Children's Home run by Ivory Cottage Limited in Worcestershire

Inspection report children’s home: 2633744 1 Registered provider: Ivory Cottage Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This home is operated by a private company. It provides care for up to three children who may have experienced childhood instability, resulting in trauma and associated complex behaviours.

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Information about this children’s home

A suitably experienced and qualified manager recently commenced her role.

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Information about this children’s home

Due to COVID-19, at the request of the Secretary of State, we suspended all routine inspections of social care providers carried out under the social care common inspection framework (SCCIF) on 17 March 2020. We returned to routine SCCIF inspections on 12 April 2021.

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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/or 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: not previously inspected

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inadequate

Overall judgement at last inspection: not applicable

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inadequate

Enforcement action since last inspection: none Inspection report children’s home: 2633744 2

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inadequate

The home has experienced considerable challenges and instability since it registered in June 2021. In part, this was due to the registered manager making the decision to resign. Following the registered manager’s departure, the responsible individual identified significant shortfalls in staff’s safeguarding practice which the former manager had not identified and addressed. The responsible individual provided staff with further training and development to address these shortfalls and there was a temporary pause on children being moved into the home.

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inadequate

The two children currently living in the home receive inconsistent care and support from staff. Some staff do not follow agreed behaviour support plans. For example, while some staff provide children with patient and nurturing care, other staff’s practice is punitive and does not support children to explore the context of their behaviours. On occasions, this inconsistent practice has resulted in challenging incidents escalating and children being exposed to unnecessary distress.

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inadequate

The repeated changes to the staff working in the home mean that children can struggle to make and maintain positive relationships with staff. A child told the inspector, ‘Staff don’t understand me. I only like one of the staff. I did like one other staff, but they left. Everyone leaves here.’

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inadequate

Staff told the inspector that they are not always able to engage with one of the children. As a result, he often refuses their offers of support. This means his progress is minimal. For example, the child has not attended education for a significant period. Staff do not consistently provide the child with alternative educational activities when he is not in school. Some staff appear to be resigned to not being able to engage the child effectively in education or other structured direct work. It is acknowledged that a school placement for the child has now been identified.

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inadequate

The home is not a clean and well-maintained environment. One child’s bedroom has a broken chest of drawers and wardrobe, while another child’s bedroom walls are damaged. The responsible individual took steps during the inspection to address this damage. Staff told the inspector that some staff do not consistently support children to keep their bedrooms clean and tidy. This lack of attention to maintaining good physical conditions in the home fails to show children that they are valued as individuals.

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inadequate

Managers do not always follow agreed plans when children move into the home. For example, one child’s risk assessment says that the child would be ‘the only young person to be placed at the home for a period of time’ to ‘enable him to get to know the staff team and settle into his new home’. Despite this, another child was moved Inspection report children’s home: 2633744 3 in a short time later. This did not give the first child time to settle and to get to know staff. This is not indicative of appropriate care planning.

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inadequate

Some children have limited opportunities to develop social skills and enjoy positive experiences. This is in part due to a lack of proactive care provided by some staff. One child has a significant amount of free time in the community. There is no plan in place to consider and manage any potential risks during these periods. During the inspection, the child’s previous carer told the inspector that the child had placed himself at risk during a period of free time with his friends. The manager was not aware of this incident. This lack of planning and information-sharing has the potential to expose the child to harm.

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inadequate

Staff provide children with regular opportunities to participate in their care. However, records of these meetings lack detail and on several occasions the manager has not signed the record to confirm that they are accurate. When children make requests, it is not always clear if these are acted on. Furthermore, one child has not engaged regularly in the meetings. Records show that staff appear resigned to this lack of engagement and do not show any initiative to encourage the child to take part in these discussions.

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

Staff recruitment processes and checks do not protect children from unsuitable individuals working in the home. A member of staff started working at the home without adequate checks being carried out. Managers did not scrutinise available information and failed to follow up on concerns about this individual.

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

During the individual’s period of employment, he was not permitted to undertake physical interventions. Despite this, records show that the individual was involved in two incidents of restraining a child. Managers failed to recognise that he should not have been involved in the restraint of the child. Although the individual was subject to a debrief following this incident, it was not recorded at the time. This means that any learning from the incident was delayed.

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

The individual was subsequently suspended in September 2021 due to allegations of inappropriate restraint of a child in the home. This is currently subject to a designated officer and police investigation.

