Children's Home run by Mulberry House Care Homes Limited in Staffordshire

Inspection report children’s home: SC060554 1 SC060554 Registered provider: Mulberry House Care Homes Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This home provides care and accommodation for up to three children with emotional and/or behavioural difficulties.

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Information about this children’s home

A new manager was registered with Ofsted on 31 March 2021. However, she has submitted her resignation and is currently working her notice period.

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Information about this children’s home

Due to COVID-19 (coronavirus), at the request of the Secretary of State, we suspended all routine inspections of social care providers on 17 March 2020.

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Information about this children’s home

We last visited this setting on 14 and 15 October 2021 to carry out an assurance visit. This report is published on our website.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

There are serious and widespread failures that mean children are not protected or their welfare is not promoted or safeguarded.

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inadequate

Date of last inspection: 18 December 2019

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inadequate

Overall judgement at last inspection: improved effectiveness

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Enforcement action since last inspection:

Not applicable. Inspection report children’s home: SC060554 2

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Inspection date Inspection type Inspection judgement

18/12/2019 Interim Improved effectiveness 08/04/2019 Full Requires improvement to be good 04/09/2018 Full Requires improvement to be good 19/07/2017 Full Good Inspection report children’s home: SC060554 3

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inadequate

Children are not always protected from harm or the risk of further harm. The provider has failed to respond to safeguarding incidents swiftly and effectively, and this has led to the judgement of inadequate.

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inadequate

At the time of this inspection, there were three children living in the home. The children who were spoken to told the inspector that it was okay living in the home, and that they liked their bedrooms and the staff team. However, one child told the inspector that staff are unable to keep them safe from their own actions.

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inadequate

Complaints made by children are not addressed in line with the provider’s policies and procedures. Complaints made by children have not been appropriately investigated. A staff practice issue arising from a complaint had not been addressed. As a result, children cannot be confident that their concerns will be responded to in order to improve the quality of care they receive.

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inadequate

Feedback from professionals was varied. One social worker reported no concerns regarding the care provided for children. However, another social worker raised concerns regarding staff members’ responses to serious incidents, the management of health issues and the sharing of information.

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inadequate

The three children currently in the home are relatively settled. Despite the restrictions imposed by COVID-19, the staff team has continued to support children to maintain contact with individuals who are important to them.

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How well children and young people are helped and protected: inadequate

Managers and staff do not take proactive steps to safeguard children when incidents occur. On two occasions, a child reported that they had ligatured themselves. On both occasions, staff failed to complete a room search, remove the item the child had used to hurt themselves and seek medical advice. Ligature cutters have since been placed in the staff bedroom, but staff have not been trained in how to use them. This means that staff cannot respond effectively to prevent children from coming to harm.

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How well children and young people are helped and protected: inadequate

The staff’s supervision and monitoring of children are poor and fail to safeguard children. On two occasions, a child was able to leave the home late at night without the staff’s knowledge. On each occasion, the child was low in mood and had made their way to a high-rise structure. Managers failed to take these concerns seriously and did not put in place strategies to prevent further incidents from occurring. As a result, this child remains at significant risk of harm. The child told the inspector that staff now lock the front door with a key and take the key to bed with them. The registered manager was not aware that staff were locking the door. This is not safe Inspection report children’s home: SC060554 4 practice and prevents children and staff from being able to leave the home quickly in case of an emergency.

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How well children and young people are helped and protected: inadequate

Two children who are living at the home smoke. Managers have failed to provide staff with guidance on how to support the children to reduce this risky behaviour. This is despite one child having a health condition which can be adversely affected by smoking. Staff do not challenge this behaviour and they allow one child to keep a lighter on their person. This presents a fire risk and is not safe for the children or staff.

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How well children and young people are helped and protected: inadequate

The staff’s recording of incidents is poor. There are gaps in key information, such as the description of events and timelines of the incident. In addition, the registered manager has failed to notify Ofsted of serious incidents. This prevents the regulator from having oversight of the home.

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How well children and young people are helped and protected: inadequate

Staff have not received the necessary training to carry out the strategies detailed in children’s risk assessments. Children’s risk documentation fails to inform staff on the risks to each child and the documents do not guide staff on the action they should take to protect children. Not all staff are familiar with the information contained in these assessments, which hinders their ability to promote children’s safety. One member of staff told the inspector that they were not aware that a risk assessment had been updated four weeks ago.

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The effectiveness of leaders and managers: inadequate

A new manager has joined the home since the previous inspection, and was registered with Ofsted on 31 March 2021. On 28 April 2021, she resigned from her position and is currently working her notice. A new responsible individual joined the company in January 2021.

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The effectiveness of leaders and managers: inadequate

At this visit, the inspector found that leaders and managers have failed to take swift and effective action in response to serious incidents that occur in the home. This shortfall places children at risk of harm.

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The effectiveness of leaders and managers: inadequate

The registered manager does not have a robust monitoring system in place that allows her to have effective oversight of the home. The registered manager’s oversight of recording and reporting is poor. She has failed to address poor recording in documentation, and has not addressed concerns with staff practice. This means that poor staff practice has remained unchallenged.

