Ambient House Limited

Inspection report for residential family centre: Ambient House Limited 1 Ambient House Limited Ambient House Limited 17 Nyewood Lane, Bognor Regis, Sussex PO21 2QB Inspected under the social care common inspection framework

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Information about this residential family centre

The centre is privately owned. It provides assessments of parenting on a residential basis and can accommodate up to four families. The building is staffed 24 hours a day. The centre is available for families from across the UK. The manager started working at the centre in April 2018 and has applied to be registered by Ofsted.

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Information about this residential family centre

Inspection dates: 17 to 18 September 2018

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Overall experiences and progress of

children and parents, taking into account Inadequate

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Overall experiences and progress of

How well children and parents are helped and protected Inadequate

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Overall experiences and progress of

The effectiveness of leaders and managers Inadequate

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Overall experiences and progress of

There are serious and/or widespread failures that mean children and parents are not protected or their welfare is not promoted or safeguarded and/or the care and experiences of children and parents are poor.

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Overall experiences and progress of

Date of previous inspection: This is the centre’s first inspection

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Overall experiences and progress of

Enforcement action since last inspection: none Inspection report for residential family centre: Ambient House Limited 2

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Key findings from this inspection

This residential family centre is inadequate because:

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Key findings from this inspection

 The centre is not managed effectively. The range and scope of the role of the manager is not sustainable.  Significant and wide-ranging shortfalls impact on the safety of families and these had not been identified because of inadequate monitoring arrangements.  The roles of the manager and responsible individual are blurred. The manager has been overridden in her decision-making about various issues including some safeguarding concerns.  There is a lack of good-quality support and guidance to the manager and staff. The induction process is of a poor quality, supervision of staff is irregular and there are significant shortfalls in staff training.  Many of the policies and procedures, including those relating to safeguarding issues, are of a poor quality.  Opportunities to learn from mistakes are missed. Safeguarding and other incidents are not reviewed and the record-keeping of these matters is poor.

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Key findings from this inspection

 Serious shortfalls were found in health and safety matters, including fire safety arrangements, infection control and the safe storage of cleaning materials.  There has been no assessment carried out in relation to the centre’s geographical location.  The medication policy is not being implemented in practice.  Staff recruitment processes do not meet regulations and standards.  No assessments are carried out about the use of CCTV for individual families at different stages in their assessment process.  Ofsted is not notified of significant events as required by regulation.  Ofsted is not being provided with updated versions of the statement of purpose or the resident’s guide.

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Key findings from this inspection

The residential family centre’s strengths:

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Key findings from this inspection

 Some parents have gained insight into their past actions and how these have impacted their children.  Some parents have been able to develop useful working relationships with some staff.  Assessments sampled were child focused.  The importance of families remaining in contact, when safe to do so, with people significant to them was recognised by staff and supported well. Inspection report for residential family centre: Ambient House Limited 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, Residential Family Centre Regulations 2002 and the national minimum standards. The registered person(s) must comply within the given timescales.

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Statutory requirements

Requirement Due date * The registered provider and the registered manager shall, having regard to the size of the residential family centre, the statement of purpose, and the number and needs of the residents, carry on or manage the centre (as the case may be) with sufficient care, competence and skill. The registered manager shall undertake from time to time such training as is appropriate to ensure that he has the skills necessary for managing the residential family centre. (Regulation 8(1)(3) The Residential Family Centres (Amendment) Regulations 2013) 30/11/2018

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Statutory requirements

* The registered person shall prepare and implement a written child protection policy which is intended to safeguard children accommodated in the residential family centre from abuse or neglect; and sets out the procedure to be followed in the event of any allegation of abuse or neglect. The procedure under paragraph (1) (b) must in particular provide for liaison and co-operation with any local authority which is making child protection enquiries in relation to any child accommodated in the residential family centre; the prompt referral to the local authority in whose area the residential family centre is situated, of any allegations of abuse or neglect affecting any child accommodated in the residential family centre; written records to be kept of any allegation of abuse or neglect, and of the action taken in response; consideration to be given in each case to the measures which may be necessary to protect children in the residential family

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Statutory requirements

centre following an allegation of abuse or neglect. (Regulation 12(1)(a)(b)(2)(a)(b)(d)(e) The Residential Family Centres (Amendment) Regulations 2013) 30/11/2018

