Children's home run by Nugent Care 2019 in Liverpool

Inspection report for children’s home - monitoring visit: SC371267 1 SC371267

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Nugent Care 2019

Monitoring visit Inspected under the social care common inspection framework

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Information about this children’s home

The home is operated by a voluntary organisation and is registered for up to 36 children and young people, between the ages of seven and 19, who have a range of special educational needs and who require either a residential-only provision or residential and specialist-school provision.

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Information about this children’s home

There is currently no registered manager at the home, as the registered manager resigned from her post in June 2019.

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This monitoring visit

This urgent on-site unannounced monitoring visit was undertaken because of a significant increase in serious incidents occurring within the service.

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This monitoring visit

During the visit, the inspectors found evidence that managers and staff had failed to take all measures necessary to protect children from harm.

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This monitoring visit

The managers and staff do not have a clear understanding of their roles and responsibilities in protecting children. Staff do not always take stringent action when there is a concern about children’s welfare. Managers and staff have made serious errors in decision-making that have placed children and staff at risk of harm.

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This monitoring visit

Leaders, managers and staff fail to recognise, minimise or prevent the risks to children’s safety and well-being. The home’s arrangements to protect children from harm are not effective. Not all risk assessments have been updated and they do not always include all known information about children’s risk-taking behaviours or guidance on how staff will manage these risks. Furthermore, strategies identified to manage risks to children are not reviewed and evaluated by managers. Inspection report for children’s home - monitoring visit: SC371267 2 Staff do not complete work with children to help them understand how to keep safe. This is despite this being recorded as a required action in children’s risk management plans.

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This monitoring visit

In Ofsted’s view, the shortfalls highlighted demonstrate safeguarding practice within the home is a serious concern and does not manage and minimise the risk to children and staff or protect them effectively from harm. A compliance notice under regulation 12, The protection of children standard has been reissued.

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This monitoring visit

During the visit, the inspectors also found that there were serious shortfalls in the leadership and management of the home which have had a detrimental impact on children’s well-being and progression and are not in keeping with the home’s statement of purpose.

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This monitoring visit

The registered provider has not ensured that there is a registered manager in post. The previous manager left the home in June 2019. This has resulted in a lack of stability and consistency for children and has significantly impacted on the quality of care. Furthermore, staff have had no clear direction and leadership which has impacted on their ability to provide a consistent team approach towards caring for children.

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This monitoring visit

Inspectors found that despite previous compliance notices, there continues to be shortfalls in the registered provider’s oversight of care planning and risk management. Some records relating to the care and safety of children, such as risk assessments and missing from home records, were found to not include any robust and effective strategies for managing and reducing risks. Records are poor and lack sufficient detail, which has resulted in a failure to identify significant patterns and trends. The monitoring systems in place had not identified these shortfalls.

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This monitoring visit

Leaders and managers do not lead and manage the home in a way that is consistent with the approach and ethos of the service or delivers the outcomes as set out in the home’s statement of purpose.

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This monitoring visit

There is no evidence of consistent monitoring and review of care practice. This lessens the analysis and evaluation of care and its impact on outcomes for children. Leaders, managers 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. This has impacted on outcomes for children and compromised their safety and well-being.

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This monitoring visit

In Ofsted’s view, the shortfalls highlighted demonstrate poor leadership and management practice, which has compromised the experiences and progress of children accommodated in this home. This impacts on the ability for children to reach their full potential and be protected from harm. Inspection report for children’s home - monitoring visit: SC371267 3 A compliance notice under regulation 13, The leadership and management standard has been reissued.

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This monitoring visit

Inspectors also found that behaviour management is ineffective. Behaviour management plans do not include robust strategies to assist and guide staff in the management of significant challenging and aggressive behaviours. This means that inappropriate and unacceptable behaviours are left unchecked. Therefore, not all children are provided with the tools to regulate their behaviours and make positive change.

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This monitoring visit

Inspectors found that the use of restrictive physical intervention for children is not conducted safely. For example, staff attempting a physical intervention often fail. This has resulted in staff being significantly assaulted by children. Records continue to lack sufficient detail. For example, debriefs with staff involved in the physical interventions have not taken place within 48 hours of the intervention in line with regulation. Furthermore, the dates of some staff debrief sessions are not evident on restrictive physical intervention records.

