Children's Home run by Pebbles Care Limited in North Yorkshire

Inspection report children’s home: SC481305 1 SC481305 Registered provider: Pebbles Care Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This children’s home is registered to provide care and accommodation for up to four children and young people who have emotional and/or behavioural difficulties. The manager has been registered since January 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 failures that mean children and young people are not protected or their welfare is not promoted or safeguarded, and the care and experiences of children and young people are poor.

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inadequate

Date of last inspection: 24 October 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: SC481305 2

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Inspection date Inspection type Inspection judgement

24/10/2018 Full Good 13/06/2017 Full Good 08/03/2017 Interim Declined in effectiveness 27/07/2016 Full Good Inspection report children’s home: SC481305 3

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Overall experiences and progress of children and young people: inadequate

A six- to eight-week period of instability due to the children’s and young people’s challenging behaviours resulted in a chaotic, unsafe and unhappy home. Serious and repeated incidents included the children smoking in bedrooms, setting fires both inside and outside the house, barricading themselves in bedrooms, assaulting staff and making verbal and physical threats to staff and peers. Incidents also involved children and young people obtaining dangerous weapons and behaving dangerously in moving cars. Children and young people broke into the staff office and took items without consent, and they caused extensive property and vehicle damage. Some staff report that they felt challenged by these behaviours and described the home at the time as not being a nice place for children and young people. During this difficult period, children and young people made allegations against staff. The management and staff actions in response

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Overall experiences and progress of children and young people: inadequate

were ineffective in ensuring that children were safe and protected.

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Overall experiences and progress of children and young people: inadequate

Some children and young people were subjected to serious bullying and intimidation. This has impacted on their physical and emotional well-being. One child attempted to harm themselves by ligature after they were bullied by other children in the home.

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Overall experiences and progress of children and young people: inadequate

The safety of children was only reached when the staff called the police to manage some of the children’s and young people’s behaviours. This led to the arrest of some children and young people, and their behaviours have been criminalised. Immediate notice has been given on two placements due to the severity of the incidents and because multiple interventions by the staff at the home were unsuccessful.

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Overall experiences and progress of children and young people: inadequate

Despite the challenging behaviours that have impacted on the children’s and young people’s experiences, some children and young people have since made good progress, and the deficits in practice are no longer as widespread as they were. However, these changes will require some time to embed fully in line with the requirements raised.

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Overall experiences and progress of children and young people: inadequate

Children’s and young people’s education progress is mixed, with the progress of some children and young people being very good, and others being less so. One child’s aspirations for education is hindered because they have not been to school since they moved to the home. This is despite the persistent efforts by the registered manager, who has advocated on behalf of the child and challenged the relevant authorities so that the child can access formal learning opportunities.

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Overall experiences and progress of children and young people: inadequate

The engagement of children and young people in activities has improved their confidence and their independence skills. Some of the activities include horse riding, trips out, attending scouts, going on bike rides, going to cinema and taking part in voluntary work, all of which positively contribute to the children’s and young people’s experiences. Children and young people are generally healthy, and they engage in primary and specialist health appointments as appropriate. Two young people have made positive moves on from the home. Inspection report children’s home: SC481305 4 The relationships between the children and young people and staff have recently improved following the period of instability. The care and nurture that the children and young people receive from the staff team are stabilising their daily routines. The children and young people say that they feel listened to, but their views are not always recorded

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Overall experiences and progress of children and young people: inadequate

and translated into actions. Similarly, while key-work sessions have taken place, staff have not used these to discuss with children and young people their plans and their presenting behaviours consistently.

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

The home environment had been inadequate and unsafe during the six- to eight-week period when children’s behaviours were challenging for staff to manage. Children and young people had caused extensive property damage, and not all of them had felt consistently safe. The fire doors had not been functioning properly due to the staff practice of dismantling the metal connectors on the top of the bedroom doors. This compromised children’s and young people’s safety in the event of a fire. The registered manager, some staff and children and young people did not share a consistent view about why this practice was occurring and whether it was appropriate.

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

Risk-management strategies during this chaotic period were not sufficiently robust, nor had they been effective in reducing the children’s and young people’s risky behaviours. The risk-management plans were not consistently detailed or updated following incidents, which has reduced the chance of successful intervention and preventative action. There was no rationale provided to rate the risk levels and to determine the reason for ceasing to monitor children and young people who were at risk of self-harm and needed monitoring during the night. This left staff without a shared understanding of the risks to children and young.

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

Individual work with some children and young people about their risky behaviours was usually reactive and in response to serious incidents. The discussions with the children and young people, such as about the risks of fire starting, smoking in the house and breaking into parts of the premises and accessing offensive weapons, did not lead to positive change. Decisive action was not always taken to follow through with room searches, particularly when there were self-harm risks.

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

Behaviour-management strategies have been ineffective in managing children’s and young people’s escalating and risky behaviours, and have led to some poor practices during this challenging and difficult time. The police were called frequently to support staff during challenging incidents, as some of the children and young people were out of the control of staff. Although rewarding good behaviour and reparation was actively promoted by the staff team, there were no consequences for poor behaviour. This made it difficult for children and young people to learn socially acceptable and boundaried behaviours.

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

The registered manager attends multi-agency meetings and has good contacts with the Inspection report children’s home: SC481305 5 police. No children and young people are currently subject to child sexual exploitation, criminal gangs and other associated risks, and the response when children go missing is appropriate. The manager’s understanding of information about a child protection issue contradicts information provided by the police in a multi-agency meeting and to the regulator. This lack of clarity was not challenged by the manager to ensure that her understanding of the concerns were accurate. Not all staff are aware of or have a good understanding of the whistleblowing policy. The provider has not ensured that staff have the knowledge they need in order to raise concerns safely.

