Children's home run by Seashell Trust

Inspection report for children’s home: SC035518 1 SC035518

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The home provides care for up to 24 children with physical disabilities, learning disabilities and/or sensory impairment. Children live in six houses on a site that includes a school and college. Most children attend the on-site school. The inspectors only inspected the social care provision at this school.

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Information about this children’s home

The manager registered with Ofsted in August 2023.

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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/or 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: good

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inadequate

Enforcement action since last inspection: none Inspection report for children’s home: SC035518 2

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Inspection date Inspection type Inspection judgement

11/07/2023 Full Good 15/11/2022 Full Good 01/12/2021 Full Good 18/02/2020 Interim Sustained effectiveness Inspection report for children’s home: SC035518 3

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Overall experiences and progress of children and young people: inadequate

There are 12 children living across different homes. Many of the children have lived at the home for some time.

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Overall experiences and progress of children and young people: inadequate

Children’s progress and experiences are hindered by serious shortfalls in safeguarding practice and leadership and management.

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Overall experiences and progress of children and young people: inadequate

Children’s plans are not consistently up to date and contain conflicting information, and this includes care plans, behaviour support plans and risk management plans. This does not ensure that staff have the correct information to support children to make progress in key areas of their lives. Furthermore, not all children have an up-to-date education, health and care plan. Managers have not consistently escalated this. Consequently, not all staff are clear about the targets and objectives the children are working towards.

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Overall experiences and progress of children and young people: inadequate

During the inspection, the inspectors identified that there was a child who uses sign language to communicate. However, he is supported regularly by agency staff who are unable to communicate with him. Furthermore, there are some children that require daily physical therapy, including respiratory therapy. However, due to a lack of skilled and experienced staff, children have not received this support in line with their plans.

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Overall experiences and progress of children and young people: inadequate

Children enjoy activities, both on and off site, such as going to parks and zoos and having trips to go bowling and to the cinema. However, one parent recently raised concerns about the lack of opportunity for his child to take part in swimming due to the staff shortages.

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Overall experiences and progress of children and young people: inadequate

Staff support children to keep in touch with their families. Families are welcomed regularly to the home. However, one parent said, ‘There are a lot of unfamiliar staff who don’t understand [name of child’s] needs.’

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Overall experiences and progress of children and young people: inadequate

Most of the homes are decorated well and personalised in line with children’s needs. However, attention is required to some homes. For example, one house had cracks in the doorframe and marks on the walls and skirting, and a child’s bedroom display board required fixing. Additionally, inspectors found that a ceiling needed repainting in another home.

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

Managers and staff do not understand their roles and responsibilities in safeguarding children and have failed to provide sufficient support in line with children’s disabilities and complex health needs. This is a significant safeguarding concern and places children at risk of harm. Inspection report for children’s home: SC035518 4 During the inspection, a whistle-blowing complaint was made. The staff member raised concerns about inadequate staffing levels and lack of management visibility. This was considered as part of the inspection.

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

A high number of staff have recently left the service. Staff morale is low, and the provider is heavily reliant on agency staff to meet the needs of children. However, not all agency staff are aware of the needs of the children, including their preferred method of communication. On occasion, there has been insufficient staff to safely care for children in line with their agreed care plan. This does not enable children to feel safe and secure in their home and is a safeguarding concern.

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

Medication administration has improved since the last inspection. On-site nurses have introduced new medication auditing systems and additional competency checks. However, there is still a high number of medication errors taking place. Additionally, not all staff have received medication training. Staff report that there have been occasions when they have had to seek assistance to help manage these processes.

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

Since the last inspection, there have been four complaints. Two of these complaints were raised by parents about concerns around staff practice. On two occasions, staff have fallen asleep when responsible for the care and support of children. This is a significant safeguarding concern. Information was not shared with the regulator to demonstrate how safeguarding procedures had been adhered to, who this information had been reported to and any lessons learned or reflection on practice after the incident.

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

Leaders and managers do not consistently review and update each child’s risk assessment, behaviour management plans and care plans. This does not ensure that the care and support needs for each child remain relevant or that the strategies in place remain effective. This does not enable staff to follow clear guidance to reduce and minimise known risks for each child. This fails to keep children and staff safe and does not demonstrate strong leadership.

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

Children take part in fire drill practices, and they all have an individual emergency fire evacuation plan. However, there is no management oversight of these plans, and not all staff have completed refreshers on fire safety. This has the potential to place children at risk of harm.

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The effectiveness of leaders and managers: inadequate

There is no effective management oversight of staff practice and the quality of care provided to children. This significantly compromises children’s welfare and safety.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not review practice in the home effectively, and there are missed opportunities to understand the impact that the quality of care is having on children. For example, several of the children’s plans and some risk management plans contain no management oversight. Consequently, shortfalls in the care and protection of children are not identified. This places children at risk of harm. Inspection report for children’s home: SC035518 5 Some staff stated they are not supported by the management team and that there is a lack of management visibility. Staff say this has impacted on staff morale and resulted in a high turnover of staff. Feedback from surveys received by the regulator states that there is poor leadership. Inspectors identified that the home is not led or managed in a way that is consistent with the approach, ethos and outcomes set out in the home’s statement of purpose.

