Coniston House

Inspection report for children’s home: SC379123 1 SC379123 Registered provider: Cove Care Residential Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This privately owned home offers care for up to five children with social, emotional and mental health difficulties and associated complex care needs.

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Information about this children’s home

The registered manager’s post has been vacant since 23 March 2023. A new manager was appointed but did not commence the role. At the last inspection, an interim manager was in post, and there were plans for her to register with Ofsted.

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Information about this children’s home

However, leaders and managers appointed a new manager from within the organisation. The new manager took up their post at the beginning of September 2023, and Ofsted has not yet received a completed application for the manager to register with the regulator.

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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 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

Overall judgement at last inspection: Inadequate

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Enforcement action since last inspection:

Inspection report for children’s home: SC379123 2 On 31 May and 1 June 2023, Ofsted conducted a full inspection and serious and widespread failures were identified. Leaders and managers had failed to meet both compliance notices issued at the assurance inspection in March 2023. Consequently, the compliance notices for Regulation 6, the quality and purpose of care standard, and Regulation 13, the leadership and management standard, were issued again, and a restriction of accommodation notice was issued.

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Enforcement action since last inspection:

On 7 June 2023, Ofsted received concerns regarding a serious incident that occurred on 6 June 2023 in relation to a child living at the home. The child alleged that they had come to harm and continued to be at risk. Consequently, on 9 June 2023, Ofsted suspended the home’s registration.

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Enforcement action since last inspection:

On 17 July 2023, a monitoring visit was undertaken to assess the progress made by leaders and managers in meeting the compliance notices issued at the full inspection and to assess whether the home was able to safely welcome new children. Leaders and managers had failed to meet the compliance notice raised in relation to Regulation 13, the leadership and management standard. Consequently, this was issued again and the suspension notice remained in force.

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Enforcement action since last inspection:

On 22 August 2023, a monitoring visit was undertaken to assess the progress made by leaders and managers in meeting the compliance notice in relation to Regulation 13 and to assess whether the home was able to safely welcome new children. Leaders and managers had addressed all the shortfalls and evidenced that they were ready to welcome children to the home.

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Enforcement action since last inspection:

This inspection is the first since the suspension notice was lifted. Inspection report for children’s home: SC379123 3

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Inspection date Inspection type Inspection judgement

31/05/2023 Full Inadequate 06/09/2022 Full Requires improvement to be good 22/03/2022 Interim Sustained effectiveness 21/07/2021 Full Requires improvement to be good Inspection report for children’s home: SC379123 4

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inadequate

One child lived at the home at the time of the inspection. Leader’s and manager’s care planning and decision-making, about this child moving into the home, were flawed. They did not exercise professional curiosity to satisfy themselves that they understood all of the child’s complex needs and that staff could meet these needs safely. This failure caused disruption and instability for the child because the provider has given notice on the child’s placement due to staff being unable to safeguard them.

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inadequate

Although the child receives some support from staff to develop routines and understand boundaries, this is not effective. A lack of routine means that the child struggles to get up in the morning and to engage with their tutor. Although the child occasionally completes some educational work set by staff, a poor daily routine affects their learning and progress as well as their general well-being.

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inadequate

The child is registered with local health services and is encouraged by staff to attend appointments. When the child refuses, staff are persistent and reschedule appointments. Staff offer different activities to try to positively engage the child. While the child rarely agrees to participate in activities in the community with staff, they do enjoy activities in the home such as cooking and movie nights.

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inadequate

Staff and managers give the child opportunities to express their wishes and feelings through key-work sessions, meetings and spending some quality one-to-one time with them. Consequently, the child has developed some positive relationships with some staff, including the manager.

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

Some professionals have raised concerns about the location of the home because of risks to children’s safety and welfare, including criminal exploitation. Leaders and managers have failed to take sufficient action to mitigate these risks. They made a decision to place a child already vulnerable to criminal exploitation in an area where there are known risks.

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

Although the location risk assessment has been reviewed recently, it does not contain all the information relating to risks within the local area or set out clear strategies to manage these risks.

