Children's Home run by Kezi & Clay Healthcare Limited in Lincolnshire

Assurance inspection report for children's home: 2791062 1 Registered provider: Kezi & Clay Healthcare Limited

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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 three children.

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Information about this children’s home

The home was registered on the 12 June 2024 and has been without a registered manager since 8 July 2024. The home has not yet appointed a suitably qualified manager.

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Information about this children’s home

At the time of the inspection, two children were living in the home.

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Inspection date: 14 August 2024

Judgement at last inspection: requires improvement to be good

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Inspection date: 14 August 2024

Enforcement action since last inspection: none

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Information about this inspection

At this inspection, the inspectors evaluated:

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Information about this inspection

 the care of children  the safety of children  the effectiveness of leaders and managers. Inspectors have looked closely at the experiences and progress of children, using the social care common inspection framework. This assurance 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’. Assurance inspection report for children's home: 2791062 2

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Findings from the inspection

We identified the following serious and widespread concerns in relation to the care or protection of children at this assurance inspection:

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Findings from the inspection

 There were significant shortfalls relating to the well-being and safety of children.  There were significant shortfalls relating to the leadership and management of the home.

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Findings from the inspection

Staff have not ensured that children’s bedrooms are safe, hygienic and free from hazards. Children have objects in their bedrooms that pose a fire risk. Children smoke and vape in their bedrooms. These risks have not been explored by staff and managers or evaluated in an up-to-date fire risk assessment. Drug paraphernalia is not removed from children’s bedrooms. This presents a risk to children and does not provide for a safe environment for children.

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Findings from the inspection

One child is subject to a court order restricting their liberty. The fire risk assessment does not consider the locking of external doors, which is required for that child in accordance with the court order. The door to another child’s bedroom does not fully close, which presents a fire risk.

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Findings from the inspection

The children’s individual safety plans do not provide staff with guidance on how to help children who may use drugs or other substances. For example, staff are giving one child monies to buy vapes without written agreement from the local authority.

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Findings from the inspection

Children are not receiving continuity of care from staff because of the high level of staff turnover. Despite this, children said they liked staff and had formed some good relationships with them.

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Findings from the inspection

Not all staff have the skills and experience to meet the children’s needs. One child is subject to a deprivation of liberty order. This order provides for staff to use physical restraint in situations where the child may pose a risk of harm to themselves or others. Staff are not trained to physically restrain children. This limits staff’s response to the child to keep them safe. Staff would be unable to fulfil this element of the child’s plan should this be required. This shortfall could have a detrimental impact on children’s safety.

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Findings from the inspection

There has been no audit of medication practice in the home. Administration of medication is inconsistently recorded. There is no record kept when controlled drugs are returned. One child had access to medication which was kept in their bedroom, without review of how this could be misused, alongside any potential substance misuse. This has the potential to place the child at risk of harm.

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Findings from the inspection

Children’s care planning and risk assessment documents are not being reviewed regularly. Information in these documents is not consistent and does not offer clear Assurance inspection report for children's home: 2791062 3 direction to staff. Additionally, rotas are not planned to take into account staff training. For example, senior leaders do not ensure that a staff member with a first- aid qualification is on each shift. This is a shortfall.

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Findings from the inspection

There have been recent changes to the management arrangements. This has had a detrimental impact on management oversight. Staff do not receive clear guidance from senior leaders to carry out their roles and responsibilities. For example, behaviour and risk management plans are inconsistent and lack the necessary details to keep children safe.

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Findings from the inspection

There has been no monitoring of the home by an independent visitor since May 2024. This means there is limited external monitoring of the effectiveness of the quality of care and safeguarding arrangements for children. This has a detrimental impact on the responsible individual’s understanding of the home’s strengths and areas for development.

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Findings from the inspection

Senior leaders have failed to ensure that there is independent scrutiny of family members who are working in the home, or safer recruitment checks. There is no risk assessment to assess conflicts of interest. Not all staff receive employment contracts when they start their employment. Ofsted is not reassured that staff have been recruited, vetted and appointed appropriately.

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Findings from the inspection

In addition, some of the staff team, including senior leaders, are related to one another. There is no policy in place to protect children if they were to share allegations of harm or if staff wanted to whistle-blow concerns of malpractice. This increases the risk of a closed culture forming and does not promote positive safeguarding practice.

