Children's Home run by 1848 Ltd in Somerset

Inspection report children’s home: 2491059 1 Registered provider: South West Mental Health Ltd

p.1

Full inspection Inspected under the social care common inspection framework

p.1

Information about this children’s home

This privately operated children’s home is currently registered to provide care and accommodation for up to three children and young people. The manager has been registered with Ofsted since October 2018.

p.1

Overall experiences and progress of

children and young people, taking into account

p.1

inadequate

How well children and young people are helped and protected inadequate

p.1

inadequate

The effectiveness of leaders and managers inadequate

p.1

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

p.1

inadequate

Overall judgement at last inspection: not applicable. This is the home’s first inspection since it was registered in October 2018.

p.1

inadequate

Enforcement action since last inspection: none Inspection report children’s home: 2491059 2

p.1

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.

p.2

Requirement Due date

The quality and purpose of care standard

p.2

Requirement Due date

The quality and purpose of care standard is that children receive care from staff who—

p.2

Requirement Due date

understand the children’s home’s overall aims and the outcomes it seeks to achieve for children;

p.2

Requirement Due date

use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

p.2

Requirement Due date

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

p.2

Requirement Due date

understand and apply the home’s statement of purpose;

p.2

Requirement Due date

understand and apply the home’s statement of purpose; protect and promote each child’s welfare;

p.2

Requirement Due date

treat each child with dignity and respect;

p.2

Requirement Due date

provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background.

p.2

Requirement Due date

that the care is delivered by a person who—

p.2

Requirement Due date

has the experience, knowledge and skills to deliver that care. (Regulation 6 (1)(a)(b)(2)(a)(b)(i)(ii)(iii)(iv)(3)(b)(c)(i)) 04/10/2019 Inspection report children’s home: 2491059 3 The health and well-being standard

p.2

Requirement Due date

The health and well-being standard is that—

p.3

Requirement Due date

the health and well-being needs of children are met;

p.3

Requirement Due date

children receive advice, services and support in relation to their health and well-being; and

p.3

Requirement Due date

children are helped to lead healthy lifestyles.

p.3

Requirement Due date

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

p.3

Requirement Due date

achieve the health and well-being outcomes that are recorded in the child’s relevant plans (Regulation 10 (i)(a)(b)(c)(2)(a)(i)) 04/10/2019

p.3

Requirement Due date

The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on—

p.3

Requirement Due date

an understanding about acceptable behaviour.

p.3

Requirement Due date

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

p.3

Requirement Due date

meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans;

p.3

Requirement Due date

help each child to develop socially aware behaviour;

p.3

Requirement Due date

encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding;

p.3

Requirement Due date

help each child to develop and practise skills to resolve conflicts positively and without harm to anyone;

p.3

Requirement Due date

communicate to each child expectations about the child’s behaviour and ensure that the child understands those 04/10/2019 Inspection report children’s home: 2491059 4 expectations in accordance with the child’s age and understanding;

p.3

Requirement Due date

understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children;

p.4

Requirement Due date

are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same;

p.4

Requirement Due date

de-escalate confrontations with or between children, or potentially violent behaviour by children. (Regulation 11 (1)(a)(b)(2)(a)(i)(ii)(iii)(iv)(v)(ix)(x)(xi))

p.4

Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

p.4

Requirement Due date

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

p.4

Requirement Due date

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;

p.4

Requirement Due date

help each child to understand how to keep safe;

p.4

Requirement Due date

have the skills to identify and act upon signs that a child is at risk of harm;

p.4

Requirement Due date

manage relationships between children to prevent them from harming each other;

p.4

Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare; and

p.4

Requirement Due date

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)(ii)(iii)(iv)(v)(vi)(b)) 04/10/2019 Inspection report children’s home: 2491059 5 The leadership and management standard

p.4

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—

p.5

Requirement Due date

helps children aspire to fulfil their potential; and

p.5

Requirement Due date

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

p.5

Requirement Due date

lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home’s statement of purpose;

p.5

Requirement Due date

ensure that staff work as a team where appropriate;

p.5

Requirement Due date

ensure that staff have the experience, qualifications and skills to meet the needs of each child;

p.5

Requirement Due date

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;

p.5

Requirement Due date

demonstrate that practice in the home is informed and improved by taking into account and acting on—

p.5

Requirement Due date

research and developments in relation to the ways in which the needs of children are best met; and

p.5

Requirement Due date

use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b)(2)(a)(b)(c)(f)(g)(i)(h)) 04/10/2019

p.5

Requirement Due date

The care planning standard is that children—

p.5

Requirement Due date

receive effectively planned care in or through the children’s home.

p.5

Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure— 04/10/2019 Inspection report children’s home: 2491059 6 that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose;

p.5

Requirement Due date

that each child’s relevant plans are followed. (Regulation 14 (1)(a)(2)(a)(c))

p.6

Requirement Due date

keep the statement of purpose under review and, where appropriate, revise it; and

p.6

Requirement Due date

notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision. (Regulation 16 (3)(a)) 04/10/2019

p.6

Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home.

p.6

Requirement Due date

In particular, the registered person must ensure that—

p.6

Requirement Due date

a record is kept of the administration of medicine to each child. (Regulation 23 (2)(c)) 04/10/2019

p.6

Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if—

p.6

Requirement Due date

if there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (e)) 04/10/2019

p.6

Overall experiences and progress of children and young people: inadequate

This is the home’s first inspection since registration in October 2018. Since then, leaders and managers have failed to meet all the needs of children living in the home. Inspection report children’s home: 2491059 7 Leaders and managers have failed to ensure that the children are effectively safeguarded, and sufficiently protected from the risk of harm. Support provided by staff for children with mental health needs is not in line with the home’s statement of purpose. As a result, both children have been placed at risk when they are upset or worried and one child’s placement is to be ended because the staff cannot meet her needs.