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Statutory requirements

*The registered person shall ensure that all permanent appointments are subject to the satisfactory completion of a period of probation; and the registered person shall ensure that all persons employed by him receive appropriate training, supervision and appraisal; and are enabled from 30/11/2018 Inspection report for residential family centre: Ambient House Limited 4 time to time to obtain further qualifications appropriate to the work they perform. (Regulation 17(1)(a)(5)(a)(b) The Residential Family Centres (Amendment) Regulations 2013) *The registered person shall after consultation with the fire authority make adequate arrangements for reviewing fire precautions, and testing fire equipment, at suitable intervals; make arrangements for persons working at the residential family centre to receive suitable training in fire prevention. (Regulation 22(1)(c)(v)(d) The Residential Family Centres (Amendment) Regulations 2013)

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Statutory requirements

* The registered person shall not allow a person to whom paragraph (2) applies, to work at the residential family centre unless that person is fit to work at a residential family centre. For the purposes of paragraph (1), a person is not fit to work at a residential family centre unless full and satisfactory information is available in relation to him in respect of each of the matters specified in Schedule 2. (Regulation 16(1)(b)(3)(d) The Residential Family Centres (Amendment) Regulations 2013) 30/11/2018

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Statutory requirements

The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the residential family centre. (Regulation 11(2) The Residential Family Centres (Amendment) Regulations 2013) In particular, ensure that the medication policy is implemented in practice. 11/12/2018

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Statutory requirements

The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the residential family centre. (Regulation 11(3) The Residential Family Centres (Amendment) Regulations 2013) 11/12/2018

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Statutory requirements

The registered person shall ensure that all parts of the residential family centre to which residents have access are so far as reasonably practicable free from hazards to their safety. (Regulation 11(4)(a) The Residential Family Centres (Amendment) Regulations 2013) In particular, ensure that dangerous substances such as bleach and cleaning fluids are securely stored. 11/12/2018

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Statutory requirements

Subject to regulation 4 (6), the registered person shall not use premises for the purposes of a residential family centre unless the location of the premises is appropriate to the needs of residents. (Regulation 21(a)(b) The Residential Family Centres (Amendment) Regulations 2013) 11/12/2018 Inspection report for residential family centre: Ambient House Limited 5 The registered person shall make suitable arrangements to ensure that the residential family centre is conducted in a manner which respects the privacy and dignity of residents. (Regulation 10(3)(a) The Residential Family Centres (Amendment) Regulations 2013) In particular, ensure that the use of CCTV or other surveillance methods are assessed and show that they are necessary to safeguarding the welfare of the resident or others or that they are assessed as being needed to support the assessment process to inform decision making. 30/11/2018

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Statutory requirements

If, in relation to a residential family centre, any of the events listed in column 1 of the table in Schedule 5 takes place, the registered person shall without delay notify the persons indicated in respect of the event in column 2 of the table. (Regulation 26(1) The Residential Family Centres (Amendment) Regulations 2013) 30/11/2018

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Statutory requirements

The registered person shall keep under review and where appropriate revise the statement of purpose and resident’s guide; and (b) notify the Commission within 28 days of any such revision. (Regulation 4(a)(b) The Residential Family Centres (Amendment) Regulations 2013) 30/11/2018

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Statutory requirements

The registered person shall ensure that there is, having regard to the statement of purpose of the residential family centre, its size and the numbers and needs of its residents; and the need to safeguard and promote the health and welfare of residents, a sufficient number of suitably qualified, competent and experienced persons working for the residential family centre. (Regulation 15(a)(b) The Residential Family Centres (Amendment) Regulations 2013) 11/12/2018

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Statutory requirements

* These requirements are subject to a compliance notice.

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Recommendations

 The assessment and final report should be linked clearly to the court instruction and/or local authority requirements and should be delivered within the timescales specified. (Residential Family Centres National Minimum Standards 2002 1.4) In particular, provide effective challenge to local authorities that do not provide letters of instruction and other court documents in a timely way.  Where parents are being supported to develop parenting skills, they are enabled to build and sustain constructive relationships with staff so that, where possible, they are able to resolve conflicts themselves in a positive manner. (Residential Family Centres National Minimum Standards 2002 4.3) Inspection report for residential family centre: Ambient House Limited 6 Ensure that all staff have the skills required to build relationships that residents can benefit from.  Ensure the centre has arrangements with specialist services such as mental and

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Recommendations

sexual health services, so that parents and their children have the services they need. (Residential Family Centres National Minimum Standards 2002 6.3) In particular, when appropriate, help parents to attend appointments with services offering help in relation to matters that have caused them distress. Inspection report for residential family centre: Ambient House Limited 7

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Overall experiences and progress of children and parents: inadequate

Not all staff have a full understanding about their role in the assessment process. Some records of observations are basic. Examples include entries that simply describe that a parent had bathed or fed the baby. Such writing fails to be evaluative. Many records failed to include relevant commentary about the quality of the parenting or the interaction between the parent and child. Consequently, the manager who is responsible for the completion of assessments cannot rely on the quality of this work and conducts many direct observations herself. Despite poor record-keeping, the assessments viewed had a strong focus on children’s needs. There was a good balance between this and the parents’ parenting capacity and their ability to promote their child’s welfare. A clear opinion is expressed about the matters detailed in the letter of instruction. In some cases, there have been significant delays in the manager receiving the letter of instruction and other

