Children's Home run by Cambian Childcare Limited in Dudley

Inspection report children‟s home: SC472465 1 SC472465 Registered provider: Cambian Childcare Ltd

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The home is part of a large limited company. It provides care for up to five children and young people who have emotional and/or behavioural difficulties.

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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 which mean that children and young people are not protected, and their welfare is not promoted or safeguarded. The care and experiences of children and young people are poor and they are not making progress.

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inadequate

Date of last inspection: 21 November 2016

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inadequate

Overall judgement at last inspection: sustained effectiveness

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inadequate

Enforcement action since last inspection: none Inspection report children‟s home: SC472465 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

 Young people are not safe. There are frequent incidents when young people go missing.  Young people at risk of child sexual exploitation continue to be at risk.  Risk assessments are poor and staff do not follow them.  Records of physical restraints do not contain all of the information necessary to safeguard young people.  Staff do not undertake direct work with young people following incidents of bullying, missing from home, self-harm and exploitation.  Staff do not have the skills to identify risk.  Fire safety procedures are not adequate, despite the fact that young people have smoked cannabis and cigarettes in the home.  The management of prescribed medication is weak. Staff do not administer medication as prescribed and fail to record this effectively.  The registered manager and responsible individual have failed to take effective action and have minimised safeguarding incidents raised within this inspection.

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Inspection date Inspection type Inspection judgement

21/11/2016 Interim Sustained effectiveness 14/07/2016 Full Good 11/02/2016 Interim Improved effectiveness 22/07/2015 Full Requires improvement Inspection report children‟s home: SC472465 3

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Statutory requirements

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

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who provide personalised care that meets each child‟s needs, as recorded in the child‟s relevant plans, taking account of the child‟s background. (Regulation 6(1) and (2)(b)(iv)) 18/01/2018

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Requirement Due date

The children‟s views, wishes and feelings standard is that children receive care from staff who take their views, wishes and feelings into account in relation to matters affecting the children‟s care and welfare and their lives. (Regulation 7(1)(c)) 18/01/2018

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Requirement Due date

The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so. (Regulation 8(1)) 18/01/2018

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Requirement Due date

The health and well-being standard is that the health and well- being needs of children are met. (Regulation 10(1)(a)) 18/01/2018

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Requirement Due date

The positive relationships standard is that children are helped to develop, and to benefit from, relationships. In particular, the standard in paragraph (1) requires the registered person to ensure that staff— understand and communicate to children that bullying is unacceptable. (Regulation 11(1) and (2)(a)(xii)) 18/01/2018

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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; that staff help each child to understand how to keep safe; take effective action whenever there is a serious 18/01/2018 Inspection report children‟s home: SC472465 4 concern about a child‟s welfare; 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) and (2)(a)(i)(ii)(vi)(d)) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the

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Requirement Due date

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— 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 the home‟s workforce provides continuity of care to 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 care provided in the home; use monitoring and review systems to make continuous improvements in the quality of care. (Regulation 13(1) and (2)(a)(e)(f)(h)) 18/01/2018

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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)) 18/01/2018

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Requirement Due date

If the Regulatory Reform (Fire Safety) Order 2005(a) applies to the home the registered person must ensure that the requirements of that Order 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)) 18/01/2018

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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 details of the child‟s behaviour leading to the use of the measure; details of any methods used or steps taken to avoid the need to use the measure ; and within 48 hours of the use of the measure, the registered person, or a person who is 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)(ii)(v)(b)(i)(ii)) 18/01/2018 Inspection report children‟s home: SC472465 5

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Overall experiences and progress of children and young people: inadequate

