Children's Home, Residential special school run by The Hesley Group Limited in Doncaster

Assurance visit report: SC008015 1 SC008015

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Information about this children’s home

This residential special school is owned by a private company. It is registered as a children’s home and offers care and accommodation for up to 32 children with learning disabilities and/or difficulties, together with complex needs.

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Information about this children’s home

The manager was registered on 05 October 2020.

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Information about this children’s home

Previous inspection date: 10 December 2019

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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: SC008015 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 visit:

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Findings from the visit

 safeguarding arrangements are not effective and do not protect children from harm  leadership and management of the service are poor, and leaders do not sufficiently consider the safety of children  the manager does not demonstrate integrity in relation to sharing safeguarding concerns with Ofsted  there are widespread shortfalls in relation to staff training  behaviour management practice is inappropriate and is failing to meet children’s needs  staff do not have sufficient knowledge of children’s individual needs, including how to communicate with children who are non-verbal.

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The care of children

There are serious and widespread concerns in several areas of practice relating to the care that children receive. This places children at serious risk of harm.

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The care of children

While some children receive an appropriate level of care and make good progress, this is not the same for all children. A significant number of the staff have not completed training to help them to understand how to interact with children with complex communication needs. This means that some children are cared for by staff who do not have the appropriate skills and understanding to meet their needs, or to understand their views, wishes and feelings.

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The care of children

Staff often use temporary confinement when children are in a state of anxiety and are displaying self-injurious behaviour. At times, children are temporarily confined without any visible oversight or support from staff. This means that children who are in a state of distress have no help to ensure their safety and well-being. Placing authorities provided feedback that they are not aware of or have been consulted regarding this practice. This practice is unlawful as it not sanctioned by a court and does not meet regulation 20. These shortfalls and lack of clear management oversight expose children to a serious risk of harm.

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The care of children

There are insufficient staff available at times to respond to a child in crisis or when a staff member requires support. This results in them calling on other staff to help, including from other houses on the site. Staff make their own decision as to whether it is safe to leave the children they are looking after. This includes children who require one-to-one supervision. On one occasion, a child was left unsupervised by staff, which resulted in the child leaving the grounds. The reactive approach to responding to children in distress and the lack of available staff to respond to Assurance visit report: SC008015 3 children in crisis results in some children’s needs being neglected. The lack of management direction and guidance in overseeing this practice exposes children to a potential risk of harm.

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The safety of children

Not all children are appropriately safeguarded in this home. A concerning number of incidents occur where children have been harmed by members of staff through either alleged deliberate acts or neglect of care. Although managers act in response to safeguarding incidents, this does not prevent further incidents. As a result, children’s safety is compromised and they continue to suffer harm.

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The safety of children

Not all staff have the training needed to protect and care for children. This includes staff not having restraint training, gaps in safeguarding training and significant gaps in communication training. This means that some children are cared for by staff who do not have the appropriate skills to meet their needs and understand their distress, anxiety and wishes. This includes some children being restrained by staff who have not been trained to do so. This places children at significant risk of harm.

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The safety of children

Children are held in response to crisis behaviour. When children sustain injuries during restraint, the injuries are not always recorded in any documents and it is unclear if medical attention has been provided. The recording of serious incidents is left to the discretion of the staff member involved. The manager’s review of restraint incidents is often significantly delayed. Records do not include debriefs with children. Many of the records lack significant details. This includes whether the child’s breathing is monitored during and following a ground hold, and whether there has been any impact on their health.

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Leaders and managers

There are serious and widespread shortfalls relating to the leadership and management of the home.

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Leaders and managers

Leaders and managers have failed to ensure that all staff are appropriately trained to understand the range of communication used by children to express emotions, including distressed behaviour. There are insufficient measures in place to help staff identify triggers of distressed behaviour and avoid the need for restraint.

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Leaders and managers

Where restraint and restrictive interventions are used, managers do not have robust systems in place to ensure that this practice is safe for children or lawful. Inspectors found temporary confinement has been used as a behaviour management technique without a Deprivation of Liberty order or the knowledge of the placing authority.

