Children's home run by Orbis Education and Care Limited

Inspection report children‘s home: 2519199 1 Registered provider: Orbis Education and Care Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

Orbis Abbey Rose is part of the Orbis Education and Care group and offers a 52-week placement which may/may not include education. The home provides care and education for up to 10 children who have autism spectrum disorder and/or learning difficulties. The home was registered with Ofsted on 2 May 2019. On 20 June 2019, Ofsted was informed that the registered manager had resigned. Following his resignation, the home was managed by an interim manager until a new permanent manager was appointed. The newly appointed manager started in post in October 2019 and has not yet applied to be registered by Ofsted. The inspection of the children’s home was aligned with the education inspection of the school. The two premises are on the same site.

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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 widespread failures that mean children are not protected or their welfare is not promoted or safeguarded and the care and experiences of children are poor and they are not making progress.

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inadequate

Date of last inspection: This is the home’s first inspection since it registered with Ofsted.

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inadequate

Overall judgement at last inspection: not applicable

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inadequate

Enforcement action since last inspection: none Inspection report children‘s home: 2519199 2

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

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

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

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

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understand and apply the home’s statement of purpose;

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understand and apply the home’s statement of purpose;

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protect and promote each child’s welfare;

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treat each child with dignity and respect;

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

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help each child to understand and manage the impact of any experience of abuse or neglect;

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provide to children living in the home the physical necessities they need in order to live there comfortably;

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provide to children personal items that are appropriate for their age and understanding; and

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make decisions about the day-to-day arrangements for each child, in accordance with the child’s relevant plans, which give 31/01/2020 Inspection report children‘s home: 2519199 3 the child an appropriate degree of freedom and choice;

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ensure that the premises used for the purposes of the home are designed and furnished so as to—

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enable each child to participate in the daily life of the home.

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

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that the care is delivered by a person who—

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

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is under the supervision of a person who is appropriately skilled and qualified to supervise that care. (Regulation 6 (1)(a)(b) (2)(a)(b)(i)(ii)(iii)(iv)(v)(vii)(viii)(ix)(c)(i)(ii)(3)(a)(b)(c)(i)(ii)) The children’s views, wishes and feelings standard is that children receive care from staff who—

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develop positive relationships with them;

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take their views, wishes and feelings into account in relation to matters affecting the children’s care and welfare and their lives.

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

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ascertain and consider each child’s views, wishes and feelings, and balance these against what they judge to be in the child’s best interests when making decisions about the child’s care and welfare;

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help each child to express views, wishes and feelings;

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help each child to understand how the child’s views, wishes and 31/01/2020 Inspection report children‘s home: 2519199 4 feelings have been taken into account and give the child reasons for decisions in relation to the child;

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regularly consult children, and seek their feedback, about the quality of the home’s care; and

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help each child to understand how the child’s privacy will be respected and the circumstances when it may have to be limited. (Regulation 7 (1)(a)(b)(c)(2)(a)(i)(ii)(iii)(iv)(v)) The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so.

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

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help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans;

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support each child’s learning and development, including helping the child to develop independent study skills and, where appropriate, helping the child to complete independent study;

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understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers;

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help each child to understand the importance and value of education, learning, training and employment;

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promote opportunities for each child to learn informally;

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maintain regular contact with each child’s education and training provider, including engaging with the provider and the placing authority to support the child’s education and training and to maximise the child’s achievement;

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raise any need for further assessment or specialist provision in relation to a child with the child’s education or training provider and the child’s placing authority;

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Requirement Due date

help a child who is excluded from school, or who is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as 31/01/2020 Inspection report children‘s home: 2519199 5 possible;

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help each child who is above compulsory school age to participate in further education, training or employment and to prepare for future care, education or employment; and

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help each child to attend education or training in accordance with the expectations in the child’s relevant plans. (Regulation 8 (1)(2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(ix)(x)) The enjoyment and achievement standard is that children take part in and benefit from a variety of activities that meet their needs and develop and reflect their creative, cultural, intellectual, physical and social interests and skills.

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

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develop the child’s interests and hobbies;

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participate in activities that the child enjoys, and which meet and expand the child’s interests and preferences; and

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make a positive contribution to the home and the wider community; and

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that each child has access to a range of activities that enable the child to pursue the child’s interests and hobbies. (Regulation 9 (1)(2)(a)(i)(ii)(iii)(b)) 31/01/2020

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The health and well-being standard is that—

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

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

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children are helped to lead healthy lifestyles.

