Children's home run by Blue Mountain Homes Ltd

Inspection report for children’s home: 2600978 1 Registered provider: Blue Mountain Homes Ltd Full inspection Inspected under the social care common inspection framework

p.1

Information about this children’s home

This children’s home is privately owned. It provides care for up to four children who have emotional and/or behavioural difficulties due to past trauma.

p.1

Information about this children’s home

The previous registered manager voluntarily cancelled his registration with Ofsted in February 2022 and is no longer working for the company. There is an interim manager in post who is yet to submit an application to register.

p.1

Overall experiences and progress of

children and young people, taking into account

p.1

inadequate

How well children and young people are helped and protected inadequate

p.1

inadequate

The effectiveness of leaders and managers inadequate

p.1

inadequate

There are serious and widespread failures that mean children are not protected or their welfare is not promoted or safeguarded, and the care and experiences of children are poor and they are not making progress.

p.1

inadequate

Date of last inspection: 25 January 2022

p.1

inadequate

Overall judgement at last inspection: Declined in effectiveness

p.1

Enforcement action since last inspection:

A compliance notice was issued under regulation 13 (the leadership and management standard) following the home’s interim inspection on 25 January 2022. A monitoring visit was carried out on 10 March 2022 to review the notice. The compliance notice was not met. A further compliance notice was issued, also under regulation 13. Inspection report for children’s home: 2600978 2

p.1

Inspection date Inspection type Inspection judgement

25/01/2022 Interim Declined in effectiveness 13/10/2021 Full Requires improvement to be good Inspection report for children’s home: 2600978 3

p.2

inadequate

There are serious failings that mean children are not protected in the home and that their welfare is not consistently promoted by staff, leaders and the manager. Since the last full inspection, inspectors have found that the care and experiences of children in the home continue to be poor. Two compliance notices were issued at the last inspection; one is not met and has been reissued, alongside an additional compliance notice under regulation 12.

p.3

inadequate

Staff do not consistently support children to develop skills to manage their health needs. For example, staff have failed to consistently promote good oral health for a child and have not ensured that their dental health needs are met appropriately. Staff do not encourage the child to use prescribed toothpaste from the dentist. This toothpaste has been left unopened for over 12 months. Staff state that children have declined to take prescribed medication, however, this is not reflected in their records. Consequently, children’s health needs are not prioritised.

p.3

inadequate

Staff do not ensure that children’s health needs are met. For example, when a child requested medical advice and medication, staff failed to take appropriate action to ensure that the child received medical support. Despite the child presenting with symptoms of being unwell, staff failed to consider seeking advice from health professionals, or escalating concerns to managers when the child reportedly declined to access support from the general practitioner. This lack of action from staff places children at potential risk of harm and could have resulted in serious consequences for the child’s health.

p.3

inadequate

The manager does not take sufficient action to ensure that staff follow the home’s medication policy. The policy states that staff should record when they have taken children’s medication off site. Inspectors found that when a child went on holiday, their risk assessment failed to make any reference to this. Furthermore, there were discrepancies in the information shared by staff when concerns were raised by inspectors. Inspectors were initially informed by a member of staff that the child had taken their medication with them on holiday. When inspectors spoke to another member of staff and the child, they confirmed that this was not accurate, and the child’s medication had been left at the home. This places children at potential risk of harm.

p.3

inadequate

Staff have now taken steps to ensure that children’s education needs are met. There are now plans in place to ensure that children receive their education entitlement and provision. Consequently, improved outcomes will be achieved for children in their education. Inspection report for children’s home: 2600978 4

p.3

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

Safeguarding arrangements in the home are inadequate. Staff do not consistently follow children’s risk assessments, and children’s records do not consistently show the actions taken by staff to keep them safe. For example, records completed by staff do not reflect that they carry out daily mobile phone checks to monitor the risks to children.

p.4

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

Staff do not take sufficient action to ensure that risk assessments and family time safety plans are updated to reflect emerging risks and how these are managed. Staff have not escalated concerns with the local authority effectively when they have not agreed with their decision-making about how risks should be managed. This practice may result in failings in the safeguarding of children.

p.4

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

Staff do not consistently complete key-work sessions with children before and after children have family time, as required in their risk assessments. Staff are also failing to consistently record their observations when they supervise family time. This impacts on the effectiveness of plans in place to prevent harm to children.