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

There have been some missed opportunities by staff and managers to safeguard the child. For, example there was an occasion when staff overheard the child’s conversation and worrying information was shared. At the same time, staff observed the child to be in possession of concerning items. They failed to act swiftly and Inspection report for children’s home: SC379123 5 decisively to safeguard the child. This left the child and potentially others at risk of harm.

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

On other occasions, the child was at ongoing risk of being exploited and staff talked to the child about the risks and what they could do to stay safe. Despite this good work and staff’s efforts, the child continued to be at risk of harm when out in the community.

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

The child went missing from home without the staff’s knowledge on occasion. This was despite the child having two staff members supporting them. However, staff have mostly responded well when the child has gone missing from home. They have notified relevant people, kept in phone contact with the child when possible and searched the area to try and locate them. They have requested for the child’s placing authority to arrange for someone independent to talk to the child after incidents to understand more about what happened and consider different ways of reducing risks.

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

Managers did request and attend multi-agency meetings to review the risks to the child and consider strategies to manage these risks. The manager escalated their increasing concerns about the child’s safety and health and requested meetings with relevant professionals to discuss this. However, there was no written safety plan agreed by the professional network. This led to claims and counterclaims about whether staff and the police had followed protocols. An uncoordinated approach did not help to keep the child safe.

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The effectiveness of leaders and managers: inadequate

The home has not had a registered manager in post for almost nine months. During this period, there have been three managers. Changes in managers have contributed to the failure to make and sustain improvements in the quality of care provided to children.

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The effectiveness of leaders and managers: inadequate

Leaders and managers did not consider whether staff had the skills and experience to meet the child’s needs safely and meet them well. Nor did they consider the risks and vulnerabilities for the child, considering the location of the home and the experiences of children who have previously lived there. This does not give confidence that leaders and managers can make safe decisions about placing children at the home whose needs they can meet.

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The effectiveness of leaders and managers: inadequate

Aspects of record-keeping are poor. For example, there is not always a clear audit trail as to what action staff have taken when concerns arise or that they share information promptly. On one occasion, a missing-from-home log showed that staff had not attempted to contact the child by mobile phone for 12 hours. The manager said that this was incorrect, as staff had made numerous phone calls to the child but had not recorded the information. Furthermore, children’s medication records are not always clear, and medication folders are referred to as patient files, which is not appropriate given that this is a children’s home. Inspection report for children’s home: SC379123 6 Staff receive regular supervision sessions and training. They feel supported by the manager.

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The effectiveness of leaders and managers: inadequate

Managers and staff have continued to maintain the home environment to a good standard for children after recent improvements were made.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not shown that they have fully implemented learning from shortfalls identified in previous inspections when enforcement action was taken by the regulator. As a result, the home is judged inadequate for a second time.

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The effectiveness of leaders and managers: inadequate

As a result of this inspection, Ofsted has issued a restriction of accommodation notice and is considering further enforcement action. Shortly after the inspection the child moved on from the home. As of 4 December 2023, no children are living at the home. Inspection report for children’s home: SC379123 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 quality and purpose of care standard is that children receive care from staff who—

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Requirement Due date

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

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Requirement Due date

use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential. (Regulation 6 (1)(a)(b)) 31 January 2024

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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

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

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Requirement Due date

that the premises used for the purpose of the home are located so that children are effectively safeguarded. (Regulation12 (1) (2)(a)(i)(iii)(vi)(c)) 31 January 2024

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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; 31 January 2024 Inspection report for children’s home: SC379123 8 and promotes their welfare.

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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

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 at the home;

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Requirement Due date

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

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Requirement Due date

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. (Regulation 14 (1)(a)) 31 January 2024

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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: SC379123 9

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Children’s home details

Registered provider: Cove Care Residential Limited

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Children’s home details

Registered provider address: 16 Waterloo Road, Wolverhampton, West Midlands WV1 4BL

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Inspectors

Rumbi Mangoma, Social Care Inspector Nurul Kabir, Social Care Inspector Inspection report for children’s home: SC379123 10 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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