Children's Home run by Hexagon Care Services Limited in Lancashire

Assurance visit report: SC479649 1 SC479649

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Information about this children’s home

The home is registered to provide care for six children who have emotional and/or behavioural difficulties. One child lives at the registered children’s home address and five other children receive outreach services in houses across the county. Each property has their own staff team, but the whole service is managed by one registered manager.

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Information about this children’s home

The service offers short-term, emergency placements for children from around the UK. Placements are generally for 28 days, but some can be longer.

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Information about this children’s home

The home forms part of a large social care company. The home has had a permanent and qualified registered manager since January 2016.

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Information about this children’s home

Previous inspection judgement: Improved effectiveness

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Information about this visit

Due to COVID-19 (coronavirus), Ofsted suspended all routine inspections in March 2020. As part of a phased return to routine inspection, we are undertaking assurance visits to children’s social care services that are inspected under the social care common inspection framework (SCCIF).

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Information about this visit

At these visits, inspectors evaluate the extent to which:

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Information about this visit

 children are well cared for  children are safe  leaders and managers are exercising strong leadership.

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Information about this visit

This visit was carried out under the Care Standards Act 2000, following the published guidance for assurance visits.

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Information about this visit

Her Majesty’s Chief Inspector of Education, Children’s Services and Skills is leading Ofsted’s work into how England’s social care system has delivered child-centred Assurance visit report: SC479649 2 practice and care within the context of the restrictions placed on society during the COVID-19 pandemic.

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Findings from the visit

We identified the following serious concerns in relation to the care or protection of children at this assurance visit:

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Findings from the visit

 Staff at the home failed to take effective action to protect a child. Subsequently, the child was sexually exploited and sexually assaulted.  Following this sexual assault, the child’s placement was terminated with immediate effect.  The registered manager failed to ensure that staff followed his advice and direction and that of the social worker to keep a child safe.  Following the incident above, the independent monitoring report was not objective, and contained inaccurate information that was favourable to the management of the home, casting doubt on the integrity of the independent visitor process.  The organisation is providing outreach services from a property without informing Ofsted.  Staff do not always administer children’s medication as prescribed.

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The care of children

Seventeen children have been admitted and 15 discharged from the service during the pandemic. The service offers a crisis intervention service and provides emergency care, from a few nights to a couple of months. Some children were given immediate notice of termination of placement, despite the country being in lockdown and the ethos of the service to provide care to the most complex and challenging children. This failed to protect the welfare of children. In addition to the breakdown of placement for children, staff were at greater risk from COVID-19 due to working with so many children.

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The care of children

On two occasions, children left the home without staff knowledge. Staff did not check on one child before he went to bed, and later found out that he had made his way to London during the evening. Staff presumed that another child was sleeping in when the morning shift started work. However, when they eventually checked on her welfare at 11.30am they discovered that she had not been in her room all night. This lack of basic care, to check on the welfare of children, fails to demonstrate a caring environment and does not treat children with dignity and respect.

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The care of children

Because children arrive in crisis they do not normally attend formal education. Where possible, staff will take children on educational visits, however, this has not been possible when the country has been in lockdown and few alternative arrangements have been introduced. One child was provided with the opportunity to take part in online lessons, but staff failed to engage the child in these sessions, prompting contact from the child’s school. Another child obtained a certificate for Assurance visit report: SC479649 3 attending a drug awareness course. This was led in-house by a member of staff. However, on the whole, there has been very little education since April 2020.

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The care of children

Most children have received good care and enjoyed excellent leisure opportunities and experiences during the lockdown period. They have enjoyed alpaca trekking, horse riding and fishing, and visited local attractions in and around the seaside town. Social workers and commissioners speak extremely positively about the placements of children and the professionalism of the staff. Many children have transitioned to new placements in a positive way.

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The safety of children

There have been 11 episodes of children being absent or missing from the home since April 2020. Children in the crisis service are staffed on a 2:1 ratio. On two occasions staff were unaware that children were missing, despite these staffing ratios. Because the children’s whereabouts were unknown and it was not known who they were socialising with. children were placing themselves and others at greater risk.

