Children's home run by New Forest Care Limited in Southampton

Inspection report children’s home: SC063767 1 SC063767 Registered provider: New Forest Care Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

A private company owns and operates this children’s home. The home provides care and accommodation for a maximum of four young people with 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 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: 6 December 2016

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inadequate

Overall judgement at last inspection: good

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inadequate

Enforcement action since last inspection: none Inspection report children’s home: SC063767 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

 The assessment and management of risk do not consistently minimise the potential for young people to come to harm.  Leaders and managers have not ensured that all staff have the necessary skills and experience to meet the responsibilities assigned to them in their roles.  Serious incidents are not always fully investigated and consequently practice is not improved when mistakes are made.  Systems for monitoring the quality of care are not sufficiently well developed to ensure continuous improvement in the service being provided.  The standard of recording is sometimes poor, particularly in relation to incidents of physical restraint and serious events.  There are inconsistencies in relation to evaluating the effectiveness of physical restraints and clarifying the views of the young person after a restraint has taken place.  On one occasion, the regulator and the designated officer were not informed

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Key findings from this inspection

when an allegation of harm was made against a member of staff.  The home’s independent visitor is not sufficiently independent to carry out the role effectively.  The high turnover of staff has resulted in inconsistency for young people.

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Key findings from this inspection

 The home provides young people with access to specialist mental health and emotional well-being professionals.  Young people receive good advice and guidance on building healthy relationships and keeping safe when accessing the internet.  Prompt and effective action is taken when staff discover that a young person has gone missing from the home.  Young people are supported to become more independent and to integrate with their local community. Young people benefit from having positive peer relationships.  Leaders and managers advocate strongly for young people when they perceive that other professionals are not working in the young person’s best interests.  The organisation uses well-established tools to measure young people’s progress.

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Recent inspection history

Inspection report children’s home: SC063767 3

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Inspection date Inspection type Inspection judgement

06/12/2016 Full Good 21/06/2016 Interim Sustained effectiveness 22/02/2016 Full Outstanding 12/08/2015 Interim Sustained effectiveness Inspection report children’s home: SC063767 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

7: The children’s views, wishes and feelings standard In order to meet the children’s views, wishes and feelings standard the registered person must ensure that an explanation is given to each child as soon as reasonably practicable after the child’s arrival about: (2)(d)(iii) what advocacy support or services are available to the child, how the child may access that support or those services and any entitlement the child may have to independent advocacy provision. Specifically, ensure that children are kept informed of how they may access the support of an independent advocate. 23/03/2018

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Requirement Due date

12: The protection of children standard In order to meet the protection of children standard, the registered person must ensure that staff: (2)(a)(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; (2)(a)(vi) take effective action whenever there is a serious concern about a child’s welfare; and (2)(b) 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. This is with specific reference to the assessment and management of risk, following the strategies specified in risk assessments and taking a proactive approach to minimise the potential for young people to go missing. 23/03/2018

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Requirement Due date

13: The leadership and management standard In order to meet the leadership and management standard the registered person must: (2)(c) ensure that staff have the experience, qualifications and 23/03/2018 Inspection report children’s home: SC063767 5 skills to meet the needs of each child; and (2)(h) use monitoring and review systems to make continuous improvements in the quality of care provided in the home. This is with specific reference to ensuring that staff are competent to undertake their roles effectively, detailed records are kept of all significant events, monitoring of all serious incidents that occur and investigating and learning from incidents where children and staff may have come to harm. 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 date, time and location of the use of the measure; and

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Requirement Due date

the effectiveness and any consequences of the use of the measure. (Regulation 35 (3)(a)(iii) and (vii)) Specifically, ensure that records specify the location where physical restraints of children take place and ensure that managers review all restraint records and comment on the effectiveness of the measure. 23/03/2018

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if: there is an allegation of abuse against the home or a person working there. (Regulation 40 (4)(c)) Specifically, ensure that Ofsted and the local authority designated officer are notified when an allegation of abuse is made against a member of staff. 23/03/2018

