Vinney Green Secure Unit

Inspection report for secure children’s home: SC035500 1 SC035500 Registered provider: South Gloucestershire Council Full inspection Inspected under the social care common inspection framework

p.1

Information about this secure children’s home

This secure children’s home is operated by a local authority and is approved by the Secretary of State to restrict children’s liberty. The home can accommodate up to 24 children aged between 10 and 18 years. At the time of this inspection, there were 16 children living at the home.

p.1

Information about this secure children’s home

All places available at the home are commissioned on a contractual basis by the Youth Custody Service (YCS). The YCS may under certain circumstances permit local authority children’s services to spot-purchase a vacant bed at the home, to enable a local authority to place a child on welfare grounds under section 25 of the Children Act 1989. Admission of any child aged under 13 under section 25 of the Children Act 1989 requires the approval of the Secretary of State.

p.1

Information about this secure children’s home

The commissioning of health services at this home is the statutory responsibility of NHS England under the Health and Social Care Act 2012. Education is provided on site in dedicated facilities.

p.1

Information about this secure children’s home

The manager registered with Ofsted in July 2015.

p.1

Overall experiences and progress of

children and young people, taking into account

p.1

inadequate

Children’s education and learning good Children’s health requires improvement to be good How well children and young people are helped and protected inadequate

p.1

inadequate

The effectiveness of leaders and managers inadequate Inspection report for secure children’s home: SC035500 2 There are serious and widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded.

p.1

inadequate

Overall judgement at last inspection: good

p.2

inadequate

Enforcement action since last inspection: none Inspection report for secure children’s home: SC035500 3

p.2

Inspection date Inspection type Inspection judgement

08/06/2021 Full Good 20/04/2021 Full Inadequate 21/01/2020 Interim Declined in effectiveness 04/06/2019 Full Requires improvement to be good Inspection report for secure children’s home: SC035500 4

p.3

inadequate

There are significant concerns about children’s care, safety and well-being. Children have been subjected to the inappropriate use of physical restraint, unjustified use of single separation (where children are locked in an area when they meet the legal criteria of being a significant risk to themselves or others) and physical restraint techniques that have caused them pain.

p.4

inadequate

These practices seriously undermine the overall positive experiences and progress of the children seen at this inspection.

p.4

inadequate

Ofsted took enforcement action following an inspection in April 2021. This related to physical restraint being used unlawfully by staff. At the inspection in June 2019 inspectors identified considerable shortfalls in relation to the use of physical restraint and ineffective management oversight. The report from an inspection in April 2018 stated, ‘Restraints when young people are held on the floor are used…Managers cannot categorically confirm the need to use this form of restraint, rather than others, to manage unsafe behaviours’, and ‘There is a lack of effective management oversight regarding events and incidents in the home that require the use of physical restraint or other measures of control.’ This history shows that any improvements in these areas are not sustained. This demonstrates failure by the registered manager and leaders to sustain improvement. This results in negative outcomes for children.

p.4

inadequate

At this inspection, inspectors have observed some warm and nurturing interactions between staff and children. There is positive feedback from external professionals about children’s relationships with staff.

p.4

inadequate

Planning for children to move on from the home is effective and given a high priority. Planning begins when children are admitted. Staff keep in touch with children when they have moved on, at children’s request. This shows that there are meaningful relationships.

p.4

inadequate

There is effective partnership work between the care, education and health teams. Managers also work closely with external agencies. When those agencies do not uphold their responsibilities to children, managers advocate on children’s behalf.

p.4

inadequate

Children’s progress is measured in a range of ways, and they make positive overall progress despite some of the serious shortfalls in staff practice identified during this inspection. They are helped to understand their cultural and identity needs are identified, planned for and met. Inspection report for secure children’s home: SC035500 5 Children understand the complaints system and use it when they feel they need to. Their complaints are responded to in a timely manner, taken seriously and are acted upon.

p.4

inadequate

Staff do not consistently respect children’s privacy and dignity. They do not always knock on children’s bedroom doors before entering or before removing the privacy curtain that covers the door viewing panel.

