Children's Home run by Pilgrims Corner Limited in Kent

Inspection report for children’s home - monitoring visit: SC473877 1 SC473877

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Pilgrims Corner Limited

Monitoring visit Inspected under the social care common inspection framework

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Information about this children’s home

The home is registered to accommodate two children. It is one of four homes operated by a privately owned organisation. The home shares a manager with a similar-size home which is situated nearby. The company also owns a separately registered school, which children living in the homes may attend. The manager was registered with Ofsted on 21 March 2019.

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This monitoring visit

A full inspection of the home was undertaken on 24 and 25 July 2019 and judged the home to be inadequate. Three compliance notices were issued on 14 August 2019. These were made under regulation 12, protection of children; regulation 13, leadership and management; regulation 25, fire precautions. The purpose of this monitoring visit was to examine and assess the effectiveness of the work that has been completed to meet the steps in the three compliance notices. The date set for meeting these steps was 8 September 2019.

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protection of children standard

The compliance notice made under regulation 12 required leaders and managers to assess whether children are at risk of harm and make arrangements to reduce any identified risks. These arrangements were to be kept under review. Leaders and managers were also required to ensure that members of staff have the skills to identify and act on signs that a child could be at risk of harm. At the time of this monitoring visit there was one child living at the home. A review of the risk assessments pertaining to this child had been undertaken. These reviews were not consistently thorough. For example, a fire safety risk assessment failed to Inspection report for children’s home - monitoring visit: SC473877 2 consider the implications of known behaviours associated with the unsafe use of fire safety equipment. Leaders and managers have not identified and assessed all known areas of risk. For example, no risk assessment had been undertaken in respect of staff working alone

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protection of children standard

with the child, even though there were clear indicators that both the child and staff could come to harm in a lone working situation. Children’s individual risk assessments do not always contain well-developed strategies for reducing the potential for the child, or children, to come to harm. A risk assessment in relation to bullying behaviour contained minimal strategies for addressing and reducing the behaviour. There are also weaknesses in how the strategies in risk assessments are implemented in practice. For example, focused key-work sessions to address areas of concern do not always take place with the regularity specified in the risk assessment. Insufficient action has been taken to determine whether the staff have the skills to identify and act on signs that a child could be at risk of harm. There have been no recent staff competency assessments or skills audits. The registered person gave inconsistent accounts of what staff training had taken place since the compliance

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protection of children standard

notice was issued. The majority of staff have received no training specific to the needs of the child currently living at the home. During a recent serious incident two members of staff failed to effectively implement the organisation’s on-call duty system. This meant that a member of staff and the child were left in a vulnerable situation. These shortfalls are indicative of a staff team that does not consistently act on signs that a child could be at risk of harm. The registered individual was not able to demonstrate that the on-call duty manager procedures are accessible to the staff team. The steps in this compliance notice have not been met.

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leadership and management standard

The compliance notice issued under regulation 13 specified that leaders and managers must ensure that the home has sufficient staff to meet the needs of all the children, and that children receive continuity of care. Monitoring and review systems were to be used to ensure continuous improvement in the standard of care being provided. The registered individual reported that staff across the organisation’s four children’s homes are ‘transitory’, meaning that they could work in any of the homes. This arrangement does not ensure that there is a core team of staff employed solely to work at this home and undermines the potential for children to receive consistency of care. Leaders and managers have not taken into consideration how ‘sufficient staffing’ also relates to the number of staff on duty at a particular time. At the full inspection in Inspection report for children’s home - monitoring visit: SC473877 3

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leadership and management standard

July 2019, it was found that there was confusion and mixed messages from managers regarding the necessary staff to children ratio. At this monitoring visit, it was apparent that effective planning regarding the numbers of staff needed to safely care for the child was still not taking place. The quality of care monitoring and review systems is not yet being effectively implemented. The home’s action plan to address the steps in the compliance notices has not been fully implemented. The plan says that aspects of the quality of care review will be undertaken on a monthly basis, but this is not yet being achieved. The monitoring activities described in the home’s statement of purpose are not being consistently implemented. The statement of purpose says that the registered manager will meet with the organisation’s directors to discuss the findings from the regulation 45 quality of care review. A quality of care review has been completed in