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The effectiveness of leaders and managers: inadequate

Managers and senior leaders have not led or managed the home in a manner that is consistent with the aims outlined in the statement of purpose. For example, managers are unable to demonstrate that the care being delivered meets the individual needs of the children and promotes their safety and welfare. In addition, leaders and managers have failed to robustly record responses to complaints, and staff practice issues have not been explored or addressed in staff supervision. As a result, children cannot be confident that their concerns will be addressed and the quality of care they receive will improve. Inspection report children’s home: SC060554 5 Staff have not had the specific training that they require to meet the needs of the children living at the home. The registered manager was unable to provide an accurate training record for all staff. In addition, staff have not been trained in the therapeutic approaches they are expected to use, as detailed in the home’s

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The effectiveness of leaders and managers: inadequate

statement of purpose and children’s risk assessments. Managers have not addressed concerns identified at the previous inspection to ensure that all staff are trained in first aid.

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The effectiveness of leaders and managers: inadequate

Not all staff have had access to regular supervision or team meetings. This does not assure Ofsted that staff are supported in their roles and have opportunities to reflect on and improve the care and support they provide for children. Managers could not provide job descriptions for all staff roles. This means that staff do not have a description of their day-to-day roles and responsibilities.

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The effectiveness of leaders and managers: inadequate

The registered manager has failed to ensure that there is an accurate roster in place that records the planned and the actual hours worked by staff. As a result, these documents cannot be relied on to identify when staff have been at work. This means that Ofsted cannot be assured that children are suitably and safely cared for.

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The effectiveness of leaders and managers: inadequate

The provider’s review of the quality of care was poor and did not meet the requirements of the regulation. Leaders and managers had failed to consult with children and professionals to obtain feedback that would inform the review process. In addition, there was no action plan to drive forward improvements and therefore ensure that children experience continuously improving care.

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The effectiveness of leaders and managers: inadequate

Staff said that they are well supported by the new registered manager and felt that things in the home had improved since she took up her post. The registered manager was aware of some of the shortfalls in practice and the oversight and monitoring of the home. However, she has had insufficient time in post to make the necessary improvements.

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The effectiveness of leaders and managers: inadequate

Following this inspection, two compliance notices were issued under regulation 12 (the protection of children standard) and regulation 13 (the leadership and management standard). Inspection report children’s home: SC060554 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

have the skills to identify and act upon signs that a child is at risk of harm;

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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;

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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)(iii)(v)(vi)(b))

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Requirement Due date

In particular, this relates to ensuring that risk assessments are up to date and include effective strategies for staff to follow. This also relates to managers and staff taking effective action in response to incidents. 14 June 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— 14 June 2021 Inspection report children’s home: SC060554 7 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 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. (Regulation 13 (1)(b) (2)(a)(c)(d)(h))

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Requirement Due date

In particular, this relates to ensuring that there are effective monitoring and review systems in place to review and improve the quality of care provided for children.

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Requirement Due date

This also relates to ensuring that staff have the experience, qualification and skills to meet the needs of children.

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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

In particular, this relates to ensuring that the care provided for children is in line with what is set out in the home’s statement of purpose. 14 June 2021

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Requirement Due date

provide each employee with a job description outlining the employee’s responsibilities. (Regulation 33 (1)(c))

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Requirement Due date

This is to ensure that all staff have a job description that outlines their roles and responsibilities. 14 June 2021

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Requirement Due date

The registered person must ensure that all employees—

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Requirement Due date

undertake appropriate continuing professional development;

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Requirement Due date

receive practice-related supervision by a person with appropriate experience. (Regulation 33 (4)(a)(b)) 14 June 2021 Inspection report children’s home: SC060554 8 This relates to ensuring that all staff receive supervision in line with the provider’s policy and procedures.

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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 specifically relates to ensuring that staff rosters are up to date and maintained in line with regulatory requirements. 14 June 2021

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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

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 any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(a)(b)(e))

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Requirement Due date

This specifically relates to ensuring that Ofsted, as the regulatory body, is notified of serious incidents. 14 June 2021

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Requirement Due date

The registered person must complete a review of the quality of care provided for children (“a quality of care review”) at least once every 6 months.

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Requirement Due date

In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating—

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Requirement Due date

the quality of care provided for children;

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Requirement Due date

the feedback and opinions of children about the children’s home, its facilities and the quality of care they receive in it; and 14 June 2021 Inspection report children’s home: SC060554 9 any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children.

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Requirement Due date

After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (“the quality of care review report”).

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Requirement Due date

The system referred to in paragraph (2) must provide for ascertaining and considering the opinions of children, their parents, placing authorities and staff. (Regulation 45 (1) (2)(a)(b)(c) (5))

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Requirement Due date

This relates to ensuring that the quality of care review is in line with the regulatory requirements.

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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 all staff should have the skills to respond to and support children with any health needs. Staff should be able to administer first aid.(‘Guide to the children’s homes regulations including the quality standards’, page 34, paragraph 7.12)  The registered person should ensure that a record of supervision should be kept for all staff, including the manager. This record should detail the contents of the discussion and any outcomes. (‘Guide to the children’s homes regulations including the quality standards’, page 61, paragraphs 13.3, 13.4)

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people, using the ‘Social care common inspection framework’. This inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with the Children’s Homes (England) Regulations 2015 and the ‘Guide to the children’s homes regulations including the quality standards’. Inspection report children’s home: SC060554 10

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Children’s home details

Registered provider: Mulberry House Care Homes Limited

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Children’s home details

Registered provider address: 2 Railway Street, Stafford, Staffordshire ST16 2EA

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Inspector

Debbie Holder, Social Care Inspector Inspection report children’s home: SC060554 11 to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for children looked after, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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