Children's home run by Manuel Cornwall Ltd

Inspection report for children's home: 2662998 1 Registered provider: Manuel Cornwall Ltd Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The children’s home provides care for up to three children who may have emotional and/or behavioural difficulties. At the time of the inspection, two children were living at the home, one having been there before it was registered with Ofsted.

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Information about this children’s home

This is the first time that Ofsted has inspected this home. The manager registered with Ofsted on 28 March 2022 but subsequently submitted a voluntary cancellation request on 1 April 2022.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

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

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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 for children's home: 2662998 2

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Recent inspection history

Not previously inspected Inspection report for children's home: 2662998 3

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inadequate

The inspection was initiated after serious safeguarding concerns were identified in a series of notifications sent to Ofsted by the home. While the provider did submit the notifications as required, these were not sent to either Ofsted or the child’s local authority in a timely way.

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inadequate

The relationship between the responsible individual and the registered manager broke down shortly after the home was registered with Ofsted. The registered manager raised their concerns with the responsible individual but reported that they did not feel they were responded to effectively. This has had a serious effect on the quality and continuity of care children receive.

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inadequate

One child has made good progress. There is a plan for them to return to live with their family. They completed GCSEs last year and are enrolled on a professional football academy apprenticeship. They also have a part-time job. However, managers have failed to recognise the negative impact that moving another child into the home has had on them. The child described to the inspector how distressing they had found living in the home since March 2022. They said that, ‘It’s absolute hell,’ adding that they tried to go out as much as possible and when they were at home they stayed in their room.

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inadequate

Staff have not provided key-work sessions for one child for many months. This is partly due to the child disengaging but also because of staff shift patterns. A member of staff raised this issue with the registered manager as they were concerned that the child was not receiving direct work. However, a plan to mitigate this has not been put in place. The child told the inspector that they felt that staff, ‘don’t give a damn about me any more’.

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inadequate

The home is clean and generally well presented. Children’s rooms are decorated to their tastes. Communal living areas are furnished in a homely way and provide a range of spaces for children. The outdoor areas are large and well maintained. However, the dining room has areas of damage caused by a child three months ago. These have not been repaired. When questioned about this by the inspector, the responsible individual stated that it was too costly to repair.

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inadequate

The inspector saw warm and caring interactions between staff and children. One child said that they like living at the home. Staff work hard to develop rapport with children and understand their interests. A parent told the inspector that they thought the team was amazing with their child. They acknowledged the team had perhaps underestimated the child’s needs initially but they felt they managed incidents well. Inspection report for children's home: 2662998 4

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

Children’s risk assessments and behaviour management plans do not provide staff with clear strategies to keep children safe. One plan advises staff to only follow the child when they leave the home if they are distressed or upset. On one occasion, this resulted in the child leaving the home unaccompanied and then harming themselves. Although it was the view of the registered manager that the child should always be accompanied, this was not reflected in the child’s plan.

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

The plan for supervision of this child is confusing, approaches by staff are inconsistent and places the child at risk of harm. Staff rely on their own judgement of the child’s emotional state or signals from the child to know how to respond. For example, when the child spends time in their room alone, the frequency of staff checks depends on how the staff think the child is feeling. This ranges from five to 30 minutes. One member of staff told the inspector that on a good evening they had not checked for one hour. There were many occasions when the child had put a ligature around their neck and staff were unaware until they checked on them.

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

Current plans are not safe. One strategy relies on a family member phoning the home when a child may be considering self-harm. Any simple failures in communication could have serious consequences for the child.

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

The staff are insufficiently trained to respond to self-harm. Incidents involving the use of ligatures are frequent; sometimes more than once a day. Only three members of staff are specifically trained to respond to use of ligatures. On one occasion, only one member of staff was on shift when the child used a ligature. This adult had no ligature training. This places the child at significant risk of fatality through accidental strangulation.

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

Managers have not ensured that the home has essential equipment for dealing with self-harm, particularly ligature cutters.

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

Risk assessments are of poor quality and are not being followed by staff. Despite one child’s plan stating that harmful objects should be removed, the child found batteries, pieces of metal and shards of sharp plastic or glass and used them to harm themselves.

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

Staff do not consistently seek medical attention for children. On one occasion, a child swallowed glass or hard shards of plastic and managers did not take them to hospital.

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

Medication, including controlled medication, is not stored or recorded correctly. The inspector saw that medication administered on the first day of the inspection was not recorded. Consequently, tablet counts are inaccurate. There is a lack of regular management oversight of staff competency in this area. Inspection report for children's home: 2662998 5 Staff have used restraint despite not being trained to do so. There have been three occasions when restraint has been used. Leaders and managers do not recognise the use of restraint and fail to ensure that records are maintained.

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The effectiveness of leaders and managers: inadequate

Leadership and management at the home are poor. Leaders and managers have failed to devise and implement plans and procedures that safeguard children. There is a lack of coordination and communication within the senior team and this has led to risks not being assessed robustly.

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The effectiveness of leaders and managers: inadequate

Leaders and managers failed to make sufficient enquiries to fully understand the needs of a child with complex mental health difficulties before the child came to live at the home. Leaders and managers accept that this has led to the team constantly ‘firefighting’ and not having the skills to manage risks effectively.

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The effectiveness of leaders and managers: inadequate

The staff team is conscientious and caring. They work hard under difficult circumstances to try to keep children safe. However, most of the team have limited experience of working in a children’s home. Furthermore, the poor leadership by leaders and managers has meant staff follow unsafe plans that lack coherent strategies to manage risk. This has led to repeated incidents when one child has been placed at risk of significant harm.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not ensure that there are always sufficient and experienced staff on shift. Children and staff are placed in unsafe situations. On one occasion, only one member of staff was on shift with two children in the home, despite their plans stating that they require one-to-one supervision.

