Children's Home run by Blue Mountain Homes Ltd in Doncaster

Inspection report children’s home: 1264438 1 Registered provider: Blue Mountain Homes 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

A private provider operates and runs this home. It provides care for children and young people who may have emotional and/or behavioural difficulties. The home was registered in December 2017 and the manager has held registered manager status since that time.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

There are serious failures that mean children and young people are not protected or their welfare is not promoted or safeguarded.

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inadequate

Overall judgement at last inspection: improved effectiveness

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inadequate

Enforcement action since last inspection: none Inspection report children’s home: 1264438 2

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Inspection date Inspection type Inspection judgement

07/03/2019 Interim Improved effectiveness 21/08/2018 Full Good Inspection report children’s home: 1264438 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 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 have the experience, qualifications and skills to meet the needs of 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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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)(c)(f)(h))

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Requirement Due date

In particular, ensure that decisive and prompt action is taken to meet the above, and to:  quality assure all records to ensure that they are completed in a timely and appropriate manner  ensure that children’s and young people’s ethnicity and cultural background are explicitly recorded in their care plans 22/11/2019 Inspection report children’s home: 1264438 4  ensure that all staff training records are up to date  confirm that staff have commenced the Diploma level 3  ensure a robust oversight of all children’s and young people’s risk management plans to ensure that they are accurate, up to date and safe, with clear strategies to reduce the identified risks

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Requirement Due date

 review the risk management documents to ensure that the information makes it explicitly clear how young people who return home under the influence of alcohol and/or substances will be monitored through the night

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Requirement Due date

 improve the quality of restraint records to ensure that they fully meet the regulations and promptly monitor the interventions to ensure that they are safe and proportionate. The registered manager’s oversight and action should be concluded within required timescales. The registered person must—

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Requirement Due date

keep the statement of purpose under review and, where appropriate, revise it; and

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Requirement Due date

notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision.

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Requirement Due date

In particular, provide an up-to-date staffing list and information about the practice of locking internal doors to communal rooms in the home. 22/11/2019

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the privacy of children is appropriately protected;

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children can access all appropriate areas of the children’s home’s premises; and

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any limitation placed on a child’s privacy or access to any area of the home’s premises—

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Requirement Due date

is intended to safeguard each child accommodated in the home;

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Requirement Due date

is kept under review and, if necessary, revised; and 22/11/2019 Inspection report children’s home: 1264438 5 allows children as much freedom as is possible when balanced against the need to protect them and keep them safe.

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Requirement Due date

(Regulation 21 (a)(b)(c)(i)(ii)(iv)) The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety. The registered person may only—

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Requirement Due date

employ an individual to work at the children’s home; or

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Requirement Due date

if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children, allow that individual to work at the home, if the individual satisfies the requirements in paragraph (3).

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Requirement Due date

the individual is of integrity and good character;

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the individual is mentally and physically fit for the purposes of the work that the individual is to perform.

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In particular, ensure that recruitment records make clear the rationale for determining the suitability of staff when information is disclosed that may have an impact on the decision to employ them. 22/11/2019

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The registered person must ensure that all employees—

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receive practice-related supervision by a person with appropriate experience.

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In particular, ensure that the staff are supervised regularly in line with the home’s statement of purpose. 22/11/2019

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Requirement Due date

In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating—

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Requirement Due date

the feedback and opinions of children about the children’s home, its facilities and the quality of care they receive in it.

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Requirement Due date

(Regulation 45 (2)(b)) 22/11/2019 Inspection report children’s home: 1264438 6 In particular, ensure that the opinions are sought of children, young people, parents, staff and other professionals involved in the children’s and young people’s care to support the review of the quality of care. Restraint in relation to a child must be necessary and proportionate.

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Requirement Due date

In particular, ensure that restraint is an approved measure, carried out by suitably trained staff. 22/11/2019

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Requirement Due date

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

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Requirement Due date

there is any other incident relating to a child which the registered person considers to be serious.

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Requirement Due date

The independent person must produce a report about a visit (“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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Requirement Due date

the conduct of the home promotes children’s well-being.

