Children's home run by Horizon Care Limited in Cannock Chase

Inspection report children’s home: SC035690 1 SC035690 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

The home provides care and accommodation for up to four children or young people who have emotional and/or behavioural difficulties. The home is privately owned and operated and forms part of a larger organisation.

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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.

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inadequate

Date of last inspection: 16 October 2017

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inadequate

Overall judgement at last inspection: Not judged

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Enforcement action since last inspection:

None Inspection report children’s home: SC035690 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

 One young person has been at repeated risk of serious harm.  Three serious incidents have occurred which could have resulted in the young person’s death or life-changing injuries.  Serious incidents have occurred, including a young person trying to start a fire in the house, trying to self-harm with a cable, and physically assaulting another child and members of staff.  Inexperienced, unqualified staff often work alone in the home with limited knowledge of the location and the risks associated with the local area.  There is insufficient staffing to meet the needs of children and young people who have been admitted since October 2017.  The manager and staff do not use essential information in children’s and young people’s care planning records to reduce risk.  Managers fail to assess the risks associated with the home’s size and location when deciding to admit children and young people.  Staff fail to ensure that the home environment is kept clean and free of

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Key findings from this inspection

hazards.  Managers do not plan or deliver staff training and development.  Managers have failed to assess the risks and implications of staff working on their own.  The manager has been away from the home for almost three weeks. During this time, staff have not received sufficient managerial support.  The manager and registered individual admit children and young people without an adequately sized staff team being in place.  The manager and registered individual admitted another child without first assessing the expressed views of a young person already living in the home.  The manager and registered individual have not ensured that a young person’s move out of the home took into account the young person’s physical and emotional needs.  The manager and registered individual have not maintained an adequate level of transparency in their communications about children’s and young people’s progress with placing authorities or with the regulator, Ofsted.

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Key findings from this inspection

 The organisation has not identified or provided the registered individual and registered manager with necessary ongoing professional development to help inform and improve their practice. Inspection report children’s home: SC035690 3 The children’s home’s strengths

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Key findings from this inspection

 Children and young people like the manager and most staff.  Staff try hard to give the remaining child the attention that they require.

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Inspection date Inspection type Inspection judgement

16/10/2017 Interim Not judged 23/11/2016 Interim Declined in effectiveness 24/05/2016 Full Good 10/11/2015 Interim Sustained effectiveness Inspection report children’s home: SC035690 4

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Statutory requirements

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

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Requirement Due date

The 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. (Regulation 12(1)(2)(a)(i)) * 25/02/2018

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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 have the skills to identify and act upon signs that a child is at risk of harm; manage relationships between children to prevent them from harming each other; and take effective action whenever there is a serious concern about a child’s welfare. (Regulation 12(1)(2)(a)(iii)(iv)(vi)) 25/02/2018

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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 the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm. (Regulation 12(1)(2)(b)) 25/02/2018

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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 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)(d)) 25/02/2018

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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 helps children aspire to fulfil their potential; 25/02/2018 Inspection report children’s home: SC035690 5 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. (Regulation 13(1)(2)(a)) The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that helps children aspire to fulfil their potential; and promotes their welfare. In particular, the standard in paragraph (1) requires the registered person to ensure that staff have the experience, qualifications and skills to meet the needs of each child, and

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Requirement Due date

that the home has sufficient staff to provide care for each child. (Regulation 13(1)(2)(c)(d)) * 25/02/2018

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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 helps children aspire to fulfil their potential; and promotes their welfare. In particular, the standard in paragraph (1) requires the registered person to 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. (Regulation 13(1)(2)(f)) 25/02/2018

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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 helps children aspire to fulfil their potential; and promotes their welfare. In particular, the standard in paragraph (1) requires the registered person to demonstrate that practice in the home is informed and improved by taking into account and acting on feedback on the experiences of children, including complaints received. (Regulation 13(1)(2)(g)(ii)) 25/02/2018

