Children's home run by The Forge Nuneaton Limited

Inspection report for children’s home: 2674760 1 Registered provider: The Forge Nuneaton Limited Full inspection 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 and is registered to provide care for up to six children who have experienced trauma.

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Information about this children’s home

The home is one of four homes on the same site. The home is part of a community that delivers the Sanctuary Model of therapeutic care.

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Information about this children’s home

The manager has been in post since April 2023 and took over the running of the home in June when the outgoing manager left. She has applied to register with Ofsted.

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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 widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded, and 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 January 2023

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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: 2674760 2

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Inspection date Inspection type Inspection judgement

17/01/2023 Full Good Inspection report for children’s home: 2674760 3

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inadequate

At the time of the inspection, six children were living in the home. All the children’s experiences and progress have been significantly affected by shortfalls in how children are cared for, helped and protected, as well as in leadership and management.

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inadequate

Since the last inspection in January 2023, four children have moved into the home and four other children have moved on. Shortfalls in care planning mean that children move into and on from the home quickly. Notice was served on the placements of all four children, who have since left the home. For one child, this was after just three days. Children who come to the home to receive care over the medium and long term are not given the opportunity to settle and be supported by staff. As a result, children do not have stability, and this negatively impacts on their experience and well-being.

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inadequate

Managers have failed to fully assess the potential impact of the needs, risks and behaviours of children moving into the home on those already living there. They do not ensure that they have all the information about the children and their potential risks and vulnerabilities before they move into the home. In addition, when the manager assessed that staff should have specific training to meet one child’s needs, this was not provided. Serious incidents have occurred, putting children at risk. These have resulted in police involvement in children’s lives and children experiencing unplanned endings.

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inadequate

Not all children receive appropriate support, advice and guidance with regards to their education. Some children have not engaged in education and have poor attendance. The manager does not prioritise on supporting children to attend school consistently. They have not ensured that there is a clear plan for staff to follow to ensure that all children are supported to regain confidence and engage with their learning. This is a missed opportunity to support all children to reach their potential in education.

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inadequate

Staff do not promote children’s health needs well. None of the children are provided with a balanced diet, and a child with specific dietary requirements is not adequately supported. Staff have not had training in how to support a child with specific health conditions. Staff support for this child is not as well informed as it could be, and shortfalls in staff practice compromise the child’s health.

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inadequate

Children’s views about the home are mixed. Children say they have had some positive experiences and enjoyed different activities. However, children also describe the home as chaotic, and when issues arise in other homes in the community, this can and does impact on them, which is unsettling. Inspection report for children’s home: 2674760 4 Children live in a clean, comfortable and spacious home environment. However, children cannot re-enter the home from the garden without asking staff, as the door can only be opened using a code, which the children do not have. This restricts children’s access around their home. Additionally, a cupboard containing snacks was locked, making them reliant on asking staff for these items.

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inadequate

Despite the serious and widespread shortfalls, some children have made progress. A child has lived at the home for almost a year, and incidents of self-harm for this child have reduced. One child has maintained good school attendance. Children develop some positive relationships with some staff.

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

There have been some significant safeguarding incidents when children have been at risk of harm. The manager and staff do not demonstrate that they have the skills and experience to keep children safe. Incidents have not always been reported, recorded and responded to appropriately by staff and managers. For example, incidents of bullying between children are not identified as such by staff and responded to.

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

There have been several incidents of children harming themselves. Despite this, staff do not do all they can to reduce these risks to children. Staff are not alert to risk, and they do not respond appropriately to try and remove items children have that they use to harm themselves. The manager’s and staff’s inability to identify and act on signs that a child is at risk of harm at an early-stage places children at further risk. Furthermore, the manager lacks professional curiosity when reviewing incidents and fails to identify what staff could have done differently. This lack of effective oversight means that opportunities for learning from incidents are not always taken up.

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

The manager and staff have not responded to or addressed reports of bullying, and when children make complaints, these are not responded to. For example, one child told the inspector that another child living in the home continues to call them names, and staff do not challenge this. This child has written a letter of complaint to the manager about this. The manager confirmed that she had received this letter; however, there was no record of this being responded to. Because of this, children feel that staff, including the manager, do not take their concerns seriously, and at times they do not feel safe living in the home.

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

When allegations are made about staff, the manager liaises appropriately with the designated officer in sharing information. However, records are poor, and so it is unclear what action has been taken and whether recommendations from the local authority designated officer and children’s social workers have been acted on. This lack of oversight and follow-up action does not promote children’s safety.

