Children's Home run by Our Place (2008) Limited in Worcestershire

Assurance inspection report for children’s home: SC407929 1 SC407929

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Registered provider: Our Place (2008) Limited

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Inspected under the social care common inspection framework

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Information about this children’s home

A private company operates this children’s home. It provides care for 10 children with learning disabilities, including autism spectrum disorder and associated challenging behaviours.

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Information about this children’s home

We last visited this home on 26 and 27 April 2022 to carry out a full inspection. This report is published on the Ofsted website.

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Information about this children’s home

A new manager has been appointed but is not yet registered with Ofsted.

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Information about this children’s home

Judgement at last inspection: requires improvement to be good

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Information about this children’s home

Enforcement action since last inspection: none

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Information about this inspection

At these inspections, the inspectors evaluated:

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Information about this inspection

 the care of children  the safety of children  the effectiveness of leaders and managers. Inspectors have looked closely at the experiences and progress of children, using the social care common inspection framework. This assurance 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’. Assurance inspection report for children’s home: SC407929 2

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Findings from the inspection

We identified the following serious and widespread concerns in relation to the care or protection of children at this assurance inspection:

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Findings from the inspection

 Children’s health needs are not consistently met.  Some areas of the home require repair.  Risk management is inadequate.  The recruitment of staff is not safe.  The manager does not have sufficient oversight of children’s records.  There are not enough staff to meet the needs of the children currently living in the home.  Staff are not adequately trained.  Managers do not take effective action to improve the quality of care in the home.

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The care of children

Since the last inspection, no children have moved in or out of the home. There are currently 10 children living in the home.

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The care of children

The manager has not ensured that children’s health needs are consistently met. For example, some children have not had vaccinations, or have blood tests or referrals to specialist health services that remain outstanding. This does not ensure that children’s health and well-being are promoted.

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The care of children

The manager has failed to identify and review the impact of children harming each other in the home. For example, records identified a child being upset when another child had pushed them to the ground. There has been no scrutiny from the manager and no support offered to staff to ensure that harm between peers is managed and prevented. This leaves the children vulnerable and compromises their safety and well-being.

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The care of children

Some areas of the home require repair. During the inspection, it was identified that there were holes in the walls of the sensory room, damage to door frames, tears to some wallpaper and damage to a child’s bathroom door. There have been delays from managers in reporting and fixing these identified areas. This does not ensure that children have a comfortable and homely environment to live in.

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The care of children

Despite the shortfalls identified at this inspection, it was observed that children have positive relationships with staff. Children living in the home are attending school full- time and are supported to take part in a range of activities. This supports the children to make educational progress and to have fun. Assurance inspection report for children’s home: SC407929 3

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The safety of children

Risk management is inadequate. Written documents do not provide staff with sufficient advice or strategies to follow. This has a detrimental impact on the care that children receive. For example, there is limited guidance for staff on how to support one child who has specific risks of hitting his head. The lack of guidance means that staff have responded in different ways when supporting and responding to this behaviour. This poor approach to risk management fails to protect children.

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The safety of children

Concerns about staff practice are not always reported to the local authority designated officer in a timely manner. Furthermore, despite the manager being aware of concerns about a staff member’s conduct, the individual was allowed to work in the home for three further shifts. This placed children at potential risk of harm. In addition, an internal investigation into the concerns related to the staff member had not been recorded. Consequently, the learning outcomes from this investigation are not clear.

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The safety of children

The manager does not sufficiently scrutinise physical intervention records to ensure that the use of restraint is necessary. Records do not contain a manager’s evaluation of staff practice and there is no consideration as to whether the restraint was proportionate or appropriate. In addition, staff do not consistently record any injuries to children that occur during restraint. Furthermore, the manager does not always ensure that staff and children are supported with a debrief following the use of a physical intervention. This poor oversight leaves children vulnerable and compromises their safety.

