Children's home run by Kisimul Group Limited in North Kesteven

Inspection report for children’s home - monitoring visit: SC367623 1 SC367623

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Kisimul Group Limited

Monitoring visit Inspected under the social care common inspection framework

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Information about this children’s home

This privately owned service provides education, care and accommodation for up to 61 children who have learning disabilities and/or challenging behaviours associated with autism spectrum disorder.

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Information about this children’s home

The manager registered with Ofsted in August 2018.

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This monitoring visit

This monitoring visit took place following serious safeguarding notifications, concerns raised by placing authorities and by parents, concerns raised by the independent visitor, concerns about the quality of internal investigations, concerns about the response to the statutory requirements and the repeated statutory requirements made over four years relating to regulation 12 and regulation 13. Parts of this visit were conducted remotely due to current COVID-19 (coronavirus) restrictions.

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This monitoring visit

The inspection was aligned with an inspection of Kisimul School, that is on the same site as Woodstock House, where the children access their education.

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This monitoring visit

Senior leaders demonstrate a lack of understanding of the provision as a registered children’s home. There is not one person who has overall responsibility for safeguarding. The headteacher’s responsibilities for the children’s home and the head of care’s responsibilities for the school are inappropriate. They demonstrate the senior leaders’ lack of understanding of the children’s homes regulations and statutory guidance. The process for dealing with safeguarding concerns is confusing. The quality of internal investigations is poor. In one case, an investigating officer concluded that there were no safeguarding concerns even though children had Inspection report for children’s home - monitoring visit: SC367623 2 witnessed inappropriate behaviour by staff. The lack of professional insight, curiosity and accountability places children at risk.

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This monitoring visit

Incidents that have potential safeguarding concerns are poorly recorded. Staff do not always follow up on marks that they observe on children, despite this being raised as a shortfall at previous inspections. Staff make assumptions about how children are injured. There is a culture of simply recording unexplained marks with no thought as to whether a safeguarding or behaviour management route needs to be followed. The risk of children having ongoing unexplained injuries is high.

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This monitoring visit

Staff are unclear about when to update risk assessments. When they do, the risk management plans are not communicated effectively with the staff team. In one case, this meant that it was unclear whether a child had been supervised while in the bath, even though this was an assessed need to keep the child safe.

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This monitoring visit

There are other safeguarding shortfalls:  Peer-on-peer aggression has not been adequately managed or followed up by staff.  Senior staff have not identified significant hazards in the environment inside and outside the home.  The required works to improve the perimeter fencing have not been actioned.  There are no plans to improve other areas of the site boundary and internal fencing that could compromise safety and security.  There is a lack of supervision of children. Some injuries are unexplained, and staff do not demonstrate a professional curiosity to investigate further.  There is poor communication with other professionals about injuries to children. A statutory report stated, ‘It is concerning that the child’s injury was not reported to the social worker within an appropriate timeframe.’

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This monitoring visit

Senior leaders have discouraged staff from whistleblowing, preferring them to raise any issues internally with the designated safeguarding lead. A senior leader, speaking on behalf of the provider, spoke of a culture of ‘false allegations’ without evidence to support this. This demonstrates that leaders have a lack of understanding of the statutory regulations as well as correct safeguarding procedures.

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This monitoring visit

The shortfalls contribute to a poor safeguarding culture that lacks accountability and clear processes. Other professionals talked of the high volume of safeguarding concerns in the setting. The safeguarding concerns have been a theme over several inspections and, despite a previous compliance notice under regulation 12 issued in January 2020, the required changes have not become embedded in practice, and similar issues are resurfacing.

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This monitoring visit

The provider took the decision not to accept any new referrals, and the number of Inspection report for children’s home - monitoring visit: SC367623 3 children accommodated has dropped to 35 children. Despite this, the staffing situation is precarious. There is still a lack of sufficient staff who are suitably trained and experienced, even though this has been made a requirement at several inspections. This means that not all children are supported 1:1 even though the placing authority funds this. Some staff work long hours, coupled with a long commute, followed by an early start the following day. A member of staff said that they are tired, and the shifts are too long. Although the use of agency staff has decreased, this has meant that there is a dependency on staff working overtime. There is no clear overarching recruitment strategy. The capacity to improve the staffing situation is limited.

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This monitoring visit

The concerns about the pressure on staffing are heightened due to staff shortages in the organisation’s school, meaning that children are spending additional time in the home. There has been a rise in children’s negative behaviour and incidents in the home. Such incidents are not consistently managed due to the inadequate staffing. Even though the school provides guidance on learning, the staff approach to support education in the home is poor.

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This monitoring visit

Despite the organisation’s voluntary reduction in numbers of children accommodated, the concerns about the lack of a qualified and experienced staff team have been a theme over several inspections, and this is not at the required levels. The number of unexplained injuries to children and the shortfalls in staffing have not been identified by senior leaders as a cause for concern.

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This monitoring visit

Senior leaders have failed to identify the significant shortfalls in the staff’s experience and qualifications, as well as the safeguarding structure and culture, through their own reviewing and monitoring systems. They have not recognised the urgency to make improvements, and their approach has been weak. Their plans to have an independent review of safeguarding practice and culture have stalled.

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This monitoring visit

Leaders do not utilise their independent visitor effectively. Although the independent visitor identifies some of the shortfalls, senior leaders do not have a process to ensure that the recommendations are carried out. Some key staff were not aware of the recommendation made by the independent visitor when they identified the long hours that staff are working.