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

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achieve the health and well-being outcomes that are recorded in the child’s relevant plans; 31/01/2020 Inspection report children‘s home: 2519199 6 understand the child’s health and well-being needs and the options that are available in relation to the child’s health and well-being, in a way that is appropriate to the child’s age and understanding;

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take part in activities, and attend any appointments, for the purpose of meeting the child’s health and well-being needs; and

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

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that each child has access to such dental, medical, nursing, psychiatric and psychological advice, treatment and other services as the child may require.

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In particular, ensure that all children receive a diet that is healthy, balanced and in line with their dietary needs. (Regulation 10 (1)(a)(b)(c)(2)(a)(i)(ii)(iii)(iv)(c)) The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on—

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an understanding about acceptable behaviour; and

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positive responses to other children and adults.

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

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

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help each child to develop socially aware behaviour;

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

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

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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 31/01/2020 Inspection report children‘s home: 2519199 7 understanding;

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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;

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help each child to develop the understanding and skills to recognise or withdraw from a damaging, exploitative or harmful relationship;

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strive to gain each child’s respect and trust;

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

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that each child is encouraged to build and maintain positive relationships with others. (Regulation 11 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(ix)(x)(xi)(b)) The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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

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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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help each child to understand how to keep safe;

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

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manage relationships between children to prevent them from 31/01/2020 Inspection report children‘s home: 2519199 8 harming each other;

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

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

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

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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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that the premises used for the purposes of the home are located so that children are effectively safeguarded;

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that the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child’s health; and

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that the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (1)(2)(a)(i)(ii)(iii)(iv)(v) (vi)(vii)(b)(c)(d)(e)) 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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helps children aspire to fulfil their potential; and

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

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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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ensure that staff work as a team where appropriate;

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

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ensure that the home has sufficient staff to provide care for each child; 31/01/2020 Inspection report children‘s home: 2519199 9 ensure that the home’s workforce provides continuity of care to each child;

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

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

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feedback on the experiences of children, including complaints received; and

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use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b)(2)(a)(b)(c)(d)(e)(f)(g)(i)(ii)(h)) The care planning standard is that children—

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

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

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that the child’s placing authority is contacted, and a review of that child’s relevant plans is requested, if—

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the registered person considers that the child is at risk of harm or has concerns that the care provided for the child is inadequate to meet the child’s needs.

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In particular, ensure that children’s behaviour support plans are adhered to. (Regulation 14 (1)(a)(2)(e)(i)) 31/01/2020

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Statement of purpose The registered person must compile in relation to the children’s home a statement (“the statement of purpose”) which covers the matters listed in Schedule 1.

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keep the statement of purpose under review and, where appropriate, revise it; and 31/01/2020 Inspection report children‘s home: 2519199 10 notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision.

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Ensure that the website is reviewed and accurately describes the children’s home. (Regulation 16 (1)(3)(a)) Restraint and deprivation of liberty Restraint in relation to a child is only permitted for the purpose of preventing—

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injury to any person (including the child);

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serious damage to the property of any person (including the child); or

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a child who is accommodated in a secure children’s home from absconding from the home.

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Restraint in relation to a child must be necessary and proportionate.

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These Regulations do not prevent a child from being deprived of liberty where that deprivation is authorised in accordance with a court order.

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In particular, ensure that locked doors do not restrict the liberty of children. (Regulation 20 (1)(a)(b)(c)(d)(2)(3)) 31/01/2020

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

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In particular, the registered person must ensure that—

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medicines kept in the home are stored in a secure place so as to prevent any child from having unsupervised access to them. (Regulation 23 (1)(2)(a)) 31/01/2020

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Fitness of workers The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety.

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full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2.

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In particular, ensure that all suitability checks of agency staff are 31/01/2020 Inspection report children‘s home: 2519199 11 completed before they work in the children’s home. (Regulation 32 (1)(3)(d)) Employment of staff The registered person must ensure that all employees—

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undertake appropriate continuing professional development; and

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receive practice-related supervision by a person with appropriate experience. This includes all agency, temporary and permanent staff. (Regulation 33 (4)(a)(b)) 31/01/2020

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Behaviour management policies and records The registered person must ensure that—

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within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes—

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details of the child’s behaviour leading to the use of the measure;

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the date, time and location of the use of the measure;

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a description of the measure and its duration;

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details of any methods used or steps taken to avoid the need to use the measure;

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the name of the person who used the measure (“the user”), and of any other person present when the measure was used;

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the effectiveness and any consequences of the use of the measure; and

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a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure;

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within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (“the authorised person”)—

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has spoken to the user about the measure; and

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has signed the record to confirm it is accurate; and

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within 5 days of the use of the measure, the registered person 31/01/2020 Inspection report children‘s home: 2519199 12 or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c)(4)) Notification of a serious event The registered person must notify HMCI and each other relevant person without delay if—

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there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(e)) 31/01/2020

