Children's Home run by First Steps Care Ltd in Worcestershire

Assurance inspection report for children’s home: 2636996 1 Registered provider: First Steps Care Ltd

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Inspected under the social care common inspection framework

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Information about this children’s home

This home opened in September 2021 and is owned by a private company. It is registered to care for up to four children who may have specific emotional needs and are likely to have experienced trauma.

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Information about this children’s home

The home has been without a registered manager since 8 February 2022. The home’s new manager had applied to register but withdrew their application during this assurance inspection.

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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 this inspection, 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: 2636996 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 are not kept safe from harm by staff when they disclose abuse.  Leaders and managers fail to safeguard children effectively.  Leaders and managers do not understand or follow safeguarding procedures, either their internal procedures or local authority statutory procedures.  Leaders and managers fail to take action when children tell them they are unsafe or have been harmed.  Leaders and managers fail to advocate for children and ensure their voice is heard.  Monitoring systems are ineffective in identifying safeguarding concerns.  Leaders and managers do not have effective systems where they record safeguarding concerns, including the action they take and any outcomes.  There has been no registered manager since February 2022. Current management arrangements are not effective.

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The care of children

Serious shortfalls in the safeguarding and care of children identified at this inspection have resulted in Ofsted issuing the provider with a notice of restriction of accommodation, alongside a compliance notice under regulation 12 (the protection of children standard).

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The care of children

At the time of this inspection, three children were living in the home. One child has lived here since before the previous inspection and two children have moved in since then. One child has moved on from the home since the last inspection, in an unplanned way. The child was not prepared for this and the move itself was poorly managed. Promises made to the child about the staff team’s future contact with them have not been kept. Leaders have not reflected on this and demonstrated any learning to support future children’s care planning.

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The care of children

Children have made complaints since the last inspection relating to their care and safety. Managers have on some occasions lost the records of these complaints. On other occasions, managers’ responses to children were poor and they did not listen to what children were saying. Insufficient action was taken to improve things for children.

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The care of children

There is a culture in the home of restrictive care. For example, children still do not have free access to a phone to talk to the important people in their lives if they want Assurance inspection report for children’s home: 2636996 3 to. Door alarms are not being used in line with children’s plans. One child asked to speak to an external professional in private at the home and leaders refused this request, without considering why the child may have needed to speak to someone. This creates an environment which is not allowing children freedom in line with their rights.

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The care of children

The home environment is well presented and homely. During the inspection, children were playing computer games with staff and cooking with them, evidencing some warm relationships.

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The safety of children

Leaders and managers have failed to protect children from harm. Managers do not understand how to safeguard children, and therefore fail to follow their own internal safeguarding procedures or local authority safeguarding procedures.

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The safety of children

When children have made disclosures of abuse and say they do not feel safe around peers in the home, staff and managers have not taken action to ensure the child feels listened to. They fail to ensure that investigations into the concern take place with partner agencies and that measures are then put in place to reduce the risk of such concerns happening again.

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The safety of children

Staff do not listen to and advocate for children when they disclose abuse outside the home. In one incident, managers failed to follow safeguarding procedures, meaning the child never had to opportunity to speak to their social worker about their disclosure. In addition, staff talked to the child about them lying, before any investigation had taken place to find out what might have happened to them. This fails to protect children from harm and continues to leave them vulnerable.

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The safety of children

Staff do not have the skills to support children effectively when they are upset and need support to help calm their behaviour. In some incidents, staff ignore children when they are clearly distressed, while in another situation, staff held a child for a lengthy period of time when other methods could have been tried to help calm the child down. Managers’ oversight of these incidents is ineffective.

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The safety of children

Staff do not meet children’s medical needs. Staff have failed to administer one child’s routine prescribed medication on multiple occasions. Managers have not investigated this effectively to address the poor practice and reduce the risk of it happening again.

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The safety of children

Serious incidents have occurred in the home. Safeguarding records are extremely poor and in some cases information is not recorded at all. Ofsted has not been notified of serious incidents when these have occurred. During the inspection, managers and staff were seen trying to piece together safeguarding records. This poor practice means that it is difficult to understand the full picture of children’s experiences and if appropriate action is taken by leaders to protect children in all cases. Assurance inspection report for children’s home: 2636996 4

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The effectiveness of leaders and managers

Leaders and managers have failed to make the necessary improvements since the previous inspection. Twelve requirements and one recommendation were issued at the last full inspection. Shortfalls have continued; 10 requirements are not met and are restated. Two requirements, relating to the review of premises and staff recruitment, will be reviewed at the next inspection. A further four requirements were made at this inspection.