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This monitoring visit

Not all physical intervention records include if children or staff have sustained any injuries because of the intervention. Furthermore, they do not include information to confirm if first-aid or medical treatment was offered or provided to children.

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This monitoring visit

Management oversight of some physical intervention records is poor. Records do not demonstrate that managers have analysed and recorded their assessment as to the effectiveness of the measure used.

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This monitoring visit

In Ofsted’s view, the lack of management oversight of physical restraint within the home continues to be a concern. This weak management oversight of physical restraint and behaviour management strategies at the home fails to minimise risk to children and does not therefore safeguard them effectively.

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This monitoring visit

A compliance notice has been issued under regulation 35, Behaviour management policies and records.

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This monitoring visit

There has been no registered manager at the home since the previous manager resigned from her post as of 30 June 2019.

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This monitoring visit

The provider informed Ofsted on several occasions that they will prioritise appointing a registered manager and will ensure that an application is submitted to Ofsted at the earliest opportunity. However, it is now over 12 months since there was a registered manager at the home and the provider has not appointed a suitable manager or submitted a registered manager application to Ofsted.

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This monitoring visit

Evidence from the inspections and monitoring visits in August 2019, January 2020, March 2020, April 2020 and July 2020 demonstrate that the current management arrangements are not effective. This has had a detrimental impact on children’s well- being and progression and is not in keeping with the home’s statement of purpose. Inspection report for children’s home - monitoring visit: SC371267 4 A compliance notice has been issued under regulation 27, Appointment of manager.

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This monitoring visit

Furthermore, Ofsted reasonably believes a child may be at risk of harm if further admissions to the home are allowed and a notice restricting accommodation has been issued. This will ensure that children currently in placement are safeguarded, while allowing time for the company to address the significant shortfalls. Therefore, in addition to the compliance notices, Ofsted has made the decision to serve a notice restricting accommodation.

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Recent inspection history

Inspection date Inspection type Inspection judgement 22/01/2020 Interim Declined in effectiveness 06/08/2019 Full Good 04/12/2018 Full Requires improvement to be good 15/08/2018 Full Inadequate Inspection report for children’s home - monitoring visit: SC371267 5

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet the Care Standards Act 2000, Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. The registered person(s) must comply within the given timescales.

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Requirement Due date

The children’s views, wishes and feelings standard is that children receive care from staff who—

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Requirement Due date

develop positive relationships with them;

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Requirement Due date

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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Requirement Due date

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

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Requirement Due date

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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Requirement Due date

help each child to express views, wishes and feelings;

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Requirement Due date

help each child to understand how the child’s views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child;

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Requirement Due date

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

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Requirement Due date

is enabled to provide feedback to, and raise issues with, a relevant person about the support and services that the child receives; 23/09/2020 Inspection report for children’s home - monitoring visit: SC371267 6 has access to the home’s children’s guide, and the home’s complaints procedure, when the child’s placement in the home is agreed and throughout the child’s stay in the home; and

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Requirement Due date

keep the children’s guide and the home’s complaints procedure under review and seek children’s comments before revising either document;

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Requirement Due date

ensure that an explanation is given to each child as soon as reasonably practicable after the child’s arrival about—

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Requirement Due date

ensure that the views of each relevant person are taken into account, so far as reasonably practicable, before making a decision about the care or welfare of a child.

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Requirement Due date

(Regulation 7 (1)(2)(a)(i)(ii)(iii)(iv)(b)(i)(e)) The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on—

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Requirement Due date

an understanding about acceptable behaviour; and

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Requirement Due date

positive responses to other children and adults.

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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

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding; 23/09/2020 Inspection report for children’s home - monitoring visit: SC371267 7 strive to gain each child’s respect and trust; understand and communicate to children that bullying is unacceptable; and

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Requirement Due date

have the skills to recognise incidents or indications of bullying and how to deal with them.

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Requirement Due date

(Regulation 11 (1)(2)(i)(iii)(iv)(v)(viii)(xii)(xiii)) The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

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

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Requirement Due date

assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child;

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Requirement Due date

help each child to understand how to keep safe;

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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

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

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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

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Requirement Due date

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

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Requirement Due date

that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm.

