Children's home run by Crystal Care Solutions Limited in Cheshire East

Inspection report children’s home: SC477209 1 SC477209 Registered provider: Crystal Care Solutions 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

This home is registered to provide care for up to three young people. The home specialises in providing a therapeutic environment for young people who display sexually harmful behaviours. A private company manages this home.

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Information about this children’s home

The home has been without a registered manager since 17 May 2019. A new manager has been appointed to the home. He took up post on 3 June 2019. He holds a level 5 qualification in leadership and management. The new manager has yet to apply to register with Ofsted.

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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, or the care and experiences of children and young people are poor and they are not making progress.

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inadequate

Date of last inspection: 7 November 2018

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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: SC477209 2

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Inspection date Inspection type Inspection judgement

07/11/2018 Full Good 08/11/2017 Full Good 22/03/2017 Interim Improved effectiveness 14/11/2016 Full Good Inspection report children’s home: SC477209 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 children’s views, wishes and feelings standard is that children receive care from staff who develop positive relationships with them; engage with them; and 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

This relates to ensuring that staff undertake individual work with young people that is focused, relevant to the young person’s needs and plans and is consistently documented. (Regulation 7 (1)(a)(b)(c)) 21/07/2019

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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 that staff assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm. (Regulation 12 (1)(2)(a)(i)(b)) 21/07/2019

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Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that helps children aspire to fulfil their potential and promotes their welfare.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that staff have the experience, qualifications and skills to meet the needs of each child.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure that the home’s workforce provides continuity of care to each child. 21/07/2019 Inspection report children’s home: SC477209 4 (Regulation 13 (1)(a)(b)(2)(c)(e))* The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. (Regulation 23 (1)) 21/07/2019

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Requirement Due date

The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33 (4)(b))* 21/07/2019

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Requirement Due date

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 name of the child; details of the child’s behaviour leading to the use of the measure; the date, time and location of the use of the measure; a description of the measure and its duration; details of any methods used or steps taken to avoid the need to use the measure; the name of the person who used the measure (‘the user’), and of any other person present when the measure was used; the effectiveness and any consequences of the use of the measure; and a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure.

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Requirement Due date

The registered person must ensure that within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (‘the authorised person’) has spoken to the user about the measure; and has signed the record to confirm it is accurate; and within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(b)(c)) 21/07/2019

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Requirement Due date

The registered person must maintain records (‘case records’) for each child which are kept up to date. (Regulation 36 (1)(b)) 21/07/19

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation; an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; there is an allegation of abuse against the home or a person working there; a child protection enquiry involving a child is instigated; or concludes (in which case, the notification must include the outcome of the child protection enquiry); or there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (1)) 21/07/2019

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Requirement Due date

The registered person must complete a review of the quality of care provided for children (‘a quality of care review’) at least once every 6 months. In order to complete a quality of care 21/07/2019 Inspection report children’s home: SC477209 5 review the registered person must establish and maintain a system for monitoring, reviewing and evaluating the quality of care provided for children; the feedback and opinions of children about the children’s home, its facilities and the quality of care they receive in it; and any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children. After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (‘the quality of care review report’).

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Requirement Due date

(Regulation 45 (1)(2)) The registered person must review the appropriateness and suitability of the location of the premises used for the purposes of the children’s home at least once in each calendar year taking into account the requirement in regulation 12(2)(c) (the protection of children standard). When conducting the review, the registered person must consult, and take into account the views of, each relevant person. (Regulation 46 (1)(2)) 21/07/2019

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Requirement Due date

* These requirements are subject to a compliance notice.

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Overall experiences and progress of children and young people: inadequate

Young people’s overall experience and progress are compromised by widespread failures in the ways in which staff help and protect young people.

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Overall experiences and progress of children and young people: inadequate

Young people do not live in a homely and nurturing environment. Previously identified shortfalls regarding food hygiene remain, placing young people’s health at risk. Despite improvements being made to the communal area, managers have not ensured that improvements have been made to young people’s personal space. For example, one young person’s requests to have restorative work completed to repair visible damage to his bedroom have been refused for five months. This response results in a longstanding sense of shame for the young person and fails to support him to respect and value his home.

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Overall experiences and progress of children and young people: inadequate

Managers fail to ensure that young people’s records include all essential information from their placing local authority. For example, managers have failed to gain a copy of a court order for three months, despite needing to ensure that the terms of the order are followed in the young person’s daily care.

