in staffing in the home. The manager completes a rota to show who has worked in the home. However, it is incomplete as it uses people’s nicknames. This does not safeguard young people or staff, as it is unclear who has worked at the home.

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The effectiveness of leaders and managers: inadequate

The manager knows what progress young people are making. Some young people make progress with staff support, but others do not. Leaders and managers have not taken effective action to meet all the requirements raised at the last inspection, in particular in relation to risk assessments, and effective monitoring and reviewing systems which are not yet in place. The report of the review of the quality of care lacks evaluation and the consideration of the views of young people, their parents, placing authorities and staff. The report has not been sent to Ofsted, preventing the regulator from having oversight of the impact of the quality of care that staff provide.

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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 difference made to the lives of Inspection report children’s home: SC472680 10 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: SC472680 11

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Children’s home details

Registered provider: New Horizons (Stockport) Ltd

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Children’s home details

Registered provider address: 5 Bramhall Park Road, Bramhall, Stockport SK7 3DQ

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Inspector

Rebecca Quested, social care inspector Inspection report children’s home: SC472680 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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