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

Managers have failed to ensure that the environment is safe for children. Some children have risks relating to fire setting. The fire risk assessment, which was Inspection report for children’s home: 2674760 5 reviewed in May 2023, highlights priority action to remedy shortfalls in a number of fire doors. However, these tasks have yet to be addressed. This lack of action by managers to ensure the safety of the premises leaves children and staff at unnecessary risk of harm. Ofsted made a referral to the fire service immediately following the inspection.

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

Managers do not ensure that systems for the safe administration of medication are in place. Record-keeping is poor. Although some staff have received training, there are no procedures to reassess their competence following medication errors. This puts children at risk of harm and does not promote their well-being.

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

Risk assessments do not provide staff with clear guidance and strategies to manage risk. For example, they do not direct staff to complete welfare checks on children following incidents of self-harm or when they are aware that children may be particularly vulnerable to hurting themselves. Children have missing-from-care plans. However, staff are not confident in the protocols and guidance they have to follow when children go missing from home. This increases the children’s vulnerability and compromises their safety.

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

Consequences given to children are not restorative in nature or in line with the home’s ethos and the children’s ages and understanding. However, the manager fails to review the consequences given to children by staff to identify and address this shortfall.

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

There have been incidents when staff have restrained children to keep them and others safe from harm. Records of restraint incidents lack the required information and robust management evaluation. This prevents effective oversight of whether the intervention used was necessary, proportionate and effective. Staff are not consistently spoken with after incidents, which limits the opportunity for reflection and learning.

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The effectiveness of leaders and managers: inadequate

Poor leadership and management and failure to take effective action to improve the quality of care in the home have compromised children’s safety, experiences and progress.

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The effectiveness of leaders and managers: inadequate

There are significant gaps in the managers’ knowledge of the strengths and weaknesses of the home. The manager does not have effective systems to review the quality of care and fully understand children’s experiences. They do not review and evaluate significant incidents effectively, including physical interventions, incidents of self-harm and bullying. Therefore, they do not understand the potential risks to children and take steps to challenge poor practice and keep children safe. Furthermore, they do not understand the impact of shortfalls in the quality of care on children’s experiences and progress, and they do not set out clear plans to bring about improvement. Inspection report for children’s home: 2674760 6 Although managers have submitted a quality of care review report to Ofsted, this is poor as it does not focus on the quality of care provided to children and the impact this care is having on children’s outcomes and welfare. Nor does it target areas for

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The effectiveness of leaders and managers: inadequate

The oversight of the management of the home has been poor. The responsible individual has recently left, and a new person has taken on the position. She is new to the organisation and is quickly familiarising herself with what has happened and devising plans to bring about improvement.

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The effectiveness of leaders and managers: inadequate

Current staffing arrangements fail to provide the children with consistent care. Since the last inspection, 13 staff members have left. Furthermore, inspectors found that children have been cared for by 27 different agency staff over the inspection period. This does not help children to develop positive and healthy relationships with a familiar adult who knows them well.

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The effectiveness of leaders and managers: inadequate

The quality of staff supervision, including the manager’s own supervision, is poor. The manager and some staff do not receive regular supervision. Managers are unable to assess whether staff are making progress and whether they understand their roles and responsibilities in providing care to children and how to keep them safe. When poor practice from staff is not challenged and is normalised, this places children at further risk of harm.

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The effectiveness of leaders and managers: inadequate

The manager and staff do not have the necessary skills to care for vulnerable children with complex needs. There are significant gaps in training for both the manager and staff team. For example, staff are not skilled to meet the current children’s complex needs, and this has resulted in the children having poor experiences while living in the home. In addition, only the manager holds the relevant qualification, and only two staff members have previous experience of working in residential childcare. These shortfalls and lack of training impact on the staff’s ability to promote children’s safety and well-being.

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The effectiveness of leaders and managers: inadequate

The manager does not always notify Ofsted when there are serious incidents. As a result, the regulator does not have access to important information that would enable them to have oversight of what is happening at the home.

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The effectiveness of leaders and managers: inadequate

The statement of purpose is not kept up to date and does not accurately reflect details of the staff working in the home. Furthermore, managers have not ensured that they are delivering the aims and objectives set out in this document, including the therapeutic model of care.