p.4

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

Staff and managers lack understanding of safeguarding procedures. On one occasion, following an allegation made by a child, staff completed an internal investigation and spoke to a child about the allegations. This is despite staff not being trained in interviewing children to achieve best evidence. Furthermore, this action had not been agreed by the police or the social worker. Staff’s actions were premature as they had limited information. Staff may also have potentially impeded the police investigation. On another occasion, staff wrongly informed a child and other agencies that a police investigation had concluded and that no further action would be taken. However, the police investigation was still ongoing.

p.4

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

Staff and managers do not demonstrate an understanding about the impact this may have on children. Poor joint working results in poor safeguarding practice, which leaves children feeling confused and at risk of further harm.

p.4

The effectiveness of leaders and managers: inadequate

Leadership and management of the home is inadequate. The manager’s monitoring and reviewing systems continue to be ineffective. The internal and external auditing systems are poor; they are failing to identify the shortfalls in staff’s practice and the quality of care provided to children. For example, a medication audit was completed recently, however, this did not identify the shortfalls found by inspectors. Furthermore, the manager has failed to address all the requirements from the previous inspection. This means that concerns about the quality of care provided to children remain.

p.4

The effectiveness of leaders and managers: inadequate

Leaders and the manager fail to ensure that all staff receive the relevant training to meet the children’s needs. For example, some staff’s medication training and physical intervention training has lapsed. This is despite some children in the home being prescribed medication and requiring support from staff to ensure that this is Inspection report for children’s home: 2600978 5 safely administered. Furthermore, inadequately trained staff could use unsafe restraint practice on children, resulting in potential harm.

p.4

The effectiveness of leaders and managers: inadequate

The manager has not reviewed the statement of purpose to ensure that it clearly states how the home uses devices for the monitoring or surveillance of children. This means it is unclear to anyone wishing to place a child in the home, or any child already placed, about the measure and how it is used. The use of bedroom door alarms in the home is not reviewed regularly and children are not helped to understand why these are used to manage their risks. As a result, the inappropriate use of door alarms is potentially used as a restrictive tool as opposed to a safeguarding measure.

p.5

The effectiveness of leaders and managers: inadequate

The manager has not completed annual appraisals for all staff. The inspectors were informed that one member of staff has had an appraisal, however, this has not been recorded. This impacts on the manager’s ability to monitor staff’s development needs and progress effectively. Inspection report for children’s home: 2600978 6

p.5

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.6

Requirement Due date

The health and well-being standard is that—

p.6

Requirement Due date

the health and well-being needs of children are met;

p.6

Requirement Due date

children receive advice, services and support in relation to their health and well-being; and

p.6

Requirement Due date

children are helped to lead healthy lifestyles.

p.6

Requirement Due date

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

p.6

Requirement Due date

achieve the health and well-being outcomes that are recorded in the child’s relevant plans;

p.6

Requirement Due date

understand and develop skills to promote the child’s well- being. (Regulation 10 (1)(a)(b)(c) (2)(a)(i)(iv))

p.6

Requirement Due date

In particular, the registered persons must ensure that staff take immediate action when required to ensure that the children’s health needs are met.

p.6

Requirement Due date

In addition, staff should ensure that children are supported and encouraged to take their prescribed medication as and when required. 5 June 2022

p.6

Requirement Due date

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

p.6

Requirement Due date

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

p.6

Requirement Due date

assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if 5 June 2022 Inspection report for children’s home: 2600978 7 necessary make arrangements to reduce the risk of harm to the child. (Regulation 12 (1) (2)(a)(i))

p.6

Requirement Due date

In particular, the registered persons must ensure that staff understand and follow actions set out in children’s risk assessments. *The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

p.7

Requirement Due date

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

p.7

Requirement Due date

understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person;

p.7

Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare; and

p.7

Requirement Due date

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

p.7

Requirement Due date

In particular, the registered persons must ensure that staff, leaders and the manager familiarise themselves with and follow safeguarding procedures and policies to ensure that children are kept safe. 5 June 2022

p.7

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.7

Requirement Due date

helps children aspire to fulfil their potential; and promotes their welfare.

p.7

Requirement Due date

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

p.7

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;

p.7

Requirement Due date

ensure that staff have the experience, qualifications and skills to meet the needs of each child; 5 June 2022 Inspection report for children’s home: 2600978 8 understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home.

p.7

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)(f)(h))

p.8

Requirement Due date

This requirement was issued at the last inspection and is restated, as shortfalls were still evident during this inspection.

p.8

Requirement Due date

In particular, the registered persons should ensure that staff undertake relevant training so that they have the skills and knowledge they need to care for the children.