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Overall experiences and progress of children and parents: inadequate

important information. These gaps in information mean that the manager and staff are not as well informed as they should be about the case and the specific purposes of the assessment. While there was evidence to show that the manager had chased this information, her efforts had not been successful in gaining the information in a timely way. A social worker said that the final report for their family was ‘an insightful evaluation of XX’s parenting capacity’. The arrangements for the storage and administration of medication are not being implemented in line with the centre’s own policy. Records are not kept of medicines that are on the premises, and for parents who self-administer there is no risk assessment plan developed in relation to this. This is a missed opportunity for parents to demonstrate that they can or cannot manage risk. The rationale for the blanket use of CCTV is unclear. Individual assessments are not

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Overall experiences and progress of children and parents: inadequate

carried out to establish if there is a safeguarding or other need that requires such close surveillance of families. There are no arrangements to step down its use. This is despite some parents spending time alone with their child away from the centre unsupervised. This unnecessarily affects their dignity and privacy. Parents were confused about the use of CCTV and about other restrictions and rules. One parent was told that he could not take part in an evening activity due to a ‘curfew’ in place. This family intended to build a life in the local community and the parent was trying to develop a hobby and friendships in the local area. Although amicably resolved with the manager, this was an unnecessary stressful issue for this parent.

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Overall experiences and progress of children and parents: inadequate

Families are helped to settle in, but relationships between them and the staff are variable in quality. Some parents say they feel that some staff do not see their views as being important. One parent spoke about how they did not feel they have been consulted and did not understand why decisions have been made. While the manager engages thoughtfully with parents, recognising specific needs that may arise from having a learning need, and tailors her style of communication Inspection report for residential family centre: Ambient House Limited 8 accordingly, this approach is not replicated by all of the staff. The quality of support that parents receive to get specialist help is variable. In one case, a parent was supported to attend a specialist assessment. This resulted in the plans of work being individualised to make sure his needs were met. As a result, the parent has been able to make the most of his opportunity to do well in the

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Overall experiences and progress of children and parents: inadequate

assessment. Another parent who disclosed historical abuse was not supported practically or emotionally to approach a support group regarding this. The staff understand how important it is for families staying in the centre to be able to keep in contact with family and friends. This is supported well by staff, as long as it is in the best interests of all. Some parents have made good progress and used their time at the centre well. One parent in particular has been able to develop strategies to manage their frustrations more effectively. This parent has begun to reflect on their past and has been able to link past actions to poor and unsafe parenting.

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How well children and parents are helped and protected: inadequate

Disagreements between the manager and the responsible individual in the management of safeguarding matters are of significant concern. One example caused a situation to escalate to a point that the police were called to manage the situation. The outcome of this incident was that the placement for this parent and child was ended prematurely. The manager, as designated safeguarding lead, has not been provided by the organisation with training in relation to this role. Despite being operational for eight months, no clear links have been established with professionals involved in safeguarding matters, such as the designated officer. The manager has not read the safeguarding policies and procedures. Information within these important documents included references to out-of-date guidance. The policies and procedures were not written in the context of a residential family centre and not all contained a procedural

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How well children and parents are helped and protected: inadequate

approach for the staff to follow. There is no effective guidance in relation to contemporary issues, such as radicalisation and exploitation. Records of safeguarding incidents and concerns are poor and, in some cases, incomplete or non-existent. This makes it difficult to establish how well safeguarding issues have been dealt with. Staff spoken to were aware of how to deal with concerns about a child, but were not clear about the responsibilities of external professionals. For example, they did not know the role of the designated officer in the investigation of allegations against professionals who work with children. A weak approach to risk assessment leaves families at risk; this includes the risk assessments used to inform decision-making about accepting a placement. Shortfalls in risk assessments include the risk assessment level being incorrectly calculated. Inspection report for residential family centre: Ambient House Limited 9

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How well children and parents are helped and protected: inadequate

This means that some high-level areas of risk are documented as being medium. Not all known risks are assessed and there are no, or inadequate, strategies and guidance for staff about how to prevent or deal with incidents. The approach to crisis management is of concern. The management of behaviour policy is contradictory about whether physical intervention is, or is not, used at this centre. A direction to staff in the behaviour policy suggests to them that incidents may be successfully de-escalated by firmly holding and guiding away a parent. Staff are not trained in safe physical intervention techniques, or in conflict management; this puts parents and staff at risk. The policy relating to staff recruitment does not meet regulations and standards because it does not detail the need to:  explore applicants’ gaps in employment histories  explore their reasons for leaving employment working  verify references.