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The safety of children

The manager does not have sufficient oversight of children’s records. Inspectors identified that when staff observe that children have bruising, there is no exploration of whether children need medical attention. Furthermore, staff do not always inform children’s social workers about these injuries. Staff have recently started to use skin maps to record any marks or bruising. However, the manager does not have any oversight of this documentation to evaluate and establish how bruising, marks or scratches have occurred. This lack of oversight undermines the manager’s ability to identify shortfalls in staff practice and bring about improvement. This poor practice leaves children at risk of harm.

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The safety of children

The recruitment of staff is not safe. Managers have failed to complete necessary checks to ensure that staff working in the home are suitable. For example, when agency staff have worked in the home, there has been no mechanism to ensure that safer recruitment checks have been completed. Furthermore, agency staff have not been provided with an induction to the home. This does not ensure that staff working in the home are suitable to work with children.

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The effectiveness of leaders and managers

Since the last inspection, a new manager has been appointed and he is applying for registration with Ofsted. The acting manager has worked at the service for several years and has acknowledged the shortfalls raised at this inspection. Assurance inspection report for children’s home: SC407929 4 The home does not have enough staff to meet the needs of the children currently living in the home. As a result, there have been nine occasions when there have not been enough staff to meet agreed staffing levels for individual children. This has compromised children’s safety and welfare on those occasions.

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The effectiveness of leaders and managers

Managers have not ensured that the staff are adequately trained. For example, staff who are responsible for administrating medication have not been trained to do so. Some staff lack the skills and knowledge to meet the children’s individual needs. On one occasion, a child who is at risk of eating non-food items was not adequately supervised. The member of staff caring for him left soap in an accessible place, resulting in the child eating the soap. This lack of awareness and oversight placed the child at risk of harm.

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The effectiveness of leaders and managers

Managers do not have an effective workforce development plan. There is no plan in place to assess staff’s training needs effectively and to ensure that the required training is completed.

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The effectiveness of leaders and managers

Managers are not providing staff with regular supervision in line with the home’s policy. For two staff members, there were no records of supervision. For another staff member, she had only received one supervision in a six-month period. This lack of support and effective oversight limits the opportunity to improve practice and help staff to reflect. This inadequate leadership has had a detrimental impact on the provision of care.

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The effectiveness of leaders and managers

The statement of purpose is not up to date and does not reflect the home’s ethos and approach to care. This does not ensure that staff practice is consistent or that Ofsted have the most up-to-date information about the home.

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The effectiveness of leaders and managers

Children’s case files do not contain all the information required from the placing authority. For example, the staff do not have a copy of children’s most recent education and care plans. These shortfalls have not been addressed by managers. This means that staff do not have all the information they need to provide good care.

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The effectiveness of leaders and managers

Managers have demonstrated poor leadership and management and a lack of ability to take effective action to improve the quality of care in the home. Little improvement has been made since the last inspection and there are repeated regulatory shortfalls. These failures have not promoted improvements to the quality of care afforded to children.

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The effectiveness of leaders and managers

Not all the requirements made at the last inspection were considered during this visit. These will be considered during the next inspection. Assurance inspection report for children’s home: SC407929 5

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Inspection date Inspection type Inspection judgement

26/04/2022 Full Requires improvement to be good 20/01/2022 Interim Sustained effectiveness 03/08/2021 Full Requires improvement to be good 27/11/2019 Full Good Assurance inspection report for children’s home: SC407929 6

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet the Care Standards Act 2000, Children’s Homes (England) Regulations 2015 and the ‘Guide to the Children’s Homes Regulations, including the quality standards’. The registered person(s) must comply within the given timescales.

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who—

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Requirement Due date

understand the children’s home’s overall aims and the outcomes it seeks to achieve for children;

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Requirement Due date

use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

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Requirement Due date

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

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Requirement Due date

provide to children living in the home the physical necessities they need in order to live there comfortably;

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Requirement Due date

ensure that the premises used for the purposes of the home are designed and furnished so as to—

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Requirement Due date

meet the needs of each child. (Regulation 6 (1)(a)(b) (2)(b)(vii)(c)(i))

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Requirement Due date

This specifically relates to the managers ensuring that the environment is improved and meets the needs of the children living in the home. 24 July 2022

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Requirement Due date

The health and well-being standard is that—

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Requirement Due date

the health and well-being needs of children are met; and children are helped to lead healthy lifestyles.

