Children's home run by The Serendipity Centre Limited in Eastleigh

Inspection report children‟s home: SC463558 1 SC463558 Registered provider: The Serendipity Centre 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 is registered to provide care for up to six children. It is privately owned by an organisation which owns other homes and a therapeutic educational setting. Its statement of purpose states that it specialises in caring for girls who have experienced physical and/or emotional trauma in their past, as well as autistic spectrum disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder and global learning delay. The home provides access to a range of therapeutic services. There is no registered manager for this home. The post has been vacant since 16 June 2018.

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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

Overall judgement at last inspection: good

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inadequate

Enforcement action since last inspection: none Inspection report children‟s home: SC463558 2

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Inspection date Inspection type Inspection judgement

16/05/2017 Full Good 31/10/2016 Full Good 29/06/2016 Interim Declined in effectiveness 09/02/2016 Full Outstanding Inspection report children‟s home: SC463558 3

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Statutory requirements

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

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Requirement Due date

The registered person may only use devices for the monitoring or surveillance of children if—

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Requirement Due date

the monitoring or surveillance is for the purpose of safeguarding and promoting the welfare of the child concerned, or other children;

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Requirement Due date

and the monitoring or surveillance is no more intrusive than necessary, having regard to the child‟s need for privacy. (Regulation 24 (1)(a)(d)) 31/08/2018

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Requirement Due date

The registered person must prepare and implement a policy (“the behaviour management policy”) which sets out—

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Requirement Due date

how appropriate behaviour is to be promoted in the children‟s home; and

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Requirement Due date

the measures of control, discipline and restraint which may be used in relation to children in the home.

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Requirement Due date

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—

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Requirement Due date

the effectiveness and any consequences of the use of the measure. (Regulation 35 (1)(a)(b)(3)(a)(vii)) 31/08/2018

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Requirement Due date

Subject to paragraph (5), the registered person must ensure that children are provided at all reasonable times with access to the following facilities which they may use without reference to persons working in the home—

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Requirement Due date

a telephone on which to make and receive telephone calls in private; and

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Requirement Due date

facilities to send and receive post and, if the necessary facilities 31/08/2018 Inspection report children‟s home: SC463558 4 are provided for the use of children, electronic mail, in private. (Regulation 22 (3)(a)(b))

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Requirement Due date

The children‟s views, wishes and feelings standard is that children receive care from staff who—

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Requirement Due date

take their views, wishes and feelings into account in relation to matters affecting the children‟s care and welfare and their lives

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to—

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Requirement Due date

ascertain and consider each child‟s views, wishes and feelings, and balance these against what they judge to be in the child‟s best interests when making decisions about the child‟s care and welfare;

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Requirement Due date

help each child to express views, wishes and feelings;

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Requirement Due date

help each child to understand how the child‟s views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child;

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Requirement Due date

regularly consult children, and seek their feedback, about the quality of the home‟s care.

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Requirement Due date

is given appropriate advocacy support. (Regulation 7 (1)(c)(2)(a)(i)(ii)(iii)(iv)(b)(iii)) 31/08/2018

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Requirement Due date

The registered person must prepare and implement a policy which sets out the procedure to be followed in the event of an allegation of abuse or neglect. (Regulation 34 (1)(b) 31/08/2018

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Requirement Due date

The care planning standard is that children—

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Requirement Due date

receive effectively planned care in or through the children‟s home; and

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Requirement Due date

that staff help each child to access and contribute to the records kept by the registered person in relation to the child. (Regulation 14 (1)(a)(2)(f)) 31/08/2018

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Requirement Due date

Case records must be kept securely in the children‟s home during the period when the child to whom the case records relate is accommodated there. (Regulation 36 (2)(c)) 31/08/2018 Inspection report children‟s home: SC463558 5 The registered person must compile in relation to the children‟s home a statement of purpose (“the statement of purpose”) which covers the matters listed in Schedule 1.

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Requirement Due date

(Regulation 16 Schedule 1 (3)(b)(14)(b)(16)(19)) 31/08/2018

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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.

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Requirement Due date

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

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Requirement Due date

are familiar with, and act in accordance with, the home‟s child protection policies; and

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Requirement Due date

that the effectiveness of the home‟s child protection policies is monitored regularly. (Regulation 12(1)(a)(vii) (2)(e)) 10/08/2018

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Requirement Due date

The registered person must ensure that all employees—

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receive practice-related supervision by a person with appropriate experience. (Regulation 33 (4)(b)) 31/08/2018

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Requirement Due date

The registered person must recruit staff using recruitment procedures that are designed to ensure children‟s safety.