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Requirement Due date

Subject to paragraphs (4) and (5), the registered person may not appoint the following as an independent person— if the registered provider is not a local authority, a person who is employed for payment by the registered provider. An employee of the registered provider is not, by reason only of that employment, disqualified under paragraph 3(a), (b) or (g) from appointment as an independent person if the employee is employed solely to examine and scrutinise critically— the way the home is carried on or managed; and the quality of care provided for children. (Regulation 43 (3)(b) and (4)(a)(b)) 23/03/2018 Inspection report children’s home: SC063767 6

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Recommendations

 Staff should understand that they have a responsibility to observe, notice and respond to children who are expressing their views, acknowledging that it is not the sole responsibility of the child to ‘tell’. (‘Guide to the children’s homes regulations including the quality standards’, page 22, paragraph 4.10) Specifically, ensure that staff respond to children who say that they would like a plan and targets to help them achieve their goals.  Any child who has been restrained should be given the opportunity to express their feelings about their experience of the restraint as soon as is practicable, ideally within 24 hours of the restraint incident, taking the age of the child and the circumstances of restraint into account. (‘Guide to the children’s homes regulations including the quality standards’, page 50, paragraph 9.6) Specifically, comments made by a child during or following a restraint incident

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Recommendations

should be fully explored.  The registered person must demonstrate every effort to achieve continuity of staffing so that children’s attachments are not overly disrupted, including ensuring that the employment of any temporary staff will not prevent children from receiving the continuity of care that they need. (‘Guide to the children’s homes regulations including the quality standards’, page 51, paragraph 10.1)  The registered person should undertake a review that focuses on the quality of the care provided by the home, the experiences of children living there and the impact the care is having on outcomes and improvements for the children. (‘Guide to the children’s homes regulations including the quality standards’, page 64, paragraph 15.2) Specifically, ensure that quality of care review reports evaluate and analyse the impact that the care is having on the children. Inspection report children’s home: SC063767 7

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Overall experiences and progress of children and young people: inadequate

Some young people have found stability and security at the home and, in most cases, they have remained in placement for significant periods. However, there are shortfalls in practice relating to the welfare and protection of young people and in the effectiveness of leaders and managers. This has resulted in some young people having negative experiences while living in the home.

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Overall experiences and progress of children and young people: inadequate

Young people expressed mixed opinions about the quality of their relationships with staff. All young people were able to name a member of staff who they would speak to if they had any concerns, and identified those staff who they got on well with. However, some young people also described difficulties in communicating with some staff members. One young person said that sometimes staff give mixed messages about boundaries and expectations of behaviour. A professional spoken to during the inspection expressed doubts about the ability of some staff to provide warm and nurturing care.

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Overall experiences and progress of children and young people: inadequate

Advocacy is under-utilised in the home. A young person expressed frustration that his request for a plan, with targets, that would lead to him being given more trust, had not been fully responded to. Another young person said that he had never met the organisation’s independent advocate, who has recently left. This was despite the young person being in placement with the organisation for four years. Not all young people know how to contact an independent advocate, and the registered manager confirmed that the home has no established links with advocacy services.

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Overall experiences and progress of children and young people: inadequate

All young people have a place at the organisation’s school and, overall, attendance is good. However, one young person is beginning to show signs of disengagement and another young person was worried that his academic grades were slipping. Staff have not communicated effectively in order to alleviate the young person’s anxieties. Staff are not always able to effectively engage young people in meaningful discussions about their education and hopes for the future. For example, one member of staff said of a young person: ‘He will not speak to us about school.’

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Overall experiences and progress of children and young people: inadequate

The organisation provides access to a range of professionals and specialist interventions to support young people’s mental health and emotional well-being. All young people engage in therapeutic counselling and this is helpful to them. However, the high turnover of staff slows the progress made by some young people, particularly those who experience attachment difficulties.

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Overall experiences and progress of children and young people: inadequate

Staff provide good advice and guidance to young people about how to enjoy a healthy lifestyle. Staff have sensitively engaged young people in discussions about adolescence, personal development and healthy relationships. Steps are taken to ensure that young people remain in good physical health, through, for example, regular appointments with healthcare professionals. Young people are encouraged to express their views about the Inspection report children’s home: SC063767 8 use of prescription medication.

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Overall experiences and progress of children and young people: inadequate

Careful and effective planning underpins the support given to young people to become more independent. This is particularly helpful to young people who have free time away from the home. One young person is integrating more successfully into his local community and is developing peer relationships outside of the home. This has had a positive effect on the young person’s self-esteem.