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The effectiveness of leaders and managers

Leaders and managers fail to understand and identify practice concerns. Managers fail to identify safeguarding concerns and take action to instigate procedures. In one incident, the previous responsible individual gave the manager inaccurate advice relating to safeguarding procedures to follow.

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The effectiveness of leaders and managers

Managers fail to alert professionals when children have disclosed abuse. They also fail to put plans in place to reduce risks. When staff practice with children has been poor, the manager has not identified this and has concluded in her oversight that the care has been good.

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The effectiveness of leaders and managers

Managers’ monitoring is ineffective. It fails to identify shortfalls and evaluate children’s experiences. The quality of care review is poor. The independent person does not consult with professionals and children effectively and has not been ensuring that they carry out monthly reviews of the care in the home.

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Inspection date Inspection type Inspection judgement

22/06/2022 Full Requires improvement to be good 31/01/2022 Full Requires improvement to be good Assurance inspection report for children’s home: 2636996 5

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Statutory requirements

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

seek to develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate having regard to the range of needs of children for whom it is intended that the children’s home is to provide care and accommodation. (Regulation 5 (a)(b)(c)(d))

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Requirement Due date

This specifically relates to the registered person ensuring that they communicate clearly with professionals and children’s families and seek to ensure other professionals fulfil their roles in supporting children.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 28 February 2023

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Requirement Due date

The children’s views, wishes and feelings standard is that children receive care from staff who—

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Requirement Due date

develop positive relationships with them;

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Requirement Due date

engage with them; and 28 February 2023 Assurance inspection report for children’s home: 2636996 6 take their views, wishes and feelings into account in relation to matters affecting the children’s care and welfare and their lives.

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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

ascertain and consider each child’s views, wishes and feelings, and balance these against what they judge to be in the child’s best interests when making decisions about the child’s care and welfare;

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Requirement Due date

help each child to express views, wishes and feelings;

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Requirement Due date

help each child to understand how the child’s views, wishes and feelings have been taken into account and give the child reasons for decisions in relation to the child;

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Requirement Due date

regularly consult children, and seek their feedback, about the quality of the home’s care;

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Requirement Due date

help each child to understand how the child’s privacy will be respected and the circumstances when it may have to be limited;

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Requirement Due date

help each child to prepare for any review of the child’s relevant plans and to make the child’s views, wishes and feelings known for the purposes of that review; and

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Requirement Due date

make each child aware of and, if necessary, remind them of each of the matters in sub-paragraph (d)(i) to (iii);

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Requirement Due date

is enabled to provide feedback to, and raise issues with, a relevant person about the support and services that the child receives;

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Requirement Due date

has access to the home’s children’s guide, and the home’s complaints procedure, when the child’s placement in the home is agreed and throughout the child’s stay in the home; and

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Requirement Due date

is given appropriate advocacy support. Assurance inspection report for children’s home: 2636996 7 (Regulation 7 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(b)(i)(ii)(iii))

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Requirement Due date

This specifically relates to the registered person ensuring that children are supported to understand how to make a complaint or provide feedback if they wish to, and that this is listened to by managers. Children should have access to the children’s guide and be supported to provide feedback on their care.

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Requirement Due date

This requirement was made at the previous inspection and is restated.

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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— that staff—

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Requirement Due date

meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans;

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Requirement Due date

strive to gain each child’s respect and trust;

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Requirement Due date

understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children;

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Requirement Due date

de-escalate confrontations with or between children, or potentially violent behaviour by children;

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Requirement Due date

understand and communicate to children that bullying is unacceptable; and

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Requirement Due date

have the skills to recognise incidents or indications of bullying and how to deal with them. (Regulation 11 (1)(a)(b)(c) (2)(i)(viii)(ix)(xi)(xii)(xiii))

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Requirement Due date

This specifically relates to the registered person ensuring that staff listen to children and care for them in a nurturing 28 February 2023 Assurance inspection report for children’s home: 2636996 8 way, providing reassurance if children are worried, and that any issues of bullying should be promptly responded to so that children are safeguarded.

