Children's home run by Carbrey Care Ltd in Gloucester

Information about this children’s home

This children’s home is owned and managed by a private organisation. It is registered for up to three children who have experienced adverse childhood experiences that have led to associated trauma and complex behaviours.

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Information about this children’s home

The manager has been registered with Ofsted since May 2020.

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Information about this children’s home

A monitoring visit was undertaken in July 2020 because of whistle-blowing concerns about safeguarding practices, and management oversight within the home. Four statutory requirements were raised as a result of the findings from the monitoring visit.

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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:  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 practice and care within the context of the restrictions placed on society during the COVID-19 pandemic. Assurance visit report: 1155761 2 Assurance visit report: 1155761 3

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Findings from the visit

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

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Findings from the visit

 Children barricaded themselves into a bedroom on 12 October 2020. The registered manager and staff failed to take effective action to safeguard the children and enter the bedroom. As a result, the children were found to still be in the room two days later during the assurance visit.  Despite the children leaving the bedroom to eat and collect food, staff took no action to prevent the children returning to the bedroom. Leaders and managers failed to provide staff with clear directions to manage this situation effectively.  Children were smoking in the bedroom. No action was taken to seek support from emergency services to gain access to the bedroom to ensure the children’s safety.  The registered manager failed to notify Ofsted and the placing authorities swiftly of this serious and ongoing incident. Managers and staff have not understood the significance and seriousness of this incident.  Children living at this home have slept in each other’s bedrooms on numerous

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Findings from the visit

occasions and there has been a lack of consistent staff oversight or action to prevent this behaviour from continuing.  Managers and staff have not ensured that children have received help in accessing sexual health services.  There has been a comprehensive mismanagement and lack of knowledge about how to keep these children safe.  Managerial oversight and monitoring of incidents is weak.

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The care of children

Since the monitoring visit on 15 July 2020, there has been a decline in the quality of care provided to children. The requirements made at the previous monitoring visit are not met.

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The care of children

Managers and staff have failed to ensure that children have been supported with sexual health appointments. This has resulted in children not being protected nor helped to maintain appropriate, healthy and safe relationships.

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The care of children

Managers have not ensured that staff have provided meaningful and individualised work with children to help with their cannabis use, missing behaviours, relationships and antisocial behaviours. Subsequently, since the last inspection, the children have engaged in criminal damage together in the community.

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The care of children

Managers and staff have not ensured that appropriate guidance and boundaries are in place. This has resulted in children staying up late, sleeping in each other’s bedrooms and going missing from the home together. Despite numerous incidents, the registered manager has not managed the situation to prevent this happening. Assurance visit report: 1155761 4

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The safety of children

Children are not safeguarded effectively at this home. This is because children were found to be barricaded in a bedroom without action to prioritise their safety. The children were smoking in the bedroom and are in a relationship.

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The safety of children

The registered manager failed to request a review of a child’s care plan with the placing authority. The registered manager recorded that the child was not safe and that staff were unable to care for him in August 2020. Consequently, the children’s behaviours escalated.

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The safety of children

There have been several safeguarding incidents since the last inspection, including risks associated with possible grooming, buying drugs and inappropriate use of social media and antisocial behaviour. These incidents lack detail and follow-up. Several of these incidents have not been reported to Ofsted.

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Leaders and managers

Managerial monitoring and oversight of the quality of care is weak. The registered manager has failed to take effective action to safeguard children living at this home. This has resulted in Ofsted suspending the home from operating and the children having to leave the home urgently.

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Leaders and managers

Staff shared during this inspection that they have not been supported well by leaders and managers and that their concerns about the care provided to children are not taken seriously. Consequently, the fractured team dynamics continue to impact on the quality of care provided to children.

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Leaders and managers

The registered manager does not ensure that there are effective arrangements for staff supervision in place and has delegated this role. This has resulted in a lack of consistent approach and oversight to address concerns.

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Leaders and managers

Staff do not receive adequate support during evenings and weekends because there is a lack of senior management availability to support and advise staff at times of crisis. Therefore, staff are not supported to manage safeguarding incidents in an effective and timely manner.

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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 Assurance visit report: 1155761 5 ‘Guide to the children’s homes regulations including the quality standards’. The registered person(s) must comply within the given timescales. Assurance visit report: 1155761 6

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Requirement Due date

The health and well-being standard is that—

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Requirement Due date

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

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Requirement Due date

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

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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—

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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

help each child to develop socially aware behaviour;

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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;

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Requirement Due date

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; 6/01/2021 Assurance visit report: 1155761 7 help each child to develop the understanding and skills to recognise or withdraw from a damaging, exploitative or harmful relationship;

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Requirement Due date

strive to gain each child’s respect and trust; 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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Requirement Due date

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

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Requirement Due date

that each child is encouraged to build and maintain positive relationships with others.

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Requirement Due date

(Regulation 11 (1)(a)((b)(c)(2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(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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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; 6/01/2021 Assurance visit report: 1155761 8 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

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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Requirement Due date

that the effectiveness of the home’s child protection policies is monitored regularly.

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Requirement Due date

(Regulation 12 (1)(2)(a)(i)(ii)(iii)(iv)(v)(vi)(vi)(vii)(b)(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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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 work as a team where appropriate;

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Requirement Due date

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

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Requirement Due date

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

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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

research and developments in relation to the ways in which the needs of children are best met; and 6/01/2021 Assurance visit report: 1155761 9 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)(c)(2)(a)(b)(c)(e)(f)(g)(i)(ii)(h)) 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; and

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Requirement Due date

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

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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

manage and review the placement of each child in the home; and

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Requirement Due date

plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements agreed with the child’s placing authority;

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Requirement Due date

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

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Requirement Due date

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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Requirement Due date

(Regulation 14 (1)(a)(b)(c)(2)(b)(ii)(iii)(e)) 6/01/2020

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Children’s home details

Registered provider address: Unit 11, Wheatstone Court, Davy Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AQ

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Children’s home details

Responsible individual: Martin Bentham Assurance visit report: 1155761 10 Registered manager: Elaine Jackson

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Inspector

Anna Gravelle, Social Care Inspector Assurance visit report: 1155761 11 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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