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The effectiveness of leaders and managers: inadequate

Due to the high turnover of staff, there are a high number of staff vacancies across the homes. The staff shortages mean that children are not receiving a consistent quality of care that meets their assessed needs and helps them to fulfil their potential. Children are not consistently cared for by people they know well and who understand their needs and plans. This is compromising children’s ability to build stable and secure relationships with staff.

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The effectiveness of leaders and managers: inadequate

The staff training matrix is not clear or accurate. As a result, it is not always clear what training staff have undertaken. Additionally, leaders and managers have not provided staff with sufficient training to support the children’s individual complex needs. As a result, the manager and staff lack the knowledge and skills to keep the children safe. Not all staff have received refresher training in safeguarding children, gastrostomy, epilepsy and adrenal crisis management, despite these being required needs for the children.

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The effectiveness of leaders and managers: inadequate

Not all staff, including agency staff, receive regular supervision in line with the organisation’s policy. Furthermore, staff have not had their performance appraised annually. This is limiting opportunities for staff to reflect critically on their practice and development needs and for managers to assess staff performance and continued suitability.

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The effectiveness of leaders and managers: inadequate

When managers have undertaken shifts in the home, this is not always clear on the home’s roster.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not met several of the requirements from the previous visit. This does not demonstrate that improvements have been made to the quality of care that children receive. Repeat requirements are therefore made.

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The effectiveness of leaders and managers: inadequate

Leaders addressed some of the immediate shortfalls in relation to staffing during the inspection. However, the shortfalls highlighted poor leadership and management practice that has compromised the experiences and progress of the children living in this home. The poor practice has had a negative impact on the ability of staff to protect children from harm and reach their potential. Inspection report for children’s home: SC035518 6

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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

In meeting the quality standards, the registered person must, and must ensure that staff—

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Requirement Due date

if the registered person considers, or staff consider, a placing authority’s or a relevant person’s performance or response to be inadequate in relation to their role, challenge the placing authority or the relevant person to seek to ensure that each child’s needs are met in accordance with the child’s relevant plans. (Regulation 5 (c))

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Requirement Due date

This specifically relates to making continuing efforts to obtain children’s local authority plans and education, health and care plans. 28 June 2024

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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

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

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Requirement Due date

ensure that the premises used for the purposes of the home are designed and furnished so as to—

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Requirement Due date

meet the needs of each child. (Regulation 6 (1)(a) (2)(c)(i))

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Requirement Due date

This specifically relates to ensuring that the patch on the ceiling is addressed, that door cracks are repaired, the display board in a child’s bedroom is suitably fixed and walls and skirting boards do not contain marks. 28 June 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. 9 June 2024 Inspection report for children’s home: SC035518 7 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. 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;

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

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Requirement Due date

This specifically relates to ensuring that there are sufficient staff in line with children’s risk management plans. Additionally, this relates to ensuring that all staff are suitably trained to meet the children’s complex needs and that all risk management plans are up to date and contain management oversight.

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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 has sufficient staff to provide care for each child; 9 June 2024 Inspection report for children’s home: SC035518 8 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))

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Requirement Due date

This specifically relates to ensuring that the home is managed in line with the home’s statement of purpose, all children’s plans contain management oversight and there are suitable levels of staff who are trained to meet the needs of the children.

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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

medicines kept in the home are stored in a secure place so as to prevent any child from having unsupervised access to them;

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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)(a)(b))

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Requirement Due date

The registered provider must ensure that there is a reduction in the number of medication errors. 28 June 2024

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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)) 28 June 2024

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Requirement Due date

The registered person must maintain records (“case records”) for each child which— 28 June 2024 Inspection report for children’s home: SC035518 9 include the information and documents listed in Schedule 3 in relation to each child;

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Requirement Due date

are signed and dated by the author of each entry. (Regulation 36 (1)(a)(b)(c))

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Requirement Due date

This specifically relates to ensuring that all children’s case records are up to date and contain accurate information.

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Requirement Due date

Schedule 4 sets out the other information that the registered person must keep in relation to a children’s home.

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Requirement Due date

maintain in the home the records in Schedule 4;

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Requirement Due date

ensure that the records are kept up to date; and

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Requirement Due date

retain the records for at least 15 years from the date of the last entry. (Regulation 37 (1) (2)(a)(b)(c))

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Requirement Due date

This specifically relates to having a roster that accurately reflects all staff hours, including when managers have covered a shift. 28 June 2024

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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

a child is involved in or subject to, or is suspected of being involved in or subject to, sexual exploitation;

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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 an allegation of abuse against the home or a person working there;

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Requirement Due date

a child protection enquiry involving a child —

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Requirement Due date

concludes (in which case, the notification must include the outcome of the child protection enquiry); or 28 June 2024 Inspection report for children’s home: SC035518 10 there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(a)(b)(c)(d)(i)(ii)(e))

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendation

 The registered person should ensure that there is a workforce development plan in place that includes details about the frequency of supervision and how the manager will manage poor performance. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 53, paragraph 10.8)

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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: SC035518 11

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Children’s home details

Provision sub-type: Residential special school

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Children’s home details

Responsible individual: Bernadette White

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Inspectors

Judith Birchall, Social Care Inspector Cathy Trengove, Social Care Inspector Inspection report for children’s home: SC035518 12 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 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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