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Overall experiences and progress of children and young people: inadequate

When staff carry out direct work with young people, this does not link to young people’s care plans and lacks clear outcomes to show the impact that this work has had on young people’s progress and experiences. Inspection report children’s home: SC477209 6 Managers fail to ensure that young people receive care from a stable and consistent staff team. Between March and June 2019, 40 different staff members have worked at the home. This prevents managers from ensuring that standards of care are consistently maintained. Recent improvements to the stability of the core staff team have resulted in young people beginning to develop positive relationships with regular staff who work at the home.

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Overall experiences and progress of children and young people: inadequate

Despite the significant shortfalls identified during this inspection, young people make some progress. One young person has improved his school attendance. Both young people are encouraged to develop skills in cooking and budgeting in preparation for adult life.

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Overall experiences and progress of children and young people: inadequate

The home operates a therapeutic parenting model. The therapy service provides guidance to staff on how to support young people.

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

Arrangements for the management of risk are inadequate.

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

Staff do not consistently implement risk management strategies in response to young people’s risk-taking behaviours. For example, staff have failed to take action in response to a young person saying that they smoke in their bedroom. Consequently, there is no risk reduction plan, and the home’s fire risk assessment has not been reviewed to reflect this new risk factor. The failure to respond to new and emerging risks leaves young people and staff at risk of harm.

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

Staff do not always follow young people’s risk management plans. For example, staff failed to supervise a young person’s internet use in accordance with an agreed plan. The young person was subsequently found to have placed himself at risk online. Staff’s failure to follow an agreed strategy placed the young person at significant risk of harm.

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

Despite a young person’s plan identifying the need to receive the support of two members of staff, the manager allowed the young person to go on a community activity with one-to-one staffing on three separate occasions. This was without agreement from the therapy team or the young person’s placing local authority. This decision to reduce staffing resulted in the young person, member of staff and members of the public being put at risk.

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

The records of management oversight of incidents of physical intervention remain weak. Some incident reports fail to demonstrate strategies used by the staff to reduce the need for physical intervention. The failure to keep accurate records prevents managers from being able to identify patterns in staff practice and to make improvements to the way in which staff manage young people’s challenging behaviour.

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

Oversight of the arrangements for the storage, administration and disposal of medication Inspection report children’s home: SC477209 7 is poor. This lack of oversight has resulted in medication going missing and staff being unable to account for what has happened. This represents a risk that medication is not being safely managed or administered correctly to young people.

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

Managers have failed to notify Ofsted of two significant incidents that have occurred at the home. This lack of transparency prevents the regulator from having oversight of the service.

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The effectiveness of leaders and managers: inadequate

Management arrangements at the home have been ineffective. As a result, none of the five requirements raised at the last full inspection in November 2018 has been met. Failure to meet previous inspection requirements has resulted in two compliance notices being issued as a result of this inspection.

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The effectiveness of leaders and managers: inadequate

Managers continue to fail to ensure that staff attend the necessary training they require to provide safe, effective care to the young people who live in the home. New members of staff have not received basic training in a timely manner, and staff do not receive the specialist training required to help them to understand the complex needs of the young people in their care. For example, despite both young people living in the home having a history of self-harm, only one member of staff has received training in how to respond to this type of situation. This leaves staff ill prepared for their roles in safeguarding young people.

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The effectiveness of leaders and managers: inadequate

There are continued failings in staff supervision. Managers have failed to ensure that all staff receive supervision in line with the organisation’s supervision policy. One member of staff about whose practice there were concerns did not receive supervision for a period of three months. This lack of oversight leaves managers unable to demonstrate how they have supported staff to reflect on and improve their practice to ensure that young people receive safe care.

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The effectiveness of leaders and managers: inadequate

Arrangements for reviewing the safety of the homes’ location remain weak. The assessment fails to consider the impact of all local risk factors or reflect the views of all relevant professionals. These omissions continue to leave staff without all the information needed to enable them to understand the risks faced by young people in the local area.

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The effectiveness of leaders and managers: inadequate

Managers have completed a quality of care review for the home. However, this fails to incorporate the views of young people, staff or wider professionals. This limits the value of this report in informing service improvement.

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The effectiveness of leaders and managers: inadequate

A new management team is now in place at the home. Managers have accepted the findings of this inspection and have started to address the shortfalls.

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Information about this inspection

Inspection report children’s home: SC477209 8 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: SC477209 9

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Children’s home details

Registered provider: Crystal Care Solutions Limited

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Children’s home details

Registered provider address: Bank House, Market Square, Congleton, Cheshire CW12 1ET

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Inspectors

Tracey Coglan Greig, social care inspector Jo Warburton, social care inspector Inspection report children’s home: SC477209 10 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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