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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

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)(vi)(vii))

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Requirement Due date

This specifically relates to the registered person ensuring that there are plans in place to keep children safe, that staff follow these plans and take action to protect children from harm, and that they and staff clearly understand and follow safeguarding procedures.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 28 February 2023

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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; 28 February 2023 Assurance inspection report for children’s home: 2636996 9 ensure that staff have the experience, qualifications and skills to meet the needs of 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

and 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))

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Requirement Due date

This specifically relates to the registered person ensuring that staff are skilled and trained to sufficiently meet children’s needs and that they monitor the quality of care in the home and use this to develop children’s care.

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Requirement Due date

This requirement was made at the previous inspection and is restated.

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Requirement Due date

The care planning standard is that children—

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Requirement Due date

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

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Requirement Due date

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

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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 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, asset out in the home’s statement of purpose;

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Requirement Due date

ensure the effective induction of each child into the home. (Regulation 14 (1)(a)(b) (2)(a)(b)(i))

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Requirement Due date

This specifically relates to the registered person ensuring that they have sufficient information to understand and assess how to meet a child’s needs before they are moved into the home.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 28 February 2023 Assurance inspection report for children’s home: 2636996 10 Restraint in relation to a child is only permitted for the purpose of preventing—

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Requirement Due date

injury to any person (including the child);

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Requirement Due date

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

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Requirement Due date

a child who is accommodated in a secure children’s home from absconding from the home.

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Requirement Due date

Restraint in relation to a child must be necessary and proportionate.

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Requirement Due date

These Regulations do not prevent a child from being deprived of liberty where that deprivation is authorised in accordance with a court order. (Regulation 20 (1)(a)(b)(c) (2) (3))

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Requirement Due date

This specifically relates to the registered person ensuring that children’s liberties are not restricted, unless this is necessary and proportionate.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 28 February 2023

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Requirement Due date

The registered person must ensure that suitable facilities are provided within the children’s home for any child accommodated there to meet privately at any reasonable time with the child’s parents, friends, relatives or any of the following persons—

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Requirement Due date

a solicitor or other adviser or advocate acting for the child;

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Requirement Due date

an officer of the Children and Family Court Advisory and Support Service appointed forthe child;

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Requirement Due date

a person authorised by the local authority in whose area the home is located;

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Requirement Due date

a person appointed pursuant to section 23ZB (independent visitors for children looked after by a local authority) of the Children Act 1989(25); 28 February 2023 Assurance inspection report for children’s home: 2636996 11 a person authorised in accordance with section 80(2) of the Children Act 1989 by the Secretary of State to conduct an inspection in relation to the home and the children there;

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Requirement Due date

a person appointed under the Children Act 1989 Representations Procedure (England)Regulations 2006(26);

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Requirement Due date

an independent person visiting the home under regulation 44.

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Requirement Due date

The facilities may be at a different address if a certificate under section 51 of the Children Act 1989(27) is in force in relation to the home.

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Requirement Due date

Subject to paragraph (5), the registered person must ensure that children are provided at all reasonable times with access to the following facilities which they may use without reference to persons working in the home—

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Requirement Due date

a telephone on which to make and receive telephone calls in private; and

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Requirement Due date

facilities to send and receive post and, if the necessary facilities are provided for the use of children, electronic mail, in private. (Regulation 22 (1)(a)(b)(c)(d)(e)(f)(g)(h)(i) (2) (3)(a)(b))

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Requirement Due date

This specifically relates to the registered person ensuring that children are able to have private conversations with their social worker and with others via phone at all times, and that they do not have to request access to be able to make such calls.

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Requirement Due date

This requirement was made at the previous inspection and is restated.

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Requirement Due date

The registered person may only use devices for the monitoring or surveillance of children if—

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Requirement Due date

the monitoring or surveillance is for the purpose of safeguarding and promoting the welfare of the child concerned, or other children;

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Requirement Due date

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

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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 28 February 2023 Assurance inspection report for children’s home: 2636996 12 intention to do the monitoring or surveillance; and

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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))

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Requirement Due date

This specifically relates to the registered person ensuring that any surveillance or monitoring imposed on children is proportionate and necessary, and that the local authority provides written consent ahead of this being used, and that this is regularly reviewed to check if it is still required.

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Requirement Due date

This requirement was made at the previous inspection and is restated.

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Requirement Due date

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

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Requirement Due date

employ an individual to work at the children’s home; or 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, if the individual satisfies the requirements in paragraph (3).

