Children's Home run by BTTLR Limited in West Northamptonshire

Inspection report for children’s home: 2592228 1 Registered provider: BTTLR LIMITED Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This home is privately owned and provides care for up to two children who may be experiencing emotional, social and behavioural difficulties.

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Information about this children’s home

The registered manager is qualified and experienced.

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Information about this children’s home

There was one child living at the home at the time of the inspection. As a result of the shortfalls identified, the child has left the home having only lived here for three weeks.

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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

Overall judgement at last inspection: requires improvement to be good

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Enforcement action since last inspection:

A condition was placed on the home on 22 February 2023. This condition was that the provider must inform Ofsted, three months in advance, of any intention to admit Inspection report for children’s home: 2592228 2 a child into the home. On 18 October 2023 Ofsted evaluated that sufficient improvement had been made to allow for this registration condition to be removed.

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Enforcement action since last inspection:

During a suitable person interview on 4 August 2023, with the nominated responsible individual, it became Ofsted’s view that the responsible individual does not have the capacity, experience, or skills to supervise the management of the home. This regulatory breach of regulation 26 of The Children’s Homes (England) Regulations 2015, resulted in the issuing of a compliance notice on 23 October 2023.

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Enforcement action since last inspection:

Communication with the provider on 20 November 2023 established that this compliance notice had not been complied with. The responsible individual, who is also the company director, has made some progress in recruiting a new responsible individual but has not yet completed their required safe recruitment checks in full. The compliance notice as above was re-issued and is due to expire on 19 February 2024. Inspection report for children’s home: 2592228 3

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Inspection date Inspection type Inspection judgement

03/05/2022 Full Requires improvement to be good 24/02/2022 Interim Sustained effectiveness 21/07/2021 Full Requires improvement to be good Inspection report for children’s home: 2592228 4

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inadequate

Widespread failures in the protection of children and in leadership mean that children have poor care experiences and do not make adequate progress. Several statutory requirements remain unmet from the last inspection, with additional requirements set at this inspection.

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inadequate

There has been no evidence of improvement during the inspection period which contributes to this inadequate judgement. The provider has been in operation for four years, and throughout this time has failed to operate to a good standard. There was one child living at the home the time of the inspection. He told the inspector he was pleased to have joined a local rugby club as this is his passion. Spending time with his family is very important to the child, the manager had made plans to support this during the inspection recognising the significance of this relationship.

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inadequate

The child living at the home was not able to build trusting and secure relationships with staff. He did enjoy spending time with the manager and was developing a positive relationship with him built on some mutual interests. Staff lacked experience, and therefore confidence, to support the child. They failed to help the child develop skills and strategies for managing his emotions. Staff did not provide clear and consistent boundaries for the child which affected the quality of care that he received.

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inadequate

In the absence of an educational package staff were unable to motivate the child into a healthy daily routine. They did not devise a structured or engaging routine of educational activities in line with the child’s age. This lack of planning was detrimental to the child’s education and social development and allows already present gaps in learning to widen.

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inadequate

The child made a complaint about his care while living at the home. The circumstances of how this complaint was captured were inappropriate and did not protect the child’s right to privacy. The system in place for handling complaints is not child focussed. The child did not know the outcome of their complaint and no written evidence was made available to the inspector to show how this had been investigated or responded to. Children’s views are not responded to adequately, and opportunities for practice to improve are missed.

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inadequate

The child’s individual care needs in respect of his ethnicity were neglected. Staff failed to talk to the child, and other relevant people, about the child’s hair care and skin care needs. Specialist care products have not been provided to the child or considered at the time of the inspection. Inspection report for children’s home: 2592228 5

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

The child’s risk assessment was of poor quality and not reflective of their complex needs. It failed to consider the child’s adverse childhood experiences and the impact these have on their presenting behaviours. Some risks were not known or comprehensively understood by staff. Information from other authorities gathered pre-admission was not used effectively to inform decision-making and care planning. For example, risks associated with aggression and violence towards adults was used as a generic term and strategies for the management of such risks were vague. A previous significant incident involving harm caused by a knife, was not considered at all in the risk assessment which places staff in a vulnerable and dangerous position.

