Children's home run by Hexagon Care Services Limited

Inspection report for children’s home: 2509367 1 Registered provider: Hexagon Care Services Ltd Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This children’s home is run by a private provider. The home is registered to provide care for up to three children who may have social and emotional difficulties.

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Information about this children’s home

The manager has been registered with Ofsted since August 2021.

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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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Information about this children’s home

A monitoring visit was conducted 10 March 2021. The report is 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/or widespread failures that mean children are not protected or their welfare is not promoted or safeguarded. The care and experiences of children are poor and they are not making progress.

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Inadequate

Date of last inspection: 23 January 2020

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Inadequate

Overall judgement at last inspection: sustained effectiveness

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Inadequate

Enforcement action since last inspection: none Inspection report for children’s home: 2509367 2

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Inspection date Inspection type Inspection judgement

23/01/2020 Interim Sustained effectiveness 16/09/2019 Full Good Inspection report for children’s home: 2509367 3

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inadequate

Serious and widespread concerns regarding the provider’s ability to keep children safe have led to an inadequate judgement.

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inadequate

Matching arrangements have been poor. Not all children have experienced planned moves on from the home. Since the monitoring visit in March 2021, notice has been served on four children’s placements. Their engagement in risk-taking behaviours had a negative impact on other children in the home. This does not provide stability for children.

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inadequate

Recent changes in the group dynamics have led to children experiencing a lot of change and turbulence. One child, who had been quite settled, has engaged in criminal and risky behaviours, such as leaving the home and smoking. As a result of poor matching decisions, staff have been unable to keep children safe, and the risks for some children have increased.

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inadequate

Some children have developed good relationships with the staff team and speak to them about their concerns. The manager and staff use a ‘worry monster’ tool to support children to share their feelings and anxieties. However, when a child shared pertinent information with staff about their family, staff avoided the discussion and changed the subject. This does not support children to make disclosures about the abuse and neglect they have experienced. Information relating to children is shared with their social workers, but some responses from the social workers are not always escalated or challenged when they have not aligned with good safeguarding practice.

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inadequate

Direct work through weekly therapy sessions from the provider’s clinical team ensures that children are given additional opportunities to discuss their concerns, and this helps them to learn new strategies to self-regulate. Input from the clinical team with staff means children’s support plans are more targeted and therapeutic parenting training is helping staff to respond to children in line with their needs The delivery of the model of care is not yet embedded in day-to-day practice.

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inadequate

Not all children attend school or benefit from a formal education placement. Staff await the outcome of education and health care plans to ensure school placements can meet children’s needs. Professionals work together to assess children’s educational needs, and to identify suitable provisions. Children receive educational support in the home during school hours, and some access online tutoring while formal arrangements are agreed. This minimises lost learning time, and children continue to have structure to their day. Inspection report for children’s home: 2509367 4 Children take part in social and recreational activities. They have been on holiday, they spend time with their families, and their friends visit the home. Two of the current children have good experiences and relationships with each other and with the staff. Positive feedback from children’s social workers highlights these good relationships and the level of support children have received. One social worker

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inadequate

identified the extensive efforts made by the manager to help the child to achieve positive outcomes. Outreach support from staff to a child who moved into semi- independent accommodation enabled them to settle in well.

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

Records relating to the physical interventions are poor and do not always provide the necessary detail required in line with the regulation. They are not always completed within the required timescales. Body maps have not always been completed, and children’s records do not consistently show that the staff involved in these restraints have always received a debrief. The manager’s evaluation is often delayed and does not provide assurances that are responsive to children’s needs and staff’s conduct. This does not promote adequate challenge and evaluation from the manager overseeing the records.

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

Staff have used the whistle-blowing procedures to report concerns about a colleagues inappropriate handling of a child. Referral to the designated officer for guidance and investigation means the manager has acted in accordance with the safeguarding policy. However, there has been delay in reporting one of the concerns, and a further allegation was not progressed to the designated officer. The manager did not recognise a child’s comment as an allegation, and therefore this was overlooked. An internal fact-finding record lacked objectivity and was presumptive in the conclusions. This does not ensure adequate scrutiny in response to allegations.

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

In response to these concerns, the provider has made additional management arrangements to increase the staffing ratio and the management presence in the home. In addition, there will be scrutiny of the restraint practice from the provider’s learning and development team, which will include a review of restraint records relating to the last 12 months. This provides some assurances that issues relating to ongoing practice will be addressed quickly and proportionately.