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leadership and management standard

recent weeks, but there is no evidence to show that the findings have been reviewed and discussed in the way described in the statement of purpose. The statement of purpose also says that the outcome of all monitoring activities will be shared with the staff team. However, there is no evidence to show that this has happened. The recommendations from the recent independent visitor report have not been discussed in team meetings. The registered individual is now undertaking internal monthly quality assurance audits, and these have identified some areas where practice needs to improve. However, not all the internal monitoring systems are proving to be as effective. The monitoring of key-work sessions did not identify that a member of staff had made an inappropriate remark to the child, and so this was not addressed. In addition, monitoring systems did not identify that a recent change in the child’s behaviour

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leadership and management standard

could possibly be linked to new medication being prescribed. The steps in this compliance notice have not been met.

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Compliance notice issued under regulation 25(2)(a)(b) – fire precautions

The compliance notice issued under regulation 25 specified that leaders and managers must ensure that the requirements of the regulatory reform (fire safety) order 2005 are complied with. The home’s compliance action plan states that a fire protection agency would visit the home and produce a report. Any recommendations made in the report would be actioned immediately. The fire protection agency that was contacted by the organisation was unable to provide the service that had been requested. On the day of this monitoring visit, leaders and managers were negotiating with an alternative provider in order to commission the service required. Therefore, the step specified in the organisation’s action plan had not been achieved when this monitoring visit took place. The home’s internal fire risk assessment has been updated. However, the assessment lacks rigour and does not provide a risk rating or identify any areas for

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Compliance notice issued under regulation 25(2)(a)(b) – fire precautions

Inspection report for children’s home - monitoring visit: SC473877 4 improvement. Regular fire safety equipment checks are taking place, but the inspector was not provided with any evidence to verify that all staff have completed fire safety training. The child living at the home now has a personal emergency evacuation plan. This document lacks detail and does not take account of all significant factors. For example, no reference is made to the child taking medication that could significantly impair his ability to evacuate the building promptly in an emergency. The steps in this compliance notice have not been met.

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Conclusion

Ofsted conducted a case review on 11 September 2019 to consider the evidence gathered at this monitoring visit. At this meeting, it was confirmed that none of the compliance notices have been met. The compliance notices will, therefore, be reissued and the date for complying with all the steps in the notices will be extended to 20 October 2019. Ofsted will also issue a restriction of accommodation notice due to the risk of harm should further children be admitted to the home. Progress towards meeting the requirements and recommendations made at the full inspection on 24 and 25 July 2019 was not examined during this monitoring visit. The requirements and recommendations are, therefore, repeated below. One additional recommendation has been made in respect of undertaking risk assessments and considering the implications of there being only one member of staff on duty with the child.

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Recent inspection history

Inspection date Inspection type Inspection judgement 24/07/2019 Full Inadequate 23/10/2018 Full Requires improvement to be good 01/11/2017 Full Good 21/02/2017 Interim Sustained effectiveness Inspection report for children’s home - monitoring visit: SC473877 5

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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 positive relationships standard is that children are helped to develop, and to benefit from, relationships based on— mutual respect and trust; an understanding about acceptable behaviour; and positive responses to other children and adults. In particular, the standard in paragraph (1) requires the registered person to ensure that staff— help each child to understand, in a way that is appropriate according to the child’s age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful. (Regulation 11 (1)(a)(b)(c)(2)(a)(vi))

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Requirement Due date

In particular, ensure that staff have the knowledge and skills to support and safely care for children who demonstrate sexually harmful behaviour. 08/09/2019

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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; have the skills to identify and act upon signs that a child is at risk of harm. (Regulation 12 (1)(2)(a)(i)(iii))

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Requirement Due date

This is with specific reference to the assessment and management of risk and ensuring that staff are aware of when a child leaves the home. 20/10/2019

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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 20/10/2019 Inspection report for children’s home - monitoring visit: SC473877 6 promotes their welfare.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to— ensure that the home has sufficient staff to provide care for each child; ensure that the home’s workforce provides continuity of care to each child; use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b)(2)(d)(e)(h))