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Requirement Due date

The care planning standard is that 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. In particular, the standard in paragraph (1) requires the registered person to ensure that arrangements are in place to manage and review the placement of each child in the home; and plan for, and help, each child to prepare to leave the home in a way that is consistent with arrangements agreed with the child’s placing authority. (Regulation 14(1)(2)(b)(ii)(iii)) 25/02/2018 Inspection report children’s home: SC035690 6 If the registered provider is an organisation, the organisation must ensure that the responsible individual undertakes such continuing professional development as is necessary to ensure that the responsible individual has the skills needed for supervising the management of the home. (Regulation 29(2)) 25/02/2018

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Requirement Due date

The registered manager must undertake such continuing professional development as is necessary to ensure that the registered manager has the skills needed for managing the home. (Regulation 29(4)) 25/02/2018

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 If it is likely that there might only be one member of staff on duty at any time, the manager should make a formal assessment of the implications for children’s care, including any likely risks. This assessment should be recorded and available for inspection by Ofsted and placing authorities. (‘The guide to the children’s homes regulations, including the quality standards’, page 54, paragraph 10.18)

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Overall experiences and progress of children and young people: inadequate

In the three months since the home has re-opened, one young person and one child have lived here. The young person’s placement came to an emergency ending on 30 December 2017 when she physically assaulted the other child in placement. She also physically assaulted a member of staff and caused serious damage to the house. This led to the staff requiring the assistance of the police. The young person made little progress with her emotional health and behavioural problems during the time that she lived here. The registered manager and responsible individual accepted her into placement when they only had two inexperienced and unqualified staff assigned to the home. Three other staff were brought in to help, but did not have either the knowledge of the risks associated with the remote location of the home, or the skills to manage and minimise them. Despite the staff’s efforts to meet the young person’s needs, they did not have the skills or support required to keep the young

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Overall experiences and progress of children and young people: inadequate

person safe. The young person had some taster sessions offered at the organisation’s school and expressed some interest in going to the school. However, funding for this was not agreed with the placing authority and this left the young person with no arrangement for formal education secured. The one remaining child living in the home has just started morning sessions at the organisation’s school and this is going well. The young person missed her family and friends. Staff supported her to see her mother on a few occasions, but plans to manage her use of her mobile phone and who she Inspection report children’s home: SC035690 7 could contact were not agreed and not understood by the young person and staff. Managers did not take the young person’s expressed concerns about the admission of another child seriously. This led to a further deterioration in the young person’s behaviour. When her placement broke down, her clothes and belongings were not taken

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Overall experiences and progress of children and young people: inadequate

to her new placement until ten days after she had moved out. Her requests to see the manager and a particular member of staff were still not met ten days after she had left the home. This demonstrates a lack of respect for and attention to the young person’s feelings and wishes. Children and young people do not live in an environment that is kept clean and tidy. Children’s and young people’s bedroom floors are left with dirty laundry, cups and rubbish. Bedrooms do not contain a bin or laundry basket. The washing machine is broken and used bedsheets are left in the hall and outside a bedroom. No household rubbish has been collected from the home since it reopened in October 2017. The child still living in the home enjoys the staff’s company. Three members of staff work in rotation on their own to support him. Staff are kind, nurturing and reassuring towards the child, including playing games with him and making sure he has fun.

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Overall experiences and progress of children and young people: inadequate

However, the child requires a high level of staff attention and this means that staff working on their own have too limited time to do other required tasks.

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

One young person was at repeated risk of serious harm throughout her six-week placement. The manager and staff did not effectively plan how to minimise her risk- taking behaviour. Plans from the young person’s placing authority clearly highlighted known and significantly high-risk behaviour that she had repeatedly shown. However, the manager and the staff team’s plan to manage these risks was vague. Written risk management plans failed to help or support unqualified staff who were new to residential childcare. For example, plans repeatedly say ‘Use de-escalation techniques, distraction and incentives’ next to almost every listed risk-taking behaviour. There were no details about what staff should actually do in practice. Consequently, managers and staff do not have systems in place to identify and manage or minimise risk. There is clear evidence of incidents occurring that could have resulted in the young

