Children's home run by Discovered Limited

Inspection report for children’s home – monitoring visit: 1272209 1

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Discovered Limited

Monitoring visit Inspected under the social care common inspection framework

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Information about this children’s home

This privately owned home was registered in April 2018. It provides care for up to five children who have had traumatic childhoods and require support in a nurturing, structured and therapeutic environment.

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Information about this children’s home

An urgent monitoring visit was carried out on 24 March 2021 in response to a number of concerns about the operation of the home that were raised directly with Ofsted. Significant shortfalls were identified. These shortfalls placed children at risk of harm. The home’s registration was suspended on 25 March 2021. All of the children have moved out of the home.

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Information about this children’s home

The home does not currently have a registered manager. The acting manager resigned with immediate effect on 22 March 2021.

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This monitoring visit

This is the home’s second monitoring visit in March 2021. It was carried out in light of very serious concerns that had been identified at the home’s previous visit.

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This monitoring visit

Ofsted is aware of the challenges that COVID-19 (coronavirus) is currently posing to those it regulates. During this visit, the inspector took into consideration the impact of any measures being taken by the home to slow the spread of COVID-19.

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This monitoring visit

Two inspectors visited the home. They spoke to the home’s responsible individual and staff, reviewed records and gathered information from other agencies.

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This monitoring visit

This monitoring visit confirmed that children had been at risk of harm and had suffered harm because of weaknesses in their care and poor management.

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This monitoring visit

Additional information gathered during this monitoring visit confirms that inadequate care has been provided for children who sustain injuries or harm themselves. For Inspection report for children’s home – monitoring visit: 1272209 2 example, a child was admitted to hospital after stating that she had taken an overdose of medicine. Senior managers served notice on the child’s placement at the home with immediate effect on the day that she was admitted to hospital. The child was left at the hospital with no staff support. No staff members checked on the child or made contact with her. No staff members said goodbye to her. The lack of care and the way the placement ended were damaging to the child’s emotional well- being.

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This monitoring visit

A review of health records confirms that there have been several other examples of injury or illness that have been responded to poorly by staff. Staff have not taken sufficient action to prevent children from receiving injuries. In some cases, the cause of injuries has not been clearly evidenced in records. The provider was not able to demonstrate that appropriate medical treatment was provided for children who had sustained injuries. This failure to respond appropriately to significant health concerns placed children at risk of further harm.

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This monitoring visit

The Local Authority Designated Officer (LADO) has not been made aware of safeguarding concerns about staff members. Concerns about staff members include an allegation from a child that a staff member had hit her. Ofsted was informed that the LADO had been notified of this allegation, but this was not the case.

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This monitoring visit

In another incident that had not been notified appropriately, a child filmed staff kicking another child’s belongings across a room. This is an example of abusive and harmful staff practice.

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This monitoring visit

Placing social workers have not been informed about key information pertaining to children’s safety. For example, they were not aware of significant injuries that had resulted from self-harming behaviour. In addition, they were not aware that a child told staff that they had swallowed a battery, or that a child’s possessions had been kicked across the room by staff.

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This monitoring visit

Ofsted has not been informed of events in the home in line with the Children’s Homes Regulations. For example, several allegations about staff members and a high number of police call-outs to the home to manage young people’s behaviours have not been notified. The failure to share information with safeguarding and regulatory bodies demonstrates a lack of transparency that has the potential to place children at risk.

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This monitoring visit

Placement matching systems are ineffective and place children at risk. A child who was particularly vulnerable was admitted to the home on 8 March 2021. Known risks were not properly considered. For example, the home’s location on a busy road was not considered against the child’s previous history of placing herself at risk on roads. A child’s risk assessment carried out at the point of admission was inaccurate. It states that: ‘[The home] currently has a consistent and experienced staff team who have experience of working with children with emotional and behavioural difficulties, learning disability and sexualised behaviours.’ This is not the case. Poor risk assessment placed this child at risk of harm. Inspection report for children’s home – monitoring visit: 1272209 3 Risk management strategies implemented at the point of admission were not adhered to. For example, sufficient numbers of suitably trained staff were not made

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This monitoring visit

available to care for children. One child’s risk assessment stated that staff working with the child should be trained in physical intervention in order to protect the child from risks associated with self-harm and suicide. There were several occasions when staff who are not trained in physical intervention worked alone with the child. As a result, the child was not adequately protected. Several new members of staff had not had an induction prior to working with the children.