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Requirement Due date

the individual is of integrity and good character;

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Requirement Due date

the individual has the appropriate experience, qualification and skills for the work that the individual is to perform;

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Requirement Due date

the individual is mentally and physically fit for the purposes of the work that the individual is to perform; and

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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)(a)(b)(c)(d))

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Requirement Due date

This specifically relates to the registered person ensuring that they obtain checks under schedule 2 prior to employees starting work.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 30 March 2023 Assurance inspection report for children’s home: 2636996 13 The registered person must ensure that—

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

a description of the measure and its duration;

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

has spoken to the user about the measure; and

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Requirement Due date

has signed the record to confirm it is accurate; and

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Requirement Due date

within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c))

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Requirement Due date

This specifically relates to the registered person ensuring that staff and children have debriefs after physical interventions and that managers properly oversee records. 28 February 2023 Assurance inspection report for children’s home: 2636996 14 This requirement was made at the previous inspection and is restated.

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Requirement Due date

The registered person must ensure that the following items, which may be kept in electronic form, are kept in an accessible manner—

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Requirement Due date

children’s case records (see regulation 36);

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Requirement Due date

other records (see regulation 37). (Regulation 38 (i)(j))

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Requirement Due date

This specifically relates to the online system used for storing plans and incident records, ensuring that this can be quickly and easily accessed and that a robust plan is in place in the event that staff are unable to access the online system. The registered person should ensure that staff and managers make use of their recording system so that records are accessible as needed.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 28 February 2023

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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;

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Requirement Due date

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 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 specifically relates to the registered person ensuring Ofsted is notified of serious incidents. 28 February 2023 Assurance inspection report for children’s home: 2636996 15 The registered person must ensure that an independent person visits the children’s home at least once each month.

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Requirement Due date

When the independent person is carrying out a visit, the registered person must help the independent person—

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Requirement Due date

if they consent, to interview in private such of the children, their parents, relatives and persons working at the home as the independent person requires; and

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Requirement Due date

to inspect the premises of the home and such of the home’s records (except for a child’s case records, unless the child and the child’s placing authority consent) as the independent person requires.

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Requirement Due date

A visit by the independent person to the home may be unannounced.

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Requirement Due date

The independent person must produce a report about a visit ("the independent person’s report") which sets out, in particular, the independent person’s opinion as to whether—

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Requirement Due date

children are effectively safeguarded; and

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Requirement Due date

the conduct of the home promotes children’s well-being.

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Requirement Due date

The independent person’s report may recommend actions that the registered person may take in relation to the home and timescales within which the registered person must consider whether or not to take those actions. (Regulation 44 (1) (2)(a)(b) (3) (4)(a)(b) (5)

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Requirement Due date

This specifically relates to the registered person ensuring that there are monthly visits from an independent person, and that in these visits the visitor reviews the care in the home and consults with professionals and children. 16 March 2023

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Requirement Due date

The registered person must complete a review of the quality of care provided for children ("a quality of care review") at least once every 6 months.

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Requirement Due date

In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating—

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Requirement Due date

the quality of care provided for children;

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Requirement Due date

the feedback and opinions of children about the children’s 30 March 2023 Assurance inspection report for children’s home: 2636996 16 home, its facilities and the quality of care they receive in it; and

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Requirement Due date

any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children. (Regulation 45 (1) (2)(a)(b)(c))

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Requirement Due date

This specifically relates to the registered person ensuring that they evaluate and review the quality of care for children in their review of care.

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Requirement Due date

The registered person must review the appropriateness and suitability of the location of the premises used for the purposes of the children’s home at least once in each calendar year taking into account the requirement in regulation 12(2)(c) (the protection of children standard).

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Requirement Due date

When conducting the review, the registered person must consult, and take into account the views of, each relevant person. (Regulation 46 (1) (2))

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Requirement Due date

This specifically relates to the registered person ensuring that they consider the hazards in the home’s locality when completing their area risk assessment.

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Requirement Due date

This requirement was made at the previous inspection and is restated. 30 March 2023

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendation

 The registered person should ensure that consequences used to address poor behaviour are restorative in nature, to help children recognise the impact of their behaviour on themselves, other children, the staff caring for them and the wider community. In some cases, it will be important for children to make reparation in some form to anyone hurt by their behaviour and the staff in the home should be skilled to support the child to understand this and carry it out. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 46, paragraph 9.38) Assurance inspection report for children’s home: 2636996 17

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Children’s home details

Registered provider: First Steps Care Ltd

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Children’s home details

Registered provider address: Kemp House, 124 City Road, London EC1V 2NX

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Inspectors

Fiona Roche, Social Care Inspector Nicola Lownds, Regulatory Inspection Manager Assurance inspection report for children’s home: 2636996 18 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

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 .

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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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