Children's home run by South West Mental Health Ltd in Somerset

Inspection report children’s home: 1185768 1 Registered provider: South West Mental Health Ltd

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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 privately operated children’s home is currently registered to provide care and accommodation for up to three children and young people.

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

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inadequate

Overall judgement at last inspection: Inadequate

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Enforcement action since last inspection:

One compliance notice was issued under regulation 6: the quality and purpose of care standard. Inspection report children’s home: 1185768 2

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Inspection date Inspection type Inspection judgement

Full Inadequate 11/02/2019 Interim Sustained effectiveness 31/07/2018 Full Requires improvement to be good 17/01/2018 Interim Sustained effectiveness Inspection report children’s home: 1185768 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 health and well-being standard is that—

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

children are helped to lead healthy lifestyles.

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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

achieve the health and well-being outcomes that are recorded in the child’s relevant plans; and

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Requirement Due date

understand and develop skills to promote the child’s well-being.

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Requirement Due date

(Regulation 10 (i)(a)(b)(c)(2)(a)(i)(iv)) 08/11/2019

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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

an understanding about acceptable behaviour.

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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

that staff— 08/11/2019 Inspection report children’s home: 1185768 4 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 socially aware behaviour;

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Requirement Due date

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

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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

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;

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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;

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Requirement Due date

de-escalate confrontations with or between children, or potentially violent behaviour by children.

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Requirement Due date

(Regulation 11 (1)(a)(b)(2)(a)(i)(ii)(iii)(iv)(v)(ix)(x)(xi))

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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;

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Requirement Due date

help each child to understand how to keep safe; 08/11/2019 Inspection report children’s home: 1185768 5 have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

are familiar with, and act in accordance with, the home’s child protection policies; and

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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.

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Requirement Due date

(Regulation 12 (1)(2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(b))

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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—

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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

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;

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Requirement Due date

ensure that staff work as a team where appropriate;

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Requirement Due date

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

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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;

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Requirement Due date

demonstrate that practice in the home is informed and improved by taking into account and acting on— 08/11/2019 Inspection report children’s home: 1185768 6 research and developments in relation to the ways in which the needs of children are best met; and

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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.

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Requirement Due date

(Regulation 13 (1)(a)(b)(2)(a)(b)(c)(f)(g)(i)(h))

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Requirement Due date

The registered person must maintain records ("case records") for each child which—

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Requirement Due date

are signed and dated by the author of each entry.

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Requirement Due date

The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so.

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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

that each child has access to appropriate equipment, facilities and resources to support the child’s learning.

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Requirement Due date

The quality and purpose of care standard

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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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 and apply the home’s statement of purpose; 08/11/2019 Inspection report children’s home: 1185768 7 ensure that staff—

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Requirement Due date

understand and apply the home’s statement of purpose;

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Requirement Due date

protect and promote each child’s welfare;

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Requirement Due date

help each child to develop resilience and skills that prepare the child to return home, to live in a new placement or to live independently as an adult.

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Requirement Due date

that the care is approved, and kept under review throughout its duration, by the placing authority;

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Requirement Due date

that the care is delivered by a person who—

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Requirement Due date

has the experience, knowledge and skills to deliver that care.

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Requirement Due date

(Regulation 6 (1)(a)(b)(2)(a)(b)(i)(ii)(vi)(3)(a)(b)(c)(i))

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Overall experiences and progress of children and young people: inadequate

Leaders and managers have repeatedly failed to provide young people with a specialised, therapeutic and safe residential home, which they report to offer in their statement of purpose.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers have failed to meet some of the requirements made at the previous inspection in June 2019. Consequently, the two young people’s outcomes have not improved.

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Overall experiences and progress of children and young people: inadequate

The inspector identified the two young people were having a detrimental effect on each other. This had resulted in an increase in admissions to hospital following incidents when the young people had harmed themselves or had attempted suicide and a young person had again, been moved into an unregulated ‘holiday’ cottage in order to move her away from the other child living at the home.

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Overall experiences and progress of children and young people: inadequate

The young people’s education and learning has been interrupted because of repeated Inspection report children’s home: 1185768 8 admissions to hospital. Furthermore, delay by leaders and managers sourcing a laptop for one young person has had a negative impact on their learning opportunities.

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Overall experiences and progress of children and young people: inadequate

Young people are cared for by a staff team that is keen to improve young people’s outcomes. However, since the previous inspection, despite the dedication and attempts by the staff, the young people have continued to be placed at risk because their complex needs are not being met. Serious incidents take place which are often difficult to manage, and staff have been injured. As a result, the young people’s mental health has deteriorated, self-injurious behaviours have continued and there have been repeated admissions to hospital. Both the young people are now facing criminal charges.

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Overall experiences and progress of children and young people: inadequate

A team of therapists is available for young people. Despite recent improvements in the range, content and frequency of direct work with the young people, this is having no measurable and sustainable impact on young people making positive choices. To date, the young people’s engagement with this service has been variable. One member of staff spoke of the delay in support they received following a serious incident and said that they would choose not to seek support from the therapy service.

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

Young people remain at risk of significant harm. Staff have failed to prevent the young people from overdosing on paracetamol, being in danger from allegedly ingesting a variety of risky objects, using ligatures, cutting themselves and assaulting staff and members of the public. There have been no reductions in frequency and duration since the previous inspection.

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

The control measures identified to mitigate the risk are inadequate and ineffective. For example, on one occasion a young person and a member of staff were placed at immediate danger of oncoming traffic. Leaders and managers have not always been able to safeguard the young people without the involvement of police and medical staff. Both young people have on more than one occasion been detained by police under section 136 (Mental Health Act 1983) and subsequently sectioned under section 2 (Mental Health Act 1983).

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

Leaders and managers have failed to prevent the young people’s behaviours from having an impact on one another. On one occasion, the two young people were both admitted to hospital on the same day following a series of incidents.

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

Leaders and managers have failed to provide staff with guidance and protocol to safeguard young people against suicide, and not all staff have completed specific training on the prevention of suicide. As a result, on one occasion staff failed to share in a timely manner a suicide note written by a young person. An investigation into this incident has not yet started.

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

Leaders and managers failed to ensure that a young person’s bedroom was recorded as safe to return to when the young person came home from hospital. Inspection report children’s home: 1185768 9 One young person has not returned to the home following an admission to hospital. Leaders and managers stated that they could not guarantee the safety of the two young people. As a result, this young person has had to move on without enough consideration to planning and the impact this will have on the young person.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to help staff prevent and reduce the number of times when the young people have been placed at risk. Staff have had to rely on the police to protect the young people from being seriously hurt and injuring members of the public.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have recruited senior members to the team, made improvements to the quality of the therapeutic service, provided supervision and training for staff and introduced a new IT system. However, this has not yet had a discernible impact on the quality of care provided.

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The effectiveness of leaders and managers: inadequate

Monitoring of the home by leaders and managers has improved since the previous inspection. However, the new electronic recording system is not yet fully supporting the staff team. Leaders and managers failed to identify several recording errors. For example, a staying safe and moving forward plan for one young person was not dated and was misleading for the staff and the young person, two physical interventions were not comprehensive and a risk assessment did not accurately reflect the risks of one young person.

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The effectiveness of leaders and managers: inadequate

Staff are supported by a manager and a senior leadership team. Time is given for staff to reflect following serious incidents. However, one member of staff spoke of the lack of support on one occasion from the on-call system.

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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 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: 1185768 10

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Children’s home details

Registered provider: South West Mental Health Ltd

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Children’s home details

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

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Inspector

Linda Bond, social care inspector Inspection report children’s home: 1185768 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 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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