Children's Home run by Hexagon Care Services Limited in Westmorland and Furness

Inspection report children’s home: 1269215 1 Registered provider: Hexagon Care Services 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

The home is operated by a private company. It provides care and accommodation for up to four children and young people.

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Information about this children’s home

The home specialises in working with children and young people who have social and emotional difficulties. The home is registered for single-gender occupancy only (female).

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Information about this children’s home

The manager has been in post since 1 August 2018 and registered with Ofsted on 24 October 2018. He is undertaking the level 5 qualification in leadership and management.

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Information about this children’s home

Inspectors were aware during this inspection that serious child protection allegations were being investigated by the appropriate authorities. While Ofsted does not have the power to investigate allegations of this kind, actions taken by the setting in response to the allegations were considered alongside other evidence available at the time of the inspection to inform inspectors’ judgements.

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Information about this children’s home

Inspection dates: 22 to 23 August 2019 and 24 September 2019

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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.

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Inadequate

Date of last inspection: 6 March 2019 Inspection report children’s home: 1269215 2 Overall judgement at last inspection: improved effectiveness

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Inadequate

Enforcement action since last inspection: none

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Inspection date Inspection type Inspection judgement

06/03/2019 Interim Improved effectiveness 08/01/2019 Full Good Inspection report children’s home: 1269215 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 registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home. In particular the registered person must ensure that—

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Requirement Due date

medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child. (Regulation 23 (1)(2)(b)) 01/11/2019

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Requirement Due date

The registered person must ensure that all employees—

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Requirement Due date

receive practice-related supervision by a person with appropriate experience. (Regulation 33 (4)(a)(b)(c)) 01/11/2019

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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—

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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

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

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Requirement Due date

understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person;

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Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare; and 01/11/2019 Inspection report children’s home: 1269215 4 are familiar with, and act in accordance with, the home’s child protection policies. (Regulation 12 (1)(2)(a)(i)(ii)(iii)(v)(vi) and (vii))

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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

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)(b)) 01/11/2019

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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—

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Requirement Due date

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—

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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

ensure that the home’s workforce provides continuity of care to each child. (Regulation 13 (1)(a)(b)(2)(a)(b)(c)(e)(h)) 01/11/2019

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Requirement Due date

The registered person must prepare and implement a policy which—

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is intended to safeguard children accommodated in the children’s home from abuse or neglect; and

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Requirement Due date

sets out the procedure to be followed in the event of an allegation of abuse or neglect.

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Requirement Due date

The procedure to be followed in the event of an allegation of 01/11/2019 Inspection report children’s home: 1269215 5 abuse or neglect must, in particular—

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Requirement Due date

provide for the prompt referral of an allegation about current or ongoing abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the home is located;

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Requirement Due date

provide for the prompt referral of an allegation about past abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the alleged abuse or neglect occurred. (Regulation 34(1)(a)(b)(2)(b)(c))

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Requirement Due date

The care planning standard is that children— receive effectively planned care in or through the children’s home; and

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have a positive experience of arriving at or moving on from the home.

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

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that each child’s relevant plans are followed. (Regulation 14 (1)(a)(b)(2)(c)) 01/11/2019

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

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are signed and dated by the author of each entry. (regulation 36(1)(b)(c) 01/11/2019

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Requirement Due date

Subject to paragraph (6), the registered person must establish a procedure for considering complaints made by or on behalf of children.

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Requirement Due date

In particular, the procedure must provide that no person who is the subject of a complaint takes any part in its consideration or investigation, except at the informal resolution stage if the registered person considers it appropriate.

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Requirement Due date

The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation. (Regulation 39(1)(2)(3)) 01/11/2019

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Requirement Due date

The independent person must produce a report about a visit 01/11/2019 Inspection report children’s home: 1269215 6 ("the independent person’s report") which sets out, in particular, the independent person’s opinion as to whether—

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Requirement Due date

children are effectively safeguarded; and

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the conduct of the home promotes children’s well-being. (Regulation 44(4)(a)(b))

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 When a child returns to the home after being missing from care or away from the home without permission, the responsible local authority must provide an opportunity for the child to have an independent return home interview. Homes should take account of information provided by such interviews when assessing risks and putting arrangements in place to protect each child. (‘Guide to the children’s homes regulations including the quality standards’, page 45, paragraph 9.30)

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Recommendations

Specifically, independent return interviews must take place following each missing episode and within the appropriate timescale.

