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

Inspection report for children’s home – monitoring visit: SC402135 1 SC402135

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New Forest Care

Monitoring visit Inspected under the social care common inspection framework

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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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This monitoring visit

At the assurance visit on 12 October 2020, serious and widespread concerns in relation to the care or protection of children were identified. These included: poor practice in relation to the use of restraint, staff training, and monitoring of physical restraint; examples of weak admissions processes; a lack of response by leaders to the weaknesses identified by the independent visitor reports and previous Ofsted inspection findings about restraint practice; and a lack of evidence to demonstrate that staff are suitably trained to look after children with psychiatric and psychological disorders.

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This monitoring visit

Following that visit, a compliance notice was issued in relation to regulation 35, behaviour management records, and nine other requirements were made. A restriction of accommodation notice was issued until 11 January 2021.

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This monitoring visit

At the monitoring visit on 18 November 2020 it was found that the compliance notice was not met and none of the requirements were met. The compliance notice in relation to regulation 35 was reissued and two further compliance notices were issued in relation to regulation 26 and regulation 28. The requirements were repeated and three additional requirements were made. Inspection report for children’s home – monitoring visit: SC402135 2 This visit was used to assess if the provider had met the requirements and the steps in the compliance notice. It was also used to consider if the restriction of accommodation notice could be lifted.

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This monitoring visit

Most inspection activities were completed off site, in accordance with current COVID-19 (coronavirus) restrictions. Relevant documents and associated information were requested, and telephone interviews with leaders, staff and other parties were completed. A brief visit was made to the home. The provider has complied with the restriction of accommodation notice.

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records

Step 1 The provider was required to detail, in a written report with timescales, how staff will be suitably trained, and supported, and records monitored, to ensure that the reasons leading to an escalation of physical intervention are clearly documented.

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records

Senior leaders have not followed their own action plan. Staff have not had the training that was stated in the provider’s written response to Ofsted. Senior leaders have not identified the success criteria with regard to assessing staff competence in restraint, and have not stated why previous training has been unsuccessful. The provider has used a trainer whose performance has been brought into question, stating that her previous experience qualifies her to deliver the training. Although the registered manager has had training in monitoring records, he stated to the independent visitor that he needs further training, but there are no plans to provide this.

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records

Step 2 The provider was required to detail, in a written report with timescales, how staff will be suitably trained, and supported, and records monitored, to ensure that the description of a restraint and its duration are clear to the reader. The report must detail the actions of staff during the restraint, especially their responsibilities to monitor vital signs during and after the intervention and identify the individual responsibilities during and after the physical intervention.

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records

A behaviour management instructor has retrained staff in the risks of using ground floor restraints. Staff demonstrate an understanding of monitoring vital signs during a high-risk physical intervention. Senior leaders have provided them with training in how to enter times correctly in the software, so that the duration of a physical restraint is calculated accurately. Senior leaders accept that training certificates do not evidence that staff are trained in advanced techniques. They have a meeting planned with the training provider to resolve this.

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records

This step is met. Inspection report for children’s home – monitoring visit: SC402135 3 Step 3 The provider was required to detail, in a written report with timescales, how a suitable review of a physical intervention is undertaken with the staff involved in the physical intervention, and who is responsible for this review with the staff involved, such that there is no conflict of interest, within 48 hours of the restraint.

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records

Although senior leaders state that the staff have been trained in undertaking a review, staff, including the registered manager, give differing accounts as to how the review takes place, who is involved in the review and where it is recorded. The training has not covered the need to consider the unmet need of the child as a trigger for the behaviour, as stated in the statement of purpose. The provider has not considered the potential risks around the balance of power when the registered manager is involved in a restraint and someone junior to him conducts the review. Senior leaders, the registered manager and staff are not aware of the deadline for the review with staff, as it is stated in the regulations.

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records

Step 4 The provider was required to detail, in a written report with timescales, how a suitable review of a physical intervention is undertaken with the child subject to the restraint, within 5 days of the use of the physical intervention.

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records

The content for a review with the child is clearer, but this does not cover the requirement to consider the unmet need of the child, in accordance with the description in the home’s statement of purpose. The process for a review is unclear, with senior leaders, the registered manager and staff giving different accounts of how the review happens, who is involved and how it is recorded. They show a misunderstanding of the regulations and the deadline for undertaking a review.

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records

Overall, this compliance notice is not met.

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Regulation 26 compliance notice – fitness of the provider

Step 1 The provider was required to demonstrate that the responsible individual has the capacity, experience and skills necessary to supervise the management of the home by meeting the compliance notice that is served under regulation 35 (3)(a)(ii)(iv)(b)(c)).

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Regulation 26 compliance notice – fitness of the provider

The provider’s failure to provide effective supervision of the management of the home, through the responsible individual, is a contributory factor in the failure to meet the compliance notice, served under regulation 35. Inspection report for children’s home – monitoring visit: SC402135 4 This step is not met.