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This monitoring visit

There are significant shortfalls in the administration of medicines. These have the potential to place children at risk of harm. There are occasions when prescribed medicines have not been administered to children, without explanation. Medication records are poorly maintained. For example, they do not show why one child is prescribed antibiotics and medicines which have a sedative effect.

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This monitoring visit

There has been no registered manager since September 2020. A manager had been in post since November 2020, but resigned with immediate effect on 22 March 2021. The home’s deputy manager also resigned with immediate effect on 23 March 2021.

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This monitoring visit

There has been an extremely high turnover of staff. Eleven staff members have left the home since 8 January 2021. Nineteen members of staff have begun work at the home since 15 January 2021. Staffing levels have not been stable enough to provide consistent care for highly vulnerable children with complex safeguarding needs. Children have had to cope with multiple changes to their carers at a time when they need stability.

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This monitoring visit

The responsible individual has not properly overseen the management of the home. For example, he was not aware of several concerns which have come to light during the two monitoring visits to the home. He has not taken sufficient action to monitor the home or to protect children. The responsible individual does not have the necessary information to establish a clear picture of the staff who work in the home, including their expertise and their training profiles. Property damage that could cause harm to children has not been repaired promptly.

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This monitoring visit

Ofsted identified several obvious concerns about children’s safety and welfare. These should have been apparent to senior managers. However, they had failed to identify the concerns or to take action themselves.

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This monitoring visit

In light of the very serious shortfalls identified at the home’s two monitoring visits, Ofsted proposes to cancel the registration of this home. The home’s ongoing suspension prevents children from being admitted.

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Recent inspection history

Inspection date Inspection type Inspection judgement Inspection report for children’s home – monitoring visit: 1272209 4 01/07/2019 Full Good 04/02/2019 Interim Sustained effectiveness 20/12/2018 Full Good Inspection report for children’s home – monitoring visit: 1272209 5

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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 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)(b))

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Requirement Due date

This is in relation to staffing levels which are unsafe and do not comply with children’s risk assessments, and to staff not seeking medical attention for children when they have significant health issues. 30 April 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 the premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child’s health. (Regulation 12 (1) (2)(d))

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Requirement Due date

This is in relation to a smashed window, and the delay in fixing this. 30 April 2021

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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; 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 6 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

ensure that the home’s workforce provides continuity of care for 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

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)(d)(e)(f)(h))

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Requirement Due date

This is in relation to children’s care not being in line with the home’s statement of purpose, to shortfalls in staff competence, skills and training, and to the very high staff turnover and ineffective monitoring by the organisation.

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if—

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Requirement Due date

a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation;

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Requirement Due date

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious;

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Requirement Due date

there is an allegation of abuse against the home or a person working there;

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Requirement Due date

a child protection enquiry involving a child—

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Requirement Due date

concludes (in which case, the notification must include the outcome of the child protection enquiry); or

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Requirement Due date

there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(a)(b)(c)(d)(i)(ii)(e)) 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 7 This is in relation to police being called, concerns about staff and several other safeguarding matters which have not been referred to Ofsted.

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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.

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Requirement Due date

The procedure to be followed in the event of an allegation of abuse or neglect must, in particular—

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Requirement Due date

provide for liaison and cooperation with any local authority which is, or may be, making a child protection enquiry in relation to a child accommodated in the home;

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Requirement Due date

provide for the prompt referral of an allegation about current or ongoing abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the home is located;

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Requirement Due date

provide for the prompt referral of an allegation about past abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the alleged abuse or neglect occurred;

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Requirement Due date

provide for records to be kept of an allegation of abuse or neglect, and the action taken in response;

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Requirement Due date

describe the measures which may be necessary to protect children following an allegation of abuse or neglect; and

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Requirement Due date

describe how and to whom staff are to report, without delay, any concern about abuse or neglect of a child. (Regulation 34 (1)(a)(b) (2)(a)(b)(c)(d)(e)(f))