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Requirement Due date

In particular, ensure that the independent visitor justifies the rationale for expressing the opinion as detailed above when reviewing information about potential safeguarding matters, such as inappropriate restraint and unexplained bruises to children.

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Recommendations

 The registered person should actively seek independent scrutiny of the home and make best use of information from independent and internal monitoring (including regulations 44 and 45) to ensure continuous improvement. (‘Guide to the children’s homes regulations including the quality standards’, page 55, paragraph 10.24)

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Recommendations

In particular, ensure that the report is submitted by the end of the following month. Inspection report children’s home: 1264438 7

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Overall experiences and progress of children and young people: inadequate

The overall experiences and progress of the children and young people are judged inadequate. This is because the judgement for how well children and young people are helped and protected is inadequate. This is a limiting judgement and has an impact on the overall judgement.

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Overall experiences and progress of children and young people: inadequate

Specifically, weaknesses in relation to safeguarding children and young people have exposed some children and young people to harm. Ineffective management oversight has missed opportunities to recognise a potential safeguarding matter. Management oversight is not robust. It fails to identify and address poor practice with sufficient scrutiny and haste to consistently safeguard children and young people.

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Overall experiences and progress of children and young people: inadequate

Although the children and young people make good progress and have forged some trusting and positive relationships with the staff and the manager, the care provided to them has been inconsistent and unsafe at times. Several staff have left the home since the last inspection. The unsettling nature of the changes has led to one young person making a complaint. Some very challenging behaviours have hindered some children’s and young people’s progress.

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Overall experiences and progress of children and young people: inadequate

The children and young people benefit from living in a clean, well-decorated and furnished home. The home is currently decorated in a Halloween-inspired theme, and this provides a fun, child-focused environment. The children’s and young people’s rooms are personalised to suit their personalities and interests. However, locks on communal room doors have the potential to restrict the children’s and young people’s free movement around the home. The lack of shared understanding between the staff and management of the rationale for locking the doors has led to some inconsistent practice.

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Overall experiences and progress of children and young people: inadequate

Overall, the children and young people benefit from regular education attendance and they are achieving and working towards their goals and aspirations successfully. The children and young people enjoy a wide range of activities, hobbies and interests. Contact is promoted and facilitated by the staff, which enables the children and young people to stay in touch with family and friends. Children’s and young people’s access to primary and specialist services meets their physical and emotional needs. Positive feedback from professionals indicates that the manager advocates for children and young people and acts in their best interests.

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

Risk management strategies are not consistent or effective to keep children and young people safe. Consequently, the gaps in safeguarding practice have exposed some children and young people to harm. Not all risk management strategies make explicitly clear how children and young people who have on rare occasions returned home under Inspection report children’s home: 1264438 8 the influence of drugs and/or alcohol are to be monitored through the night, particularly when the staff carry out sleep-in duties. This lack of monitoring does not promote a shared understanding between the staff team of managing risk, increasing children’s and young people’s vulnerabilities.

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

Unsafe practice relating to the use of non-approved restraints has placed children and young people at risk. Not all staff carrying out restraints have received the approved restraint training as part of their induction. Despite the management oversight of a serious physical intervention carried out with a child while in London, the registered manager has not recognised the inappropriateness of the techniques used. Medical attention for the child, who had several unexplained bruises on their body following the intervention was not sought. The registered manager and staff have failed to follow the safeguarding procedures, despite the nature of the bruises being recorded on a body map by the staff. They have failed to escalate the concerns to the placing local authority who confirmed during the inspection that they were not aware of any bruising or need for physical intervention whilst in London.

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

The risk assessment completed prior to the visit to London was weak. It did not fully consider the different risks that could arise in a different location. Following the incident, the risk assessment has not been reviewed to inform future risk management strategies. This lack of oversight does not provide enough assurances that staff have a shared understanding of risk and can learn from unsafe practice.

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

The independent monitoring system has failed to identify the incident as a potential safeguarding issue. External scrutiny from the regulation 44 visitor following the incident suggested that the home was effectively safeguarding children and young people and promoting their welfare.

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

Most children and young people feel safe. Those children who do not feel safe said that this is due to several of the staff members leaving. However, the children and young people can still identify staff whom they trust and can talk to and have good relationships with. There are no incidents relating to children and young people being subject to child sexual or criminal exploitation. Missing incidents are minimal. Clear routines and boundaries are helping the children and young people to self-regulate their behaviours and emotions, which has reduced incidents.