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Leaders and managers

Managers do not ensure that all staff are trained to use restraint safely and appropriately. When restraint and restrictive interventions are used, managers do not have sufficient oversight of these practices. Systems to review how appropriate restraint is used in individual cases are not effective. The failure to ensure that Assurance visit report: SC008015 4 debriefs take place and ensure that children receive medical review leaves children at risk of harm.

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Leaders and managers

Where allegations are made in respect of children being harmed by staff, notifications are made to the safeguarding agency. However, when managers review allegations, and where disciplinary investigations or actions take place, there is no evidence that managers are extrapolating any learning from repeated incidents to prevent reoccurrence. They do not analyse patterns or trends to inform changes in approach where necessary. This leaves children at risk of potential harm from repeated poor practice.

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Leaders and managers

There is a lack of transparency by managers in relation to the reporting of safeguarding incidents to the regulator. This includes providing misleading information regarding which staff are implicated in an allegation of causing harm to children.

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Leaders and managers

Staffing rotas do not accurately reflect the staff who are on duty. Inspectors found anomalies when duty rotas were triangulated with listed staff working with children who were not on the employed list. This means that managers cannot be assured that children are being protected and cared for by vetted and safe staff and staff who are able to meet their needs.

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Leaders and managers

Following this visit, the service has been suspended. Six requirements are issued to address areas identified as having serious and widespread concerns. The previous visit, which was a monitoring visit carried out on 12 March 2021, resulted in a compliance notice under regulation 32, a requirement under regulation 13 regarding monitoring and review systems, and a recommendation being issued. These remain in place.

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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

that staff— 24 March 2021 Assurance visit report: SC008015 5 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. (Regulation 12 (1) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(b)) 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

use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b) (2)(h)) 2 May 2021

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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—

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Requirement Due date

helps children aspire to fulfil their potential; and 24 March 2021 Assurance visit report: SC008015 6 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

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

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. (Regulation 13 (1)(a)(b) (2)(a)(b)(c)(e)(f)(g)(ii)(h)) 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

Subject to paragraph (6), the registered person must ensure that the home is at all times conducted in a manner which is consistent with its statement of purpose. (Regulation 16 (1) (5)) 24 March 2021

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Requirement Due date

Restraint in relation to a child must be necessary and proportionate.

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Requirement Due date

These Regulations do not prevent a child from being deprived of liberty where that deprivation is authorised in accordance with a court order. (Regulation 20 (2) (3)) 2 May 2021 Assurance visit report: SC008015 7 An individual may only carry on a children’s home if the individual satisfies the requirements in paragraph (5).

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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 (1) (7)(b))

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Requirement Due date

This specifically relates to the responsible individual’s capacity and skills to supervise the management of the home effectively. 24 March 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

the person is of integrity and good character;

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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)(a)(b)(i))

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Requirement Due date

This specifically relates to the registered manager’s capacity and skills to manage the home effectively. 24 March 2021

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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

employ an individual to work at the children’s home.

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Requirement Due date

the individual is of integrity and good character;

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Requirement Due date

full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32 (1) (2)(a) (3)(a)(d)) 2 May 2021

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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— 24 March 2021 Assurance visit report: SC008015 8 a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure;

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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)(viii)(b)(i)(ii)(c))

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendations

 The registered person should ensure that the home is a nurturing, homely and supportive environment. (‘Guide to the children’s homes regulations including the quality standards’, page 15, paragraph 3.9)

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Children’s home details

Registered provider: Hesley Services Limited

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Children’s home details

Registered provider address: Hesley Hall Coach House, Hesley, Doncaster, South Yorkshire DN11 9HH

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Inspectors

Paula Kelly, Social Care Inspector Jacqueline Tate, Social Care Inspector Tina Ruffles, Social Care Inspector Assurance visit report: SC008015 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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Inspectors

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Inspectors

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Inspectors

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Inspectors

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