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Recommendations

 Staff need the knowledge and skills to recognise and be alert for any signs that might indicate a child is in any way at risk of harm. The registered person should ensure that skills in safeguarding are gained, refreshed and recorded in the home’s workforce plan. (‘Guide to the children’s homes regulations including the quality standards’, page 43, paragraph 9.12)  The registered person should have a workforce plan which can fulfil the workforce related requirements of Regulation 16, schedule 1 (paragraphs 19 and 20). The plan should: – detail the necessary management and staffing structure, (including any staff commissioned to provide health and education), the experience and qualifications of staff currently working within the staffing structure and any further training required for those staff, to enable the delivery of the home’s Statement of Purpose; – detail the processes and agreed timescales for staff to achieve induction,

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Recommendations

probation and any core training (such as safeguarding, health and safety and mandatory qualifications); – detail the process for managing and improving poor performance; – detail the process and timescales for supervision of practice (see Regulation 33 (4)(b)) and keep appropriate records for staff in the home. The plan should be updated to include any new training and qualifications completed by staff while working at the home and used to record the ongoing training and continuing professional development needs of staff – including the home’s manager. (‘Guide to the children’s homes regulations including the quality standards’, page 53, paragraph 10.8) Inspection report children‘s home: 2519199 13

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Overall experiences and progress of children and young people: inadequate

Prior to and during the inspection, Ofsted received several specific concerns and allegations about practices in the home. During the inspection, these concerns were reviewed, and Ofsted identified serious weaknesses in the management of the home that placed the children at significant risk of harm. Ofsted took immediate action to suspend the home’s registration and to inform the local authorities with responsibility for the children.

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Overall experiences and progress of children and young people: inadequate

The quality of children’s experiences is inadequate. Significant staffing changes mean that children’s opportunities to develop relationships, to make progress and to join in with purposeful activities are vastly reduced. Some children’s engagement at school is poor and their learning is interrupted because staff do not manage the behaviours of other children in class effectively or ensure that children attend school regularly. During the inspection period, one child’s sleep pattern was disrupted, meaning that he was asleep during the school day and awake at night.

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Overall experiences and progress of children and young people: inadequate

Children’s after-school activities are repetitive and uninspiring. Activity schedules state that children are supported to go swimming and into the local community, but this is not happening for all children. Plans are not made in advance each day to ensure that children’s time in the home is purposeful, fun and aspirational. During the inspection, staff told inspectors that there was nothing planned for the evening and that they routinely leave it to children to decide what they want to do. As a result, a number of children spent time repeatedly watching DVDs and walking around the grounds. In contrast to these poor-quality daily activities, one child recently enjoyed a lovely holiday to Paris and another child to a more local holiday area.

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Overall experiences and progress of children and young people: inadequate

Children’s behaviour support plans are comprehensive documents providing staff with a wealth of information about the care and support that children require. However, these important plans are not read by every member of staff and are not followed effectively. For example, aids to support children to communicate and to develop independence skills are not consistently provided or used. Too often, inspectors observed children not being given choices about the food they ate and being allowed to eat with their fingers.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers have failed to ensure that the children’s home is always kept clean, tidy and well maintained. The arrangements for staff and children to keep clean are insufficient and result in poor infection control and environmental issues. Incidents of staff, children and the premises being smeared with faeces are a regular occurrence. Despite plentiful supplies on-site, one house only contained one toilet roll between six bathrooms and the staff bathroom did not contain any handwash or handtowels.

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Overall experiences and progress of children and young people: inadequate

Too often, staff give children processed and fast food to eat. Staff visit a fast food outlet daily and provide one child with approximately 122 chicken nuggets and 14 litres of fizzy drink each week. One member of staff reported having to bring food in from their home to ensure that the children could have a wholesome cooked meal. Leaders and managers Inspection report children‘s home: 2519199 14 are seeking the advice of a dietician and employing a chef, but direct action to prevent poor diets from continuing is slow.

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Overall experiences and progress of children and young people: inadequate

Inspectors did observe some positive interactions with children, and several permanent members of staff spoke passionately about wanting to support the children well. Some examples were given to the inspectors about children’s achievements. For example, one child has visited the hairdresser successfully and another child has positively attended a health appointment. Previously, both these activities were difficult for the children.

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Overall experiences and progress of children and young people: inadequate

Feedback from placing authorities and parents about children’s experiences and progress in the home is mixed. Some are positive about the support given to children and others report concerns about the use of temporary staff and poor communication.

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

Children are at serious risk of harm. Many of the current weaknesses have been known to leaders and managers. However, their action to address these weaknesses is too slow, leaving children with poor day-to-day experiences. For example, restrictive practices, including the locking of doors, has taken place and routinely locking a kitchen door to prevent children from having access without asking staff is a daily occurrence.

