Children's home run by Horizon Care Limited

Inspection report children’s home: SC068223 1 SC068223 Registered provider: Horizon Care 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 is a privately run children’s home offering care and accommodation for up to three young people who may 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 widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded and 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: 6 September 2017

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inadequate

Overall judgement at last inspection: inadequate

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Enforcement action since last inspection:

The home was judged inadequate at the full inspection on 18 July 2017. A follow-up inspection was completed on 6 September 2017 and the home was again judged as inadequate. Following the inspection, compliance notices were issued under Regulation 12 and Regulation 13. Both notices were met at a monitoring visit on 24 October 2017. Inspection report children’s home: SC068223 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

 Leadership and management arrangements in the home continue to be ineffective.  Transitions for young people in and out of the home are poor.  The provider has failed to take effective action to meet the requirements made at the last inspection resulting in a lack of improvement in the service.  The registered manager has failed to ensure that she makes child-centred decisions about young people coming to live in the home.  Risk management arrangements in the home continue to be poor and do not protect young people from harm.  The registered manager has failed to ensure that she has used the monitoring and review systems to make continuous improvements in the quality of care provided in the home.  Recording in the home is poor and fails to provide an accurate account of young people’s care experience.

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Key findings from this inspection

 A stable and experienced staff team work in the home.

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Inspection date Inspection type Inspection judgement

06/09/2017 Full Inadequate 18/07/2017 Full Inadequate 15/03/2017 Full Good 06/07/2016 Interim Sustained effectiveness Inspection report children’s home: SC068223 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

In meeting the quality standards, the registered person must, and must ensure that—

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Requirement Due date

if the registered person considers, or staff consider, a placing authority’s or a relevant person’s performance or response to be inadequate in relation to their role, challenge the placing authority to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans. (Regulation 5(c)) 23/02/2018

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Requirement Due date

In order to meet the protection of children standard the registered provider must ensure that—

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Requirement Due date

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.

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Requirement Due date

that the premises used for the purposes of the home are located so that children are effectively safeguarded. (Regulation 12(2)(a)(i)(c)) 23/02/2018

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Requirement Due date

In order to ensure the care planning standard is met, the registered provider must ensure that—

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Requirement Due date

children receive effectively planned care in or through the children’s home and have a positive experience of arriving at or moving on from the home. (Regulation 14(1)(a)(b)) 23/02/2018

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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 their welfare. (Regulation 13(1)(b))

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Requirement Due date

(2) ) 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; 23/02/2018 Inspection report children’s home: SC068223 4 ensure that the staff have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

the home has sufficient staff to provide care for each child; Use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(2)(a)(c)(h)) The registered person must provide for records to be kept of an allegation of abuse and the action taken in response. (Regulation 34(2)(d)) 23/02/2018

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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 effectiveness and the consequences of the measure. (Regulation 35(3)(a)(vii)) 23/02/2018

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Requirement Due date

The registered person must maintain records (‘case records’) for each child which include the information and documents listed in Schedule 3 in relation to each child; are kept up to date; and are signed and dated by the author of each entry. (Regulation 36(1)(a)(b)(c)) 23/02/2018

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Overall experiences and progress of children and young people: inadequate

Poor leadership and management practice and inadequate risk management in the home have compromised the experience and progress of young people. This has left young people at risk of harm.

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Overall experiences and progress of children and young people: inadequate

Since the monitoring visit on 24 October 2017, the provider has admitted two young people to the home. The inspector found significantly poor practice and regulatory breaches in transition planning for the young people. Prior to the placement, the registered manager did not carefully consider the individual needs of the young people. This has impeded young people’s progress and caused them considerable disruption in their lives. This has resulted in very short placements and poor outcomes for the young people.

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Overall experiences and progress of children and young people: inadequate

Transitions for young people in and out of this home are poor. The home’s statement of purpose states that the ‘admission of any child, whether planned or in an emergency, would be subject to receipt of the relevant paperwork.’ The registered manager admitted a young person to the home without the required paperwork for a child looked after. The placement ended two days later, as the placing authority failed to provide this paperwork. During this period, the young person was extremely distressed and went missing from the home. When the police located the young person, staff refused to allow her back into the home, indicating that her placement had ended. This was not a positive experience or transition for this young person and contributed to her reaching Inspection report children’s home: SC068223 5 crisis point and being at risk of harm and a further placement move.

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Overall experiences and progress of children and young people: inadequate

The registered manager had not considered the risks in the local area when considering new admissions. There is a guided bus way next to the house. The home’s location risk assessment, completed by the registered manager, states that referrals will not be accepted if young people have a history of suicide risk, due to the tracks being easily accessible. However, the registered manager has agreed to the admission of young people with a known risk of self-harm. There is no evidence in the impact risk assessment, initial risk assessment or placement plan that there has been any assessment of this risk in considering whether the placement was suitable or safe. This lack of assessment and planning for new admissions leaves young people at significant risk of harm.

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Overall experiences and progress of children and young people: inadequate

Due to the limited time that young people have lived at the home, it is not possible to measure how staff have contributed to their progress in areas such as health or education. One young person’s placement ended in under 48 hours, and she had been missing from the home within this time. Another young person had been in placement for less than one week. Staff had registered the young person with the relevant health services but her educational needs were not prioritised.

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

Inadequate management of risk within this home compromises the safety of young people. This was a concern at the last full inspection on 6 September 2017, resulting in a compliance notice being served under regulation 12(2) (a) (i). For one young person, the risk assessment identified that they are at high risk of self-harm. Despite this level of risk, the registered manager has failed to ensure that there are recorded measures in place to support staff to reduce the risk of self-harm for young people. There is a lack of written guidance for staff to follow to reduce known risks, including risks associated with alcohol and substance misuse. This means that there is no clear guidance for staff to follow to ensure a safe and consistent response in these circumstances. This does not ensure that young people are kept safe from harm.