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Recommendations

 Records must be kept detailing all individual incidents when children go missing from the home. Evaluation of missing incidents should be undertaken to identify any gaps in training, skills or knowledge for staff or to record and retain evidence of what worked well. This evaluation should inform the review of the quality of care. (‘Guide to the children’s homes regulations including the quality standards’, page 45, paragraph 9.31)

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Recommendations

Specifically, the manager’s evaluation will be recorded following each episode of going missing and take account of any concerns arising from the independent return interview. However, the detailed content of the independent interview should not routinely be part of this record to be viewed by staff in the home.

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Recommendations

 Regulation 19(2) details sanctions that are prohibited in behaviour management. Any sanctions used to address poor behaviour should be restorative in nature, to help children recognise the impact of their behaviour on themselves, other children, the staff caring for them and the wider community. (‘Guide to the children’s homes regulations including the quality standards’, page 46, paragraph 9.38)

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Recommendations

Specifically, staff should ensure that sanctions are relevant and proportionate to the behaviour exhibited. Inspection report children’s home: 1269215 7  Any external agency staff should meet the requirements in regulation 32(4) regarding mandatory qualifications, and the registered person should consider their skills, qualifications and any induction necessary before they commence work in the home. The use of agency staff should be carefully monitored and reviewed to ensure children receive continuity of care. (‘Guide to the children’s homes regulations including the quality standards’, page 54, paragraph 10.16)

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Overall experiences and progress of children and young people: inadequate

Children at this home are not all making good progress. Children have made allegations about staff which are currently under investigation. Although there is no outcome yet of the investigations, the fact that such a high number of allegations have been made indicates that children and staff do not always have positive and supportive relationships.

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Overall experiences and progress of children and young people: inadequate

The home has been reliant on casual, bank and agency staff because of ongoing investigations in relation to staff practice at the home. Children are not, therefore, receiving continuity of care from a stable staff team. Children reported to the inspectors that they were not always happy at the home and did not always feel that they could rely on and trust staff to support them.

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Overall experiences and progress of children and young people: inadequate

Children know how to make complaints. However, complaints procedures are not always followed when complaints are made. This means that children are not properly listened to or their views acted on. When managers have been made aware that a child has made a complaint, they have not taken effective and immediate action.

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Overall experiences and progress of children and young people: inadequate

Two children have recently moved on from the home. One was a planned move to a semi-independence setting, and one child was found an alternative placement as a result of them refusing to engage with staff and effectively barricading themselves in their bedroom. The children who remain in the home report that they are glad that the other young people have left the home, which suggests that they did not have positive relationships with each other.

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Overall experiences and progress of children and young people: inadequate

Although children’s rooms are searched on occasions, for safeguarding reasons, staff do not follow ‘Searching children and their belongings’ procedure. There is no log of room searches. It is unclear how many have taken place and the reasons why they are carried out are not recorded. There is no clear record of whether children have consented to searches of their belongings and their bedrooms.

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

The registered manager and staff have demonstrated a lack of understanding in relation to their roles and responsibilities in protecting children and have not always taken effective action when there is a concern about children’s welfare. They have made serious errors in decision-making that have placed children at risk of harm. In one example, a child with a known history of drug misuse and of child sexual exploitation Inspection report children’s home: 1269215 8 was transported by an agency member of staff to several locations to meet with an unknown male. The child later informed other staff that they had bought cannabis while out with this member of staff, and later that day presented to staff as being under the influence of cannabis.

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

Children have made numerous allegations relating to poor safeguarding practice in the home. At the time of this inspection, the investigations into the allegations were ongoing, and, as such, there was no evidence available in respect of whether these allegations were substantiated or not. However, it is evident that not all allegations have been reported within an appropriate timescale to the local area designated officer and the children’s placing authorities.