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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 help each child to— 24 July 2022 Assurance inspection report for children’s home: SC407929 7 take part in activities, and attend any appointments, for the purpose of meeting the child’s health and well-being needs. (Regulation 10 (1)(a)(c) (2)(a)(iii))

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Requirement Due date

This specifically relates to the manager ensuring that the actions set by medical professionals within children’s health reviews are completed.

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Requirement Due date

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

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Requirement Due date

an understanding about acceptable behaviour; and

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Requirement Due date

positive responses to other children and adults.

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Requirement Due date

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

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Requirement Due date

meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans. (Regulation 11 (1)(b)(c) (2)(a)(i))

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Requirement Due date

This specifically relates to provider ensuring that staff support children to keep safe and that staff follow children’s plans. 24 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

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; 24 July 2022 Assurance inspection report for children’s home: SC407929 8 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;

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Requirement Due date

that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm;

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Requirement Due date

that the premises used for the purposes of the home are located so that children are effectively safeguarded; and

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Requirement Due date

that the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (a)(i)(ii)(iii)(iv)(v)(vi)(vii)(b)(c)(e))

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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

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; 24 July 2022 Assurance inspection report for children’s home: SC407929 9 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; 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)(b)(c)(d)(e)(f)(h))

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Requirement Due date

The registered person must recruit staff using recruitment procedures that are designed to ensure children’s safety.

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Requirement Due date

employ an individual to work at the children’s home; or

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

full and satisfactory information is available in relation to the individual in respect of each of the matters in Schedule 2. (Regulation 32 (1) (2)(a)(b) (3)(d))

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Requirement Due date

This specifically relates to the registered manager ensuring that all gaps in agency employment are checked and that information about the worker is clear and consistent. 24 July 2022

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Requirement Due date

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 (5))

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Requirement Due date

This specifically relates to the statement of purpose being up to date with the care that is provided in the home. 24 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 24 July 2022 Assurance inspection report for children’s home: SC407929 10 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

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

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 (1)(a)(b) (3)(a)(vii)(viii)(b)(i)(ii)(c)

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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—

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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. (Regulation 23 (1) (2)(a))

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Requirement Due date

In particular, the registered person must ensure that medication is stored safely.

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Requirement Due date

This requirement was raised at the last inspection and was not reviewed during this inspection. 1 June 2022

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Requirement Due date

The registered person may only use devices for the monitoring or surveillance of children if— 1 June 2022 Assurance inspection report for children’s home: SC407929 11 the monitoring or surveillance is for the purpose of safeguarding and promoting the welfare of the child concerned, or other children. (Regulation 24 (1)(a))

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Requirement Due date

This specifically relates to ensuring that door alarms, CCTV and two-way radios are only used as set out in a child’s agreed risk assessment.

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Requirement Due date

This requirement was raised at the last inspection and was not reviewed during this inspection.

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Requirement Due date

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; and

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Requirement Due date

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

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Requirement Due date

This specifically relates to managers ensuring that all staff working in the home receive practice-related supervision and appraisals. 24 July 2022

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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. (Regulation 36 (1)(a)(b))

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Requirement Due date

This specifically relates to the need for the home to have children’s up-to-date care plans and education plans. 24 July 2022

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendation

 The registered person should have a workforce plan which can fulfil the workforce-related requirements of regulation 16, schedule 1. The plan should be updated to include any new training and qualifications completed by staff and used to record the ongoing training and continuing professional development needs of staff, including the home’s manager. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 53, paragraph 10.8) Assurance inspection report for children’s home: SC407929 12

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Children’s home details

Registered provider: Our Place (2008) Limited

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Inspectors

Sophie Hills, Social Care Inspector Sarah Billett, Social Care Inspector Assurance inspection report for children’s home: SC407929 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.

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Inspectors

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Inspectors

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Inspectors

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Inspectors

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