p.5

inadequate

Three children had their mattresses removed by staff for safety reasons. They were left without these for the entire night and instead were provided with anti-ligature bedding. The decision to remove the mattresses for the entire night was not justified as there were opportunities for them to be returned once risk had diminished. When this was raised with the registered manager, she stated that this policy and practice are in need of review.

p.5

inadequate

A child who was admitted to the home during the inspection spent a considerable time on his own. Although checked on regularly staff did not use this time constructively and the checks were without meaningful interaction. It was the child’s first time in a secure facility. Staff did not provide him with fundamental support and reassurance.

p.5

inadequate

Children spoke positively about their health and education needs being met. They spoke particularly highly of the broad range of educational opportunities available to them. They are able to choose the pathway that gives them the greatest chance of success, with guidance from education staff.

p.5

Children’s education and learning: good

A broad and balanced curriculum is provided to children that offers them a range of academic and vocational subjects, and broader skills development opportunities. They have access to specialist facilities such as the motor vehicle and carpentry workshops and the music studio. Each area is well resourced to support children to safely learn new skills. Following the easing of COVID-19 restrictions, children can once again attend enrichment activities that take place at the end of the school day.

p.5

Children’s education and learning: good

Children develop new knowledge, skills and behaviours in academic and vocational subjects and social settings, and make good progress. Teachers provide helpful feedback to children on their work so that they know what to do to improve. Children make progress in all subjects, but in particular in English and mathematics. Vocational teachers use their specialist skills well to teach children new practical skills that will be useful to them now and in the future.

p.5

Children’s education and learning: good

Education staff effectively assess and identify children’s starting points and what children know and can do, and make good use of this information to plan and sequence an appropriate curriculum for each child in each subject.

p.5

Children’s education and learning: good

Education managers monitor effectively the progress each child makes. Since the last inspection, managers have developed and introduced several monitoring Inspection report for secure children’s home: SC035500 6 systems that focus on different aspects of the children’s development. For example, they monitor their academic progress and achievements, their behaviours, attitudes to learning, wider social interactions and their attendance and engagement in education. Managers identify whether children are making the expected progress in their core subjects of English and mathematics and take action if they are not. They demonstrated awareness of the need to consolidate and embed these new systems.

p.5

Children’s education and learning: good

Education staff are ambitious for children and work hard to encourage them to be ambitious for themselves. For example, teachers encourage and support children to work towards GCSE exams and other qualifications, including at level 3 where available. Some children do not at first have the self-belief in their own ability, but the patience and support of education staff often convince the children otherwise and they go on to successfully complete exams and gain qualifications. Children are proud of what they achieve.

p.6

Children’s education and learning: good

Children with additional learning needs are well supported. The special educational needs co-ordinator makes good use of the information gathered about children’s additional learning needs. This is shared with the education team to ensure that the needs of each child are being met. Teachers feel well informed and know how to seek additional support and guidance if they need it.

p.6

Children’s education and learning: good

Children’s attendance at education is very good and the majority of them enjoy their learning and can explain the progress they have made since they arrived. Children were able to reflect on their progress in reading and their ability to complete tasks.

p.6

Children’s education and learning: good

Children behave well in education. They form positive relationships with education staff and the vast majority actively engage in their lessons. Where this is not the case, teachers work hard with the child to find a topic that interests them, and to motivate them to re-engage in learning.

p.6

Children’s education and learning: good

Children develop personal and social skills through a comprehensive programme that is structured appropriately to meet their needs. They develop their knowledge and understanding about equality and diversity, protected characteristics and healthy living.

p.6

Children’s education and learning: good

The careers programme is at an early stage. Managers have now appointed a qualified careers leader and a teacher to deliver employability and business. The careers lead has begun to develop a careers programme, but this is still in its infancy and not yet fully formalised.

p.6

Children’s health: requires improvement to be good

The unlawful use of physical restraint, single separation and the use of physical restraint techniques that have caused pain have had a detrimental impact on the health and emotional well-being of children. This undermines the positive aspects and outcomes in this area. Inspection report for secure children’s home: SC035500 7 The well-resourced and experienced health team ensures that children’s physical and emotional health needs are identified and met, and as a result children’s general health improves during their stay at the home. Healthcare staff know the children they are working with well and build good relationships with them. The health service is centred around the child, ensuring that children have every opportunity to engage with healthcare and that their views are heard and considered in any plan. Positive feedback from children is regularly received.