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Requirement Due date

full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32 (3)(d)) 31/08/2018

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Requirement Due date

provide each employee with a job description outlining the employee‟s responsibilities. (Regulation 33 (1)(c)) 31/08/2018

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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—

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helps children aspire to fulfil their potential;

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In particular, the standard in paragraph (1) requires the registered person to—

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ensure that staff have the experience, qualifications and skills to 10/08/2018 Inspection report children‟s home: SC463558 6 meet the needs of each child;

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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;

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Requirement Due date

use monitoring systems and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

The registered person must complete a review of the quality of the care provided for children (“a quality of care review”) at least once every six months.

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Requirement Due date

In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating—

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Requirement Due date

any actions that the registered person considers necessary in order to improve or maintain the quality of the care provided for children. (Regulation 45 (2)(c)) 31 August 2018

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 For children‟s homes to be nurturing and supportive environments that meet the needs of their children, they will, in most cases, be homely, domestic environments. Children‟s homes must comply with relevant health and safety legislation (alarms, food, hygiene, etc). However, in doing so, homes should seek as far as possible to maintain a domestic rather than „institutional‟ impression. („Guide to the children‟s homes regulations, including the quality standards‟, page 15 paragraph 3.9) This relates to the recommendations made by the Hampshire fire and rescue service‟s visit on 22 June 2018. It also applies to the removal of redundant call button devices installed that give an institutional impression.  Managing medicines in care homes (March 2014) is a guidance that applies across both health and social care. („Guide to the children‟s homes regulations, including the quality standards‟, page 35 paragraph 7.17)

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Recommendations

This relates to ensuring that a written medication error protocol supports the management of errors if they occur, and that it is easily accessible to staff.

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Inspection judgements

Inspection report children‟s home: SC463558 7

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Overall experiences and progress of children and young people: inadequate

The staff team‟s approach to behaviour management is risk averse. The excessive use of closed circuit television (CCTV) and the locking of bedroom windows is not supported by regular reviews or sufficiently detailed risk assessments. The use of such measures creates an institutional feel and suggests that the children need this high and intrusive level of surveillance, which impacts on their privacy and freedom of movement. This oppressive environment is exacerbated by poor decisions in relation to risk management strategies. Examples include decisions by senior staff to prevent a child from accessing a local swimming pool because of one incident of inappropriate behaviour six months previously. Another child has been denied access to a bath for ten months because of the perceived risk of drowning, without regular review and in contrast to the child‟s social worker believing this to have been resolved. Such examples

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Overall experiences and progress of children and young people: inadequate

hinder children‟s progress. They are unable to learn how to manage or to take appropriate and measured risks, in line with their age, understanding and need to develop. Children receive mixed messages in relation to consequences for their actions. Examples of children receiving an initial sanction, subsequently altered by senior leaders, undermines staff and fails to provide children with consistent messages about how to regulate their own behaviour. Excessive measures are also used, for example a trampoline and swing being removed and not reinstated due to staff‟s inability to manage the children‟s refusal to come off this equipment. Children are being unduly penalised for their behaviour and these examples have not been sufficiently reviewed to determine their continuing relevance or effectiveness. Children describe varying levels of satisfaction and understanding about the care that they receive. When describing their experiences, children gave the inspectors examples

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Overall experiences and progress of children and young people: inadequate

where they did not understand the reasons for certain practices, for example the lengthening of imposed sanction periods and the need to ask permission to make telephone calls. Although children are provided with contact telephone numbers for external organisations and helplines, and most have their own mobile phones, they do not always feel able to make such contact without asking staff for their phones or for access to electronic communication. Independent advocacy arrangements are in place; however, two children said that they had not seen their advocates for some months. Children are given medication in accordance with the home‟s policy and procedures. A recent medication error did result in a suitable investigation, with actions put in place for individual staff development. However, there is no written protocol to instruct staff to manage medication errors safely and this shortfall had not been identified through

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Overall experiences and progress of children and young people: inadequate

monitoring. This was a missed opportunity to ensure safer practice and has the potential to result in inconsistencies in the event of further medication errors. Children are supported to access education and have mostly achieved good attendance levels. Staff demonstrate genuine care and affection for the children. Meal times are social events with everyone eating together, and children are encouraged by staff to maintain a healthy diet. Inspection report children‟s home: SC463558 8

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

The process for the management of allegations is unclear. Procedural guidance for staff does not include sufficient guidance should they have concerns about any member of the senior leadership team. The involvement and role of the local authority designated officer is not clearly defined. The practice of making notification to other managers and leaders in the other homes and in the school about persons unconnected with their service is not appropriate and a breach of data protection. These shortfalls and omissions seriously restrict staff‟s ability to take well-informed and appropriate action in the best interests of protecting children. The home is considered by the fire service to be broadly fire compliant. When, during the inspection, inspectors identified potentially serious fire safety concerns, senior managers took immediate action to review these arrangements. The local fire and rescue service visited the home and made some recommendations, including the need

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

for risk assessments to be more explicit in relation to the locking of an exit during the night. Unclear recording systems in relation to safeguarding incidents compromise leaders‟ and managers‟ ability to track cases and be confident about the action taken. During the inspection, records were sought and subsequently supplied from a variety of locations external to the home. This practice compromises confidentiality and makes the tracking of cases extremely difficult. It increases the risk of errors. Examples of poor incident records show omissions with regards to any follow-up action taken and leaders and managers were unable to identify whether some safeguarding cases were open or closed. This practice fails to demonstrate that leaders and managers have a sufficient grasp of managing actual and potential safeguarding risks and events competently.