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

Staff do not take timely and effective action to protect children. For example, one member of staff witnessed two separate incidents of a child being inappropriately restrained. There was a significant delay in this member of staff escalating their concerns about these incidents to managers. This was a missed opportunity for safeguarding agencies to intervene and keep the child safe.

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

The responsible individual has been slow to ensure that staff understand their roles and responsibilities in keeping children safe. For example, there has been a delay in organising whistle-blowing training for staff. During the inspection, the responsible individual made plans to provide this training. Inspection report children’s home: 2633744 4 During this inspection, the manager told the inspector that a child had made an allegation in November 2021. This information had not been shared with relevant safeguarding partners, including the designated officer. Action was taken during the inspection to share the child’s allegation with the relevant individuals.

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

Risk assessments are of a variable quality. For example, some assessments lack details about the historical context of children’s behaviours. This means that staff are not always given all the information they need to understand how best to keep children safe. The manager is aware of this issue and had already begun to update children’s risk assessments and behaviour management plans.

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

A child’s complaint has not been documented. In addition, the child did not receive a written response about the outcome of his complaint. This means that children may not understand what has happened because of their complaint.

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

Staff do not consistently support children to reflect on challenging incidents and to learn from them. For example, the quality of some one-to-one support is variable and not in line with the children’s needs. This means that children do not always have opportunities to reflect on their behaviour.

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

Despite the shortfalls identified, in some instances staff do take appropriate action to protect children. For example, during incidents of a child going missing from the home, staff worked proactively to locate and return the child.

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The effectiveness of leaders and managers: inadequate

The manager has only recently started in post and has therefore had limited time to improve the home. The manager has a clear development plan. There are early indicators that staff practice and the quality of children’s care are beginning to improve. For example, there are now improved routines and structure for children. External professionals told the inspector that the manager has made a positive impact on children’s care.

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The effectiveness of leaders and managers: inadequate

Although the manager recognises that improvements are required, her monitoring systems are not yet sufficient for her to fully understand the scale of improvements required. The manager has adopted a ‘hands on’ approach to mentor the relatively new staff team. Although this has been necessary, it has reduced her capacity to undertake her own management tasks.

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The effectiveness of leaders and managers: inadequate

The manager has not received the necessary support and guidance since she commenced her role. This has hindered her ability to make timely progress. The responsible individual plans to appoint an operations manager imminently to support the manager to embed the necessary improvements.

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The effectiveness of leaders and managers: inadequate

The changes to the management of the home mean that at times staff have not always received the support and guidance they need. This has included a variable quality of supervision sessions. The manager is working hard to address this. Staff Inspection report children’s home: 2633744 5 speak positively of the manager and recognise the improvements that have been made. A staff member told the inspector, ‘[The manager] has changed a lot in this home. It seems much more settled. Communication between staff is better. She has encouraged us to be more proactive and better organised.’

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The effectiveness of leaders and managers: inadequate

The manager has taken steps to improve care planning. These changes are still being embedded. A social worker told the inspector, ‘I feel that the new manager has made a difference. She organised a meeting recently to discuss the child’s progress. It helped us to agree joint strategies. She wants the best for [the child].’

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The effectiveness of leaders and managers: inadequate

In response to the widespread concerns identified during the inspection, Ofsted issued a notice restricting the accommodation. In addition, 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: 2633744 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 quality and purpose of care standard is that children receive care from staff who—

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Requirement Due date

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

provide to children living in the home the physical necessities they need in order to live there comfortably. (Regulation 6 (1)(a)(b) (2)(b)(vii))

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Requirement Due date

This relates to the provider ensuring that the home environment is well presented and maintained. 10 January 2022

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Requirement Due date

The children’s views, wishes and feelings standard is that children receive care from staff who—

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Requirement Due date

develop positive relationships with them;

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Requirement Due date

take their views, wishes and feelings into account in relation to matters affecting the children’s care and welfare and their lives.