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Requirement Due date

The registered person must ensure that— children can access all appropriate areas of the children’s home’s premises. (Regulation 21 (b))

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Requirement Due date

This is with specific reference to using the lounge as a staff sleep-in room. 08/09/2019

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Requirement Due date

*If the Regulatory Reform (Fire Safety) Order 2005(a) applies to the home— the registered person must ensure that the requirements of that Order and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the home. (Regulation 25 (2)(b))

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Requirement Due date

This is with specific reference to consulting the fire service and reviewing and updating the home’s fire risk assessment when there is a significant change in circumstances. 20/10/2019

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Requirement Due date

An organisation may only carry on a home if— each director of the organisation, except for a director who is the responsible individual, who is involved in the carrying on of a home by that organisation satisfies the requirements in paragraph (6).

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Requirement Due date

The requirements are that— the individual is of integrity and good character.

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Requirement Due date

A responsible individual must— have the capacity, experience and skills to supervise the management of the home, or the homes, in respect of which the responsible individual is nominated. (Regulation 26 (6)(a)(7)(b)) 08/09/2019

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Requirement Due date

The registered person must ensure that all employees— undertake appropriate continuing professional development. 08/09/2019 Inspection report for children’s home - monitoring visit: SC473877 7 (Regulation 33 (4)(a))

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Requirement Due date

This is with particular reference to ensuring that staff who provide practice-related supervision have received the necessary training and guidance to make them competent to do so.

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Requirement Due date

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

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Requirement Due date

This is with specific reference to managing allegations made against members of the senior management team. 08/09/2019

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if— there is an allegation of abuse against the home or a person working there. (Regulation 40 (4)(c)) 08/09/2019

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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. (Regulation 45(1)) 08/09/2019

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendations

 Children should be encouraged to develop positive relationships with others both in and outside the home as set out in the positive relationships standard. However, staff should be alert to the possibility that children may be at risk from such relationships including with other children in the home, staff, family members, friends and others outside the home, and they therefore should take appropriate steps to protect a child where there are concerns for a child’s safety. (‘Guide to the children’s homes regulations including the quality standards’, page 43, paragraph 9.13) In particular, ensure that staff take effective action to prevent children from physically harming one another.  For children’s homes to be nurturing and supportive environments that meet the needs of their children, they will, in most cases, be homely, domestic environments. Children’s homes must comply with relevant health and safety

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Recommendations

legislations (alarms, food hygiene etc.); however, in doing so, homes should seek as far as possible to maintain a domestic rather than ‘institutional’ impression. (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9) This is with specific reference to ensuring that worn carpets are replaced and Inspection report for children’s home - monitoring visit: SC473877 8 the home is kept clean.  The children’s home must produce a children’s guide. The children’s guide must be made available to all children when their placement in the home is agreed (or on arrival at the home if the placement is made in an emergency) and must be age appropriate, provided in an accessible format and explained to each child to make sure they understand it. (‘Guide to the children’s homes regulations including the quality standards’, page 24, paragraph 4.21)  Contingency plans should be prepared in the event of a shortfall in staffing

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Recommendations

levels. If it is likely that there might only be one member of staff on duty at any time the manager should make a formal assessment of the implications for children’s care, including any likely risks. This assessment should be recorded and available for inspection by Ofsted and placing authorities. (‘Guide to the children’s homes regulations including the quality standards’, page 54, paragraph 10.18)

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Information about this inspection

The purpose of this visit was to monitor the action taken and the progress made by the children’s home since its last Ofsted inspection.

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Information about this inspection

This inspection was carried out under the Care Standards Act 2000. Inspection report for children’s home - monitoring visit: SC473877 9

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Children’s home details

Registered provider: Pilgrims Corner Limited

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Children’s home details

Registered provider address: Suite 5, The Links, Herne Bay, Kent CT6 7GQ

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Children’s home details

Registered manager: Shanelle Maxwell-Amayigha

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Inspector

Stephen Collett, social care inspector Inspection report for children’s home - monitoring visit: SC473877 10 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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Inspector

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Inspector

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Inspector

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