Due to the ineffective leadership of this home, young people are not safe, they are at risk of harm and their welfare is not promoted. Young people are not provided with good-quality, nurturing care. This is in contradiction to the home‟s statement of purpose which states, „Through our parenting approach and therapeutic input, we aim to build on the young people‟s self-worth and self-esteem giving them a positive outlook on life. In turn, our overall outcomes focus on building resilience, and increased positive life opportunities through reduced safeguarding concerns, and other welfare issues.‟ Young people‟s health needs are not met. Staff do not provide sufficient health support for young people. For example, young people‟s immunisations are not up to date and staff do not encourage young people to wear their prescription glasses. Staff do not ensure that medication is administered as prescribed or recorded appropriately. Staff do

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Overall experiences and progress of children and young people: inadequate

not know when young people have had their medication due to poor record-keeping. These shortfalls negatively impact on young people‟s physical well-being. Staff do not have high aspirations for young people in respect of their education and fail to make sure that young people complete their homework when they are not attending school. Three young people are not attending education full time. Young people‟s current personal education plans are not accessible to staff and, as a result, staff are not aware of young people‟s educational needs. Consequently, staff are unable to support young people adequately. As a result, young people do not fulfil their potential to learn and achieve. The physical appearance of the home is not welcoming for young people. Offensive language is written on the walls in communal areas. There are bars on a window, window blinds are broken, and there are hazards such as a hole in the stairs and mess in

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Overall experiences and progress of children and young people: inadequate

the back garden, including a can of spray oil solution. The bedrooms for some young people are extremely untidy, with graffiti on the door of one young person‟s room. Direct work with young people does not reflect the aims and objectives of their care plans. Staff do not plan direct work, but rather undertake it reactively following incidents. Furthermore, staff do not complete direct work when requested by the registered manager. For example, stranger danger work, after a young person went missing, was not completed. Consultation with young people is ineffective. Staff do not consistently seek feedback or young people‟s views, wishes and feelings in respect of the home or their individual care planning. As a result, young people do not influence the running of the home or their own plans.

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

A lack of management oversight, coupled with dangerous staff practice, places young people at risk. Staff fail to keep young people safe. Risk assessments lack rigour and lead to insufficient management of presenting risks. They do not clearly identify risks or the strategies that staff need to follow in order to Inspection report children‟s home: SC472465 6 reduce them. Furthermore, managers and staff do not update risk assessments after significant incidents, such as young people running in front of moving cars. Staff do not follow guidance to reduce safeguarding incidents. For example, staff do not undertake room searches to identify and remove dangerous items in order to reduce the risk that young people will use these items to harm themselves. This means that young people are at risk of harm. In addition, the responsible individual refused to remove a water hose from the garden as she did not want to make the home „institutionalised‟, despite

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

the fact that this could be used as a ligature. The responsible individual does not follow risk assessments that state that items that could be used as ligatures are removed from the home. As a result, the responsible individual does not act as a positive role model to influence staff practice. This continues to place young people at risk of harm. Young people have gone missing on 40 occasions since the last inspection, despite them being supervised on a 1:1 basis. Young people who are assessed as being of high risk of child sexual exploitation have been sexually exploited when missing. Staff do not have the skills to identify when young people are at risk and do not take effective action. For example, staff do not always follow young people on foot or follow them down „alleyways‟ if it is dark. As a result, young people evade staff and go missing. On one occasion, a member of the public found a young person who had self-harmed in the

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

middle of the night and returned her home in a taxi. Direct work following safeguarding incidents is ineffective. Staff do not ensure that definitive work is undertaken to address risk-taking behaviours. As a result, there is a lack of preventative work in order to minimise future incidents. Consequently, young people remain at risk. Staff do not protect young people. Inspectors observed poor standards of care in young people‟s bedrooms. For example, rubbish had not been cleared away and clothes were all over the floor and in the bottom of wardrobes. Furthermore, the inspector found a cable in a young person‟s bedroom that could potentially be used by the young person to self- harm. Although the registered manager gave the inspector assurances that she would remove the cable, the inspector found the following day that no such action had taken place. The registered manager did not take immediate or effective action to ensure the