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

Known risks from the child ingesting harmful objects such as batteries and electrical fuses were not evaluated adequately. Staff were not provided with clear direction about how to manage such significant risks safely. Staff did not consistently adhere to agreed safety plans in this regard. For example, some staff allowed the child to keep a battery-operated remote control in his bedroom overnight without supervision against the agreed risk assessment. Such poor safeguarding practices, against a known risk, placed the child at potential risk of serious harm.

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

On one occasion, contrary to the child’s agreed staffing ratios and risk assessment, one adult was left alone to care for the child. This left the child and the adult in an unsafe situation. The manager failed to address this misconduct issue with the two staff involved, so an opportunity to improve safeguarding practice has been missed.

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

Incidents of physical intervention are not consistently recorded. Inadequacies in report writing mean that it is difficult for the manager or regulator to evaluate the quality of care properly. Incidents involving the manager are not evaluated by a senior manager or other independent person. This prevents oversight of staff practice and learning from incidents. Leaders cannot assure themselves that care practices are safe and that children are protected from harm. The child was not routinely spoken to following incidents, or there is no evidence of such, which prevented them from expressing their views and having a voice in their care. There is no evidence of restorative practice following incidents which would have helped to improve relationships and increase the child’s sense of personal responsibility.

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

On one occasion the child called emergency services to report an allegation of harm against an adult in the home. The child confided in staff that they were scared of the particular adult and felt unsafe. Staff failed to act immediately to protect the child and were not clear about their own safeguarding responsibilities in this instance. The manager failed to investigate the allegation quickly and did not refer the matter to the local authority designated officer until three days later. This failure to act quickly allowed the adult subject to the allegation to continue working at the home, placing both the child and them at potential risk. Inspection report for children’s home: 2592228 6 Medication errors and discrepancies identified by the inspector were brought to the manager’s attention. A dosage error on the child’s risk assessment could have resulted in repeated overdoses of a prescribed medication. No-one working at the

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

home had raised this error with the manager which could have led to significant implications for the child. A senior member of staff has not completed the necessary medication training. There is no evidence of medication competencies or effective auditing being undertaken. This prevents a thorough evaluation of safe medication practices in the home.

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

The manager does not pay sufficient attention to the safe recruitment checks required by the regulations. The manager does not assure himself that adults working at the home are safe to do so and does not complete his own robust evaluation of recruitment. During the inspection, the manager was not able to provide samples of safe recruitment checks for specific staff, because the office was closed and the administrative colleague unavailable. This is an ineffective system and an example of a poor safeguarding culture.

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The effectiveness of leaders and managers: inadequate

The registered manager was appointed by the provider in June 2023. He is a qualified social worker with the relevant experience in children’s residential care.

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The effectiveness of leaders and managers: inadequate

The responsible individual has been evaluated as unsuitable by the regulator. A compliance notice was issued in respect of this breach in October 2023. The provider was directed to recruit and appoint a new responsible individual within the agreed time frame. Initial steps have been taken to achieve this, with the new responsible individual making her introductions at the point of this inspection. She is yet to start in her role meaning the current responsible individual retains responsibility for the service. A shortfall of this situation is that the current responsible individual does not have the required skills, knowledge, and experience to supervise and challenge the registered manager professionally. This has contributed to ineffective leadership and this inadequate judgement.

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The effectiveness of leaders and managers: inadequate

The home has not been adequately staffed to meet the needs of the child who lived there. Most staff are new to their employment and remain in an extended probation period. Many of the staff lack the required residential childcare experience. The team is still developing and needs extensive role modelling and mentoring. At times, staff have been unable to cope with the demands of the child’s complex care needs and have relied heavily on the manager to resolve difficult situations. This has detracted from the manager’s ability to fulfil his leadership responsibilities and tasks.

