Children's home run by Carbrey Care Ltd in Gloucester

Inspection report for children's home: 1155761 1 Registered provider: Carbrey Care Ltd Full inspection Inspected under the social care common inspection framework

p.1

Information about this children’s home

The home is owned by a private provider and offers care for up to three children, aged up to 18 years, with social and/or emotional difficulties. At the time of this inspection, three children were living in the home.

p.1

Information about this children’s home

The manager has been in post since November 2022 and has applied for registration with Ofsted.

p.1

Overall experiences and progress of

children and young people, taking into account

p.1

inadequate

How well children and young people are helped and protected inadequate

p.1

inadequate

The effectiveness of leaders and managers inadequate

p.1

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.

p.1

inadequate

Overall judgement at last inspection: requires improvement to be good

p.1

inadequate

Enforcement action since last inspection: none Inspection report for children's home: 1155761 2

p.1

Inspection date Inspection type Inspection judgement

11/04/2022 Full Requires improvement to be good 12/10/2021 Full Good 30/04/2019 Full Good 25/07/2018 Full Good Inspection report for children's home: 1155761 3

p.2

inadequate

The inspector found many positives in the quality of care and progress being made by children. However, there are serious shortfalls in safer recruitment practice. Had these not been identified at inspection, children currently living in the home, and potentially others living here in the future, may have been placed at risk of harm. This is a serious oversight.

p.3

inadequate

Before children move to this home, they are supported to visit and meet the staff and the other children and are helped to understand what living in the home might be like for them. Leaders and managers consider the needs of the child moving in, how staff can support them, and the impact of the child moving into the home on the children currently living there, and vice versa.

p.3

inadequate

Children are making progress from their starting points. Children’s healthcare and educational needs are mostly being met. All children are attending school and, although they are not in full-time education, their attendance has increased. When children are not in school, appropriate educational activities are provided by the staff.

p.3

inadequate

Children say that they enjoy living in this home. Some children explained that they would prefer to be living with their family, but their current home is the next best thing. Children say that staff listen to them and ‘pick up on the things they like’ so that they can explore their interests together. Children enjoy regularly going swimming, playing pool and going shopping. These activities are often done as a group, which has supported the development of positive relationships between the children and the staff.

p.3

inadequate

External professionals and a family member were able to outline the progress their children had made since moving to the home. They said the staff were doing a good job and that the care children were receiving was contributing to their positive outcomes.

p.3

inadequate

Children’s bedrooms are clean and tidy and are decorated in line with their wishes. The back garden has recently benefited from a paved terrace being laid. However, inside the home, there is damage to the walls and some broken furniture. Moreover, there are physical restrictions in place, such as window restrictors, door alarms, and a canvas is screwed to the wall with metal brackets. Managers are unable to provide a sound rationale for physical restrictions, which detract from the otherwise homeliness of the environment. Inspection report for children's home: 1155761 4

p.3

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

Robust safer recruitment procedures are not in place. In one case, a permanent member of staff started to work with the children without the relevant Disclosure and Barring Service check being received. A risk assessment was put in place and leaders said this member of staff was supervised. Notwithstanding these additional measures, the gravity of this serious failure could have had significant consequences for the safety and protection of children. Furthermore, leaders and managers do not verify the safer recruitment checks completed for agency staff by the agency that employs them. As a result, leaders and managers cannot always determine the suitability of the staff working with the children in the home and assure themselves they have been safely and rigorously vetted.

p.4

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

Three concerns about staff practice have been raised by the children since the last inspection in September 2022. On one occasion, staff did not report a concern raised by a child swiftly, which resulted in delayed action to keep children safe. When concerns are reported, leaders and managers respond quickly to ensure the safety of children. However, on another occasion, despite a concern being reported to the local authority designated officer and an internal investigation taking place, appropriate actions and outcomes were not identified. As a result, learning opportunities for staff were missed and the child who raised the concern was not provided with a resolution.

p.4

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

Restraint has been used on one occasion since the last inspection. However, the restraint record lacks sufficient detail, making it difficult to understand what happened and how the restraint was applied. Incident reports also lack information with regard to the strategies staff have used to support children. In addition, follow- up actions are not always identified, so responses to difficult situations are not always curious.

p.4

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

Medication records and recording procedures are unclear and risk error. When medication errors occur, they are discussed in team meetings and steps are taken to help avoid future mistakes. Despite this, key information remains missing from administration records.

p.4

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

Emergency evacuation records are inconsistent in quality. Some records demonstrate that children can safely exit the building on hearing the fire alarm during the day. However, managers have not considered the support children may require to safely evacuate the building during the night. This is of particular importance given the needs of the children in the home. Inspection report for children's home: 1155761 5

p.4

The effectiveness of leaders and managers: inadequate

There has been a period of instability in the management of the home. However, during this period, management responsibilities have been allocated to appropriate people. The current manager is settling into the home following a period of handover from the previous interim manager.

p.5

The effectiveness of leaders and managers: inadequate

Leaders and managers have some understanding of the strengths of the home and areas for development. The home’s development plans reflect some of the shortfalls identified at this inspection. Leaders and managers are clear that the home has been on, and is still on, a ‘journey of improvement’.

