Children's Home, Residential special school run by Kisimul Group Limited in Lincolnshire

Inspection report for children’s home: SC034241 1 SC034241 Registered provider: Kisimul Group Ltd Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This residential special school is registered as a children’s home because children stay overnight for more than 295 days per year. The home provides care for up to 37 children and young people with severe learning difficulties.

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Information about this children’s home

The home is led by an acting manager who is not registered with Ofsted.

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Information about this children’s home

The home also incorporates a school, which the children attend. Inspectors only inspected the social care provision on this site.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

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

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inadequate

Date of last inspection: 17 November 2022

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inadequate

Overall judgement at last inspection: good

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inadequate

Enforcement action since last inspection: none Inspection report for children’s home: SC034241 2

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Inspection date Inspection type Inspection judgement

17/11/2022 Full Good 24/08/2021 Full Good 10/09/2019 Full Requires improvement to be good 18/06/2019 Full Inadequate Inspection report for children’s home: SC034241 3

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inadequate

There are three homes under the same registration. Two are settled, with evidence of children making good progress and having positive relationships with staff. This is a significant contrast to the third home, where there are serious concerns identified in relation to safeguarding children and leadership.

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inadequate

In the two settled homes, the environment was calm, supportive, nurturing and tailored to children’s individual needs.

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inadequate

In the third home, the environment was chaotic, and not well personalised to the children’s needs. There was a strong odour of urine and faeces in some areas of the home. One staff member said, ‘It always smells like that in here.’

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inadequate

During the inspection, staff at the third home appeared to be rushed and disorganised. There have been staffing shortages, resulting in high levels of agency staff being used. As a result, the quality of care provided to children has been affected. Not all staff have a thorough understanding of children’s individual complex care needs and how to support them. A child was heard to be crying in her bedroom without emotional support and there was a lack of empathy from staff.

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inadequate

Several staff members have left recently. This has impaired the children’s capacity to form and maintain positive, trusting relationships with staff. Changes in routines and staffing have led to increased instability for children.

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inadequate

In the two settled homes, there is evidence of individualised planning for children to be able to express their views. Communication tools are evident throughout these homes, with positive and proactive planning for this. In the third home, there is very little evidence of the children’s communication systems being used. For some children, the communication tools used do not reflect their specific communication needs. As a result, not all children are not able to share their views.

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inadequate

Not all children have access to independent advocacy services. Some children are receiving advocacy support. However, several children who are geographically and socially isolated do not have independent advocacy services in place. This prevents those child’s views and wishes from being sought and acted on.

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

When safeguarding incidents occur, the recording and reporting of significant information is, in some cases, poor. Information is not always shared with relevant safeguarding agencies in a timely manner. Such practice prevents effective monitoring of the home by safeguarding agencies and limits their ability to protect children. Inspection report for children’s home: SC034241 4 A staff member delayed reporting a significant safeguarding concern about a colleague. This was investigated once leaders became aware. However, there is conflicting information about the incident and new information came to light during the inspection. This is still being investigated. Systems and processes for managing allegations against staff are not robust.

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

When another safeguarding incident occurred, there was also a delay in this being referred to the local authority, the local authority designated officer and the police. This delay compromised the child protection investigation. The home’s and the local area safeguarding procedures have not been followed.

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

Physical intervention is not always proportionate. On one occasion, staff held a child unnecessarily on the floor. On another occasion, a child was held on the floor for seven minutes by four staff. This incident has not been reviewed by leaders. This lack of management oversight places children at risk and impairs staff’s and leaders’ capacity to learn from incidents.

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

Staff members have reported other concerns to the acting manager, who has not acted on these. For example, staff reported concerns about a staff member sleeping on a waking night shift and the acting manager did not act. Staff have lost faith in the acting manager’s ability to act on their concerns to safeguard children.

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

Leaders have failed to ensure that staff implement children’s plans and assessments. Despite plans being regularly reviewed and detailing children’s individual needs and communication systems, these are not always implemented by the staff. For example, one child’s assessment outlines their communication aids to be used to prevent the child from becoming frustrated . However, these systems are not always used. This prevents the child from being supported to manage their feelings and behaviours and impedes their ability to have their voice heard.

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The effectiveness of leaders and managers: inadequate

Dedicated managers have a strong presence in two of the homes. Staff in these homes feel listened to and appreciated. The leadership and management of the third home has deteriorated at pace since the last inspection.