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The effectiveness of leaders and managers: inadequate

Staff have not completed specific training relevant to children’s needs, which would provide them with a greater knowledge and understanding. Training is basic and most is covered online as self-directed learning modules. Induction and training activities appear to be isolated with no evidence of reflective practice or professional discussion afterwards. The manager could not provide the most up-to-date training records for staff. He is behind with the supervision of staff and record-keeping Inspection report for children’s home: 2592228 7 because of other demands on his time. This prevents staff from developing as competent childcare professionals and prevents the manager from evaluating the strengths and vulnerabilities of his staff team. Where there are concerns about individual conduct or development, these have not been addressed effectively by the provider.

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The effectiveness of leaders and managers: inadequate

Leadership in the manager’s absence is a concern. The home does not have a deputy manager or any senior members of staff. The one team leader appointed is not experienced enough to lead a team in the manager’s absence and only works office hours. Evenings and weekends are operated entirely by residential care staff who are inexperienced and left without adequate supervision and leadership direction. The manager can be consulted during these times but cannot physically be at the home. It is the inspectors view that the safety and well-being of the child decreased significantly in the absence of the manager. The responsible individual has not considered a planned period of absence of the manager effectively. The provider has failed to recognise this planned absence as a major risk factor and does not have robust plans in place to mitigate this risk adequately.

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The effectiveness of leaders and managers: inadequate

The statement of purpose requires attention. It does not accurately reflect the care provided for children. It does not include all required matters as outlined by regulations and must detail the experience and qualifications of staff and details of the management and staffing structure of the home, including arrangements for the professional supervision of staff.

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The effectiveness of leaders and managers: inadequate

There is no quality-of-care report for this inspection period. The manager does not yet have a robust auditing system in place whereby he can review the quality of care provided for children. There is not yet an effective system for the registered person to gather feedback of children’s opinions about the children’s home, its facilities, and the quality of care they receive in it.

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The effectiveness of leaders and managers: inadequate

Leaders have not taken sufficient action in relation to the previous statutory requirements. Those, along with additional requirements, have been reset. To ensure the safety of children, and given the concerning history of the provider’s competence, the regulator has issued a restriction notice to the provider preventing any new admissions to the children’s home. Inspection report for children’s home: 2592228 8

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

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Requirement Due date

develop positive relationships with them;

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Requirement Due date

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

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

regularly consult children, and seek their feedback, about the quality of the home’s care;

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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)(a)(b)(c) (2)(a)(iii)(iv)(b)(i))

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Requirement Due date

This is in relation to staff building trusted relationships with children in their care effectively, taking into consideration the children’s views about such care. This also relates to the effective handling of children’s complaints. 29 March 2024

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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— 29 March 2024 Inspection report for children’s home: 2592228 9 mutual respect and trust;

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Requirement Due date

an understanding about acceptable behaviour.

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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

help each child to develop and practise skills to resolve conflicts positively and without harm to anyone;

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Requirement Due date

communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding;

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Requirement Due date

understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children;

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Requirement Due date

are provided with supervision and support to enable them to understand and manage their own feelings and responses to the behaviour and emotions of children, and to help children to do the same;

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Requirement Due date

de-escalate confrontations with or between children, or potentially violent behaviour by children. (Regulation 11 (1)(a)(b) (2)(a)(i)(ii)(iii)(iv)(v)(ix)(x)(xi))

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Requirement Due date

This is in relation to staff recognising and understanding the reasons for children’s behaviour and how previous traumatic experiences have an impact on such behaviour. This also relates to effective behaviour management with skills of resolving conflict and reducing violence. Inspection report for children’s home: 2592228 10 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; 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

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Requirement Due date

are familiar with, and act in accordance with, the home’s child protection policies;

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Requirement Due date

that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm;

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Requirement Due date

that the 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; and

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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)(ii)(iii)(v)(vi)(b)(d)(e))