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

Since the last inspection, the registered manager and staff have undertaken further training in the procedures they are required to follow when young people go missing from the home. Young people have missing from home risk assessments and staff follow young people and report them to the police when they go missing. However, missing from home risk assessments are generic and do not include guidance for staff to follow to manage the identified risk for specific young people. For example, for young people who are at high risk of self-harm, there is no specific reference to staff checking known areas of risk in the local area or for this information to be passed on to the police. This lack of coordinated response leaves young people at risk of harm.

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

The provider has not ensured that all staff have received training in ligature use despite this being a known risk for some young people in the home. Furthermore, the registered manager has not ensured that there is clear guidance for staff to follow on the use of ligature cutters. This limits staff’s ability to take effective action to keep the young Inspection report children’s home: SC068223 6 person safe.

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

In the short time that the young people have been living at the home, there have been a number of significant events for staff to manage. Staff use strategies to try to de- escalate young people’s behaviour but these strategies are not always effective. There have been two restraints since the last inspection. The use of restraint is in accordance with the legislative framework and as a last resort to protect the young person or others around them. Incidents are recorded and the views of the young person are obtained . However, the registered manager does not consistently evaluate the effectiveness of any restraints carried out. This lack of management oversight of restraint practice means that any issues with staff practice are not identified. Since the last inspection, a young person made an allegation about staff practice. The registered manager stated that she had spoken to the designated officer, but failed to

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

maintain an up-to-date record of the allegation, including the outcome of the investigation or the feedback from the designated officer. This failure to follow procedures compromises the safety of young people.

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The effectiveness of leaders and managers: inadequate

During the full inspection, the inspector found that there continues to be a lack of effective leadership and management in the home. The registered manager has failed to ensure that she has used the monitoring and review systems to make continuous improvements in the quality of care provided in the home. Consequently, until the inspection, areas of weakness had not been identified or decisive action taken to resolve these issues.

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The effectiveness of leaders and managers: inadequate

The registered manager has not been effective at addressing the shortfalls that have been raised during previous inspections to make positive and sustained change. The requirements that were raised during the full inspection on 18 July 2017 were still not met. These requirements have been repeated. In addition, this inspection identified further breaches in The Children’s Homes (England) Regulations 2015.

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The effectiveness of leaders and managers: inadequate

Throughout the inspection, the registered manager was asked about the progress of the home. She said, ‘I have not had as much time on it as I would like; [name of young person] has only been here a few days. My focus has been with her, building relationships, verbally giving guidance to the staff, who have been on the phone to me about what they should be doing. I had only looked at them [young person documents and assessments] briefly but not in depth.’ The registered manager failed to understand the importance of the required documentation and had failed to monitor and make improvements to the quality and care provided in the home in an effective manner, leaving young people at risk of harm. Consequently, young people do not benefit from positive experiences and improved outcomes during their time at this home.

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The effectiveness of leaders and managers: inadequate

Managers have failed to take effective action in challenging a placing authority when they considered that the placing authority actions were inadequate in relation to their role. Throughout the inspection, the registered manager and regional operations manager did not take full responsibility for the manner in which transitions into the home occurred, expressing the view that it was the placing authority at fault. However, Inspection report children’s home: SC068223 7 other than emails to the placing authority requesting the children looked after paperwork, there was no evidence that the registered manager or the regional operations manager challenged the local authority effectively. This resulted in a poor outcome for a young person.

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The effectiveness of leaders and managers: inadequate

The registered manager assured inspectors, at the monitoring visit on 24 October 2017, that there were new systems in place for recording and monitoring. However, the inspector found that recording in the home continues to be inadequate. The registered manager could not find an agreement that she reported was in place with the placing authority to manage the risks for a young person with a history of fire starting. This should have been accessible on the young person’s file. In addition, the registered manager had not recorded a conversation with the designated officer regarding an allegation that a young person had made and there was a lack of recording around the decision-making process for a young person’s transition into the home. The registered manager informed the inspector that conversations with a young person’s previous home about risks of traffic and the bus lane were ‘notes on a bit of paper’. Poor recording

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The effectiveness of leaders and managers: inadequate

means that there is a lack of transparency about events in the home and this potentially leaves young people at risk of harm.

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The effectiveness of leaders and managers: inadequate

The registered manager has received support from a regional area manager since the last inspection. She reported that she has found this support helpful. Despite this, she still lacks confidence in the leadership role. She commented during the inspection, ‘I still need to be stronger; I am out of my comfort zone, and it’s not me as a person. To a degree, I have got better. I do think I have improved a lot but have some way to go. It’s not naturally me, it’s a lot easier when someone behind me who will back and support me.’ This demonstrates that the registered manager lacks the confidence to lead and manage the home robustly.

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The effectiveness of leaders and managers: inadequate

A stable and experienced staff team works in the home. Staff report that they feel well supported in their roles. The registered manager has ensured that staff have regular supervision and appraisals. Since the last inspection, staff have undertaken training in missing from home procedures, risk assessments and whistle-blowing to help them understand their roles and responsibilities in relation to the young people they are looking after. It is evident from team meeting minutes that managers and staff have reflected on their practice and are committed to making the required changes. Unfortunately, despite the training, the staff have been unable to translate this into practice that promotes the safety and welfare of young people.

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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, 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 Inspection report children’s home: SC068223 8 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: SC068223 9

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Children’s home details

Registered provider: Horizon Care Limited

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Children’s home details

Registered provider address: Venture House, 12 Prospect Business Park, Longford Road, Cannock, Staffordshire WS11 0LG

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Inspector

Sarah Billett, social care inspector Inspection report children’s home: SC068223 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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