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Overall experiences and progress of children and young people: inadequate

Careful consideration is given to how new young people are welcomed to the home. This improves their chances of settling quickly. One young person who experienced high levels of disruption when his last placement broke down has settled well, with a reduction in the frequency and severity of challenging behaviours.

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Overall experiences and progress of children and young people: inadequate

Staff work effectively with professionals and family members, where appropriate, to ensure that family contact arrangements are planned in advance. This has ensured that young people’s visits to their family are generally positive experiences. For most young people, relationships with family members have improved over time and contact visits have been extended.

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

Deficiencies in practice relating to the protection of young people mean that the potential for them to come to harm is not always minimised. There are significant failings in the assessment and management of risk. Young people’s individual risk assessments are not consistently updated in a timely way following serious incidents. In one case, staff did not follow the strategies that were detailed in a young person’s risk assessment and this resulted in a young person and a member of staff being in a dangerous situation during a car journey.

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

There have been four occasions since the last full inspection in December 2016 when young people have gone missing from the home. In one case, prompt action was not taken to reduce the risk of a young person leaving the home during the night through an upstairs window. This was rectified when the behaviour was repeated soon afterwards. In order to keep young people safe during the night a waking night member of staff is employed. However, there have been three occasions when young people have left the home during the night and this was not discovered until the morning.

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

Other aspects of practice relating to young people who go missing are stronger. There is a coordinated approach to locating young people when it is discovered that they have left the home, and local police consider this to be positive. Debrief meetings with young people following episodes of going missing are thorough and provide the young person with the opportunity to explore their worries and the motivation behind their behaviour. The registered manager is proactive in ensuring that independent return home interviews are arranged.

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

A high number of physical restraints have been used to manage young people’s behaviour since the last inspection, although the frequency of these incidents has Inspection report children’s home: SC063767 9 reduced recently. A sample of the records relating to physical restraint were examined during this inspection. In one of the records, the locations where the restraint had taken place had not been recorded. The details of one physical restraint had not been transferred to the log book and, consequently, the registered managed had failed to monitor or evaluate the effectiveness of the intervention. One record of a debrief meeting with a young person following a restraint indicated that comments made by the young person about the appropriateness of the measure were not subsequently followed up.

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

Young people’s behaviour management plans contain a number of strategies for staff to follow in order to promote positive behaviour and to de-escalate potentially volatile situations. A restorative approach is taken to resolve any conflicts, and generally the young people maintain positive peer relationships. The young people said that they have no concerns about bullying in the home. Some young people have been affected by bullying in previous placements. It is positive that these behaviours have not been repeated in this home.

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

Although in most cases child protection concerns are shared with the relevant professionals and in a timely way, one incident was identified where this had not happened. Within the context of a complaint, a young person alleged that he had been harmed by a member of staff. No notification was made to Ofsted and the designated officer was not consulted. During this inspection, the designated officer informed the inspector that overall the organisation has a good record of seeking advice and reporting concerns.

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

Although the inspector identified a number of shortfalls in relation to keeping young people safe and protecting them from harm, some better practice was seen. Staff have engaged young people in work to raise their awareness of the risks associated with the internet and social media, and to understand better how to build and maintain healthy personal relationships. Staff use a range of resources to keep young people interested in this work. Staff have good awareness of each young person’s particular vulnerabilities, and were able to give clear descriptions of what might alert them to a young person becoming exploited. Great care is taken to ensure that young people who have overnight stays with friends in the local community remain safe.

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

The organisation adopts a safe and thorough approach to the recruitment of staff and ensures that all necessary checks are completed during the recruitment process. This minimises the potential for unsuitable adults to be employed by the home. At the time of this inspection, the home was being redecorated throughout and staff were observed to be taking steps to ensure that there were no avoidable hazards to young people’s safety. The home’s health and safety risk assessment was updated just over a year ago.

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The effectiveness of leaders and managers: inadequate

Overall, staff turnover is high. Twelve members of staff have left the home since the inspection in December 2016. This has unsettled some of the young people. However, some staff members have worked at the home for a number of years, and this provides Inspection report children’s home: SC063767 10 a level of consistency for young people.