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Findings from the inspection

A requirement under regulation 47 was set at the recent full inspection and this is restated. The responsible individual acknowledges the shortfalls and has started to take steps to improve practice. Assurance inspection report for children's home: 2791062 4

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Inspection date Inspection type Inspection judgement

23/07/2024 Full Requires improvement to be good Assurance inspection report for children's home: 2791062 5

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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. (Regulation 12 (1) (2)(a)(i)(ii)(iii)(v)(vi)(b)(d))

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Requirement Due date

In particular, this relates to ensuring that risk assessments for children are in place, up to date and accurate, reflecting the current risks for children. The registered person should ensure the environment is free from hazards, in particular, that children’s bedrooms are in a hygienic and safe state.

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Requirement Due date

The registered person should implement safety plans agreed with the local authority for children who smoke, vape or use substances.

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Requirement Due date

The registered person should provide training for staff to exercise such restrictions as permitted in a child’s deprivation of liberty order, should these be required in response to risk of harm, in particular, the use of restrictive physical intervention. 15 September

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Requirement Due date

*After consultation with the fire and rescue authority, the registered person must—

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Requirement Due date

take adequate precautions against the risk of fire, including the provision of suitable fire equipment in the children’s home; 15 September Assurance inspection report for children's home: 2791062 6 provide adequate means of escape from the home in the event of fire. (Regulation 25 (1)(a)(b))

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Requirement Due date

The fire risk assessment should take into account the locking of doors as part of a child’s deprivation of liberty order, alongside risks associated with children smoking and vaping.

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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

employ an individual to work at the children’s home; or if an individual is employed by a person other than the registered person to work at the home in a position in which the individual may have regular contact with children, allow that individual to work at the home,

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Requirement Due date

if the individual satisfies the requirements in paragraph (3).

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Requirement Due date

the individual has the appropriate experience, qualification and skills for the work that the individual is to perform; 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

For the purposes of paragraph (3)(b), an individual who works in the home in a care role has the appropriate qualification if, by the relevant date, the individual has attained—

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Requirement Due date

the Level 3 Diploma for Residential Childcare (England) ("the Level 3 Diploma") a qualification which the registered person considers to be equivalent to the Level 3 Diploma.

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Requirement Due date

in the case of an individual who starts working in a care role in a home after 1st April 2014, the date which falls 2 years after the date on which the individual started working in a care role in a home; or in the case of an individual who was working in a care role in a home on 1st April 2014, 1st April 2016. (Regulation 32 (1) (2)(a)(b) (3)(b)(d) (4)(a)(b)(5)(a)(b)) 15 September Assurance inspection report for children's home: 2791062 7 In particular, an independent person should undertake an audit of safer recruitment checks for all workers in the home in compliance with schedule 2.

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Requirement Due date

An independent person should undertake an audit of recruitment records to ensure all documentation is reflective of the provider’s recruitment policy and includes a contract of employment.

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Requirement Due date

An independent person should complete a work practice risk assessment in regard to family members who are employed to work at the home. Staff practice and recruitment processes should not be overseen by a relative.

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Requirement Due date

*The registered person must ensure that an independent person visits the children’s home at least once each month.

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Requirement Due date

When the independent person is carrying out a visit, the registered person must help the independent person—

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Requirement Due date

if they consent, to interview in private such of the children, their parents, relatives and persons working at the home as the independent person requires; and

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Requirement Due date

to inspect the premises of the home and such of the home’s records (except for a child’s case records, unless the child and the child’s placing authority consent) as the independent person requires.

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Requirement Due date

A visit by the independent person to the home may be unannounced.

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Requirement Due date

The independent person must produce a report about a visit ("the independent person’s report") which sets out, in particular, the independent person’s opinion as to whether— children are effectively safeguarded; and

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Requirement Due date

the conduct of the home promotes children’s well-being. The independent person’s report may recommend actions that the registered person may take in relation to the home and timescales within which the registered person must consider whether or not to take those actions.

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Requirement Due date

If the independent person becomes aware of a potential conflict of interest (whether under regulation 43(3) or otherwise) after a visit to the home, the independent person must include in the independent person’s report— 15 September Assurance inspection report for children's home: 2791062 8 details of the conflict of interest; and

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Requirement Due date

the reasons why the independent person did not notify the registered provider of the conflict of interest before the visit.