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

Children’s placement plans are not always accurate, and staff do not always benefit from clear guidance or strategies on how to respond to children. Some key documentation is not available in order to inform the children’s plans, such as the minutes of placement planning meetings, review meetings and strategy discussions. The lack of multi-agency records relating to children means that staff are not provided with the oversight needed to keep children safe or to care for them in line with their needs. However, staff do know some of the children very well, and there are some strong relationships between staff and the children. This has enabled some children to make progress from their starting point. Inspection report for children’s home: 2509367 5 Children’s safety online has been strengthened following a child gaining access to the Wi-Fi and, as a result, contacting someone with whom they should only have

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

supervised contact. Children’s placement and risk management plans address the key issues, but gaps in the plans, relating to how staff should manage family time arrangements or children’s safety online, mean that consistent practice is not promoted.

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

Key-work sessions with children take place, but staff have not been proactive at discussing the risks when online safety concerns have come to light. This does not provide children with sufficient strategies to keep themselves safe.

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

Since some of the older children have moved on from the home, the frequency of the current children being missing from home has reduced. For some children, missing from home is rare. However, the guidance for staff for when children are missing is inconsistent, and although independent return home interviews are offered, there has not always been a record of the outcome or impact for the child. This does not provide assurances that children have had an opportunity to discuss their concerns with someone independent or have had their risk reassessed.

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The effectiveness of leaders and managers: inadequate

There are widespread shortfalls in the management and leadership arrangements.

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The effectiveness of leaders and managers: inadequate

The manager has failed to ensure that specific staff have completed refresher training in restraints despite this being identified as an action in the lesson learned. Consequently, further inappropriate incidents of restraint have occurred that could have compromised children’s safety.

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The effectiveness of leaders and managers: inadequate

New recruitment of staff to the home means that a more experienced team is now present in the home. However, some gaps in the interview notes and interview assessment sheets do not demonstrate how decisions to appoint staff were made. All checks prior to staff commencing work at the home are robust and ensure that staff are suitable to work with children.

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The effectiveness of leaders and managers: inadequate

Staff speak positively about their induction to work in the home and the support they receive from managers. Staff receive supervision, but some supervision and probationary records for a member of staff were not available. This does not provide assurances that discussions about the suitability of staff practice and conduct are reflected on.

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The effectiveness of leaders and managers: inadequate

The requirement relating to administration of medication, identified at the monitoring visit, has not been met, and there have been further medication errors linked to recording. The requirement has therefore been reissued. The manager has notified the regulator when there have been incidents of concerns, but on one occasion, an allegation of abuse against a person working in the home was overlooked by the manager and not progressed to the regulator. This prevents the Inspection report for children’s home: 2509367 6 regulator from having oversight and assurances that the provider is responding appropriately.

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The effectiveness of leaders and managers: inadequate

The managers monitoring systems are not effective at helping them to identify the gaps in children’s case files. This does not ensure that staff are fully briefed on children’s plans, and it can lead to inappropriate responses to children’s needs.

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The effectiveness of leaders and managers: inadequate

Children live in a homely environment. They personalise their bedrooms, and they now have a sensory room, which helps them to feel safe. There are plans for ongoing refurbishment and redecoration. Maintenance systems are efficient in remedying damage caused during incidents. Inspection report for children’s home: 2509367 7

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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

In meeting the quality standards, the registered person must, and must ensure that staff—

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Requirement Due date

seek to involve each child’s placing authority effectively in the child’s care, in accordance with the child’s relevant plans;

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Requirement Due date

seek to secure the input and services required to meet each child’s needs;

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Requirement Due date

if the registered person considers, or staff consider, a placing authority’s or a relevant person’s performance or response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans. (Regulation 5 (a)(b)(c))

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Requirement Due date

The registered person must ensure that they provide sufficient challenge to social workers in their response to managing disclosures of abuse made by children, and in undertaking their responsibility to complete and share the outcomes of an independent return home interview when a child has been missing from care.

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Requirement Due date

The registered person must ensure that they are proactive in securing key documentation from placing authorities relating to a child’s care, including placement planning meeting minutes, strategy meeting minutes and review minutes. 20 March 2022

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Requirement Due date

*The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

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

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Requirement Due date

that staff— 20 March 2022 Inspection report for children’s home: 2509367 8 assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child;

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Requirement Due date

help each child to understand how to keep safe;

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Requirement Due date

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

are familiar with, and act in accordance with, the home’s child protection policies. (Regulation 12 (1) (2)(a)(i)(ii)(v)(vii))

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Requirement Due date

The registered person must ensure that children’s placement and risk management plans assess and provide guidance to staff in supporting children to spend time with family and safely use the internet and technological devices.