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The effectiveness of leaders and managers: inadequate

In recent months, some staff who have been promoted and taken up new responsibilities have not been consistently effective in their roles. This view was expressed by some young people and was acknowledged by the registered manager. Following a recent serious incident where a young person and member of staff were put at risk, leaders and managers did not put in place a coordinated response to examine the underlying reasons for the failure. The event was discussed in some staff members’ individual supervision sessions, and advice about decision making was provided in a shift leaders’ meeting. However, the overall response from leaders and managers failed to address the gravity of the situation. Importantly, lessons were not learned.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not ensured recording is of a sufficiently high standard. A report that was written following a serious incident did not provide the level of detail that was required to convey the seriousness of the situation. Shortfalls in the standard of physical restraint reports are still evident, despite a requirement being made in relation to this breach of regulation at the last three inspections. Fire drill records do not name the young people or the staff who have taken part in the drill.

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The effectiveness of leaders and managers: inadequate

Systems for monitoring the quality of care that is provided are not well developed. Senior leaders have not required the registered manager to examine or assess the effectiveness of staff practice following all significant events. The registered manager has only recently introduced quality of care checklists, after becoming aware that issues were ‘being missed’. The regulation 45 report does not consistently identify the strengths and weaknesses of the home. The associated reports provide little evaluation or analysis of the data and information being gathered.

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The effectiveness of leaders and managers: inadequate

The home’s independent visitor is not sufficiently independent. At the time of the inspection, she was also employed by the organisation to perform tasks that are not solely related to scrutinising the management of the home and the quality of care being provided. These additional tasks were largely related to human resource functions. Soon after the inspection, Ofsted was informed that the employee will no longer undertake these additional duties, enabling her to perform the quality assurance role with sufficient independence.

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The effectiveness of leaders and managers: inadequate

The registered manager holds the National Vocational Qualification level 4 management and leadership award. He is well supported by an experienced team leader. He told the inspector that his views about which young people should be admitted to the home are respected. There is no rush to admit new young people, and the decision is made based on whether the home can meet the needs of the young person being referred. During the process of young people being referred to the home, leaders and managers ensure that placing local authorities provide them with sufficient information to make an informed decision about whether the home can meet the needs of the young person. Although the inspection identified a number of shortfalls in relation to the effectiveness of leaders and managers, there was also evidence of good practice in some areas. In one case, managers took effective action when concerns came to light about the practice

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The effectiveness of leaders and managers: inadequate

of a member of staff. The disciplinary process was effective in establishing the facts and Inspection report children’s home: SC063767 11 addressing the issue so that young people were not put at risk of harm. In another case, swift and effective action was taken when staff discovered that there had been an error in the administration of a young person’s medication. Priority was given to ensuring that the young person was not at risk of harm because of the error.

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The effectiveness of leaders and managers: inadequate

The registered manager ensures that plans for how young people are cared for are reviewed and kept up to date. These plans also set clear and achievable goals for young people to aim for. However, one young person said that his plan does not take account of all of the targets he would like to see included. The organisation uses well-established tools for measuring young people’s progress across many aspects of their lives. The information obtained is then used to make young people’s plans more relevant and focused on meeting their individual needs.

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The effectiveness of leaders and managers: inadequate

Senior managers and other professionals from the organisation advocate strongly for young people when they consider that other professionals are not working in the young person’s best interests. This has included making representations to other agencies when there are doubts about the likely effectiveness of transition plans. Leaders, managers and staff maintain a professional dialogue with placing authorities, and keep them well informed about young people’s progress and about any concerns regarding the welfare of the young people.

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The effectiveness of leaders and managers: inadequate

The organisation provides staff with a good range of training opportunities. Staff are confident that arrangements would be made for any specialist training that is required to help them to meet the specific needs of a young person. Training that is relevant to the home’s particular model of care is provided. Plans are in place for staff to receive this training at a higher level to raise the standard of care being provided to young people. Inspection report children’s home: SC063767 12

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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: SC063767 13

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Children’s home details

Registered provider: New Forest Care Limited

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Children’s home details

Registered provider address: New Forest Care Limited, West Shore House, West Street, Hythe, Southampton SO45 6AA

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Inspector(s)

Stephen Collett: social care inspector Inspection report children’s home: SC063767 14 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(s)

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Inspector(s)

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Inspector(s)

T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: http://www.gov.uk/ofsted

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