Children's Home run by Coastal Quality Care Limited in Lancashire

Inspection report for children's home: 2716515 1 Registered provider: Coastal Quality Care Limited

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Inspected under the social care common inspection framework

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Information about this children’s home

The home is operated by a private organisation. The home is registered to care for up to two children who have social and emotional difficulties.

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Information about this children’s home

The home registered with Ofsted in January 2023. The registered manager post has been vacant since January 2024.

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Information about this children’s home

At the time of this inspection, one child was living at the home. The child was spoken to by inspectors.

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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. The care and experiences of children and young people are poor.

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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: 2716515 2

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Inspection date Inspection type Inspection judgement

05/07/2023 Full Good Inspection report for children's home: 2716515 3

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Overall experiences and progress of children and young people: inadequate

The child’s experiences and progress are hindered by ineffective care planning and serious shortcomings in safeguarding practices, as well as poor leadership and management of the home.

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Overall experiences and progress of children and young people: inadequate

High staff and manager turnover, excessive use of bank staff from the organisation and poor staff practice have led to inconsistency for the child. The child said they feel unsafe and scared in the home. ‘You can see I am stressed, it has been terrible for the last few months, there has been loads of staff coming in and out,’ they said. ‘I do not feel like the staff or my social worker believe me.’

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Overall experiences and progress of children and young people: inadequate

The previous registered manager advocated on behalf of the child to secure an appropriate education provision. However, staff lack access to important information about the child’s educational goals and their personal education plan. This does not help the staff to support the child to meet their educational targets.

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Overall experiences and progress of children and young people: inadequate

The child is supported to attend routine health appointments. However, staff do not have access to the child’s health assessment or child looked after review minutes. This means they are unable to address any actions raised in the assessment or the review in a timely manner.

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Overall experiences and progress of children and young people: inadequate

Staff listen to the child’s views regarding the home, the food they would like to eat and activities. However, staff do not monitor the child’s emotional health and well-being to monitor their welfare. This has led to the child feeling frustrated, upset and not fully listened to.

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Overall experiences and progress of children and young people: inadequate

Areas of the home are unclean and the decor in some rooms is tired and worn. The stair carpet is damaged and the cooker is unhygienic and unsuitable for cooking on. The garden area contained hazardous items. This does not ensure that the home and garden are safe and inviting for the child.

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

Leaders, managers and staff fail to proactively manage risk and reduce harm to the child. Additionally, staff have failed to use the whistle-blowing procedures, despite witnessing poor care practices. During the inspection, the child made allegations to inspectors about poor staff practices. These have now been referred to the local authority designated officer.

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

The child has made allegations of physical and emotional harm by the managers and staff at the home. The child has also alleged that they have been spoken to inappropriately by managers and staff. Two allegations of abuse have not been managed in line with safeguarding procedures. When a child reported that they had been Inspection report for children's home: 2716515 4 assaulted and verbally abused by a member of the organisation’s management team, other staff were witness to this and failed to intervene or share their concerns more widely. Leaders and staff did not report the allegation in line with safeguarding and organisational procedures. These allegations have now been reported in line with safeguarding procedures.

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

There is a lack of professional curiosity and risk assessment, and poor recruitment practice by leaders and managers. This has led to an interim manager managing the home since January 2024, without relevant recruitment checks being conducted. This fails to ensure that only suitable adults work with children.

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

Staff do not consistently follow the child’s risk management plans. The child’s plan states that the child should have a two-to-one staffing ratio due to their vulnerabilities. However, the child has been left alone in the home on numerous occasions. On one occasion, the independent person arrived at the home to carry out a visit to find the child home alone. It is unclear why the child was left alone or how long the child was left alone for. On another occasion, two members of staff walked off shift leaving the child home alone, and subsequently resigned from their positions.

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

The child has been missing from home on two occasions. Staff followed missing-from- home procedures and worked with the police to locate the child and return them home safely. However, independent return home interviews were not undertaken following the incidents. This was a missed opportunity to identify triggers and implement new strategies to mitigate the risks.

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

The child has been held on a number of occasions by managers and staff. Although staff are trained in physical intervention and de-escalation techniques, the physical intervention reports do not describe the holds used or include details of all the staff involved. The child is not given the opportunity to reflect and share their views and feelings following a physical intervention. This is a missed opportunity for leaders and managers to evaluate staff practice and identify and address any shortfalls in a timely manner.

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

Consequences are not recorded in sufficient detail. Two consequences given to the child were punitive, disproportionate and not restorative, causing the child further distress. Furthermore, the child does not have the opportunity to reflect on incidents and consequences to help them to develop strategies for managing their own behaviour.

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

Leaders and managers fail to identify and address shortfalls in safeguarding practice. As a result, staff continue to work in the home and in the wider organisation without the additional risks they may pose being assessed. The child continues to be at risk of harm due to staff not having the required skills or knowledge to respond effectively to safeguarding incidents to keep them safe.

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

Serious incidents have not been notified to Ofsted and the placing authority in a timely manner, or not notified at all. This means that the regulator and placing authority do not have sufficient oversight and scrutiny of the management of safeguarding incidents. Inspection report for children's home: 2716515 5

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The effectiveness of leaders and managers: inadequate

Effective management oversight of staff practice and the quality of care provided to the child is lacking, significantly compromising the child’s welfare and safety.

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The effectiveness of leaders and managers: inadequate

Significant shortfalls in the management oversight of incidents, allegations and poor staff practice have left the child unsafe and receiving inadequate care. Leaders and managers fail to maintain the home in accordance with the aims outlined in its statement of purpose, policies and procedures.