p.6

Children’s health: requires improvement to be good

Assessments using the comprehensive health assessments tool are undertaken at the earliest opportunity and within the expected timescales unless there are exceptional circumstances. This ensures that children’s health and well-being needs are identified in a timely manner. Subsequent care plans are developed and referrals made to specialist services to ensure that children’s needs are met.

p.7

Children’s health: requires improvement to be good

Children have good access to age-appropriate primary care. This includes immunisations and vaccinations, sexual health support and access to both a male and female GP. On admission to the home, all children see both a dentist and optician in the community. The booking process for community appointments has recently been revised to ensure timely access to services. While a nurse-led service is available to children during the usual working week, there are occasions when children have not been able to attend their appointment. This is because communication from care to health staff is not always effective in considering the best approach to support a child to attend.

p.7

Children’s health: requires improvement to be good

‘Secure Stairs’ (a framework of integrated care that involves providing psychologically-informed care to children) has been embedded throughout the home and staff have mostly embraced the ethos. Weekly ‘formulation huddles’ offer care staff access to the psychology team for support and advice to underpin their work with the children. Tools and plans have been developed to support children with attention deficit hyperactivity disorder and autism spectrum condition. All children are offered an assessment with the speech and language therapist and a substance misuse worker supports children with individualised work based on their needs.

p.7

Children’s health: requires improvement to be good

There are strong and effective working relationships across disciplines in the home. This includes a weekly meeting to discuss children’s progress, risks and identified needs, and the sharing of essential information about children’s care. Collaborative work is also undertaken by the speech and language and occupational therapists.

p.7

Children’s health: requires improvement to be good

Nurses are informed in a timely manner about significant incidents involving children, for example, the use of physical restraint. They review and assess the child’s well-being. A mental health-trained member of staff sees a child within five days of an incident to allow children to explore what led to the incident, how it made them feel and how to better support children going forward.

p.7

Children’s health: requires improvement to be good

Planning for children moving on is excellent and starts at the earliest opportunity. This includes healthcare staff in the home supporting community services in how best to meet the child’s needs. Health staff stay in touch with children when they have left the home, providing ongoing help and advice. Inspection report for secure children’s home: SC035500 8 Children have access to any medication they need when they need it. All care staff receive training before they dispense medication to the children, so they can do so safely. Daily checks and regular audits are carried out, any errors are investigated, and action is taken as required.

p.7

Children’s health: requires improvement to be good

The health team is well supported by colleagues and managers. They receive training and have managerial and clinical supervision on a regular basis. This ensures that they maintain their skills to help and support vulnerable children.

p.8

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

Children are placed at this home by the Youth Custody Service because they are deemed too vulnerable to be placed elsewhere in the youth custodial estate. Children have been subject to unlawful painful holds during physical restraint by staff. Health staff records show that of 20 incidents between 1 April 2021 and 31 March 2022 where the ‘finger and thumb hold’ was used on children by staff (one of the home’s approved methods) five children reported suffering pain. Two children told inspectors that physical restraint incidents have caused them pain. One child described the pain to inspectors as significant. Children have not been listened to or actions taken as a result. Physical restraint of children has also been used unlawfully to bring about children’s compliance with staff requests. Practices at this home have had a significant impact on children’s wellbeing.

p.8

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

Quality assurance and monitoring by managers is ineffectual. It does not identify all breaches of regulations and leaders have deemed the actions of staff as appropriate.

p.8

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

These findings by inspectors follow the home identifying incidents of physical restraint in October and November 2021 that were contrary to regulations. The actions taken by managers at that time led to referrals to the local authority designated officer (LADO). The LADO’s investigations substantiated that the children were unlawfully restrained. The home’s managers did not take appropriate action to address shortfalls with all the staff concerned.