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The effectiveness of leaders and managers: inadequate

The staff team was not able to care for and protect children and young people adequately during the six- to eight-week period, in line with the home’s statement of purpose. Although the inspector saw some improvements at the time of the inspection, there is more work needed to be done in order to embed the required changes.

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The effectiveness of leaders and managers: inadequate

The registered manager’s loyalty and commitment towards maintaining placements impacted on some children’s and young people’s experiences and led to some weaknesses in management oversight and staff support. Staff did not feel that senior leaders were consistently visible or proactive when the staff experienced some significant challenges and risks.

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The effectiveness of leaders and managers: inadequate

Newly recruited staff have filled vacancies at the home. However, the registered manager does not have a full and coherent understanding of the rationale for appointing staff when there are clear issues about their suitability that may impact on their care of children and young people.

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The effectiveness of leaders and managers: inadequate

The quality of the children’s and young people’s records is not consistent. Information in some of the key-work sessions is not clear. Some of the records about children and young people give the wrong meaning, suggesting inconsistent measures of risk. Other entries provide no clear outcome measures, and this makes it difficult to see the progress of individual children and young people.

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The effectiveness of leaders and managers: inadequate

The registered manager has not notified Ofsted about all safeguarding incidents, allegations or concerns raised about staff. For instance, not all police interventions that resulted in the arrest of children and young people have been notified to Ofsted. An incident involving a young person who was previously at high risk of child sexual exploitation had not been notified to Ofsted. Failure to report safeguarding incidents appropriately to Ofsted prevents the regulatory body from monitoring the home’s safeguarding practices.

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The effectiveness of leaders and managers: inadequate

Staff are motivated, and most speak highly about the support, supervision and training opportunities from the registered manager and deputy. The relationships formed between the home and other professionals are positive. This enables the registered manager to appropriately challenge other professionals who do not effectively meet children’s and young people’s plans. The registered manager has addressed the previous Inspection report children’s home: SC481305 6 recommendations.

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The effectiveness of leaders and managers: inadequate

The premises are undergoing considerable refurbishment, and further placements have been blocked by the provider in order to promote a period of stability at the home. This will enable the manager to address the serious deficits in practice. It is too soon to assess the impact on the children’s and young people’s experiences and progress. A team reflection exercise is planned to review the past few weeks and take forward any learning points to prevent such extreme incidents from happening again. Inspection report children’s home: SC481305 7

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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 must comply within the given timescales.

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Requirement Due date

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

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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

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

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Requirement Due date

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

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Requirement Due date

communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding;

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Requirement Due date

help each child to develop the understanding and skills to recognise or withdraw from a damaging, exploitative or harmful relationship. (Regulation 11(1)(a)(2)(a)(i)(iv)(v)(vii)) 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–

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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; 21/07/2019 Inspection report children’s home: SC481305 8 have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

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

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Requirement Due date

are familiar with, and act in accordance with, the home’s child protection policies. (Regulation 12 (1)(2)(a)(i)(iii)(vi)(vii))

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Requirement Due date

Managers are to:  have a robust oversight of all children’s and young people’s risk management plans to ensure that they are up to date and safe, with clear strategies to reduce the identified risks  ensure that clear reasons are provided to rate risk in the risk assessments  make clear the rationale for stopping risk management checks when children and young people self-harm  take decisive action when decisions are made to carry out room searches when concerns come to light about risks to children’s and young people’s health, well-being and safety  improve the quality and frequency of individual work on risky behaviours with children and young people and include the child’s comments  ensure that all fire doors are safely maintained  ensure that all staff understand the whistleblowing policy so that staff practice safeguards children. The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the

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Requirement Due date

helps children aspire to fulfil their potential; and

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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

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; (Regulation 13(1)(a), (2)(f)) 21/07/2019 Inspection report children’s home: SC481305 9 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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Requirement Due date

helps children aspire to fulfil their potential; and

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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

use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13(1)(a)(b), (2)(h))

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Requirement Due date

Specifically:  review the behaviour management policy and individual behaviour management plans to ensure that they make explicitly clear how appropriate behaviour is to be promoted in the home and the measures of control and discipline that may be used to promote socially acceptable behaviours  improve children’s and young people’s records to ensure that they are secure and provide clarity of information and outcomes  improve the quality and content of the children’s and young people’s meeting records to clearly show how their wishes and feelings are responded to  ensure that any information from strategy meetings that is considered incorrect is raised with professionals for review and, if necessary, amendment  ensure that recruitment and vetting practices robustly safeguard children and young people and minimise potential risks to them  submit the outcome and learning points of the management/team review following the serious incidents in

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Requirement Due date

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

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Requirement Due date

a child is involved in or subject to, or is suspected of being involved in or subject to sexual exploitation;

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Requirement Due date

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; 21/07/2019 Inspection report children’s home: SC481305 10 there is an allegation of abuse against the home or a person working there;

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Requirement Due date

(Regulation 40(4)(a)(b)(c)) Inspection report children’s home: SC481305 11

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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 difference 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: SC481305 12

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Children’s home details

Registered provider address: 2 Wyther Lane, Leeds, Yorkshire LS5 3BT

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Inspector

Jacqueline Malcolm, social care inspector Krista Hardy, social care inspector (shadowing) Inspection report children’s home: SC481305 13 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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