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Requirement Due date

The registered person must ensure that missing-from-care and Philomena protocols provide consistent information regarding the timings for reporting a child missing from care.

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Requirement Due date

The registered person must ensure that staff undertake age- appropriate learning with children around online safety.

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Requirement Due date

The registered person must ensure that training is completed to ensure staff and managers understand their responsibility to report and record allegations of abuse.

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Requirement Due date

The registered person is to ensure that all allegations against staff made by children and whistle-blowing concerns are recorded and responded to in line with child protection policies and procedures.

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Requirement Due date

The registered person must ensure that internal investigations into allegations are sufficient in detail.

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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

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Requirement Due date

promotes their welfare. 20 March 2022 Inspection report for children’s home: 2509367 9 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

demonstrate that practice in the home is informed and improved by taking into account and acting on—

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Requirement Due date

feedback on the experiences of children, including complaints received; and

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Requirement Due date

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

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Requirement Due date

The registered person must ensure that interview notes and interview assessments provide a clear understanding of how the panel have rated and concluded that the answers provided have deemed the candidate suitable for post.

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Requirement Due date

The registered person must ensure that staff supervision and probationary review records are complete.

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Requirement Due date

The registered person must ensure that lessons learned from incidents, including the need for additional training for staff, take place.

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Requirement Due date

The registered person must ensure that complaints made by children relating to staff members’ practice are addressed in line with allegation procedures, and when injuries are sustained as a result of incidents that these are fully recorded and assessed.

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Requirement Due date

The registered person must ensure that management oversight and evaluation of incidents are conducted and recorded in a timely manner. The evaluation is to consider all aspects of the incident, including a robust analysis of the appropriateness of physical intervention used.

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Requirement Due date

The registered person must implement a monitoring system to ensure that children’s case file records include accurate and current information and that management tasks, such as the sharing of the homes statement of purpose and Inspection report for children’s home: 2509367 10 manager’s quality of care review, take place within timescales. The manager’s monitoring system is to identify and regularly review actions to improve the quality of care children receive.

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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. (Regulation 14 (1)(a)(b))

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Requirement Due date

In particular, the registered person must ensure that children’s care is planned to ensure that placements are effectively managed and sustained. 20 March 2022

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Requirement Due date

Restraint in relation to a child must be necessary and proportionate. (Regulation 20 (2))

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Requirement Due date

The registered person must have systems in place to ensure that any physical restraint of a child is necessary, proportionate and permitted within regulation.

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Requirement Due date

The registered person must ensure that the children’s placement and behaviour support plans provide accurate and current guidance to staff about the use of physical restraint.

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Requirement Due date

The registered person must ensure that when restrictive interventions are used, children’s health needs are monitored.

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Requirement Due date

The registered person must ensure that when incidents occur, the manager provides a robust analysis of all physical interventions used. 20 March 2022

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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— a record is kept of the administration of medicine to each child. (Regulation 23 (1) (2)(c)) 20 March 2022 Inspection report for children’s home: 2509367 11 The registered person must ensure that records of medication are legible, fully complete and dual signed when required.

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Requirement Due date

within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes—

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Requirement Due date

details of the child’s behaviour leading to the use of the measure;

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Requirement Due date

the date, time and location of the use of the measure;

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Requirement Due date

a description of the measure and its duration;

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Requirement Due date

details of any methods used, or steps taken to avoid the need to use the measure;

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Requirement Due date

the name of the person who used the measure (“the user”), and of any other person present when the measure was used;

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Requirement Due date

the effectiveness and any consequences of the use of the measure; and

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Requirement Due date

a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure;

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Requirement Due date

within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (“the authorised person”)—

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Requirement Due date

has spoken to the user about the measure; and

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Requirement Due date

has signed the record to confirm it is accurate; and

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Requirement Due date

within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3) (1)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c)) 20 March 2022 Inspection report for children’s home: 2509367 12 In particular, the registered person is to ensure that a clear and accurate record of any restraint and injury sustained to a child is recorded. The registered person is to ensure that incidents are recorded in a timely manner and that a thorough management evaluation and debrief of the staff are included.

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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

there is an allegation of abuse against the home or a person working there. (Regulation 40 (4)(c)) 20 March 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 for children’s home: 2509367 13

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Children’s home details

Registered provider: Hexagon Care Services Ltd

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Children’s home details

Registered provider address: Unit 1 Tustin Court, Riversway, Preston, Lancashire PR2 2YQ

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Children’s home details

Responsible individual: Thomas Cappleman

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Inspector

Alex Howitt, Social Care Inspector Inspection report for children’s home: 2509367 14 regulates and inspects 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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