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This monitoring visit

Senior leaders implemented daily checks, but these are failing. For example, staff have not recognised the hazards in the environment. Senior leaders do ‘site sweeps’ to observe practice but they do not keep records of this. This means that there is no meaningful information obtained leading to an improvement plan. Senior leaders said that a quality compliance team provides another layer of monitoring. No records of such visits were supplied. There are no findings that are purposefully translated into recommendations and systems for improvement. Although some placing authorities have visited to conduct an audit, there are no clear descriptions of their findings or evidence that senior leaders have actively requested them so they can address any shortfalls. Inspection report for children’s home - monitoring visit: SC367623 4 Overall, the monitoring systems are not applied in practice. Senior leaders miss the

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This monitoring visit

Staff recruitment practice is not compliant with regulations because employment histories are not appropriately explored. Similarly, interviewers’ notes do not make clear how a person has been judged as suitable and why. In some cases, the record of reference checks is missing, with no-one taking responsibility for the missing information. The organisation has not yet fully implemented a system to ensure that Disclosure and Barring Service checks are routinely reviewed and checked. These shortfalls in employment practice mean that there is the potential for children to be exposed to unsuitable adults.

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This monitoring visit

Care planning and practice are poor. Some parents reported that children come home in other children’s clothes. Some children with sensory issues have their name label sewn in the neckline of a garment, which aggravates them, despite repeated requests by the parent that staff do not do this. Some parents said that they do not feel listened to.

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This monitoring visit

A placing authority expressed concerns to the provider about a child whom they have placed in the home and for whom a safety plan was agreed. Despite this, daily record sheets for this child are poor and inconsistent. This hampers the identification of the work being done and the measurement of progress.

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This monitoring visit

There is a lack of clarity as to what constitutes an incident and when one occurs what the response is. There is no clear process for learning from incidents and for what will be done differently to prevent recurrence. The arrangements for the storage of information are confusing, with some records held electronically and other information held as paper copies in another location. Information-sharing with social workers and parents is so poor that senior leaders are only at the stage of considering sending a monthly update.

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This monitoring visit

Senior leaders have recognised that there is a significant structural gap between team leaders and the deputy heads of care. They have appointed care managers for most of the homes, but their role and impact are in their infancy. There is a gap in knowledge of children’s services, as appointments have been made from the adult sector. The creation of a new therapy team has been a positive initiative. The team has begun to provide baseline training for staff in communicating with children with severe communication difficulties. There has been some limited success, such as a child being supported to move to a new bedroom while minimising the child’s anxiety.

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This monitoring visit

It is not clear how the training plan for the middle management team has been developed. The plan details very little about the scale of the overall training and development needs of these teams. Therefore, it is difficult to measure the scale and complexity of this task for the registered manager.

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This monitoring visit

There is a support plan for the registered manager. This focuses on tasks and Inspection report for children’s home - monitoring visit: SC367623 5 deadlines to achieve these. There is no analysis of the registered manager’s strengths and weaknesses. Senior leaders want her to improve the quality of staff supervision, but the audit of her own practice is not due until March 2021. Overall, the plan and its implementation are seriously flawed by the failure to conduct a skills and knowledge audit of the registered manager’s practice before deciding how best to support and develop her areas of perceived weakness.

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This monitoring visit

Given the previous breaches of regulation over several inspections and the failure to embed changes permanently in practice, the capacity of senior leaders to improve the service is not convincing.

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This monitoring visit

Ofsted has issued compliance notices relating to regulation 12 and regulation 13.

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Recent inspection history

Inspection date Inspection type Inspection judgement 14/01/2020 Interim Declined in effectiveness 02/07/2019 Full Good 09/01/2019 Interim Sustained effectiveness 03/07/2018 Full Requires improvement to be good Inspection report for children’s home - monitoring visit: SC367623 6

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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 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

that the premises used for the purposes of the home are designed, furnished and maintained so as to protect each 18 April 2021 Inspection report for children’s home - monitoring visit: SC367623 7 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)(vii) (b) (d) (e))

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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.

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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

ensure that the home has sufficient staff to provide care for 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.

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Requirement Due date

(Regulation 13 (1)(a)(b) (2)(c)(d)(h)) 18 April 2021

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Requirement Due date

A responsible individual must 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.

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Requirement Due date

The care planning standard is that children receive effectively planned care in or through the children’s home.

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Requirement Due date

The registered person must prepare and implement a policy which—

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Requirement Due date

is intended to safeguard children accommodated in the children’s home from abuse or neglect; and

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Requirement Due date

sets out the procedure to be followed in the event of an allegation of abuse or neglect. 18 April 2021 Inspection report for children’s home - monitoring visit: SC367623 8 (Regulation 34 (1)(a)(b))

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Requirement Due date

The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so.

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Requirement Due date

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

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Requirement Due date

help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans;

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Requirement Due date

support each child’s learning and development, including helping the child to develop independent study skills and, where appropriate, helping the child to complete independent study.

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Requirement Due date

(Regulation 8 (1) (2)(a)(i)(ii)) 18 April 2021

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Requirement Due date

The independent person’s report may recommend actions that the registered person may take in relation to the home and timescales within which the registered person must consider whether or not to take those actions.

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Requirement Due date

The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety.

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Requirement Due date

A person may only manage a children’s home if the person has the appropriate experience, qualification and skills to manage the home effectively and lead the care of children.

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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. Inspection report for children’s home - monitoring visit: SC367623 9

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Children’s home details

Provision sub-type: Residential special school

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Children’s home details

Registered provider: Kisimul Group Limited

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Children’s home details

Registered provider address: Kisimul School, The Old Vicarage, High Street, Swinderby, Lincoln, Lincolnshire LN6 9LU

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Inspectors

Keith Riley, Social Care Inspector Sophie Wood, Regulatory Inspection Manager Andy Whippey, Her Majesty’s Inspector Inspection report for children’s home - monitoring visit: SC367623 10 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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