Children's home run by Courtyard Care Limited

Assurance inspection report for children’s home: 2650054 1 Registered provider: Courtyard Care 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 is owned by a private provider. It is registered to care for up to six children with learning disabilities.

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Information about this children’s home

There has been no registered manager since 11 May 2022.

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Information about this children’s home

Date of last inspection: 14 February 2023

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Information about this children’s home

Enforcement action since last inspection: none

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Information about this inspection

At these inspections, the inspectors evaluated:

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Information about this inspection

 the care of children  the safety of children  the effectiveness of leaders and managers. Inspectors have looked closely at the experiences and progress of children, using the social care common inspection framework. This assurance inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with the Children’s Homes (England) Regulations 2015 and the ‘Guide to the Children’s Homes Regulations, including the quality standards’. Assurance inspection report for children’s home: 2650054 2

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Findings from the inspection

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

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Findings from the inspection

 There are serious allegations of children being inappropriately physically handled by staff.  Medication is incorrectly administered to children.  There are concerns about the leadership and management of the home.  Children are not being assessed for injuries appropriately after physical intervention.  Staff are not able to keep children safe, and children’s care plans and risk assessments are not always followed by staff or routinely updated.  Physical interventions are not accurately recorded or reviewed.

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The care of children

Staff do not follow or regularly update children’s risk assessments in relation to their health needs. Staff do not understand children’s health needs or how to safely manage any associated risk. For example, one child has a nut allergy and nuts were found in the home. This poses a significant risk to the child. Additionally, staff were unable to locate lifesaving medication for this child in a timely way and not all staff have been trained in how to use it.

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The care of children

Staff do not always follow direct instructions given by the manager. On occasion, this has put children at risk of harm. Furthermore, it highlights concerns relating to the quality of leadership and management. There are several staff members currently suspended and this has left new or temporary staff caring for children when they are not suitably experienced. A significant proportion of these staff do not have the appropriate training required to meet the needs of the children.

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The care of children

Staff do not make children’s toys available for them to play with as identified in their care plans, and staff do not follow or routinely update children’s care plans. This limits children’s freedom to choose where to play. Despite a significant number of changes in staff, there are some good examples of positive relationships being built. For example, staff try to support children to play games and use their imagination.

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The safety of children

Staff do not always supervise children according to their agreed assessed needs. This leaves some children vulnerable. One staff member was observed to leave three children unsupervised. This placed children at an increased risk of harm.

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The safety of children

The whistle-blowing procedure is not used effectively, and core staff do not report poor practice when they have observed it. When concerns are reported, they are not Assurance inspection report for children’s home: 2650054 3 effectively acted on. In addition, there has been one occasion when Ofsted was not informed of a serious safeguarding incident. This did not allow Ofsted to be able to regulate the home in line with regulations.

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The safety of children

Staff have failed to record incidents of poor practice when they have observed it, especially regarding staff using non-prescribed methods of physical intervention with a child. The manager had not reviewed an incident that took place in April 2023. Daily recording logs are not accurate and body maps are not consistently completed. The lack of management oversight increases the risk of injuries to children not being recognised or escalated appropriately. Debriefs are not routinely completed with children, resulting in staff not knowing how the child feels following a physical intervention. The lack of staff debriefs can also result in poor practice not being noticed or prevented.

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The effectiveness of leaders and managers

Medication practices are not yet safe. The auditing systems for children’s medications are poor, leaving the children vulnerable to potential errors. Discrepancies in the amount of medication have gone unnoticed and staff have numerous packets of medication open at once. On one occasion, leaders and managers did not take effective action to safeguard a child who was given an incorrect dosage of medication. This left the child at risk.

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The effectiveness of leaders and managers

Staff are not regularly having formal reflective time through supervision with the manager. For example, out of 15 staff members reviewed, there were only six supervisions recorded since February 2023. The lack of management oversight of each member of staff’s practice results in reduced opportunities to prevent shortfalls through reflective practice.

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The effectiveness of leaders and managers

Leaders and managers do not routinely ensure that fire drills are undertaken. These are not completed in a timely manner for new children in the home or staff. This could limit children’s and staff’s understanding of how to respond in an emergency. There was a failure to assess risks in relation to a recent substantial power outage and the impact that this would have on the fire alarm system in the home.

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The effectiveness of leaders and managers

Children’s well-being and safety are negatively impacted by poor management oversight. Several staff members who have leadership responsibilities are currently suspended. As a result, the overseeing leaders are struggling to have a clear sense of what is happening within the home. Staff are not consistently updating parents about changes to their children’s key workers and care team. This has a negative impact on working relationships with parents. Assurance inspection report for children’s home: 2650054 4

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Inspection date Inspection type Inspection judgement

14/02/2023 Full Good 16/11/2022 Full Inadequate 16/11/2021 Full Good Assurance inspection report for children’s home: 2650054 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

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

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Requirement Due date

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

is enabled to provide feedback to, and raise issues with, a relevant person about the support and services that the child receives. (Regulation 7 (1)(c) (2)(i)(ii)(iii)(b))

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Requirement Due date

In particular, this relates to ensuring that children’s wishes and feelings are explored after incidents and that emotional support is provided to them. 13 August 2023

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Requirement Due date

The health and well-being standard is that—

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Requirement Due date

the health and well-being needs of children are met; 13 August 2023 Assurance inspection report for children’s home: 2650054 6 children are helped to lead healthy lifestyles.