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Requirement Due date

(Regulation 12 (1)(2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(b)) * 23/09/2020 Inspection report for children’s home - monitoring visit: SC371267 8 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 has sufficient staff to provide care for each child;

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Requirement Due date

ensure that the home’s workforce provides continuity of care to each child;

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Requirement Due date

understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home;

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

(Regulation 13 (1)(a)(b)(2)(a)(b)(c)(d)(e)(f)(g)(ii)(h)) * 23/09/2020

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Requirement Due date

The care planning standard is that children—

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Requirement Due date

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

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure— 23/09/2020 Inspection report for children’s home - monitoring visit: SC371267 9 that each child’s relevant plans are followed.

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Requirement Due date

(Regulation 14(1)(a)(2)(d)) Restraint in relation to a child is only permitted for the purpose of preventing—

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Requirement Due date

injury to any person (including the child);

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

(Regulation 20(1)(a)(b)(c)(2)) 23/09/2020

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Requirement Due date

The registered provider must appoint a person to manage the children’s home if—

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Requirement Due date

there is no registered manager in respect of the home; and

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Requirement Due date

is not, or does not intend to be, in day-to-day charge of the home.

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Requirement Due date

If the registered provider appoints a person to manage the home, the registered provider must, without delay, give HMCI notice of—

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Requirement Due date

the name of the person so appointed; and

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Requirement Due date

the date on which the appointment takes effect.

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Requirement Due date

(Regulation 27 (1)(a)(b)(i)(ii)(iii)(2)(a)(b)) * 23/09/2020

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Requirement Due date

The registered person must prepare and implement a policy (“the behaviour management policy”) which sets out—

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Requirement Due date

how appropriate behaviour is to be promoted in the children’s home; and 23/09/2020 Inspection report for children’s home - monitoring visit: SC371267 10 the measures of control, discipline and restraint which may be used in relation to children in the home.

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Requirement Due date

The registered person must keep the behaviour management policy under review and, where appropriate, revise it.

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Requirement Due date

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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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

a description of the measure and its duration;

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Requirement Due date

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

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Requirement Due date

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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Requirement Due date

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

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Requirement Due date

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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Requirement Due date

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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Requirement Due date

has spoken to the user about the measure; and

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Requirement Due date

has signed the record to confirm it is accurate; and

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Requirement Due date

within 5 days of the use of the measure, the registered person or the authorised person adds to the record Inspection report for children’s home - monitoring visit: SC371267 11 confirmation that they have spoken to the child about the measure.

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Requirement Due date

Paragraph (3) does not apply in relation to restraint that is planned or provided for as a matter of routine in the child’s EHC plan or statement of special education needs.

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Requirement Due date

(Regulation 35 (1)(a)(b)(2)(3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c)(4)) * The registered person must complete a review of the quality of care provided for children (“a quality of care review”) at least once every 6 months.

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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 quality of care provided to children;

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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; and

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Requirement Due date

any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children.

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Requirement Due date

After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (“the quality care review report”).

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Requirement Due date

supply HMCI a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed; and

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Requirement Due date

make a copy of the quality of care review report available on request to a placing authority, if the placing authority is not the parent of a child accommodated at the home.

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Requirement Due date

The system referred to in paragraph (2) must provide for ascertaining and considering the opinions of children, their parents, placing authorities and staff. 23/09/2020 Inspection report for children’s home - monitoring visit: SC371267 12 (Regulation 45 (1)(2)(a)(b)(c)(3)(4)(a)(b)(5)) The registered person must notify HMCI and each other relevant person without delay if—

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Requirement Due date

a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation;

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Requirement Due date

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious;

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Requirement Due date

there is an allegation of abuse against the home or a person working there;

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Requirement Due date

a child protection enquiry involving a child-

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Requirement Due date

concludes (in which case, the notification must include the outcome of the child protection enquiry); or

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Requirement Due date

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

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Requirement Due date

(Regulation 40(4)(a)(b)(c)(d)(i)(ii)(e)) 23/09/2020

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Requirement Due date

*These requirements are subject to a compliance notice.

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Information about this inspection

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

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Information about this inspection

This inspection was carried out under the Care Standards Act 2000.

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Children’s home details

Provision sub-type: Residential special school

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Children’s home details

Registered provider address: 99 Edge Lane, Edge Hill, Liverpool L7 2PE

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Children’s home details

Registered manager: Post vacant Inspection report for children’s home - monitoring visit: SC371267 13

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Inspectors

Catherine Fargin, social care inspector Maria McGranaghan, social care inspector

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Inspectors

to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for children looked after, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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