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The effectiveness of leaders and managers: inadequate

There are shortfalls in safer recruitment practices and suitability checks are not sufficiently robust. References are not always obtained from previous employers where staff have been dismissed, and gaps in employment history are not explored.

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The effectiveness of leaders and managers: inadequate

Staff say they feel supported by the management team. However, a new inexperienced member of staff has not received an induction, probation period review or supervision since starting in the role some months ago. This demonstrates that not all staff receive adequate support in their roles.

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The effectiveness of leaders and managers: inadequate

Team meetings do not regularly take place and some records lack clarity regarding attendance and who has led the meeting. More recently, some safeguarding practices have been discussed, including whistle-blowing. However, this has had very little impact on staff, who have failed to follow the procedure. Leaders and managers are unable to assure themselves that staff continue to meet the needs of the child and keep them safe.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not regularly seek feedback from professionals, family members or the staff, and do not use research to inform their practice. During the inspection, no reviewing, monitoring or auditing information was available. This is a missed opportunity for leaders and managers to identify and reflect on themes, patterns and trends and shortfalls in practice. As a result, poor and inconsistent practice continues to go unaddressed.

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The effectiveness of leaders and managers: inadequate

The review report on the quality of care lacks clear, measurable targets and does not incorporate feedback from the child, professionals, family members or staff. This impacts on the leadership of the home as it does not support leaders and managers in their efforts to strengthen and develop the service.

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The effectiveness of leaders and managers: inadequate

One requirement raised at the last inspection has been met. Two requirements have been restated. One recommendation has now been raised as a requirement. Inspection report for children's home: 2716515 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

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;

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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)(vii)(b)(d)(e)) 21 July 2024 Inspection report for children's home: 2716515 7 The quality and purpose of care standard is that children receive care from staff who—

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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) (2)(c)(i))

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Requirement Due date

Specifically, the registered person must ensure that the home is clean, tidy and decorated and maintained to a good standard and the garden area is free of hazards. 21 July 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—

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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

strive to gain each child’s respect and trust;

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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. (Regulation 11 (1)(a)(b)(c) (2)(a)(i)(viii)(ix)(x))

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Requirement Due date

Specifically, the registered person must ensure that all staff and managers build a positive relationship with children based on mutual respect. Staff should be supported to gain the competence and skills to develop positive relationships and understand their own responses to children. 21 July 2024 Inspection report for children's home: 2716515 8 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

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; and

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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)(b) (2)(a)(b)(c)(d)(e)(f)(g)(i)(ii)(h)) 21 July 2024

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Requirement Due date

The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so. 21 July 2024 Inspection report for children's home: 2716515 9 In particular, the standard in paragraph (1) requires the registered person to ensure—

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Requirement Due date

help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans. (Regulation 8 (1) (2)(a)(i))

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Requirement Due date

Specifically, the registered person must ensure that children’s personal education plans are accessible to the staff to support children with their targets.

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Requirement Due date

The registered person must prepare and implement a policy which—

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Requirement Due date

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. (Regulation 34 (1)(a)(b))

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Requirement Due date

Specifically, the registered person must ensure that all managers and staff understand and follow safeguarding and allegation management policies. 21 July 2024

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Requirement Due date

ensure that each employee completes an appropriate induction;

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Requirement Due date

ensure that each permanent appointment of an employee is subject to the satisfactory completion of a period of probation.

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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. (Regulation 33 (1)(a)(b) (4)(a)(b)) 21 July 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

the individual is of integrity and good character; 21 July 2024 Inspection report for children's home: 2716515 10 the individual has the appropriate experience, qualification and skills for the work that the individual is to perform;

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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.

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Requirement Due date

The registered person must take reasonable steps to ensure that any individual who is working at the home and who does not fall within paragraph (2)(a) and (b) is appropriately supervised while carrying out the individual’s duties. (Regulation 32 (1) (3)(a)(b)(d) (8))

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Requirement Due date

Specifically, the registered person must ensure that satisfactory Disclosure and Barring Service checks remain current, satisfactory references are obtained and gaps in employment history are explained and explored. If a person has previously worked in a position involving work with children, verification and assessment of the reason the employment or position ended should take place, supported by a clear rationale about the person’s suitability for the role.

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Requirement Due date

a description of the measure and its duration. (Regulation 35 (3)(a)(iv))

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Requirement Due date

Specifically, the registered person should ensure that all managers and staff record the description of any hold used and for how long. Also, ensure that any consequences given are restorative in nature and consideration is given to the duration of the consequences.

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Requirement Due date

This requirement is restated. 21 July 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 — 21 July 2024 Inspection report for children's home: 2716515 11 is instigated; or

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Requirement Due date

concludes (in which case, the notification must include the outcome of the child protection enquiry); or

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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)(a)(b)(c)(d)(i)(ii)(e))

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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. (Regulation 45 (1) (2)(a)(b)(c))

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Requirement Due date

Specifically, the registered person must ensure that the report covers six months, targets set are measurable and feedback is included from children, staff, professionals and parents (where possible), to support the development of the service. 21 July 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: 2716515 12

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Children’s home details

Registered provider: Coastal Quality Care Limited

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Children’s home details

Registered provider address: Premier House, Premier Way, Poulton Industrial Estate, Poulton-le-Fylde FY6 8JP

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Inspectors

Julie Elder, Social Care Inspector Debbie Dawson, Social Care Inspector Inspection report for children's home: 2716515 13 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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