Children's home run by New Forest Care Limited in Southampton

Assurance visit report: SC402135 1 SC402135

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Information about this children’s home

The home provides care and accommodation for up to four children. According to the statement of purpose, the home specialises in caring for children who have complex emotional, behavioural and educational difficulties including those who have certain diagnosed psychiatric or psychological disorders. The age range of children is not specified.

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Information about this children’s home

The manager registered with Ofsted in January 2020.

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Information about this children’s home

Previous inspection date: 26 February 2020

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Information about this children’s home

Previous inspection judgement: Sustained 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. 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: SC402135 2

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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

 The poor practice and approach to physical restraint is embedded in the culture of the home. Senior leaders do not recognise the risk of serious harm to children. They do not adequately monitor high-risk physical interventions.  Insufficient consideration and risk management has been given to individual children’s health needs before physically restraining them.  Not all staff demonstrate that they have the skills, experience or competency to safely restrain children. Senior leaders did not evidence that all staff have had the necessary training in ground floor restraints.  Impact risk assessments do not always consider the reasons for a child coming to live in the home and the potential risk to children already living there.  Leaders and managers have not responded to the weaknesses identified by the independent visitor reports and previous Ofsted inspection findings about restraint practice.  The statement of purpose states that children with psychiatric or

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Findings from the visit

psychological disorders can be accommodated, but this is unclear and specific staff training is not evident.

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The care of children

The children’s care has been disrupted due to leadership failures to assess risks for the children when another child moved in. Leaders did not consider all the relevant information when conducting an impact risk assessment. Consequently, some children are having a poor experience of care, with one child being moved to alternative temporary accommodation.

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The care of children

Arrangements for children living in alternative, temporary accommodation are unsuitable. This provision has been poorly assessed for basic needs, such as laundry arrangements and whether bedroom door sensors are necessary. While visiting the temporary accommodation, the inspector observed that control measures necessary to protect staff, children and visitors from COVID-19 were not always being followed.

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The care of children

The rationale for internal moves within the organisation is not always clear. One child commented on how many moves they have made to alternative accommodation during their time with this provider. This included a move to another ‘lodge’ even when accommodated on one temporary site.

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The care of children

Children’s individual needs are not always fully considered when care plans and strategies are agreed. In one example, leaders did not ensure that a child’s health Assurance visit report: SC402135 3 condition was suitably assessed by a medical professional before deciding that physical restraint, including ground holds, may be used. Despite a clear recommendation for a follow-up GP appointment in June 2020, this has still not occurred. Consequently, leaders cannot demonstrate that they have paid suitable regard to the significant risks that such practice may pose for this child. Although this child’s care plan states that their inhaler must always be available, a ground restraint has been used while the inhaler was not in the immediate possession of the staff involved. The failure of leaders to consider that this serious incident should be used to review, and potentially stop, the use of such techniques with this child is of

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The care of children

Despite the organisation’s own therapy team, one example of care planning found poor consideration given to a child’s mental and emotional well-being. Although written restraint records note that staff are aware of the child’s personal history, and consequent distress at having their limbs held, this child has been subject to prone and supine restraints by three staff members on more than one occasion.

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The care of children

Although children see a therapist regularly, leaders could not identify the type of therapy this is. Consequently, it is not clear that the staff understand the impact of the therapy for the children and how they can complement this. In other aspects of care planning, one example of poor communication included the registered manager’s failure to share with the staff that a child’s deprivation of liberty safeguards order (DoLS) had been reviewed.

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The care of children

Although the staff trained as instructors in physical intervention are suitably qualified, leaders were unable to demonstrate that some of the staff team have the advanced training and skills that would be necessary to carry out ground floor restraints safely. The description that was given about such intervention was not supported by the records provided. There are other training shortfalls, for example, there is not an audit trail to demonstrate that staff are suitably trained to work with children with sexually harmful behaviour.

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The care of children

One child has left the setting to return to his parents. Another child has had increased time with her family following staff advocating for a review of the supervised contact arrangements.

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The safety of children

Staff have used physical interventions without demonstrating that they have had sufficient cause to do so. There are examples of physical restraint records that do not clearly describe how and why situations have escalated to such an extent that high-risk physical interventions such as ground floor restraints have become necessary.

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The safety of children

This is exacerbated by the failure of leaders and managers to oversee high-risk physical interventions with rigour. Restraint records do not indicate that sufficient care and attention is paid to monitor the children’s breathing, circulation and communication during and after ground floor holds. One staff member told the Assurance visit report: SC402135 4 inspector they were not aware of the need to do this. Another said that this is recorded in the daily logs, but this was not evidenced.

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The safety of children

Leaders have not ensured that children and staff routinely have an adequate debrief after such interventions. When debriefs have occurred, some of the records are of poor quality and do not always address the pertinent points.

