Children's home run by Cambian Asperger Syndrome Services Limited in Hammersmith and Fulham

Inspection report children’s home: SC482294 1 SC482294 Registered provider: Cambian Asperger Syndrome Services Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This privately owned home is registered to care for up to 42 children with learning disabilities. Children live across nine houses and all the children access the school, which is located on the same site. Care is provided to children with a primary diagnosis of autism spectrum disorder. The home offers a flexible package, providing care on a weekly, termly or annual boarding basis, depending on the child’s needs. There has been no registered manager since October 2020. 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. We last visited this setting on 3 November 2020 and 25 February 2021 to carry out monitoring visits. The reports are published on the Ofsted 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, and the care and experiences of children are poor and they are not making progress.

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inadequate

Overall judgement at last inspection: good

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inadequate

Enforcement action since last inspection: none Inspection report children’s home: SC482294 2

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Inspection date Inspection type Inspection judgement

03/07/2019 Full Good 20/02/2019 Full Good 04/10/2017 Full Good 07/12/2016 Interim Sustained effectiveness Inspection report children’s home: SC482294 3

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inadequate

The experiences and progress of some children are inadequate because of systemic and widespread safeguarding failures. Since the last monitoring visit in February 2021, there have been 11 child protection incidents relating to peer-on-peer sexual abuse. Consequently, some children have not been protected from harm.

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inadequate

The achievements, success and positive opportunities that many of the children benefit from have been undermined by the child protection shortfalls across the home.

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inadequate

Senior leaders and managers are aware of weaknesses and areas for development in the home. However, their attempts to reduce the risk and improve services for the children have not been effective in addressing the serious concerns identified during the inspection.

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inadequate

While progress has been made in recruitment, a common theme commented on by the children, staff and families is around staffing shortages. There remain significant staff vacancies. This is compounded by the high rates of staff turnover. One child described ‘getting used to staff changes’ but also finding it confusing. This affects the quality and consistency of care that the children experience.

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inadequate

The children benefit from the education structure provided by the wider organisation, as well as the provision of specialist clinical services. Children spoke positively about school. The staff work effectively with education professionals to make sure that the children’s learning is well supported.

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inadequate

Children are supported well by the staff to develop new interests and skills at the home and in the wider community. Staff recognise that participation in leisure activities helps the children grow in confidence and improves their self-esteem.

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

The quality of risk assessments is inconsistent and they are not always updated following significant incidents. Children’s risk assessments do not adequately identify their risk and impact on other children who live at the home. Managers have a confused understanding of the purpose of impact risk-assessment planning. Consequently, staff lack guidance on how to reduce risk and do not understand how associated risks for one child can impact others. This means that the children are left vulnerable.

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

Risks relating to a child presenting with high levels of sexualised behaviour were identified as a low-level risk in their personal risk assessment. This demonstrates an unclear understanding of the assessment of risk. As a result, some children are not Inspection report children’s home: SC482294 4 receiving the specialised support and help they need. Moreover, the staff have not been provided with the training they require to ensure that they can safely meet the children’s specific needs.

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

There is a weak understanding of managing problematic sexualised behaviour (PSB). Some children have been demonstrating PSB for prolonged periods and have not made progress.

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

The day-to-day arrangements and the supervision of some children are insufficient to ensure that the children are consistently protected from harm. This results in some children putting themselves and others at risk.

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

Child protection concerns are not consistently managed well. Leaders and managers do not have effective oversight of safeguarding. Several child protection incidents have not been reported promptly, or at all, to the appropriate safeguarding agencies, including Ofsted. Other failings include the organisation investigating serious safeguarding concerns before reporting to appropriate external agencies, including staff asking children leading questions. As a result, on these occasions, children were not protected.

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The effectiveness of leaders and managers: inadequate

A new management team has recently been appointed and is working to make improvements in line with the home’s workforce development plan. However, the managers have underestimated the extent of, and normalisation of, peer-on-peer abuse within the culture at the home. Leaders and managers have not shown the necessary drive in monitoring the service.

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The effectiveness of leaders and managers: inadequate

Internal monitoring to review the quality of care has not been completed consistently. Managers do not conduct internal investigations following serious incidents. They fail to learn from mistakes and implement lessons learned.

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The effectiveness of leaders and managers: inadequate

The head of care has not prioritised formal supervision with the three residential house managers for whom she is accountable. This means there are no records that show a two-way accountable process that supports and enables the development of good practice to improve the quality of service provided. As a result, leaders cannot be confident in, or have oversight of, the quality of care that all the children receive.

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The effectiveness of leaders and managers: inadequate

One front door was kept locked, limiting the children’s access to playing outside. While this may be appropriate for some children’s safety, no assessments for this restrictive practice were recorded or agreed upon. This prevents choice and decreases opportunities for the children to learn how to be independent. This was addressed immediately by the head of care during the inspection. Inspection report children’s home: SC482294 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— that staff—

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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. (Regulation 12 (1) (2)(a)(i)) 18 July 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— that staff—

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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. 18 July 2021 Inspection report children’s home: SC482294 6 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)(ii)(iii)(iv)(v)(vi)(vii)(b))

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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— is instigated; or 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)) 18 July 2021

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Requirement Due date

any limitation placed on a child’s privacy or access to any area of the home’s premises— is necessary and proportionate; is kept under review and, if necessary, revised; and allows children as much freedom as is possible when balanced against the need to protect them and keep them safe. (Regulation 21 (c)(ii)(iii)(iv))

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Requirement Due date

This relates to the registered person ensuring that front doors are not locked unless in line with a child’s care plan, and that, in such a case, this practice is kept under regular review. 18 July 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 18 July 2021 Inspection report children’s home: SC482294 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

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

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

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Requirement Due date

This relates to the registered person ensuring:  that staff have access to specialist training and guidance to meet the children’s specific needs  that all staff receive regular supervision  continued priority on staff recruitment and retention so that children receive continuity of care.

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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. (Regulation 45 (1)) 18 July 2021

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Requirement Due date

* This requirement is subject to a compliance notice.

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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: SC482294 8

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Children’s home details

Provision sub-type: Residential special school

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Children’s home details

Registered provider: Cambian Asperger Syndrome Services Limited

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Children’s home details

Registered provider address: Metropolitan House, 3 Darkes Lane, Potters Bar EN6 1AG

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Inspectors

Anne-Marie Davies, Social Care Inspector Stephen Collett, Social Care Inspector Kelly Marchmont, Social Care Inspector Inspection report children’s home: SC482294 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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