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

young person‟s safety. Placing authorities, the police and the child and adolescent mental health team have all raised concerns about whether staff and managers are able to keep young people safe. However, managers and staff are not alert to these risks. They do not act swiftly enough to manage them and minimise potential risks to young people‟s well-being. There have been 31 physical restraints since the last inspection. The recording of the restraints does not provide an adequate account of the rationale for the use of the measure. Staff do not always document the actions that they have taken to try to de- escalate the situation prior to a restraint, or document the young person‟s actual behaviour. In addition, young people‟s views of the restraint are not always recorded. The manager has not identified these issues or followed them up with staff. Further, the registered manager has not followed the home‟s procedures in respect of reviewing

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

physical interventions. Specifically, the registered manager has been involved in an incident of restraint and then proceeded to review the restraint herself. The registered manager did not act in accordance with the home‟s procedures and request a review by the responsible individual. This demonstrates a failure to appropriately review incidents Inspection report children‟s home: SC472465 7 and to take effective action. Managers and staff do not respond to incidents of bullying effectively. Staff do not undertake any direct work with the young people involved. This means that young people do not understand the impact that bullying has on others. Young people who are bullied do not have the opportunity to talk about their feelings. Young people have been subjected to threats of violence and physical assaults. One young person asked for staff to stay in her room with her for fear of being „attacked‟ by another young person. As a

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

result, young people‟s self-esteem, self-confidence and physical safety are all compromised. Management oversight of fire safety is weak. During the inspection, the registered manager was unaware of one of the three incidents that had occurred when young people were smoking cigarettes and cannabis in the home. Staff have not amended or updated the risk assessments of the young people involved. Further, staff have failed to ensure that this information is documented and made known to other staff and managers. This means that young people‟s behaviour has not been challenged effectively and represents an avoidable risk that staff are failing to manage. Smoking on the premises is a breach of the home‟s smoking policy. Neither the home‟s fire risk assessment nor young people‟s risk assessments take this into account, or outline suitable strategies to reduce this risk. This places young people, staff and visitors at

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The effectiveness of leaders and managers: inadequate

A suitably qualified registered manager is in post. Poor management oversight means that the registered manager has not identified significant weaknesses in practice and procedures. The registered manager‟s lack of scrutiny has contributed to the poor quality of care provided to young people. Despite the deputy manager identifying practice issues with staff, the registered manager has not taken any action to ensure that this improves. The registered manager minimises areas where improvement is necessary. For example, the deputy manager raised in a team meeting concerns about the attitude of some staff who see young people as „a burden‟. The minutes of the meeting show that the deputy manager informed staff that they „can‟t come in a bad mood and take it out on the kids… culture of staff got to change, disciplinarians will happen. Have to parent kids... needs to be a nicer atmosphere.‟ The registered manager and responsible individual minimised

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The effectiveness of leaders and managers: inadequate

these concerns, the responsible individual referring to the comments as „a motivational speech‟. Consequently, due to the attitude of some of the team, young people do not benefit from consistent, good-quality care from staff. Furthermore, the registered manager and responsible individual do not acknowledge or reflect on concerns raised or drive forward improvement. Poor practice is not challenged and has been allowed to continue. This home lacks strong, safe and proactive management. Managers do not adequately monitor or review practice. Managers do not understand the impact that the poor quality of care provided to young people has on their safety and experiences. Managers are ineffective in identifying areas where the service has not met regulations, or the areas of greatest risk. Managers‟ monitoring and scrutiny of serious incidents, the safety of the Inspection report children‟s home: SC472465 8

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The effectiveness of leaders and managers: inadequate

home, and the actions of staff are all ineffective. Because of the serious deficits in this service, Ofsted has imposed a restriction until 7 March 2018 to prevent any further admissions to the home. Ofsted will visit during this period to monitor compliance with the restriction.

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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: SC472465 9

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Children’s home details

Registered provider: Cambian Childcare Ltd

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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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Children’s home details

Responsible individual: Alison Blyth-Bishop

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Inspector

Sandra King, social care inspector Inspection report children‟s home: SC472465 10 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 children looked after, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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