p.8

Requirement Due date

Also, leaders and managers must ensure that there are effective monitoring and reviewing systems in place to continue to support staff and children. The care planning standard is that children—

p.8

Requirement Due date

receive effectively planned care in or through the children’s home; and

p.8

Requirement Due date

have a positive experience of arriving at or moving on from the home.

p.8

Requirement Due date

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

p.8

Requirement Due date

that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose. (Regulation 14 (1)(a)(b) (2)(a))

p.8

Requirement Due date

This requirement was issued at the last inspection and is restated as no children have been admitted to or discharged from the home since then.

p.8

Requirement Due date

This specifically relates to the manager ensuring that they fully consider the needs of children before they move into the home. In addition, the manager must fully consider the needs of children already living at the home and any other factors such as recent incidents. 7 August 2022 Inspection report for children’s home: 2600978 9 The registered person must compile in relation to the children’s home a statement ("the statement of purpose") which covers the matters listed in Schedule 1

p.8

Requirement Due date

keep the statement of purpose under review and, where appropriate, revise it; and

p.9

Requirement Due date

notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision.

p.9

Requirement Due date

Subject to paragraph (6), the registered person must ensure that the home is at all times conducted in a manner which is consistent with its statement of purpose. (Regulation 16 (1) (3)(a)(b) (5))

p.9

Requirement Due date

In particular, the manager should ensure that the statement of purpose is kept under review, and that it is sufficiently detailed. 5 June 2022

p.9

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.

p.9

Requirement Due date

In particular the registered person must ensure that—

p.9

Requirement Due date

medicines kept in the home are stored in a secure place so as to prevent any child from having unsupervised access to them;

p.9

Requirement Due date

medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child; and

p.9

Requirement Due date

a record is kept of the administration of medicine to each child.

p.9

Requirement Due date

Paragraph (2) does not apply to medicine which— is stored by the child for whom it is provided in such a way that other persons are prevented from using it; and

p.9

Requirement Due date

may be safely self-administered by that child. (Regulation 23 (1) (2)(a)(b)(c))

p.9

Requirement Due date

In particular, the registered persons should ensure that there are adequate arrangements for the safekeeping, safe administration and safe disposal of children’s medication. 5 June 2022

p.9

Requirement Due date

The registered person may only use devices for the monitoring or surveillance of children if— 5 June 2022 Inspection report for children’s home: 2600978 10 the monitoring or surveillance is for the purpose of safeguarding and promoting the welfare of the child concerned, or other children.

p.9

Requirement Due date

the child’s placing authority consents in writing to the monitoring or surveillance.

p.10

Requirement Due date

so far as reasonably practicable in the light of the child’s age and understanding, the child is informed in advance of the intention to do the monitoring or surveillance; and

p.10

Requirement Due date

the monitoring or surveillance is no more intrusive than necessary, having regard to the child’s need for privacy. (Regulation 24 (1)(a)(b)(c)(d))

p.10

Requirement Due date

In particular, the registered persons should ensure that consent is sought from the local authority for the use of monitoring and surveillance in the home.

p.10

Requirement Due date

In addition, staff and the manager should ensure that this is reviewed and updated regularly, and that this is only used for the purposes of safeguarding and promoting the welfare of children. If the Regulatory Reform (Fire Safety) Order 2005(a) applies to the home—

p.10

Requirement Due date

the registered person must ensure that the requirements of that Order and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the home. (Regulation 25 (2)(b))

p.10

Requirement Due date

In particular, the registered persons must ensure that the fire risk assessment is updated. 5 June 2022

p.10

Requirement Due date

The registered person must ensure that all employees—

p.10

Requirement Due date

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

p.10

Requirement Due date

In particular, the registered persons must ensure that all staff have an annual appraisal and that this is clearly recorded. 5 June 2022

p.10

Requirement Due date

*These requirements are subject to a compliance notice. Inspection report for children’s home: 2600978 11

p.10

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: 2600978 12

p.11

Children’s home details

Registered provider: Blue Mountain Homes Ltd

p.12

Children’s home details

Registered provider address: 17 Leeland Mansions, Leeland Road, London W13 9HE

p.12

Children’s home details

Responsible individual: Pradeep Manaktala

p.12

Inspectors

Mazviita Makiyi, Social Care Inspector Michelle Spruce, Social Care Inspector Inspection report for children’s home: 2600978 13 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.12

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.13

Inspectors

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

p.13

Inspectors

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

p.13