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Requirement Due date

The independent person must provide a copy of the independent person’s report to—

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Requirement Due date

the registered provider and, if applicable, the registered manager; and the responsible individual (if one is nominated). (Regulation 44 (1) (2)(a)(b)(3) (4)(a)(b) (5) (6)(a)(b) (7)(a)(b)(c)(d)(e))

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Requirement Due date

In particular, the registered person must ensure that an independent person visits the home at least once a month and provides a written report which includes the independent person’s opinion of whether children are effectively safeguarded and if the conduct of the home promotes the children’s well-being.

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Requirement Due date

The quality and purpose of care standard is that children receive care from staff who—

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Requirement Due date

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

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Requirement Due date

use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

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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 and manage the impact of any experience of abuse or neglect. (Regulation 6 (1)(a)(b) (2)(b)(v))

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Requirement Due date

In particular, that children’s care planning and risk assessment documents should be reviewed regularly. Information should be consistent and offer clear direction to staff. 23 October 2024 Assurance inspection report for children's home: 2791062 9 When children are unable to maintain their bedrooms, staff should intervene to ensure that children live in a clean, safe environment.

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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 promotes their welfare.

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Requirement Due date

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

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Requirement Due date

lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home’s statement of purpose;

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Requirement Due date

ensure that the home has sufficient staff to provide care for 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)(d)(f)(h))

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Requirement Due date

In particular, this relates to ensuring that the staff team is stable and is supported to meet the children’s needs.

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Requirement Due date

Additionally, this relates to ensuring there is adequate oversight of planning to enable the home to meet the needs of each child and that there are clear systems in place to monitor and review the quality of care the home is providing. 23 October 2024

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Requirement Due date

The care planning standard is that children—

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Requirement Due date

receive effectively planned care in or through the children’s home; and

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Requirement Due date

have a positive experience of arriving at or moving on from the home.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure— 23 October 2024 Assurance inspection report for children's home: 2791062 10 that arrangements are in place to—

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Requirement Due date

manage and review the placement of each child in the home; and that, subject to regulation 22 (contact and access to communications), contact between each child and the child’s parents, relatives and friends, is promoted in accordance with the child’s relevant plans. (Regulation 14 (1)(a)(b) (2)(a)(b)(ii)(c)(d))

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Requirement Due date

In particular, this relates to ensuring clear plans are in place for a child when moving into the home. This also relates to ensuring that plans for children’s contact with important people are in place from the day the child moves into the home.

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Requirement Due date

The registered person should ensure that staff have the relevant training at the time a child is placed to meet the child’s immediate safety needs.

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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

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

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Requirement Due date

In particular, an independent person should review the storage and administration of medication. Controlled drugs must be disposed of in line with guidance. Children should not have access to medication unless this has been risk assessed. 15 September

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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 (b))

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Requirement Due date

In particular, this relates to the responsible individual being accountable for the care and safety of children in the home. 23 October 2024 Assurance inspection report for children's home: 2791062 11 Where practice is not to an acceptable standard, the responsible individual must challenge this appropriately.

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Requirement Due date

The registered provider must appoint a person to manage the children’s home if—

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Requirement Due date

there is no registered manager in respect of the home. (Regulation 27 (1)(a)) 23 October 2024

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Requirement Due date

at all times, at least one person on duty at the home has a suitable first aid qualification. (Regulation 31 (1) (2)(a)) 15 September

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Requirement Due date

The registered provider must carry on the children’s home in such manner as is likely to ensure that the home will be financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. (Regulation 47 (1))

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Requirement Due date

In particular, this relates to ensuring that the home remains financially viable. 23 October 2024

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Requirement Due date

*These requirements are subject to a compliance notice. Assurance inspection report for children's home: 2791062 12

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Children’s home details

Registered provider: Kezi & Clay Healthcare Limited

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Children’s home details

Registered provider address: Suite 2B, Randall Business Centre, Randall Park Way, Nottinghamshire DN22 7WF

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Children’s home details

Responsible individual: Nompumelelo Mahlangu

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Inspectors

Andi Lilley-Tams, Social Care Inspector Laura Walker, Social Care Inspector Assurance inspection report for children's home: 2791062 13 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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Inspectors

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