p.8

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

Single separation is not always used in line with regulations, significantly impacting on children’s rights, care and well-being. A child subject to an inappropriate compliance restraint, which was a serious breach of regulation, was then placed in single separation for two hours. Records show that the criteria for single separation were not met before or during the two-hour period. The registered manager provided evidence for consideration by inspectors that the child chose to be in separation. This is contrary to the findings of the LADO investigation, which deemed that the use of physical restraint was unlawful; because the child was placed in separation by staff using physical restraint, the legal grounds for separation were also not met. Another incident saw a child locked in their bedroom over a three-day period. Records justified this action for the first day due to the serious risk to others,

p.8

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

but there is no evidence that the registered manager’s decision to keep the child locked in their bedroom for a further two days was justified. In another incident, mitigation provided by managers was from a theoretical model from 1983 that Inspection report for secure children’s home: SC035500 9 states children require a 90-minute period to calm. However, the use of single separation for two hours was in the first instance not appropriate and in breach of regulations, and the home’s records show that a number of children have spent short periods of much less than 90 minutes in single separation. This contradicts the home’s asserted position.

p.8

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

Safeguarding concerns are referred to the local authority in line with the home’s procedures. The LADO spoke positively of the professional relationships with the home.

p.9

The effectiveness of leaders and managers: inadequate

As referred to in the overall experiences and progress section of this report, there are repeated failures in leadership at this home over a number of years that has impacted upon children’s rights, care and wellbeing. Leaders have failed to consistently and effectively ensure that at least good standards of care and safety are provided for children. Leaders reactively address shortfalls raised at inspections, but improvements are short-lived.

p.9

The effectiveness of leaders and managers: inadequate

Some of the practices at this home are worrying and this brings into question the culture that is set by the registered manager and senior leaders.

p.9

The effectiveness of leaders and managers: inadequate

A recommendation from the last inspection has not been met. Records of sanctions imposed on children contain no evidence of any attempts by staff to consider a restorative approach. This is now a requirement.

p.9

The effectiveness of leaders and managers: inadequate

Inspectors remain concerned that the registered manager, leaders and staff do not understand the legal criteria for physical restraint and single separation. The registered manager has authorised staff to use physical restraint and single separation contrary to regulations. In one incident, the registered manager authorised a child to be subjected to the ongoing use of single separation for two further days (three days in total) when there was no evidence to justify such action. It is not clear at this stage whether there have been other incidents of this nature, given the failure of management oversight and ineffectual quality assurance processes. It is also not clear whether the children involved have been informed of the outcome of investigations that have taken place. Shortfalls undermine other efforts that have seen children make progress at this home.

p.9

The effectiveness of leaders and managers: inadequate

During the inspection and following feedback from inspectors, the registered manager made the decision to direct all staff to cease using a restraint method that has caused pain to children. Nevertheless, despite there being occasions when children had complained of pain, the technique had continued to be used and seen as acceptable practice.

p.9

The effectiveness of leaders and managers: inadequate

The COVID-19 pandemic has made staffing the home a challenge. This has meant that children have had to spend time in their rooms away from their peers so that safe staffing levels can be maintained. For example, at mealtimes children take turns Inspection report for secure children’s home: SC035500 10 to be separated in their rooms while their peers use the dining room. The registered manager stated that this practice is being phased out as staffing levels recover.

p.9

The effectiveness of leaders and managers: inadequate

There are regular meetings involving managers across disciplines where information about the care of children is shared. Rostering is well planned and members of staff who require additional support and guidance receive this.

p.10

The effectiveness of leaders and managers: inadequate

Staff have access to a wide selection of training. This enables them to have the knowledge to care for the children; however, they are not applying their learning effectively as seen through the shortfalls identified in this report. While supervision is regular, two records from a sample of three showed that shortfalls in practice relating to the unlawful use of physical restraint were not sufficiently explored or addressed.

p.10

The effectiveness of leaders and managers: inadequate

Feedback from external stakeholders in relation to communication and collaboration is positive. Good efforts are made by the staff in some areas of practice, particularly in relation to preparing children for moving on from the home.

p.10

The effectiveness of leaders and managers: inadequate

Diversity and difference are acknowledged and celebrated. Children are enabled to practice their own religious beliefs and learn about others. The staff team and children represent a diverse mix of cultures, backgrounds and beliefs and this rich mix enables them to learn from each other and develop tolerance and understanding.