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Requirement Due date

This is in relation to staff being prepared and supported to respond to any incidents of challenging or unsafe behaviour. It relates to ensuring staff have an understanding of their own safeguarding responsibilities and a duty to act on these when concerns arise. It relates to effective risk assessments as safeguarding tools, and staff ensuring these are adhered to. It also relates to the home environment and making this as safe as possible. 29 March 2024 Inspection report for children’s home: 2592228 11 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 work as a team where appropriate;

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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

demonstrate that practice in the home is informed and improved by taking into account and acting on—

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Requirement Due date

research and developments in relation to the ways in which the needs of children are best met;

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Requirement Due date

feedback on the experiences of children, including complaints received; and

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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)(b)(c)(d)(e)(f)(g)(i)(ii)(h))

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Requirement Due date

This is in relation to sufficiency and quality of staff and leaders to make sure that care is delivered in line with the 29 March 2024 Inspection report for children’s home: 2592228 12 home’s statement of purpose. It relates to the experience and qualifications of staff, and that these are sufficient for the children placed. It also relates to auditing and monitoring systems, which are needed to understand the impact of care provided.

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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)) 29 March 2024

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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. (Regulation 23 (1))

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Requirement Due date

This relates to ensuring all records relating to the safe administration of medication, including risk assessments and care plans, are accurate and current for each child. It also relates to ensuring staff have received adequate training in respect of such tasks and that competency checks are undertaken regularly. 29 March 2024

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Requirement Due date

have the capacity, experience and skills to supervise the management of the home, or the homes, in respect of which the responsible individual is nominated. (Regulation 26 (7)(b)) 19 February 2024

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Requirement Due date

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

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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) (3)(d)) 29 March 2024 Inspection report for children’s home: 2592228 13 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)) 29 March 2024

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Requirement Due date

The registered person must prepare and implement a policy which—

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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 liaison and co-operation with any local authority which are, or may be, making a child protection enquiry in relation to a child accommodated in the home;

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Requirement Due date

provide for the prompt referral of an allegation about current or ongoing abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the home is located;

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Requirement Due date

provide for the prompt referral of an allegation about past abuse or neglect in relation to a child to the placing authority and, if different, the local authority in whose area the alleged abuse or neglect occurred;

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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;

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Requirement Due date

describe the measures which may be necessary to protect children following an allegation of abuse or neglect; and

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Requirement Due date

describe how and to whom staff are to report, without delay, any concern about abuse or neglect of a child. (Regulation 34 (1)(b) (2)(a)(b)(c)(d)(e)(f))

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Requirement Due date

This relates to ensuring that there is an effective and understood policy in the event of an allegation against an adult who works in the home. 29 March 2024 Inspection report for children’s home: 2592228 14 The registered person must ensure that—

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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 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

This relates to ensuring effective and accurate record- keeping of any measures of restraint used in the children’s home. 29 March 2024 Inspection report for children’s home: 2592228 15 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").

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Requirement Due date

supply to HMCI a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed; and

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Requirement Due date

make a copy of the quality of care review report available on request to a placing authority, if the placing authority is not the parent of a child accommodated in the home.

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Requirement Due date

The system referred to in paragraph (2) must provide for ascertaining and considering the opinions of children, their parents, placing authorities and staff. (Regulation 45) (1) (2)(a)(b)(c) (3) (4)(a)(b) (5)) 29 March 2024

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Requirement Due date

* These requirements are subject to a compliance notice.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people, using the social care common inspection framework. This inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, Inspection report for children’s home: 2592228 16 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: 2592228 17

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Children’s home details

Registered provider address: Office 3, Ground Floor, Michael Way, Raunds, Wellingborough, Northamptonshire NN9 6GR

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Children’s home details

Responsible individual: Shamiso Ringisai

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Inspector

Rachael Sprigg, Social Care Inspector Inspection report for children’s home: 2592228 18 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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Inspector

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Inspector

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Inspector

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