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The effectiveness of leaders and managers: inadequate

Management oversight is not consistently effective. The provider has missed opportunities to identify and address shortfalls in recording and managing risk quickly. This includes their lack of oversight and action following a serious safeguarding incident in July 2019 which was not escalated as a safeguarding matter. The child’s social worker was not made aware of the incident or the bruising. In addition, it is very concerning that the manager disputed the existence of the child’s bruising despite a body map that staff created evidencing the location of the bruises. This does not demonstrate effective safeguarding insight or practice and places children and young people at serious risk of harm. Inspection report children’s home: 1264438 9 Whistleblowing concerns since the last inspection involving the registered manager and some of the staff led to the provider undertaking an investigation. However, not all the

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The effectiveness of leaders and managers: inadequate

actions and lessons learned identified by the provider have been discussed with the manager or implemented. This undermines the integrity and impact of the provider-led investigation.

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The effectiveness of leaders and managers: inadequate

Prior to the inspection, the manager had submitted a voluntary cancellation and intends to leave at the end of November 2019. A new manager has been appointed to take over the role, and there are several new members of staff who have been appointed since the last full inspection. No up-to-date statement of purpose has been sent to Ofsted to show the staffing changes.

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The effectiveness of leaders and managers: inadequate

The majority of the staff team members do not have the relevant diploma level 3 qualification. This means that there is not always a mix of experienced and knowledgeable staff on shift at the home to meet children’s and young people’s needs. Gaps in training records indicate that some staff are not trained in the approved behaviour management technique, despite this being part of the induction process. The training records are not up to date, which leaves the manager, provider and regulator unclear about the training staff have received.

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The effectiveness of leaders and managers: inadequate

Weakness in recruitment practices means they are unsafe. The provider has appointed some staff to the home without implementing appropriate management arrangements. This has led to some conflicting relationships within the staff team and personal and professional boundaries being crossed. The provider has failed to explore sufficiently applicant’s suitability to care for vulnerable children and young people before making appointments. Management oversight of the registered manager and staff are inconsistent. The registered manager has only recently started to receive regular supervision from a senior manager. The importance of this was raised at the initial registration visit and the last full inspection and has not been acted upon. Gaps in staff supervision are not in line with the home’s own policy and statement of purpose. Therefore, it is unclear how the manager and provider oversee children and young

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The effectiveness of leaders and managers: inadequate

people’s progress. It is also unclear how incidents and practice are reflected on and addressed.

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The effectiveness of leaders and managers: inadequate

Management oversight of records is poor. Recording shortfalls noted in children’s records are not identified in a consistent and systematic way. For example, not all impact risk assessments include key safeguarding information relating to risk of, and involvement in historical child sexual exploitation. Not all the gaps in the restraint records have been addressed quickly. Not all the entries relating to restraints include the date and time of the measure, children’s and young people’s comments and the managerial oversight. This limits any reflection that could improve practice and contribute to children’s and young people’s safety. The children’s and young people’s ethnicity is not routinely recorded. This does not help the staff team to understand and celebrate children’s and young people’s cultural needs.

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The effectiveness of leaders and managers: inadequate

Managers have not notified Ofsted of a serious safeguarding incident, which has impeded Ofsted from accurately monitoring the home’s safeguarding practices. Not all the Inspection report children’s home: 1264438 10 requirements and recommendations have been met. The regulation 44 reports are not consistently sent to Ofsted in a timely manner. The regulation 45 report does not make clear the feedback and opinions of children, young people, parents, staff and other professionals about the quality of care. The requirement and recommendation are repeated.

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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: 1264438 11

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Children’s home details

Registered provider: Blue Mountain Homes Limited

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Children’s home details

Registered provider address: Flat 17, Leeland Mansions, Leeland Road, London, Middlesex W13 9HE

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Children’s home details

Responsible individual: Pradeep Manaktala

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Inspectors

Jacqueline Malcolm, social care inspector Parveen Hussain, regulatory inspection manager Inspection report children’s home: 1264438 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 children looked after, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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