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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— 10 January 2022 Inspection report children’s home: 2633744 7 ascertain and consider each child’s views, wishes and feelings, and balance these against what they judge to be in the child’s best interests when making decisions about the child’s care and welfare;

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Requirement Due date

help each child to express views, wishes and feelings;

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Requirement Due date

help each child to understand how the child’s views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child;

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Requirement Due date

regularly consult children, and seek their feedback, about the quality of the home’s care;

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Requirement Due date

is enabled to provide feedback to, and raise issues with, a relevant person about the support and services that the child receives. (Regulation 7 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(b)(i))

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Requirement Due date

This relates to staff providing children with proactive care that supports children to fully engage and express their views.

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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—

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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

understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers;

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Requirement Due date

help each child to understand the importance and value of education, learning, training and employment; 10 January 2022 Inspection report children’s home: 2633744 8 promote opportunities for each child to learn informally;

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Requirement Due date

help a child who is excluded from school, or who is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as possible;

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Requirement Due date

that each child has access to appropriate equipment, facilities and resources to support the child’s learning. (Regulation 8 (1) (2)(a)(i)(ii)(iii)(iv)(v)(viii)(b))

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Requirement Due date

This relates to staff providing children with appropriate education support during periods of non-school attendance.

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Requirement Due date

The enjoyment and achievement standard is that children take part in and benefit from a variety of activities that meet their needs and develop and reflect their creative, cultural, intellectual, physical and social interests and skills.

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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

develop the child’s interests and hobbies;

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participate in activities that the child enjoys and which meet and expand the child’s interests and preferences; and

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Requirement Due date

make a positive contribution to the home and the wider community; and

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Requirement Due date

that each child has access to a range of activities that enable the child to pursue the child’s interests and hobbies. (Regulation 9 (1) (2)(a)(i)(ii)(iii)(b))

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Requirement Due date

This relates to staff providing children with proactive care and providing them with regular opportunities to take part in activities and enjoyable experiences. 10 January 2022

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Requirement Due date

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 10 January 2022 Inspection report children’s home: 2633744 9 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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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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help each child to develop and practise skills to resolve conflicts positively and without harm to anyone;

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

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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. (Regulation 11 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(ix))

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Requirement Due date

This relates to staff providing children with regular, good- quality one-to-one support in line with their needs, to support them to make sense of their challenging behaviours.

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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— 10 January 2022 Inspection report children’s home: 2633744 10 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;

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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; 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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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)(vii)(b))

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Requirement Due date

This relates to staff understanding and implementation of safeguarding procedures and their role in keeping children safe. In addition, this relates to ensuring that children’s risk assessments are up to date and reflect all known risks.

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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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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

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 the home’s workforce provides continuity of care to each child; and 10 January 2022 Inspection report children’s home: 2633744 11 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)(e)(h))

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Requirement Due date

This relates to the need for staff to provide children with consistent care and make the necessary improvements to their practice as identified by the manager. In addition, this relates to the need for effective monitoring systems.

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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. (Regulation 14 (1)(a))

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Requirement Due date

This specifically relates to the need for admissions to be well planned and in the best interests of children. In addition, this relates to the need to appropriately assess and plan children’s free time in the community. 10 January 2022

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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; or

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Requirement Due date

if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children, allow that individual to work at the home,

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Requirement Due date

if the individual satisfies the requirements in paragraph (3).

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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)(b) (3)(d))

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Requirement Due date

This relates to the need for the provider to complete appropriate safe recruitment checks on all new staff. 10 January 2022

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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; 10 January 2022 Inspection report children’s home: 2633744 12 receive practice-related supervision by a person with appropriate experience; and

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Requirement Due date

have their performance and fitness to perform their roles appraised at least once every year. (Regulation 33 (4)(a)(b)(c))

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Requirement Due date

This relates to the need for staff to receive appropriate supervision support.

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Requirement Due date

Subject to paragraph (6), the registered person must establish a procedure for considering complaints made by or on behalf of children.

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Requirement Due date

The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation. (Regulation 39 (1)(3))

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Requirement Due date

This relates to the need for staff to follow the complaints procedure in order to make accurate records of the complaint and the provider’s response. 10 January 2022

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Requirement Due date

* These requirements are 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: 2633744 13

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Children’s home details

Registered provider: Ivory Cottage Limited

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Children’s home details

Registered provider address: C/O Sky Tax Accounting, 37th Floor, 1 Canada Square, Canary Wharf, London E14 5AA

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Children’s home details

Responsible individual: Caroline Wigmore

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Inspector

Gareth Leckey, Social Care Inspector Inspection report children’s home: 2633744 14 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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