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Requirement Due date

This is in relation to safeguarding matters where the organisation has failed to follow its own safeguarding procedures and failed to inform the relevant authorities. 30 April 2021

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who— 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 8 understand the children’s home’s overall aims and the outcomes it seeks to achieve for children;

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Requirement Due date

use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

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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 the premises used for the purposes of the home are designed and furnished so as to—

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Requirement Due date

enable each child to participate in the daily life of the home. (Regulation 6 (1)(a)(b) (2)(c)(i)(ii))

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Requirement Due date

This is in relation to the home’s staffing arrangements, which have not ensured that children receive care that meets their needs. The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on—

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Requirement Due date

an understanding about acceptable behaviour; and

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Requirement Due date

positive responses to other children and adults.

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Requirement Due date

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

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Requirement Due date

meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans;

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Requirement Due date

help each child to develop socially aware behaviour;

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Requirement Due date

encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding;

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Requirement Due date

help each child to develop and practise skills to resolve conflicts positively and without harm to anyone; 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 9 communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding;

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Requirement Due date

help each child to understand, in a way that is appropriate according to the child’s age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful;

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Requirement Due date

help each child to develop the understanding and skills to recognise or withdraw from a damaging, exploitative or harmful relationship;

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Requirement Due date

strive to gain each child’s respect and trust;

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Requirement Due date

understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children;

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Requirement Due date

are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same;

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Requirement Due date

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

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Requirement Due date

understand and communicate to children that bullying is unacceptable; and

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Requirement Due date

have the skills to recognise incidents or indications of bullying and how to deal with them. (Regulation 11 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(ix)(x)(xi)(xii)(xiii))

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Requirement Due date

This is in relation to the staff’s inability to meet each child’s behavioural and emotional needs.

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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; and

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Requirement Due date

have a positive experience of arriving at or moving on from the home. 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 10 In particular, the standard in paragraph (1) requires the registered person to ensure—

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Requirement Due date

that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose. (Regulation 14 (1)(a)(b) (2)(a))

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Requirement Due date

This is in relation to the poor admission process and the way that children are discharged from the home.

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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 (5))

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Requirement Due date

This in relation to an inaccurate staff list in the home’s statement of purpose. 30 April 2021

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home.

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Requirement Due date

In particular the registered person must ensure that—

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Requirement Due date

medicines kept in the home are stored in a secure place so as to prevent any child from

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Requirement Due date

medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child; and

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Requirement Due date

a record is kept of the administration of medicine to each child.

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Requirement Due date

Paragraph (2) does not apply to medicine which—

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Requirement Due date

is stored by the child for whom it is provided in such a way that other persons are prevented from using it; and

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Requirement Due date

may be safely self-administered by that child. (Regulation 23 (1) (2)(a)(b)(c) (3)(a)(b)) 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 11 This is in relation to unsafe arrangements for the administration of medicines to children.

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Requirement Due date

Schedule 4 sets out the other information that the registered person must keep in relation to a children’s home.

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Requirement Due date

maintain in the home the records in Schedule 4;

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Requirement Due date

ensure that the records are kept up to date; and

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Requirement Due date

retain the records for at least 15 years from the date of the last entry. (Regulation 37 (1) (2)(a)(b)(c))

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Requirement Due date

This is in relation to the home’s staff roster, which is inaccurate. 30 April 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; and

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Requirement Due date

children are helped to lead healthy lifestyles.

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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

achieve the health and well-being outcomes that are recorded in the child’s relevant plans;

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Requirement Due date

understand the child’s health and well-being needs and the options that are available in relation to the child’s health and well-being, in a way that is appropriate to the child’s age and understanding;

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Requirement Due date

take part in activities, and attend any appointments, for the purpose of meeting the child’s health and well-being needs; and

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Requirement Due date

understand and develop skills to promote the child’s well- being. (Regulation 10 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)) 30 April 2021 Inspection report for children’s home – monitoring visit: 1272209 12 This is in relation to when children need medical attention after injury or illness.

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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: 4–4a Blackburn Road, Accrington, Lancashire BB5 1HD

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Inspectors

Caroline Brailsford, Social Care Regulatory Inspector Amanda Ellis, Social Care Regulatory Inspector Inspection report for children’s home – monitoring visit: 1272209 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 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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