Children's home run by Castle Homes Limited in North Northamptonshire

Inspection report children’s home: SC419330 1 SC419330 Registered provider: Castle Homes Limited

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Inspected under the social care common inspection framework

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Information about this children’s home

This home is registered to accommodate three young people who have emotional and/or behavioural difficulties. It is owned by a large private organisation.

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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 and/or widespread failures that mean young people are not protected or their welfare is not promoted or safeguarded and/or the care and experiences of children and young people are poor and they are not making progress.

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inadequate

Overall judgement at last inspection: sustained effectiveness

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Enforcement action since last inspection:

None Inspection report children’s home: SC419330 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

 Poor admissions practice meant that the home failed to plan effectively for a young person’s move into and out of the home.

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Key findings from this inspection

 Risk-management practice is poor. Staff do not receive the guidance they need in order to increase young people’s safety or to promote their welfare.

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Key findings from this inspection

 Guidance for staff in relation to when and how to administer medication is contradictory. This omission has gone unnoticed by leaders and managers.

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Key findings from this inspection

 Inadequate internal monitoring systems mean that management has failed to identify serious shortfalls.

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Key findings from this inspection

 Care staff demonstrate a strong commitment towards the young people.

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Inspection date Inspection type Inspection judgement

28/03/2017 Interim Sustained effectiveness 13/09/2016 Full Good 28/01/2016 Interim Improved effectiveness 07/10/2015 Full Requires improvement

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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, 23/02/2018 Inspection report children’s home: SC419330 3 and must ensure that staff-

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Requirement Due date

(a) seek to involve each child’s placing authority effectively in the child’s care, in accordance with the child’s relevant plans; In particular, this is in relation to sending incident forms without delay and ensuring that staff are able to use recording processes effectively.

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Requirement Due date

(c) 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 or the relevant person to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans. In particular, this is with regard to challenging the local authority regarding its plans for a young person’s move from the children’s home.

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Requirement Due date

(d) seek to develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate having regard to the range of needs of children for whom it is intended that the children’s home is to provide care and accommodation. In particular, this is to ensure that a parent is aware of serious incidents regarding their child. (Regulation 5(a)(c)(d))

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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.

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Requirement Due date

(2) In particular, the standard in paragraph (1) requires the registered person to ensure-

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Requirement Due date

(i) 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. In particular, this is so that risk assessments inform staff regarding strategies to minimise risk and are updated in response to a change in circumstances; this includes clarity in relation to the administration of the use of medication. (Regulation 12(1)(2)(a)) 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- 23/02/2018 Inspection report children’s home: SC419330 4 (b) promotes their welfare; In particular, this is in relation to a young person’s experience of living in the home and her emotional welfare.

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Requirement Due date

(2)(c) ensure that staff have the experience, qualifications and skills to meet the needs of each child; This is in relation to ensuring that all staff, including agency workers have the necessary qualifications and skills.

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Requirement Due date

(e) ensure that the home’s workforce provides continuity of care to each child; This is in relation to one young person’s experience of living in the home and moving from the home.

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Requirement Due date

(h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. This is in particular to ensure that essential paperwork is completed and regularly reviewed. (Regulation 13(1)(b)(2)(c)(e)(h)) The care planning standard is that children-

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Requirement Due date

(a) receive effectively planned care in or through the children’s home; In particular, this is to ensure that the matching process and placement plan give the necessary guidance to staff to manage a young person’s complex needs.

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Requirement Due date

(b) have a positive experience of arriving at or moving on from the home. In particular, this is with regard to ensuring a move from the children’s home is sensitively managed and well planned. (Regulation 14(1)(a)(b)) 23/02/2018

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Requirement Due date

The registered person must ensure that for the purposes of paragraph (3)(b), an individual who works in the home in a care role, has the appropriate qualification if, by the relevant date, the individual has attained the Level 3 Diploma for Residential Childcare (England) (‘the Level 3 Diploma’); or a qualification which the registered person considers to be equivalent to the Level 3 Diploma. In particular, this includes agency workers. (Regulation 32(4)(a)(b)) 23/02/2018 Inspection report children’s home: SC419330 5

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Overall experiences and progress of children and young people: inadequate

Inadequate processes for moving one young person into the home resulted in leaders and managers failing to plan effectively for this young person’s care. The lack of recognition of her needs and the failure to create a clear care plan resulted in this young person experiencing a negative journey into and out of the home.