p.6

Overall experiences and progress of children and young people: inadequate

Progress made by children is too variable. Staff are not always provided with clear and succinct direction in respect of the expectations on them when caring for the children. Behaviour and care plans are not always read or followed by staff. This has resulted in children, when upset, not being cared for in a sensitive, safe and considered way. For example, one member of staff intentionally turned the outside light off late at night when a child was outside. This resulted in the child feeling scared and unsafe in the dark.

p.7

Overall experiences and progress of children and young people: inadequate

Leaders and managers have failed to identify, recognise and address poorly written care records that include the use of derogatory language and reports of one child eating unhealthy foods, for example 20 chicken nuggets in one meal. Some staff reported being unclear about the day-to-day planning for both children, and this has led to missed appointments and poorly planned activities. For example, a member of the senior leadership team booked a hotel room for a member of staff and child that left them sharing a bedroom.

p.7

Overall experiences and progress of children and young people: inadequate

In the main, children attend health appointments. However, a chaotic approach to planning and organising the day has led to one child either missing an appointment or arriving late. Poorly constructed and incomplete therapeutic files result in a lack of meaningful therapeutic support.

p.7

Overall experiences and progress of children and young people: inadequate

The academic progress of children is variable. One child has made progress from their starting points and has completed GCSEs and is looking forward to college. However, staff have not been able to engage another child in meaningful formal education for more than 10 hours per week.

p.7

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

Monitoring of the quality and safety of care is not effective. Leaders and managers have failed to recognise several concerns and, as a result, children have been at risk of harm. For example, one child, on two occasions, accessed an upstairs window and threatened to jump out. The registered manager failed to produce the risk assessment, following these incidents, for approximately three weeks. The risk assessment that was undertaken was misleading, inaccurate and placed the child at risk in the event of a fire.

p.7

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

Attempts by staff and the registered manager to support both children when they are upset or anxious are, on occasion, ineffectual and unsafe. This has led to both children becoming increasingly more upset, self-injuring and staff being hurt. Records of these incidents are poorly and formulaically recorded, with errors, insufficient detail and a lack of management oversight. The registered manager failed to identify these weaknesses. Inspection report children’s home: 2491059 8 Physical intervention is used by staff when they are challenged by the children’s behaviours. The quality and completion of restraint records is poor, and reflection and learning are not always obvious. Records and conversations with staff suggest that some physical interventions could have been avoided had staff better understood the children’s behaviours.

p.7

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

Leaders and managers fail to ensure that staff correctly record the administration of medication. Despite supervision and refresher training for some staff, repeated errors in the recording of medication continue.

p.8

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

Leaders and managers fail to ensure that children are provided with the level of support they need in line with their risk assessment. For example, the registered manager agreed to having a newly appointed member of staff work alone to care for a child in a caravan throughout the day and overnight. This was despite the child’s risk assessment stating the child was to be cared for on a two-to-one ratio and the new member of staff not having fully read the child’s care plans. This poor practice placed the child and the member of staff at risk of harm.

p.8

The effectiveness of leaders and managers: inadequate

Monitoring by leaders and managers has lacked rigour and has failed to identify and address significant weaknesses. Incomplete records and poor-quality risk assessments fail to accurately reflect the complex needs of both children. Neither has the registered manager ensured that children receive the level of therapeutic intervention that they need. This has had a negative effect on the quality of care provided to both children, as well as a negative effect on their behaviour.

p.8

The effectiveness of leaders and managers: inadequate

Not all staff receive training and supervision in line with the home’s workforce development plan. There are gaps in the frequency of supervision, the quality of supervision is variable, and some staff said that they do not find supervision to be helpful. Records are not complete and there is little evidence of attention to ensuring that staff fulfil their responsibilities to children and can consider and improve their practice.

p.8

The effectiveness of leaders and managers: inadequate

Monitoring by leaders and managers is weak. Internal audits have failed to identify and correct poor practice. Furthermore, the registered manager has not demonstrated rigour in their role. They have failed to ensure that all policies, the statement of purpose and the workforce development plan accurately reflect the current staffing and senior leadership team.

p.8

The effectiveness of leaders and managers: inadequate

External monitoring by an independent visitor takes place. However, the registered manager has not addressed the recommendations, following each visit, in a timely manner. Furthermore, on one occasion the registered manager failed to notify Ofsted of a serious incident. Inspection report children’s home: 2491059 9

p.8

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.

p.9

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: 2491059 10

p.9

Children’s home details

Registered provider: South West Mental Health Ltd

p.10

Children’s home details

Registered provider address: H & H Accountants Ltd, Old Bank Buildings, East Street, Ilminster, Somerset TA19 0AJ

p.10

Children’s home details

Responsible individual: Victoria Hayward

p.10

Inspector

Linda Bond: social care inspector Inspection report children’s home: 2491059 11 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.

p.10

Inspector

If you would like a copy of this document in a different format, such as large print or Braille, please telephone 0300 123 1231, or email enquiries@ofsted.gov.uk . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit http://www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

p.11

Inspector

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

p.11

Inspector

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

p.11