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

Risk assessments reviewed during the inspection did not contain up-to-date information about the risk of children going missing from the home One child in particular is highly vulnerable. However, the systems for assessing and recording the level of risk are poor and they fail to accurately reflect the actual level of risk. Other risk assessments that are used also fail to accurately identify the levels of risks associated with children’s known behaviours because the staff do not consistently calculate the presenting risk scores in the same way.

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

Children are reported to frequently misuse cannabis. There are reports of children doing so in their bedrooms. Some risk management strategies in the children’s risk assessments were weak. For example, one child’s risk assessment identified notifying a child’s social worker as a strategy to reduce the risk of her smoking cannabis. This action alone would not effectively reduce risk.

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

There is no evidence that staff who are new to the home, including agency staff, have read children’s risk assessments before working with them. This means that they could be lone working with a child without knowing the risks to be alert to.

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

Staff are responsive on those occasions when children go missing from the home. Staff are familiar with the procedures and local protocols to follow when children go missing. Although the home notifies placing authorities when children go missing, independent return interviews do not routinely take place within the required timescale. When they do occur, they are inappropriately recorded in the home’s missing log. This means that children are not routinely given the opportunity to have a timely discussion with an independent person.

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

Children understand that there are consequences when their behaviour is less than satisfactory. Staff try to be restorative in their practice, involving children by supporting them to reflect on their behaviour and contribute their ideas about appropriate sanctions. Although children feel that this is fair and have not voiced any complaints, some records that were reviewed suggested that sanctions are not always fair and proportionate.

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

The home has good arrangements in place for the safe storage, management and administration of medication. However, an error was made in the administration of antibiotics for one child. The error was swiftly dealt with by managers. Arrangements Inspection report children’s home: 1269215 9 were made for staff to participate in further training to refresh their knowledge and skill in this area.

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The effectiveness of leaders and managers: inadequate

Leadership and management of the home lack strength. The home is not currently being managed in a way that is consistent with the approach and ethos, and that delivers the outcomes, set out in the home’s statement of purpose.

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The effectiveness of leaders and managers: inadequate

Managers have not always taken prompt and effective action when incidents have occurred and allegations have been made. Managers have not ensured that staff and children have positive relationships or that staff have worked as a cohesive team.

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The effectiveness of leaders and managers: inadequate

Errors were noted in some records, which suggests that oversight of records is weak. Issues such as incorrect risk ratings should have been identified by managers at an earlier stage. Not all records are fully up to date.

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The effectiveness of leaders and managers: inadequate

There is no system in place to ensure that staff new to the home undertake a full induction and orientation prior to working with children. This means that they may not know what is expected of them and may not be aware of children’s care plans and risk assessments. This leads to the delivery of a poor quality of care. Agency staff employed to work at the home do not always have their suitability, qualifications, skills and experience assessed by the manager before they commence working with children.

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The effectiveness of leaders and managers: inadequate

Not all staff have been supervised at the stated frequency. Supervision notes sampled did not show that staff attitude and inappropriate terminology was challenged during supervision. This does not promote best practice.

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The effectiveness of leaders and managers: inadequate

The responsible individual created an action plan in response to the high number of allegations being made at the home. This plan was not shared with the registered manager, and therefore some key elements of the plan had not been complied with at the time of this inspection.

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The effectiveness of leaders and managers: inadequate

External monitoring of the home is not providing managers with the correct level of scrutiny. Reports from the independent visitor do not highlight the issues identified at this inspection and so are not effective in identifying deficits in care practice and in promoting improvement.

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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 Inspection report children’s home: 1269215 10 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: 1269215 11

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Children’s home details

Registered provider: Hexagon Care Services Limited

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Children’s home details

Registered provider address: 1 Tustin Court, Port Way, Ashton-On-Ribble, Preston, Lancashire PR2 2YQ

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Inspectors

Charlie Bamber, social care inspector Gillian Walters, social care inspector Inspection report children’s home: 1269215 12 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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Inspectors

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Inspectors

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Inspectors

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