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Regulation 26 compliance notice – fitness of the provider

Step 2 The provider was required to demonstrate that the responsible individual has the capacity, experience and skills necessary to supervise the management of the home by meeting the requirements made at the inspection on 12 October 2020 under:

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Regulation 26 compliance notice – fitness of the provider

a) Regulation 20 Restraint and deprivation of liberty b) Regulation 13 The leadership and management standard c) Regulation 10 The health and well-being standard d) Regulation 16 Statement of purpose e) Regulation 40 Notification of a serious event f) Regulation 14 The care planning standard g) Regulation 5 Engaging with the wider system to ensure children’s needs are met h) Regulation 12 The protection of children standard

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Regulation 26 compliance notice – fitness of the provider

Senior leaders have not considered how they will ensure that physical restraint is necessary and proportionate. Their stated intent is to continue to restrain children if the children leave the home without consent but would now seek the consent of the placing authority to do this. The regulation 20 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Senior leaders do not identify which diagnosed psychiatric conditions the home can cater for. This is despite the statement of purpose stating that the home cares for children with certain psychiatric conditions.

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Regulation 26 compliance notice – fitness of the provider

A large proportion of staff lack experience and qualifications, and cannot identify which psychiatric conditions they would feel confident about supporting. Senior leaders have provided various training sessions in other areas because of the recent enforcement action that Ofsted has taken. They have no plans how to determine the effectiveness of the additional training and how staff will apply this in practice. There is no recruitment strategy to strengthen the staff team. The regulation 13 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Senior leaders have included the need to consider a child’s health in the child’s behaviour management plan, as a prompt to assess the risks of restraining a child with a medical condition. Senior leaders have not reviewed the suitability of using the provider’s mental health nurse to undertake this assessment, when it concerns the physical/medical condition of a child. They were unable to explain the role of the responsible individual in this process, even though this was included in their written response to Ofsted. The regulation 10 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Senior leaders have not revised the statement of purpose to show how they assess staff competence in using restraint techniques. The statement of purpose states that Inspection report for children’s home – monitoring visit: SC402135 5 children with certain psychiatric conditions can be accommodated, but does not specify what these conditions are. It does not state which training and experience the staff must have to meet such needs. The statement of purpose states that the organisation believes that children display negative behaviour because of an unmet need. Senior leaders do not guide staff in how to apply this belief in practice. The statement of purpose does not state the experience and qualifications of the on-call staff, nor does it specify a lower age limit for the children who are to be accommodated. The regulation 16 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Staff have had training in submitting notifications of significant incidents to the relevant agency within the necessary time frame and with enough detail. The regulation 40 requirement is met.

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Regulation 26 compliance notice – fitness of the provider

Care planning is poor. Senior leaders have not considered why key information was not included in an impact risk assessment. Because of a safeguarding incident, senior leaders decided a child needed to leave the placement. They placed the child in unsuitable temporary accommodation. Although senior leaders reflect that this was a rash decision, they have a stated intent to use such accommodation again, when they see no alternate option due to their non-exclusion policy. They have not addressed why there was a lack of integrated care planning, and why there was poor communication with the placing authority. The regulation 14 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Staff demonstrate an understanding of the therapy team and its role in supporting the children. Staff understand the communication channels with the therapy team. The regulation 5 requirement is met.

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Regulation 26 compliance notice – fitness of the provider

Senior leaders have not acted to improve the quality of internal safeguarding investigations. They have not followed their own action plan to address the issues in staff supervision. There has been no reflection or learning from the previous poor investigations. Furthermore, senior leaders have not reflected on what the investigating officer should do differently if similar situations occur in future. The regulation 12 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Step 3 The provider was required to demonstrate that the responsible individual has the capacity, experience and skills necessary to supervise the management of the home by meeting the statutory requirements made at the inspection on 18 November 2020 under:

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Regulation 26 compliance notice – fitness of the provider

i. Regulation 35 (2) Behaviour management policies and records j. Regulation 40 (5)(a)(i) Notification of a serious event k. Regulation 14 (1)(a)(b)(2)(c)) The care planning standard Inspection report for children’s home – monitoring visit: SC402135 6 The behaviour management policy does not reference the documents that the registered manager advised are used to record the review with staff involved in a physical restraint. The policy still does not indicate where staff are to record such reviews. Consequently, staff, including senior leaders, give differing accounts of where to record this information, and made no reference to the documents that the registered manager stated are to be used. The regulation 35 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

The quality of statutory notifications of significant incidents was poor. Senior leaders have now ensured that the necessary training has taken place, including the need to indicate why police involvement was necessary. The regulation 40 requirement is met.

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Regulation 26 compliance notice – fitness of the provider

A court order specified a 2:1 staffing ratio for a child. On five occasions, staff did not comply with this arrangement. The registered manager’s explanation was that this was due to staffing and other priorities. Senior leaders have not analysed why staff did not comply with the court order. They stated that the shortfall was due to ‘operational reasons’. This means that no action has been taken to correct this shortfall and the risk of recurrence is high. The regulation 14 requirement is not met.