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Requirement Due date

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

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Requirement Due date

achieve the health and well-being outcomes that are recorded in the child’s relevant plans;

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Requirement Due date

understand the child’s health and well-being needs and the options that are available in relation to the child’s health and well-being, in a way that is appropriate to the child’s age and understanding;

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Requirement Due date

understand and develop skills to promote the child’s well- being. (Regulation 10 (1)(a)(c) (2)(i)(ii)(iv))

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Requirement Due date

This relates to ensuring that staff have the appropriate training and understanding to meet the children’s health needs, particularly regarding a child’s nut allergy. It also relates to ensuring that staff follow the care plans of each child.

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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

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

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Requirement Due date

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

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Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare; and 13 August 2023 Assurance inspection report for children’s home: 2650054 7 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)(i)(iii)(v)(vi)(vii)(b)(e))

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Requirement Due date

In particular, this relates to the management of safeguarding concerns about staff practice and the sharing of information with external agencies in a timely manner. It also relates to staff following care plans and risk assessments for 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 lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home’s statement of purpose;

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Requirement Due date

ensure that staff have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

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

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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

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

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)(d)(e)(f)(h)) 13 August 2023 Assurance inspection report for children’s home: 2650054 8 In particular, this relates to improving the management oversight and monitoring of the home. It also relates to staff working collectively to address concerns around practice.

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home.

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Requirement Due date

In particular the registered person must ensure that—

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Requirement Due date

medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child. (Regulation 23 (1) (2)(b))

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Requirement Due date

In particular, this relates to the effective recording and auditing of medication, and management’s response to errors. It also relates to staff competency training. 13 August 2023

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Requirement Due date

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

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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))

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Requirement Due date

In particular, this relates to ensuring that fire drills are routinely completed and involve children and members of staff, including those supporting from other homes. 13 August 2023

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Requirement Due date

The registered person must operate a disciplinary procedure which, in particular—

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Requirement Due date

provides for the suspension from work of an employee if necessary in the interests of the safety or welfare of children; and

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Requirement Due date

provides that the failure on the part of an employee to report an incident of abuse, or suspected abuse, whether past or present, in relation to a child to the appropriate person is a ground on which disciplinary proceedings may be instituted.

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Requirement Due date

The registered person must ensure that all employees—

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Requirement Due date

undertake appropriate continuing professional development; 13 August 2023 Assurance inspection report for children’s home: 2650054 9 receive practice-related supervision by a person with appropriate experience; and

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Requirement Due date

have their performance and fitness to perform their roles appraised at least once every year. (Regulation 33 (2)(b) (4)(b)(c))

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Requirement Due date

In particular, this relates to staff following whistle-blowing procedures. It also relates to staff having regular and meaningful supervisions and appraisals.

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Requirement Due date

The registered person must prepare and implement a policy (“the behaviour management policy”) which sets out—

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Requirement Due date

how appropriate behaviour is to be promoted in the children’s home; and

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Requirement Due date

the measures of control, discipline and restraint which may be used in relation to children in the home.

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Requirement Due date

The registered person must keep the behaviour management policy under review and, where appropriate, revise it.

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

has spoken to the user about the measure;

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Requirement Due date

has signed the record to confirm it is accurate;

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Requirement Due date

within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (1)(a)(b) (2) (3)(a)(vii)(viii)(b)(i)(ii)(c)) 13 August 2023 Assurance inspection report for children’s home: 2650054 10 In particular, this relates to the effective oversight of debriefs with children and members of staff following incidents to ensure that their views are sought and support is offered. It also relates to ensuring that body maps are accurately and routinely completed following any physical intervention.

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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 given an appropriate degree of freedom and choice in relation to their day-to-day arrangements for their care. This is in relation to activities and personal items, such as leisure items. This specifically relates to ensuring that children have access to their toys in the rooms that they wish to spend time in. (‘Guide to the Children’s Homes Regulations, including the quality standards, page 17, paragraph 3.21) Assurance inspection report for children’s home: 2650054 11

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Children’s home details

Registered provider: Courtyard Care Limited

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Children’s home details

Registered provider address: 3 Siskin Drive, Middlemarch Business Park, Coventry CV3 4FJ

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Inspectors

Ellen Monk, Social Care Inspector Sarah Orriss, Social Care Inspector Assurance inspection report for children’s home: 2650054 12 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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