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

person suffering death or life-changing injuries. For example, the young person managed to get hold of the home’s car keys and drive away in the vehicle. She drove the car a long distance, for some hours, before stopping and calling the police herself. On another occasion, she wrapped a cable around her neck and held it tight for a long period. This caused her to faint and necessitated an ambulance crew and police having to attend to help. Other serious incidents have also occurred. This has included the young person trying to start a fire, using different ways to self-harm, such as trying to use glass and wires, as well as breaking down doors and physically assaulting the other child and members of staff. The young person also went missing from the home on foot, on a high, unlit moorland in winter and jumped off a seven-foot bridge. The manager advised staff that, if the young person was ‘heightened’ or in distress, they should give

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

her 20 minutes outside ‘to cool off’ before going to look for her. Police told the manager that this was unsafe advice, given the risks that the young person took and the location Inspection report children’s home: SC035690 8 of the home. The manager took an over-optimistic evaluation of the staff team’s ability to keep the young person safe and the impact of admitting a new child. This poor decision-making led to the managers making the decision to admit a nine-year-old child. Two weeks later, on 30 December 2017, the police needed to be called by the staff on duty to help safeguard the younger child. This resulted in the police arresting the young person after she had thrown the younger child to the floor and had kicked both him and the staff on duty. Children and young people are not safe because risks related to the location of the home, as well as conditions inside the home, are not safely managed. In particular,

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

managers have failed to correctly assess the dangers posed by lone working and having minimal levels of staff on duty. Staff worked alone with the young person and managers only increased the staff team when the nine-year-old child was admitted. The decision- making over the staffing levels is not based on children’s and young people’s individual needs. This poor quality of decision-making also failed to take account of the large, six- bedroom house which also has four exit doors across five downstairs rooms. Consequently, staff cannot easily know if children and young people are going out or if anyone is coming into the house. There are poor telephone and internet signals, no doorbells, and exit door alerts are only set after bedtime because staff can only hear them in their sleeping-in room. This means that children and young people can easily go missing and/or harm themselves without the staff knowing.

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

There are not enough staff on duty to keep the environment clean and free of hazards that pose unacceptable risks to young people and children. For example, staff have not had the time to clean up the young person’s bedroom ten days after she had left. The young person’s bedroom contains broken furniture with splinters of wood all over the floor and a large, rusty nail by the bed. Staff have not cleared away large rocks from the dry stone wall that are littered all around the front of the home. There are trailing wires all around the house, including cables pulled away from the wall. These hazards make children and young people unsafe. Staff have received some training about self-harm, but they do not feel confident to keep young people safe. They do not have ligature cutters on the premises and have not received any training on how to use them.

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The effectiveness of leaders and managers: inadequate

The manager agreed to take an extremely complex young person into the home before she had trained and prepared the staff team. The young person arrived when there were no qualified or experienced staff in post. The manager and registered individual did not prepare or develop the staff team so that they could provide safe care to this particular young person. The manager unwisely relied on her own direct input with the young person and the relationship that she formed with the young person to inform her decisions. Despite staff reporting incidents of concern, the manager still agreed to admit another child without enough consideration being given to the already resident young person’s risk-taking behaviour increasing, and despite the fact that the young person expressed her own significant concerns over having another child being admitted. Inspection report children’s home: SC035690 9 Staff expressed serious concerns about their ability to safeguard the young person

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The effectiveness of leaders and managers: inadequate

because they did not have the skills, experience or training to do so. As a result, staff were unable to prevent three different life-threatening incidents in the space of six weeks. The manager and the registered individual left the home without adequate staffing or direct management cover from 23 December to the day of inspection. The absence of managerial oversight and inadequate staffing resulted in further serious incidents occurring and the unplanned and poorly executed end to the young person’s placement. Staff did not have the knowledge, confidence or skills to challenge the registered manager or the registered individual about their concerns. For example, one member of staff told the inspector, ‘We thought that all homes were run like this.’

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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: SC035690 10

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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

Rachel Britten, social care inspector Inspection report children’s home: SC035690 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 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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