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The safety of children

One child, whose risk assessment showed that she was at risk of sexual exploitation, and despite 2:1 staffing, was collected in a car, by an unknown male, on three consecutive weekends. She was then missing for over 24 hours. The manager and staff did not follow the instructions of her social worker to remove her phone at night. This was a routine that had been successfully followed in her previous placement. In addition, staff failed to follow the direction of the registered manager about how to keep the child safe. Measures such as an internal door alarm or waking night staff were not put in place, and a relationship with a child from another care provision was not explored. As a result, the child was seriously sexually assaulted by a male with whom she had been in contact via her mobile phone throughout her stay at the children’s home. The service served immediate notice to terminate her placement while the child was recovering from the serious sexual

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The safety of children

Staff did not protect children in their care from self-harm. For example, one child was able to obtain a broken glass bottle while out walking with staff, subsequently threatening to stab staff and self-harming. Another child was able to hide a razor in her sleeve before self-harming with it.

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The safety of children

One child informed staff that her night-time medication had been making her drowsy. Staff reduced the amount of her medication to one tablet without obtaining medical advice. On another occasion, a child had been suffering with severe toothache and staff had not obtained an emergency dental appointment. A routine appointment was made five days later, leaving the child in severe pain. Two teeth had to be extracted.

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Leaders and managers

Assurance visit report: SC479649 4 The registered manager failed to take significant action to promote children’s welfare and keep children safe. He did not ensure that staff followed the direction of the social worker or his suggestions on keeping children safe. Some children have had their placement ended abruptly and without notice. As a result, children have not always had the best outcomes during their placement.

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Leaders and managers

The service has bought, and accommodated children in, a new house for outreach services, but failed to notify Ofsted of this change. The manager has not updated the statement of purpose since March 2020 to reflect this change and changes to the staff team.

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Leaders and managers

A notification received by Ofsted failed to clearly detail an incident when a child came to significant harm. The notification failed to describe the seriousness of the incident. Ofsted was only aware of the incident because another provider submitted their notification for the same event. This failure to provide the regulator with accurate notifications fails to keep the regulator aware of incidents at the home and, therefore hinders the regulator’s decision about the quality of care being provided.

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Leaders and managers

The independent visitor conducted virtual visits during the lockdown. Staff spoke about the independent visitor ringing and speaking to the children, however, the reports confirm that no contact had been made with children. The manager was unclear why staff suggested otherwise. At the last visit, the independent visitor reviewed the serious safeguarding event and found that staff and managers had worked well to protect the child but that the child had made ‘poor decisions’. His report contained facts that were incorrect. This demonstrates that monitoring systems are not sufficiently robust.

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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 quality and purpose of care standard is that children receive care from staff who— understand the children’s home’s overall aims and the outcomes it seeks to achieve for children; use this understanding to deliver care that meets the children’s needs and supports them to fulfil their potential.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to— 30/09/2020 Assurance visit report: SC479649 5 ensure that staff— understand and apply the home’s statement of purpose; protect and promote each child’s welfare; and treat each child with dignity and respect.

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Requirement Due date

(Regulation 6 (1)(a)(b)(2)(b)(i)(ii)(iii))

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Requirement Due date

The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on— mutual respect and trust. In particular, the standard requires the registered person to ensure— that staff— 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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Requirement Due date

(Regulation 11 (1)(a)(2)(a)(vi)) 30/09/2020

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Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure— that staff— 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; help each child to understand how to keep safe; have the skills to identify and act upon signs that a child is at risk of harm; manage relationships between children to prevent them from harming each other; understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person; take effective action whenever there is a serious concern about a child’s welfare; and are familiar with, and act in accordance with, the home’s child protection policies; and 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)) 30/09/2020 Assurance visit report: SC479649 6 The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children’s home that— helps children aspire to fulfil their potential; and promotes their welfare. In particular, the standard requires the registered person to— 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

*(Regulation 13 (1)(a)(b)(2)(a)) 30/09/2020

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Requirement Due date

The registered person must— keep the statement of purpose under review and, where appropriate, revise it; and notify HMCI of any revision and send HMCI a copy of the revised statement within 28 days of the revision.

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Requirement Due date

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

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Requirement Due date

In particular, the registered person must ensure that— medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and no other child

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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

*These requirements are subject to a compliance notice.

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Recommendations

 Evaluation of missing incidents should be undertaken to identify any gaps in training, skills or knowledge for staff or to record or retain evidence of what Assurance visit report: SC479649 7 worked well. (‘Guide to the children’s homes regulations including the quality standards’, page 46, paragraph 9.31)

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Children’s home details

Registered provider: Hexagon Care Services Ltd

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Children’s home details

Registered provider address: Tustin Court, Riversway, Preston, Lancashire PR2 2YQ

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Inspector

Elaine Clare, Social Care Inspector Assurance visit report: SC479649 8 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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Inspector

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Inspector

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Inspector

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Inspector

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