Children's Home run by Mulberry House Care Homes Limited in Staffordshire

Assurance inspection report for children’s home: SC060554 1 SC060554

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Registered provider: Mulberry House Care Homes Limited

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Inspected under the social care common inspection framework

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Information about this children’s home

This home provides care for up to three children who have been affected by adverse childhood experiences that have led to associated trauma and complex behaviours.

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Information about this children’s home

The manager registered with Ofsted in November 2022 and also manages another children’s home in the same company.

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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: SC060554 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

 Safeguarding arrangements in the home are inadequate, for example in relation to child sexual exploitation, online safety, substance misuse and when children go missing from the home.  Leaders’ and managers’ oversight of the care provided for children is inadequate and does not ensure that children are safeguarded, or their welfare promoted.  Some staff do not have the skills, experience or knowledge to consistently meet the children’s needs.  Staff are not provided with clear advice or guidance on how to meet children’s needs, including on how best to safeguard them against known risk factors.  Staff are not effective at managing children’s behaviours, and, as a result, one child faces being criminalised for physically assaulting staff.  Leaders have not taken sufficient action to address requirements made at previous inspections.

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The care of children

There was one child living in the home during the inspection.

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The care of children

During this inspection, the inspectors identified serious and widespread concerns in the safeguarding arrangements and leadership and management of the home. The monitoring and oversight of the home have failed to identify several shortfalls that have had an impact on children’s safety, progress and day-to-day experiences at the home. In response, Ofsted has issued a notice restricting accommodation at the home. In addition, compliance notices were issued under regulations 12, the protection of children standard and regulation 13, the leadership and management standard.

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The care of children

Since the last inspection, two children have left the home. For one child, staff supported the child to move into independence in line with the child’s plans. The move was planned effectively with the local authority. However, following a physical assault on a younger child in the home, another child left the home suddenly and the child moved into the company’s supported living setting. Staff told inspectors that the child was ‘very unhappy’, and that they were ‘sad at how the placement had ended for him.’’ Assurance inspection report for children’s home: SC060554 3 Some staff do not always apply the home’s therapeutic model of care to support children. For example, following a recent increase in incidents with one child, staff told the inspectors that the child was not ‘sorry’ and had not apologised for their recent behaviour and actions. Also, staff do not carry out specific work with children in relation to children’s individual needs. For example, staff have failed to complete

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The care of children

direct work around online safety with one child. Failing to understand the impact of childhood trauma and not applying therapeutic care to support children increases their vulnerability.

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The care of children

While staff understand the importance of education for children, one child has not attended formal education since 9 November 2022. Staff have worked with the relevant professionals to seek an appropriate place for the child’s education. However, for one child not in education staff have not provided support to enable them to access appropriate educational activity throughout the day.

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The safety of children

Safeguarding arrangements in the home are inadequate. Leaders and managers have failed to consistently work effectively with external professionals to put in place measures to keep children safe. Staff do not fully understand children’s risks and do not take effective action to reduce these risks. For example, despite one child being at risk of exploitation when using the internet, leaders have failed to ensure that clear guidance and protocols are in place for staff to follow in order to keep the child safe online. As a result, managers and staff told the inspectors conflicting information about how they will respond to risks to the child and have not taken action to increase the child’s safety. One external professional said, ‘[The child living in the home] was not safe with the amount of freedom [they are currently having access to,’] and ‘[The child] does not feel safe in the local area due to threats

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The safety of children

Protocols to keep children safe are either unclear or do not exist. This means that staff practice is inconsistent and ill informed. For example, managers and staff gave different accounts to the inspectors on whether they should physically follow one child when they leave the home. As a result of this indecisive action, one child left the home during the inspection without staff supervision and returned under the influence of substances. However, staff did take some action to monitor the child’s welfare following the child returning home.

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The safety of children

Inspectors found serious shortfalls in how staff manage children’s behaviour. For example, staff told the inspectors that they are not able to physically restrain one child in order to keep them safe, due to a possible health condition. However, managers told inspectors that staff should physically intervene. There was no clear guidance on what staff should do, should the child display violent and/or aggressive behaviours. Consequently, during significant incidents, the child was able to assault staff, who are now pressing charges against the child. This means that the child may be criminalised for this behaviour. In response to these incidents, a police professional said, ‘There was a clear lack of staff and ability [to provide care for Assurance inspection report for children’s home: SC060554 4 children] despite advice previously being given.’ These shortfalls leave children and others at risk of harm.

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The safety of children

The registered manager has failed to notify Ofsted of significant incidents involving children. For example, on one occasion, a child left the home at 22:30pm in a distressed state whereby she informed staff that she had met up with an unknown male in the community. This led to staff reporting the matter to the police as staff could not be sure that the child was safe. On another occasion, a sharp knife was found to have been brought into the home, which led to the registered manager involving the police. However, the manager failed to notify Ofsted of these incidents. Consequently, Ofsted is unable to carry out its monitoring function to ensure that the provider takes appropriate action to safeguard children.

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The safety of children

Despite the shortfalls, the inspectors found that, on some occasions, staff have taken action to gather and share intelligence with the police and external professionals. This has led to external professionals taking enforcement action to safeguard the child.

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The effectiveness of leaders and managers

Leaders and managers have failed to consistently work effectively with external professionals in order to put in place measures to improve children’s experiences, progress and safety. In addition, they have not advocated or challenged consistently the responses of external agencies to ensure that effective safeguarding arrangements are in place for the child. For example, the registered manager does not agree with the placing authority’s decision for the child to have free time and has not challenged this. As a result, the multi-agency team around the child’s response has been muddled and confused and has failed to increase the child’s safety.