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The effectiveness of leaders and managers: inadequate

Staff do not receive regular supervision. Sessions are often postponed due to insufficient staffing, staff sickness and leave. Despite staff reporting to the inspector that they found supervision helpful, records of these sessions are not available for review as managers have failed to document the sessions promptly.

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The effectiveness of leaders and managers: inadequate

There is a lack of management oversight in all areas. Managers do not complete regular checks to ensure that day-to-day practice is of a good standard. They do not ensure that staff complete children’s records accurately or in a timely way. The inspector noted that records were missing or were updated on the day of the inspection. They do not track the progress of children and understand their needs fully. They do not continually assess the work of the team to ensure the staff have the necessary skills and training to keep children safe.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have failed to appoint an independent person to monitor the home. A lack of critical feedback has meant that widespread failings have not been recognised. The registered manager told the inspector, ‘It is the blind leading the blind.’

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The effectiveness of leaders and managers: inadequate

Due to the seriousness of the concerns identified at this inspection Ofsted made the decision to suspend the registration of the home with immediate effect. Inspection report for children's home: 2662998 6 Inspection report for children's home: 2662998 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

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

understand and apply the home’s statement of purpose;

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Requirement Due date

understand and apply the home’s statement of purpose;

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Requirement Due date

protect and promote each child’s welfare;

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Requirement Due date

provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background;

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Requirement Due date

help each child to develop resilience and skills that prepare the child to return home, to live in a new placement or to live independently as an adult. (Regulation 6 (1)(a)(b) (2)(a)(b)(i)(ii)(iv)) 20 July 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 July 2022 Inspection report for children's home: 2662998 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

have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

manage relationships between children to prevent them from harming each other;

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

This relates to having risk assessments and care plans that understand children’s needs and provide staff with clear and consistent strategies to respond to them and keep them safe.

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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 the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (1) (2)(e))

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Requirement Due date

This relates to ensuring that there is management oversight of safety plans for children and that they are reviewed regularly, particulalry when significant incidents occur. 20 July 2022

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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 promotes their welfare. 20 July 2022 Inspection report for children's home: 2662998 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 work as a team where appropriate;

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Requirement Due date

ensure that staff have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

ensure that the home has sufficient staff to provide care for each child;

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Requirement Due date

ensure that the home’s workforce provides continuity of care to each child.

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Requirement Due date

understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home.

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Requirement Due date

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

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Requirement Due date

This relates to the registered provider ensuring that the home has a skilled and knowledgeable staff team and that it has sufficient staff to care for the children living in the home. There should be consistency in the approach taken by staff when caring for children. There should be robust monitoring of the care provided.

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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. In particular the registered person must ensure that—

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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;

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Requirement Due date

a record is kept of the administration of medicine to each child. (Regulation 23 (1) (2)(a)(c)) 20 July 2022 Inspection report for children's home: 2662998 10 The registered person must ensure that all employees—

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Requirement Due date

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

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Requirement Due date

This relates to all staff receiving regular, quality supervision and that records of this are made in a timely way. 20 July 2022

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Requirement Due date

The registered person must prepare and implement a policy ("the behaviour management policy") which sets out—

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Requirement Due date

how appropriate behaviour is to be promoted in the children’s home; and

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Requirement Due date

the measures of control, discipline and restraint which may be used in relation to children in the home.

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Requirement Due date

The registered person must keep the behaviour management policy under review and, where appropriate, revise it. (Regulation 35 (1)(a)(b) (2))

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Requirement Due date

This relates to having policies in place so that all staff understand what restraint is and when to use it. 20 July 2022

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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; Inspection report for children's home: 2662998 11 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)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c))

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Requirement Due date

This relates to the accurate recording of each separate occasion when a child has been subject to a restraint by a member of staff.

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Requirement Due date

The registered person must maintain records ("case records") for each child which—

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Requirement Due date

include the information and documents listed in Schedule 3 in relation to each child;

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Requirement Due date

are signed and dated by the author of each entry. (Regulation 36 (1)(a)(b)(c))

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Requirement Due date

This relates to all staff keeping accurate records of the child’s life while living in the home. 20 July 2022

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if—

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Requirement Due date

a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation;

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Requirement Due date

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; 20 July 2022 Inspection report for children's home: 2662998 12 there is an allegation of abuse against the home or a person working there;

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Requirement Due date

a child protection enquiry involving a child — is instigated; or

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Requirement Due date

concludes (in which case, the notification must include the outcome of the child protection enquiry); or

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Requirement Due date

there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(a)(b)(c)(d)(i)(ii)(e))

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Requirement Due date

This relates to serious incidents being reported to Ofsted and other agencies in a timely way.

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Requirement Due date

The registered provider must appoint, at the registered provider’s expense, a person ("the independent person") to visit and report on the children’s home carried on by the registered provider. (Regulation 43 (1)) 20 July 2022

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Requirement Due date

The registered person must ensure that an independent person visits the children’s home at least once each month. (Regulation 44 (1)) 20 July 2022

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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: 2662998 13

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Children’s home details

Registered provider: Manuel Cornwall Ltd

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Inspectors

Penelope Kutz, Social Care Inspector Angela Weston, Social Care Inspector Inspection report for children's home: 2662998 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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Inspectors

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Inspectors

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Inspectors

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

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