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Regulation 26 compliance notice – fitness of the provider

Overall, this compliance notice is not met.

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Regulation 28 compliance notice – fitness of manager

Step 1 The registered manager was required to demonstrate that he has the appropriate experience, qualification and skills to manage the home effectively and lead the care of children by meeting the compliance notice that is served under regulation 35 (3)(a)(ii)(iv)(b)(c)).

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Regulation 28 compliance notice – fitness of manager

This compliance notice issued under regulation 35 remains unmet, following the extended deadline given in which to meet it. The registered manager has not exercised the required level of skill and expertise to make the necessary improvements with regard to behaviour management practices.

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Regulation 28 compliance notice – fitness of manager

Step 2 The registered manager was required to demonstrate that progress is being made in meeting the requirements made following the assurance visit of 13 October 2020, under:

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Regulation 28 compliance notice – fitness of manager

a. Regulation 20 Restraint and deprivation of liberty b. Regulation 13 The leadership and management standard Inspection report for children’s home – monitoring visit: SC402135 7 c. Regulation 10 The health and well-being standard d. Regulation 16 Statement of purpose e. Regulation 40 Notification of a serious event f. Regulation 14 The care planning standard g. Regulation 5 Engaging with the wider system to ensure children’s needs are met h. Regulation 12 The protection of children standard

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Regulation 28 compliance notice – fitness of manager

The poor response to demonstrating progress in meeting the requirements listed above, means that the registered manager has not demonstrated sufficient skill in improving the quality of the care provided for children.

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Regulation 28 compliance notice – fitness of manager

Step 3 The registered manager was required to demonstrate that progress is being made in meeting the requirements made following the monitoring visit conducted on 18 November 2020 under:

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Regulation 28 compliance notice – fitness of manager

i. Regulation 35 (2) Behaviour management policies and records j. Regulation 40 (5)(a)(i) Notification of a serious event k. Regulation 14 (1)(a)(b)(2)(c)) The care planning standard

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Regulation 28 compliance notice – fitness of manager

The registered manager has failed to exercise the level of skill and expertise required to make sufficient progress in meeting all of the requirements listed above.

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Regulation 28 compliance notice – fitness of manager

Overall, this compliance notice is not met.

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Regulation 28 compliance notice – fitness of manager

Weaknesses in the senior leadership’s practice continue. This is exacerbated by the absence of definitive plans to support and improve practice. Despite the previous requirements and compliance notices issued, senior leaders do not demonstrate that lessons are being learned. In one example, they did not address the inadequate care planning for a child who was placed in unsuitable accommodation. There is a lack of joined-up work in the senior management team. This causes confusion.

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Regulation 28 compliance notice – fitness of manager

The potential impact of the number of unmet requirements means that Ofsted is not reassured that children will receive the level and quality of care that they may require. Consequently, a further restriction of accommodation notice has been issued up to 5 April 2021.

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Regulation 28 compliance notice – fitness of manager

Ofsted will consider the next steps. Inspection report for children’s home – monitoring visit: SC402135 8

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Recent inspection history

Inspection date Inspection type Inspection judgement 26/02/2020 Interim Sustained effectiveness 05/06/2019 Full Good 13/11/2018 Full Requires improvement to be good 24/01/2018 Full Good Inspection report for children’s home – monitoring visit: SC402135 9

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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

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

a description of the measure and its duration;

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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 confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(ii)(iv)(b)(c)) 7 February 2021

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Requirement Due date

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).

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Requirement Due date

Restraint in relation to a child must be necessary and proportionate. (Regulation 20 (1)(a)(b)(2)) 7 February 2021 Inspection report for children’s home – monitoring visit: SC402135 10 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

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

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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. (Regulation 13 (2)(c)(h)) 7 February 2021

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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. (Regulation 10 (1)(a)(b)) 7 February 2021

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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.

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Requirement Due date

keep the statement of purpose under review and, where appropriate, revise it. (Regulation 16 (1)(3)(a)) 7 February 2021

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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. (Regulation 14 (1)(a)) 7 February 2021

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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—

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Requirement Due date

that staff— 7 February 2021 Inspection report for children’s home – monitoring visit: SC402135 11 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

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

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Requirement Due date

have the capacity, experience and skills to supervise the management of the home, or the homes, in respect of which the responsible individual is nominated. (Regulation 26 (7)(b)) 7 February 2021

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Requirement Due date

A person may only manage a children’s home if—

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Requirement Due date

having regard to the size of the home, its statement of purpose, and the number and needs (including any needs arising from any disability) of the children—

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Requirement Due date

the person has the appropriate experience, qualification and skills to manage the home effectively and lead the care of children. Regulation 28 (1)(b)(i) 7 February 2021

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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

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

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Children’s home details

Responsible individual: Laura Cave Inspection report for children’s home – monitoring visit: SC402135 12 Registered manager: Roderick Macaskill

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Inspector

Keith Riley, Social Care Inspector Inspection report for children’s home – monitoring visit: SC402135 13 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 looked after children, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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