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The effectiveness of leaders and managers

Not all staff have the skills, experience, or knowledge to identify and act on risk to children. For example, some staff have not completed training to help them to understand and respond effectively to issues relating to children who go missing from home and children who are vulnerable to exploitation. In addition, not all staff are trained in keeping children safe when using the internet. As a result, some staff are unaware of the action they should take to keep vulnerable children safe. Staff are not curious, and their lack of knowledge has meant that they have not used opportunities to monitor children in order to increase their safety, such as carrying out regular phone checks. This has contributed to staff not identifying patterns or trends that cause concern, such as a child advising that they are ‘putting out the cat’ as a mechanism to leave the home.

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The effectiveness of leaders and managers

Leaders and managers have failed to identify the wide-ranging shortfalls in the safeguarding and care planning arrangements for children. The responsible individual informed inspectors that she had not been receiving alerts to safeguarding incidents in the home via the home’s recording system due to errors in the system. This meant that she was not fully aware of the shortfalls identified until alerted by the inspectors. Consequently, leaders’ decision-making in relation to children’s risk Assurance inspection report for children’s home: SC060554 5 management plans is inadequate. Ineffective monitoring systems do not support the protection of children or improve the quality of care that they receive.

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The effectiveness of leaders and managers

Management oversight and monitoring of the home are poor. Leaders and managers have not taken sufficient action to address requirements made at previous inspections. At the last full inspection, Ofsted raised five requirements and one recommendation. However, leaders and managers have failed to meet three of the requirements and the recommendation. Repeated breaches of regulation do not assure Ofsted that leaders and managers have the capacity to take effective action to bring about the change necessary to improve the quality of care that children receive. Assurance inspection report for children’s home: SC060554 6

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Inspection date Inspection type Inspection judgement

04/10/2022 Full Requires improvement to be good 10/08/2021 Full Requires improvement to be good 26/04/2021 Full Inadequate 18/12/2019 Interim Improved effectiveness Assurance inspection report for children’s home: SC060554 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 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; and

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Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare. (Regulation 12 (1) (2)(a)(i)(vi))

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Requirement Due date

In particular, the registered persons should ensure that staff assess children’s risks effectively and take action to keep children safe.

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Requirement Due date

This requirement was made at the last inspection and is restated. 19 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; 26 March 2023 Assurance inspection report for children’s home: SC060554 8 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; 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)(c)(f)(h))

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Requirement Due date

In particular, the registered persons must ensure that the home has suitably trained and skilled staff to work with children and protect them from harm.

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Requirement Due date

In addition, the registered persons should ensure that they have effective oversight and monitoring of children’s risks and staff’s responses to significant incidents in the home. It further relates to the manager’s oversight of the quality of care children receive in the home. Managers must also have clear monitoring and review systems in place to improve practice and understand children’s progress and experiences.

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Requirement Due date

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

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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

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 (c)(d))

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Requirement Due date

In particular, the registered persons should ensure that they work effectively with external professionals to put in place measures to keep children safe. Also, the registered persons should ensure that they consistently challenge the relevant 26 March 2023 Assurance inspection report for children’s home: SC060554 9 professionals’ performance when their response and support does not reflect the level of risk for children.

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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;

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Requirement Due date

encourage each child to take responsibility for the child’s behaviour, in accordance with the child’s age and understanding;

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Requirement Due date

help each child to develop and practise skills to resolve conflicts positively and without harm to anyone;

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Requirement Due date

help each child to understand, in a way that is appropriate according to the child’s age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful; and

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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. (Regulation 11 (1)(a)(b)(c) (2)(a)(i)(iii)(iv)(vi)(ix))

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Requirement Due date

In particular, the registered persons should ensure that staff understand and are equipped with the skills to identify that children’s previous experiences and trauma may be communicated through their behaviour. Also, leaders are to ensure that staff carry out specific and direct work with children in line with their needs to help them learn from their experiences. 26 March 2023

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Requirement Due date

The care planning standard is that children— 26 March 2023 Assurance inspection report for children’s home: SC060554 10 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

plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements agreed with the child’s placing authority. (Regulation 14 (1)(a)(b) (2)(b)(iii))

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Requirement Due date

In particular, the registered persons should ensure that they work effectively with placing authorities to support children to leave the home in a manner which does not impact on children’s emotional well-being.

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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

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious; and

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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)(b)(e))

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Requirement Due date

In particular, leaders must ensure that all significant incidents with children and incidents that require police involvement are notified to Ofsted.

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Requirement Due date

This requirement was made at the last inspection and is restated. 26 March 2023

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendations

 The registered person should ensure that children are in full-time education while they are of compulsory school age, unless their personal education plan contained within the care plan or other relevant plan states otherwise. The home must aim to support full-time attendance at school unless the child’s relevant plan indicates Assurance inspection report for children’s home: SC060554 11 this is not in their best interests. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 28, paragraph 5.14) Assurance inspection report for children’s home: SC060554 12

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Children’s home details

Registered provider: Mulberry House Care Homes Limited

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Children’s home details

Registered provider address: 2 Railway Street, Stafford, Staffordshire ST16 2EA

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Inspectors

Dean Wilton, Social Care Inspector Mark Dickinson, Social Care Inspector Assurance inspection report for children’s home: SC060554 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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