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Overall experiences and progress of children and young people: inadequate

Managers failed to implement a compatibility risk assessment at the point of receiving this referral. Consequently, staff skill deficits were not considered and neither was the impact of this young person on other young people already living in the home.

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Overall experiences and progress of children and young people: inadequate

Therapeutic support for the young person was identified as essential; however, this was not provided. Staff did not have support from external health professionals to advise them on the management of the young person’s mental health needs. Managers failed to recognise the significance of this young person’s complex needs. Consequently, weak care planning resulted in no clear guidance for staff and the young person’s needs were not met.

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Overall experiences and progress of children and young people: inadequate

The decision of leaders and managers to serve immediate notice to end the young person’s placement led to further trauma for the young person. The move was ill- planned and the young person was not consulted or helped to prepare for the move. For this young person, the experience of living in this home has done nothing to aid her sense of security and permanence.

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

Weak safeguarding practice and the lack of detailed care planning guidance undermine staff’s ability to safely manage young people’s complex needs. In one example, managers failed to recognise that risks to a young person were increasing, despite clear indicators of this through her increasingly concerning behaviour. Consequently, staff were unable to minimise the risks she faced.

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

Managers fail to respond to changing risks. Consequently, staff guidance lacks sufficient and up-to-date details. In some cases, staff rely on verbal instructions from each other on managing risky situations. This increases the likelihood of inconsistent staff practice. In one example, managers failed to implement a clear plan in response to a young person’s return from hospital. Not all staff were clear about the plan for the young person’s care. Consequently, the young person was exposed to further risk as a result of being unsupervised.

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

Contradictory health protocols are confusing. In one example, two different documents, regarding the protocol for seizure management, led to medication being offered to a young person incorrectly. Inspection report children’s home: SC419330 6

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The effectiveness of leaders and managers: inadequate

Leaders and managers failed to sufficiently scrutinise referral information in order to make informed admission decisions. They failed to recognise staff deficiencies in respect of the staff team’s training and skills, resulting in poor experiences for a young person and the staff team.

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The effectiveness of leaders and managers: inadequate

The registered manager fails to demonstrate effective leadership. This is exacerbated by the amount of time she spends away from the home in other roles for the organisation. Insufficient time and energy are spent on monitoring the quality of the care provided in the home. Examples include the failure to recognise poor-quality risk assessments and care planning guidance for staff. One example of insufficient monitoring demonstrates that a near-miss medication incident has not been reviewed.

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The effectiveness of leaders and managers: inadequate

Staffing levels are sufficient in number but the deployment of staff is not always driven by the needs of the young people. One example is the use of an unqualified agency staff member to lead a waking-night shift. This example is of particular concern, given the known risks about one young person at the time.

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The effectiveness of leaders and managers: inadequate

Leaders and managers provide inconsistent support for the staff team. One staff member said that she felt well supported by the registered manager; however, she expressed concerns about the support offered by the wider organisation. Another staff member who experienced a traumatic incident described poor support during and after this incident. This lack of practical or emotional support during a crisis undermines staff morale and staff’s ability to respond confidently should they be faced with a similar situation in the future.

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The effectiveness of leaders and managers: inadequate

Staff report that the electronic recording process is difficult to use and not all staff are trained to use it. Additional organisational monitoring processes mean that serious incident records go through a quality assurance process. This results in important documents not being sent to other professionals promptly, compromising their ability to respond swiftly.

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The effectiveness of leaders and managers: inadequate

Similar shortfalls relate to poor communication with other stakeholders. The registered manager failed to notify a parent of a serious incident in a timely manner. Managers have failed to challenge the poor practice of a local authority who decided to inform a young person by telephone of their imminent move from the home. Leaders and managers colluded with this action that failed to follow basic good care principles.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to exercise sufficient leadership and expertise, resulting in poor outcomes for a young person. An avoidable negative experience has occurred because of systematic failings throughout all of the stages of this poorly planned placement. Inspection report children’s home: SC419330 7

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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: SC419330 8

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Children’s home details

Registered provider: Castle Homes Limited

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Children’s home details

Registered provider address: Fifth Floor, 80 Hammersmith Road, London W14 8UD

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Children’s home details

Responsible individual: Christopher Wells

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Inspector:

Suzy Lemmy, social care inspector Inspection report children’s home: SC419330 9 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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