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The safety of children

Records of investigations into safeguarding concerns are not always sufficiently investigated. In a recent example, records of the investigation did not consider or explore all the information available. For example, the record of an investigation of a staff conduct concern did not demonstrate further exploration of the allegation that there was a lack of staff, even though a court order specified clear staffing ratios for a child. Incident reports were amended after the investigation that made audit trails difficult and potentially masked important chronologies to the reader.

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The safety of children

Staff do keep detailed chronologies when children go missing from care. They work with other agencies to keep children as safe as possible. In one example, staff have agreed strategies to minimise the child’s desire to go missing, for example by increasing the frequency of supervised time to see individuals who are important to the child. However, the registered manager has not arranged training for staff to supervise such meetings. In another example, staff used physical restraint to prevent a child from leaving the home, fearing the child would place themselves at risk of harm. This child is not subject to a DoLS order. Consequently, consent from the child’s local authority to use such measures was not in place.

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The safety of children

In the event of children making complaints, staff take these seriously. Current records showed that staff have investigated the concerns raised and provided an outcome to the children.

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Leaders and managers

Some aspects of management monitoring are weak and do not provide necessary safeguards for the children. The poor approach to physical restraint has been a theme over three inspections and the requirement under regulation 35 has been repeated. The failure of senior leaders to address the underlying reasons for the poor practice of physical restraint, recording and oversight, places children at risk of harm.

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Leaders and managers

Some of the staff demonstrate a lack of understanding of the risks when restraining children on the ground and some staff expressed a lack of confidence in writing the incident reports. Examples of these reports were found to lack the detail required in describing incidents and how these escalated to requiring high levels of physical intervention. Such gaps and omissions are not always challenged or unpicked by the manager’s review. Consequently, it is not possible to be confident that every use of such techniques has been proportionate and necessary.

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Leaders and managers

The statement of purpose does not specify how staff competence in restraint will be assessed, as required by regulation. This document also describes that the home can accommodate children who have psychiatric or psychological disorders. Assurance visit report: SC402135 5 However, leaders could not specify what those disorders are. Staff have not had training in such disorders. This presents a risk that children could be inappropriately placed in the home with staff who cannot meet their needs.

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Leaders and managers

Ofsted and placing social workers have not always been notified of significant events in a timely manner. This compromises the ability of the regulator and local authorities to undertake their own monitoring.

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Leaders and managers

Gaps are identified with regards to some of the policy and procedural guidance available for the staff. For example, the room search policy calls for permission to be sought from the emergency duty team. Staff could not provide a reason for this practice which stands to present unnecessary delays, should a search be needed urgently.

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Leaders and managers

Independent visitor monitoring does provide scrutiny and a challenging approach. Two recent independent monitoring reports, by different organisations, raised concerns. One concern was about restraint practice, the other was in relation to poor records of restraints. Although it was stated that a staff meeting was subsequently scheduled to provide training on restraint recording, the inspector was not provided with the minutes of this staff meeting. Despite two separate independent monitoring reports describing concerns about restraint practice, it is concerning that this was not picked up or followed in the registered manager’s own most recent regulation 45 monitoring report. He has not risen to the challenges made through independent monitoring and has therefore missed the opportunity to improve practice and the experiences for the children.

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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 registered person must ensure that— 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— details of the child’s behaviour leading to the use of the measure; a description of the measure and its duration; 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")— 12/11/2020 Assurance visit report: SC402135 6 (has spoken to the user about the measure; and has signed the record to confirm it is accurate; and within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(ii)(iv)(b(c) Restraint in relation to a child is only permitted for the purpose of preventing— 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); Restraint in relation to a child must be necessary and proportionate. (Regulation 20 (1)(a)(b)(2)) 12/11/20

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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— helps children aspire to fulfil their potential; and promotes their welfare. In particular, the standard in paragraph (1) requires the registered person to— ensure that staff have the experience, qualifications and skills to meet the needs of each child; use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (2)(c)(h)) 12/11/2020

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Requirement Due date

The health and well-being standard is that— the health and well-being needs of children are met; children receive advice, services and support in relation to their health and well-being. (Regulation 10 (1)(a)(b)) 12/11/2020

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Requirement Due date

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. The registered person must— keep the statement of purpose under review and, where appropriate, revise it. (Regulation 16 (1)(3)(a)) 12/11/2020

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if— an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; 12/11/2020 Assurance visit report: SC402135 7 there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(b)(e)) The care planning standard is that children— receive effectively planned care in or through the children’s home. (Regulation 14 (1)(a)) 12/11/2020

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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. 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; that the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (2)(a)(i)(e)) 12/11/2020

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Requirement Due date

Seek to develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate having regard to the range of needs of children for whom it is intended that the children’s home is to provide care and accommodation. (Regulation 5 (d)) 12/11/2020

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Requirement Due date

*This requirement is subject to a compliance notice. Assurance visit report: SC402135 8

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Children’s home details

Registered provider address: New Forest Care Ltd, West Shore House, West Street, Hythe, Southampton, Hampshire SO45 6AA

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Inspector

Keith Riley, Social Care Inspector Assurance visit report: SC402135 9 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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