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How well children and parents are helped and protected: inadequate

There is no mention of, or links to, the regulations and standards for residential family centres. In relation to staff pre-employment checks, no recruitment checks have been carried out on professionals employed on a commissioned basis, such as a counsellor. Shortfalls found in the sample of care staff files viewed included:  insufficient attention to gaining two references  insufficient attention to making sure one reference was from the applicant’s present or most recent employer  not verifying the references that had been received  not making sure that the referee had the permission of the leadership of their organisation to provide the information  one member of staff not providing a full employment history to enable any gaps to be explored. The missing policy and guidance for staff in this centre is more aligned to working in a children’s home. This, coupled with poor attention to developing relevant risk

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How well children and parents are helped and protected: inadequate

assessments and confused instructions in the behaviour management policy, means that staff have no clear, safe guidance about how to deal quickly and effectively with a potential or actual incident of parents and/or children going missing. Shortfalls in the attention paid to the safety of the environment present risks to residents and staff. For example:  there is damage to two of the fire doors that has the potential to compromise the soundness of the doors  in the airing cupboard, bedding was piled high directly on top of the water tank and some wiring coming from the tank in the airing cupboard Inspection report for residential family centre: Ambient House Limited 1  the doors to the airing cupboard are not locked despite a sign saying they should be  fire alarm and emergency lighting checks have not been carried out in line with the frequency detailed in the fire safety policy  not all staff have completed fire safety training, so it is not certain that they

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How well children and parents are helped and protected: inadequate

would all know how to support residents in the event of a fire  there is no policy for infection control  not all staff have been trained in infection control  bleach and other cleaning products were accessible to residents because the locking system for the door was not being used by staff  the risk assessment in relation to the location of the home does not take into account any risks arising from the local area.

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The effectiveness of leaders and managers: inadequate

Leaders and managers are failing to demonstrate that they have the required competence and skill to run the service safely and effectively. The lack of clarity about the roles and responsibilities of the manager and the responsible individual is of significant concern. The range and scope of the work that the manager is carrying out is too great to be sustainable. The job description for the manager role is inadequate. There is no description of the post-holder’s responsibilities in relation to the designated safeguarding lead role or her role as a registered manager. There is no job description for the staff supervisor and this risks further uncertainty and confusion. While the manager has supervision over practice issues in relation to her assessment work, there is no clear framework for support to her in relation to organisational issues or the operation of the service. There is a lack of a clear quality assurance framework. Inadequate monitoring

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The effectiveness of leaders and managers: inadequate

arrangements have failed to identify the serious shortfalls found during this inspection. Additionally, as the manager is currently the only qualified social worker- at the service, there is no other professional who can take responsibility for the quality assurance process for the assessments. When incidents or safeguarding issues occur, there is no analysis or evaluation of these so that any lessons learned can be used to develop practice. There is no written development plan, so the capacity for improvement is in doubt. The staff induction process does not equip staff to carry out their role to a high standard. Staff have not all completed the training stated as being the minimum in the statement of purpose. This risks commissioners being misled about the skills of the staff team. The supervision of staff has not been at the frequency stated and Inspection report for residential family centre: Ambient House Limited 1

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The effectiveness of leaders and managers: inadequate

there have only been two team meetings since the service opened. Other significant regulatory breaches have occurred in respect of the responsibilities of leaders and managers. Examples include the failure to notify Ofsted of significant events and the failure to provide Ofsted with the revised statement of purpose and monitoring reports made under regulations. As such, Ofsted has not been able to reliably monitor the service.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and parents. Inspectors considered the quality of work and the differences made to the lives of children and parents. They watched how professional staff work with children and parents and each other and discussed the effectiveness of help and care provided. Wherever possible, they talked to children and parents. In addition, the inspectors have tried to understand what the residential family centre knows about how well it is performing, how well it is doing and what difference it is making for the children and parents 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 Residential Family Centre Regulations 2002 and the national minimum standards. Inspection report for residential family centre: Ambient House Limited 1

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Residential family centre details

Registered provider: Ambient House Limited

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Residential family centre details

Registered provider address: Moore Stephens LLP, City Gates, 2-4, Southgate, Chichester, Sussex PO19 8DJ

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Residential family centre details

Responsible individual: Georgina Puttock

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Inspectors:

Rosie Dancer, social care inspector Sophie Wood, social care regulatory manager Inspection report for residential family centre: Ambient House Limited 1 to 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:

T: 0300 123 4234 E: enquiries@ofsted.gov.uk W: http://www.gov.uk/ofsted

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