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The effectiveness of leaders and managers: inadequate

Leaders and managers are failing to identify serious shortfalls that impact on the safety and the quality of care of the children. Poor monitoring systems have failed to identify significant shortfalls, for example in respect of safeguarding policy and procedural guidance, as well as practice issues in respect of behaviour management. The excessive and intrusive use of CCTV is not underpinned by a comprehensive risk assessment to justify its use. Access to the images is not clearly defined in the policy and it is unclear why images of children in the home who do not attend the organisation‟s school are stored on a hard drive at the school. Regulation 45 monitoring reports are weak and fail to recognise or tackle shortfalls competently. An example of this relates to the six-monthly report, dated 30 May 2018, which commented on behaviour management practice positively but failed to recognise any of the shortfalls identified at this inspection. Other areas in this report focus on the

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The effectiveness of leaders and managers: inadequate

completion of tasks, such as the need for children to sign records of physical restraint. This example fails to sufficiently analyse or evaluate the actual use of physical restraint during the period. The increased use of physical restraint is attributed to the unsettling impact of a child moving into the home on the other children, but there is no analysis of Inspection report children‟s home: SC463558 9 how staff might have supported this better, nor if any learning has been undertaken to improve future practice. The statement of purpose is incomplete. It does not provide up-to-date, sufficiently detailed information for stakeholders to enable well-informed placement decision- making. For example, it does not detail the extent of the use of CCTV, or that staff are not trained in post-traumatic stress disorder, attention deficit disorder or global learning delay. Case records for children are not securely stored. The electronic share point system is

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The effectiveness of leaders and managers: inadequate

accessible to staff across the organisation, including staff who work at the school. Consequently, children‟s sensitive information is not sufficiently protected, yet children‟s ability to access their own records is unduly restricted. The inspectors were told by staff that children were not allowed to access their records based on the understanding that this would be a breach of regulation. This is inaccurate and such practice also restricts the children‟s ability to contribute to their own plans. Through case tracking, inspectors requested sight of children‟s placement plans. For two children, the local authority‟s documentation was produced. Staff were unable to provide the home‟s own placement plans for these two children. Staff supervision sessions are poorly recorded. The sampled records were brief and did not include reference to safeguarding matters, measuring the staff member‟s knowledge of safeguarding practice, or monitoring the effectiveness of the training attended by

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The effectiveness of leaders and managers: inadequate

staff. The poor quality of these records lets staff down and fails to ensure that their practice is adequately monitored or developed. Recruitment procedures do not consistently meet safer recruitment standards. This puts children at risk. Poorly organised recruitment records prevented the inspectors‟ ability to confirm that all necessary checks had been completed. In one case, an up-to-date DBS check had not been received. The sampling of staff files found the absence of job descriptions in some cases. These included the job descriptions for the previous registered manager and a residential care worker. Senior leadership roles and arrangements are not embedded. The chief executive officer was not available during this inspection and completes her notice period next month. The head of human resources is currently an interim position and a new director of care joined last week. Six care staff members have left since the last inspection and the

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The effectiveness of leaders and managers: inadequate

registered manager left a week ago. Although the registered manager gave notice in April this year, no reference to, or planning for, this is detailed within the latest regulation 45 report. Exit interview forms have been completed for some staff, but not all. No overall analysis of this high staff turnover was made available. The regulation 45 monitoring report states that „Staff retention will continue to be developed‟, but no other description is provided. Inspectors were, therefore, unable to determine how leaders and managers are working to improve staff retention or satisfying themselves of the impact of such a turbulent period on the children. Two interim managers are currently being deployed to oversee the daily operation of the home. During this inspection, numerous records were either difficult or impossible to locate. Serious shortfalls in respect of the quality of the care provided to the children

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The effectiveness of leaders and managers: inadequate

were identified as being widespread and declining since the last inspection. Leadership Inspection report children‟s home: SC463558 10 arrangements have been ineffective during this same period.

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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: SC463558 11

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Children’s home details

Registered provider: The Serendipity Centre Limited

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Children’s home details

Registered provider address: 1st Floor, Goodlands House, St Lukes Close, Hedge End, Southampton SO30 2US

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Inspectors:

Liz Driver, social care inspector Keith Riley, social care inspector Inspection report children‟s home: SC463558 12 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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Inspectors:

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Inspectors:

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Inspectors:

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