p.10

The effectiveness of leaders and managers: inadequate

Managers oversee complaints and ensure that children have access to independent advocates and helplines, as well as direct consultation with managers and staff. Complaints are taken seriously and resolved to the children’s satisfaction. Inspection report for secure children’s home: SC035500 11

p.10

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.

p.11

Requirement Due date

*Restraint in relation to a child is only permitted for the purpose of preventing—

p.11

Requirement Due date

injury to any person (including the child);

p.11

Requirement Due date

serious damage to the property of any person (including the child).

p.11

Requirement Due date

Restraint in relation to a child must be necessary and proportionate. (Regulation 20 (1)(a)(b) (2))

p.11

Requirement Due date

In particular, immediately cease using any restraint method that causes pain to children and immediately cease using physical restraint and single separation where the legal criteria are not met or where the legal criteria no longer continue to be met.

p.11

Requirement Due date

Ensure that all staff and managers fully understand and implement the legal criteria that determines the circumstances when physical restraint and single separation can be used with children. 05 June 2022

p.11

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—

p.11

Requirement Due date

helps children aspire to fulfil their potential; and

p.11

Requirement Due date

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

p.11

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; 05 June 2022 Inspection report for secure children’s home: SC035500 12 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)(h))

p.11

Requirement Due date

Particularly, ensure that all leaders and managers fully understand the legal criteria for physical restraint and single separation, and carry out robust monitoring of physical restraints and single separations. Any shortfalls in staff practice must be identified and appropriate action taken to reduce the risk of a recurrence.

p.12

Requirement Due date

The registered person must ensure that— the privacy of children is appropriately protected;

p.12

Requirement Due date

In particular, ensure that staff do not enter children’s bedrooms or remove the cover to the viewing panels without knocking on the door and checking with the child that is it appropriate to do so. 05 June 2022

p.12

Requirement Due date

The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on— mutual respect and trust;

p.12

Requirement Due date

an understanding about acceptable behaviour; and positive responses to other children and adults.

p.12

Requirement Due date

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

p.12

Requirement Due date

that each child is encouraged to build and maintain positive relationships with others. (Regulation 11 (1)(a)(b)(c) (2)(b))

p.12

Requirement Due date

In particular, ensure that a restorative approach is maintained with children so that they can reflect upon and consider their behaviour. 5 June 2022

p.12

Requirement Due date

The registered person must ensure that all employees—

p.12

Requirement Due date

receive practice-related supervision by a person with appropriate experience. (Regulation 33 (4)(b))

p.12

Requirement Due date

Specifically, that all staff receive good-quality supervision and that their supervision records reflect any conversations and learning about significant events such as restraints. 31 July 2022 Inspection report for secure children’s home: SC035500 13 *These requirements are subject to a compliance notice.

p.12

Recommendations

 The registered person should ensure that the ethos of the home supports each child to learn. In particular, managers should: embed and secure the new monitoring and tracking tools into the work of the school so that the increased shared understanding this provides informs the planning of the curriculum for each child, and, formalise the careers programme so that it can be tailored to the needs of individual children based on their aspirations and plans. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 29, paragraph 5.18)

p.13

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 secure children’s home: SC035500 14

p.13

Secure children’s home details

Registered provider: South Gloucestershire Council

p.14

Secure children’s home details

Registered provider address: South Gloucestershire Adults, Children’s and Health, PO Box 1955, Bristol BS37 0DE

p.14

Inspectors

Paul Taylor, Social Care Inspector Helen Simmons, Social Care Inspector Shaun Common, Senior Officer, Secure Estate Judy Lye-Forster, Her Majesty’s Inspector, Further Education and Skills Catherine Raycraft, Health and Justice Inspector, Care Quality Commission Inspection report for secure children’s home: SC035500 15 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.

p.14

Inspectors

If you would like a copy of this document in a different format, such as large print or Braille, please telephone 0300 123 1231, or email enquiries@ofsted.gov.uk . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

p.15

Inspectors

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

p.15

Inspectors

T: 0300 123 1231 Textphone: 0161 618 8524 E: enquiries@ofsted.gov.uk W: www.gov.uk/ofsted

p.15