p.5

The effectiveness of leaders and managers: inadequate

Care plans are varied in quality. Most plans provide staff with the information they require to meet children’s needs, while one child’s plans lack sufficient detail. Some children’s plans are written in the first-person narrative, although they have not been written by the child. The home has recently sourced external therapeutic support to provide input into the care being provided by staff.

p.5

The effectiveness of leaders and managers: inadequate

Team meetings are well attended and are used to provide messages to staff about the operation of the home. However, meetings are not always used to reflect effectively on the needs of the children or the care being provided. As a result, the ability to improve the quality of care is limited.

p.5

The effectiveness of leaders and managers: inadequate

Supervisions provide staff with a space to reflect on the needs of the children and the progress they are making. However, on one occasion, when a staff member raised concerns about the team’s inability to meet a child’s needs, there was no further reflection, challenge, or resolution.

p.5

The effectiveness of leaders and managers: inadequate

Staff say that they enjoy their job and feel supported by leaders and managers. They can identify the improvements that have been made since the current manager started in their role. Staff are clear that the children’s best interests are at the forefront and they recognise how the positive relationships they have developed with the children are supporting the progress that is being made. Inspection report for children's home: 1155761 6

p.5

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.

p.6

Requirement Due date

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

p.6

Requirement Due date

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

p.6

Requirement Due date

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

p.6

Requirement Due date

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

p.6

Requirement Due date

provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background. (Regulation 6 (1)(a)(b) (2)(b)(iv))

p.6

Requirement Due date

In particular, the registered person should support staff to reflect on the needs of the children and the support they provide to them. Staff should be supported to evaluate the quality of care provided and take appropriate actions where necessary.

p.6

Requirement Due date

In addition, all care plans should contain sufficient detail to support staff to meet the needs of children. 10 July 2023

p.6

Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

p.6

Requirement Due date

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

p.6

Requirement Due date

assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if 26 June 2023 Inspection report for children's home: 1155761 7 necessary, make arrangements to reduce the risk of any harm to the child;

p.6

Requirement Due date

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

p.7

Requirement Due date

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

p.7

Requirement Due date

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

p.7

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. (Regulation 12 (1) (2)(a)(i)(iii)(v)(vi)(b))

p.7

Requirement Due date

In particular, the registered person should ensure staff are able to identify and report safeguarding concerns in a timely manner.

p.7

Requirement Due date

In addition, when safeguarding concerns are reported, the registered person should ensure appropriate actions and outcomes are identified. Feedback should be provided to the staff and children involved, as appropriate.

p.7

Requirement Due date

After consultation with the fire and rescue authority, the registered person must—

p.7

Requirement Due date

ensure, by means of fire drills and practices at suitable intervals, that persons working at the home and, so far as reasonably practicable, children are aware of the procedure to be followed in case of fire. (Regulation 25 (1)(d))

p.7

Requirement Due date

In particular, the registered person should assess children’s ability to safely evacuate the property should the fire alarm sound. This should include considering the needs of the children and the support they may need if an evacuation was required during the night. 26 June 2023

p.7

Requirement Due date

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

p.7

Requirement Due date

employ an individual to work at the children’s home; or 19 June 2023 Inspection report for children's home: 1155761 8 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,

p.7

Requirement Due date

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

p.8

Requirement Due date

the individual is of integrity and good character;

p.8

Requirement Due date

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

p.8

Requirement Due date

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

p.8

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))

p.8

Requirement Due date

In particular, the registered person should ensure that relevant safer recruitment checks are completed before staff start to work with children in the home.

p.8

Requirement Due date

In addition, the registered person should ensure that they can determine the suitability of agency staff working in the home.

p.8

Recommendations

 The registered person should ensure that the children’s home is a nurturing and supportive environment. The home should seek, as far as possible, to maintain a domestic rather than ‘institutional’ impression. In particular, the registered person should ensure that repairs to the home are completed in a timely manner. Moreover, they should review and assess the need for physical restrictions, such as window restrictors and door alarms, throughout the property. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 15, paragraph 3.9)  The registered person should ensure that records are kept of the administration of all medication. They should ensure that they make suitable arrangements to manage, administer and dispose of any medication. These are fundamentally the same sorts of arrangements as a good parent would make but are subject to additional safeguards. In particular, they should ensure medication records are

p.8

Recommendations

clear and accurate. In addition, the registered person, following risk assessment, Inspection report for children's home: 1155761 9 should support children to safely manage their own medication. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 35, paragraph 7.15)  The registered person should understand the importance of careful, objective and clear recording. Information about children must always be recorded in a way that will be helpful to them. In particular, the registered person should carefully consider the appropriateness of recording children’s information using the first- person narrative. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 62, paragraph 14.4)

p.8

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: 1155761 10

p.9

Children’s home details

Registered provider address: Unit 3 Ambrose House, Meteor Court, Barnett Way, Barnwood, Gloucester, Gloucestershire GL4 3GG

p.10

Inspector

Martin Brown, Social Care Inspector Inspection report for children's home: 1155761 11 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.

p.10

Inspector

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 . You may reuse this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence , write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk .

p.11

Inspector

Interested in our work? You can subscribe to our monthly newsletter for more information and updates: http://eepurl.com/iTrDn .

p.11

Inspector

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

p.11