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The effectiveness of leaders and managers: inadequate

Following this inspection, three compliance notices have been issued under Regulations 10, 12 and 13. Inspection report for children’s home: 2674760 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, The 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 health and well-being standard is that—

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Requirement Due date

the health and well-being needs of children are met;

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Requirement Due date

children receive advice, services and support in relation to their health and well-being; and

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Requirement Due date

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 and develop skills to promote the child’s well- being. (Regulation 10 (1)(a)(b)(c) (2)(a)(i)(iv)) 8 October 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

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

help each child to understand how to keep safe;

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Requirement Due date

have the skills to identify and act upon signs that a child is at risk of harm; 8 October 2023 Inspection report for children’s home: 2674760 8 manage relationships between children to prevent them from harming each other;

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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

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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 premises used for the purposes of the home are designed, furnished and maintained so as to protect each child from avoidable hazards to the child’s health. (Regulation 12 (1) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(b)(d))

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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;

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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’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)(e)(f)(h)) 5 November 2023 Inspection report for children’s home: 2674760 9 The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so.

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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

understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers;

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Requirement Due date

help each child to understand the importance and value of education, learning, training and employment;

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Requirement Due date

help each child to attend education or training in accordance with the expectations in the child’s relevant plans. (Regulation 8 (1) (2)(a)(iii)(iv)(x)) 5 November 2023

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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

help each child to develop socially aware behaviour;

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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

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. 5 November 2023 Inspection report for children’s home: 2674760 10 (Regulation 11 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(xii)(xiii))

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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, as set out in the home’s statement of purpose. (Regulation 14 (1)(a)(b) (2)(a)) 8 October 2023

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Requirement Due date

The registered person must compile in relation to the children’s home a statement ("the statement of purpose") which covers the matters listed in Schedule 1.

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Requirement Due date

keep the statement of purpose under review and, where appropriate, revise it; and

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Requirement Due date

notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision. (Regulation 16 (1) (3)(a)(b)) 5 November 2023

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Requirement Due date

the privacy of children is appropriately protected;

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Requirement Due date

children can access all appropriate areas of the children’s home’s premises; and

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Requirement Due date

any limitation placed on a child’s privacy or access to any area of the home’s premises—

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Requirement Due date

allows children as much freedom as is possible when balanced against the need to protect them and keep them safe. (Regulation 21 (a)(b)(c)(iv)) 8 October 2023 Inspection report for children’s home: 2674760 11 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; and

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Requirement Due date

a record is kept of the administration of medicine to each child. (Regulation 23 (1) (2)(b)(c)) 5 November 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

take adequate precautions against the risk of fire, including the provision of suitable fire equipment in the children’s home;

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Requirement Due date

provide adequate means of escape from the home in the event of fire. (Regulation 25 (1)(a)(b)) 30 September

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Requirement Due date

A person may only manage a children’s home if—

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Requirement Due date

having regard to the size of the home, its statement of purpose, and the number and needs (including any needs arising from any disability) of the children—

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Requirement Due date

the person has the appropriate experience, qualification and skills to manage the home effectively and lead the care of children. (Regulation 28 (1)(b)(i)) 5 November 2023

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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;

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Requirement Due date

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 (4)(a)(b)(c)) 5 November 2023

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Requirement Due date

The registered person must prepare and implement a policy which— 5 November 2023 Inspection report for children’s home: 2674760 12 is intended to safeguard children accommodated in the children’s home from abuse or neglect; and

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Requirement Due date

sets out the procedure to be followed in the event of an allegation of abuse or neglect.

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Requirement Due date

The procedure to be followed in the event of an allegation of abuse or neglect must, in particular—

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Requirement Due date

provide for records to be kept of an allegation of abuse or neglect, and the action taken in response. (Regulation 34 (1)(a)(b) (2)(d))

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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 5 November 2023 Inspection report for children’s home: 2674760 13 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

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;

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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)) 8 October 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 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.

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Requirement Due date

After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review ("the quality of care review report"). (Regulation 45 (1) (2)(a)(b)(c) (3)) 5 November 2023

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Requirement Due date

* These requirements are subject to a compliance notice. Inspection report for children’s home: 2674760 14

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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: 2674760 15

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Children’s home details

Registered provider: The Forge Nuneaton Limited

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Children’s home details

Responsible individual: Rebecca Grimshaw

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Inspectors

Marianne Grandfield, Social Care Inspector Mark Dickinson, Social Care Inspector Sarah Billett, Social Care Inspection Manager Inspection report for children’s home: 2674760 16 regulates and inspects 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 looked after children, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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