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

The response to safeguarding concerns is weak. Two of the designated senior staff responsible for child protection do not have the appropriate safeguarding training. On occasions, staff have remained working alone with children despite allegations being made about them by other staff. Allegations are investigated, but insufficient action is taken to scrutinise additional concerns about potential poor practice that arise during the original investigation.

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

During the inspection, inspectors found several safeguarding concerns that had not previously been known by managers or reported to Ofsted as required. Leaders and managers do not know what action has been taken in response to these safeguarding concerns, as child protection records are disorganised and do not always clarify the action or confirm the outcome. Leaders and managers do not monitor effectively body maps that are used to document marks and injuries to children. It is not clear from these records what action has been taken in response to ensure that children’s health needs are met and they are kept safe.

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

Staff lack de-escalation skills to manage incidents safely. Several serious incidents have occurred since the home was registered in May 2019, for example highly dangerous behaviours by children, including smashing car windows, throwing furniture, causing extensive damage to rooms and assaulting staff. On two occasions, one child was not prevented from eating wild mushrooms and another child was not prevented from misusing the internet despite both children having at least one-to-one support from staff. Incidents have occurred when one child has harmed and attempted to harm other children. On one occasion, staff locked themselves and the child at risk of harm in a bathroom. As a direct result of these incidents, children and staff have had to attend hospital for medical attention and the police have been required to support staff. Inspection report children‘s home: 2519199 15 Not all staff are well prepared to care for the children. Agency staff do not have access

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

to the online recording system to review children’s records and to document the care they give to children. Some staff said they had not had the time to read the children’s files. This is unsafe practice and places children at risk.

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

Medication is not always managed safely or in accordance with the provider’s administration policy. Leaders and managers did not know that staff were storing their food alongside medicine in a medication fridge. Not all staff responsible for second checking medication are trained to undertake this role. In addition, they do not observe the medication being prepared and therefore cannot confirm that it is the right medication that is being given.

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

Leaders and managers were unable to confirm that all the required safer recruitment checks are carried out on agency staff as required by the children’s homes regulations.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to provide consistent leadership and direction since the home was registered in May 2019. Repeated changes to the senior leadership team and poor retention of staff remain as concerns. The previous registered manager resigned six weeks after being registered with Ofsted, followed by a period when the children’s home was managed by an interim manager. In October 2019, a permanent manager was appointed and has not yet applied to register with Ofsted.

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The effectiveness of leaders and managers: inadequate

Agency staff are used regularly and relied on to cover staff vacancies. During one day of the inspection, more than 50% of the staff caring for children were from an external agency. Often, it is these staff who are assigned to support the children with the most complex needs. Despite this, leaders and managers do not assure themselves that agency staff have read and understood children’s support plans and do not provide them all with regular supervision. Consequently, leaders and managers are unable to assess their practice effectively, are not addressing poor performance and are not providing agency staff with the necessary support. Since the home opened, allegations have been made about four agency staff.

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The effectiveness of leaders and managers: inadequate

Leaders and managers are aware that the staff induction programme is inadequate and does not equip staff with the skills to support the children with extremely complex behaviours. For example, the new manager told the inspectors that since she started in post she is concerned that she is having to provide staff who already work in the home with basic care training. Several staff told inspectors that the training in autism spectrum disorders is poor despite this being an area of specialism for the provider.

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The effectiveness of leaders and managers: inadequate

Staffing arrangements are poorly planned. Leaders and managers have not ensured that children are provided with consistency of care, good routines and stability. Neither have they ensured that staff are suitably skilled, adequately trained and properly supervised to meet the children’s needs and to care for them safely. Staff are allocated to work with children each day and children are not provided with the same staff and do not know in Inspection report children‘s home: 2519199 16 advance who is going to support them. One child has been supported to choose the staff who support him, but this same provision is not available to the remaining children.

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The effectiveness of leaders and managers: inadequate

Leaders and managers fail to monitor and review practice and records adequately. For example, not all staff receive regular supervision and training, and several records of physical restraint that include a child being held on the floor were not recorded on the central record. During the inspection, agency staff restrained a child, but no record of this incident and their actions was recorded. Furthermore, some documents including the children’s homes website and statement of purpose remain out of date and an up-to- date Annex A and a workforce strategy plan were not made available for the inspectors.

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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: 2519199 17

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Children’s home details

Registered provider: Orbis Education and Care Limited

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Children’s home details

Registered provider address: Vision Court, Caxton Place, Pentwyn, Cardiff CF23 8HA

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Inspectors

Linda Bond: social care inspector Paula Lahey: social care inspector Inspection report children‘s home: 2519199 18 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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