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The effectiveness of leaders and managers: inadequate

There is currently no overall registered manager in post. The acting manager had started the process of registering with Ofsted; however, his application was returned to him as incomplete three months ago and he has not progressed it since. Leaders were not aware of this.

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The effectiveness of leaders and managers: inadequate

Senior leaders have identified significant shortfalls in the leadership and management of the home themselves. Although they had started to intervene, this level of support did not go far enough to minimise the serious and widespread concerns that were emerging within the home. Inspection report for children’s home: SC034241 5 Leaders have failed to ensure that effective oversight and monitoring systems are in place for the third home. The acting manager has not consistently evaluated important documents and there is a lack of analysis and review. This has led to several shortfalls which relate to the day-to-day running of the home. For example, not all restraint records have been reviewed, information about a child was not gathered prior to them moving into the home, and one child’s local authority plan was not held on file with no attempts to request this information. The acting manager has failed to ensure that staff consistently work in line with children’s plans

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The effectiveness of leaders and managers: inadequate

and assessments. This prevents children from receiving good, individualised, consistent care.

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The effectiveness of leaders and managers: inadequate

Managers have failed to act on staff’s concerns. Repeated concerns have been raised by staff in relation to care and staffing and not acted on quickly enough by the acting manager. This has impacted on staff’s confidence in the acting manager to act on their concerns.

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The effectiveness of leaders and managers: inadequate

Several staff have left recently and the dynamics in the team have changed. Not all staff have received training to equip them to meet children’s individual needs. For example, one staff member has worked in the home for 18 months and has not yet received training in restraint. This has the potential to place children and staff at increased risk of harm. High levels of agency staff and staff from other homes within the organisation are being used daily to cover shortfalls in the rota. A staff member said, ‘There are so many inexperienced staff, resulting in new staff being coached by inexperienced staff.’ There are not enough core staff who are trained and experienced.

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The effectiveness of leaders and managers: inadequate

Following significant shortfalls being identified during this inspection, senior managers responded without delay. Some immediate action was taken to address the shortfalls and an action plan was devised to minimise any further impact on children. Inspection report for children’s home: SC034241 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 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

take their views, wishes and feelings into account in relation to matters affecting 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

help each child to express views, wishes and feelings;

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Requirement Due date

is given appropriate advocacy support; (Regulation 7 (1)(a)(b)(c) (2)(a)(ii)(b)(iii))

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Requirement Due date

This specifically relates to ensuring that children have access to advocacy services and are provided with an opportunity to express their views and wishes, including after a restraint. 12 June 2023

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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

have the skills to identify and act upon signs that a child is at risk of harm; 12 June 2023 Inspection report for children’s home: SC034241 7 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 effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (1) (2)(a)(iii)(v)(vi)(vii)(b)(e))

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Requirement Due date

This is specifically in relation to ensuring that safeguarding information is acted on and shared with professionals without delay. It also relates to ensuring that staff are confident in reporting poor practice and understand their roles and responsibilities to safeguard children.

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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

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

This specifically relates to managers improving monitoring systems in the home to improve the quality of care. It also relates to the home having sufficient staffing without regular use of staff from other homes and agency staff members. 12 June 2023 Inspection report for children’s home: SC034241 8 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.

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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

manage and review the placement of each child in the home. (Regulation 14(1)(a) (2)(b)(ii))

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Requirement Due date

This specifically relates to managers ensuring that children’s care plans are accurate and up to date. 12 June 2023

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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)(b)(i)(ii)(c))

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Requirement Due date

This specifically relates to the manager ensuring that records of physical intervention are reviewed in a timely manner and child debriefs are completed within the required timescale. 12 June 2023

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Requirement Due date

* These requirements are subject to a compliance notice.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people, using the social care common inspection framework. This inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with the Children’s Homes (England) Regulations 2015 and the ‘Guide to the Children’s Homes Regulations, including the quality standards’. Inspection report for children’s home: SC034241 9

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Children’s home details

Provision sub-type: Residential special school

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Children’s home details

Registered provider address: Kisimul School, The Old Vicarage High Street, Swinderby, Lincoln, Lincolnshire LN6 9LU

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Inspectors

Zoey Lee, Social Care Inspector Bev Allison, Social Care Inspector Thirza Smith, Social Care Inspector Inspection report for children’s home: SC034241 10 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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