Children's Home run by Central and Southern Homes Limited in Devon

Inspection report for children’s home: 2717528 1 Registered provider: Central and Southern Homes Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

The home provides long-term care for up to four children who experience social and emotional difficulties.

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Information about this children’s home

Two children have moved into the home since the previous inspection. Three children now live in the home and were present during the inspection.

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Information about this children’s home

There have been four changes of manager since the previous inspection. A new manager was appointed on 31 July 2024 and has applied to register with Ofsted.

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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 are not protected, their welfare is not promoted or safeguarded. The care and experiences of children 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: 2717528 2

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Inspection date Inspection type Inspection judgement

29/08/2023 Full Good Inspection report for children’s home: 2717528 3

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Overall experiences and progress of children and young people: inadequate

Children’s emotional, social and educational needs are not being sufficiently met. For example, leaders and managers did not consider important information regarding a new child moving in and the suitability of the children living together. As a result, staff are unable to manage the competing and differing needs of the children effectively. Children have expressed that they feel unhappy living with the other children in the home. This impacts on their willingness to engage in group activities, limits their social interactions with others and leads to children wanting to spend more time in their bedrooms alone.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers have not prioritised children’s education well enough. When children are not in school, staff do not provide alternative educational activities to enable children to learn and make progress. The manager has not considered the impact on children’s general health and wellbeing of them travelling significant distances to and from school each day. These concerns have not been raised with the children’s placing authorities.

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Overall experiences and progress of children and young people: inadequate

Staff are not sufficiently helping all children to develop interests and positive, healthy daily routines. Staff do not accurately understand children’s experiences of living in the home and the impact on them of the competing needs of the other children. This has resulted in clear signs of concerning behaviour, with aspects of the children’s emotional well-being and mental health being overlooked. Staff do not have a clear or effective approach to assessing risks in respect of all children’s social media use and the potential impact this could have on their wellbeing.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers have not ensured that placement plans for children reflect their day-to-day experiences in the home. The information does not give staff clear guidance on how to support children and some of the goals are unrealistic and generalised. Plans are not readily updated, which makes it difficult to track children’s progress.

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Overall experiences and progress of children and young people: inadequate

Due to the lack of effective guidance and not being able to effect positive change, staff have resorted to using some punitive and inappropriate consequences for children in a misguided attempt to change behaviours that children display when they are distressed. Such consequences include a young child of primary school age not being allowed their bedtime story and another child being told family time will be removed when staff have been unable to manage children’s behaviour. These approaches are not effective and fail to consider the previous lived experiences of the children before entering residential care. This impacts on children’s emotional well-being and mental health and their attachments to the adults who care for them.

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Overall experiences and progress of children and young people: inadequate

Children enjoyed a one-week holiday together recently, which was a positive experience for them and demonstrated that they enjoy opportunities to participate in activities. However, there is a lack of planning or routine activities outside of planned Inspection report for children’s home: 2717528 4 holiday time to include opportunities outside of the home. Staff rely heavily on television and electronic devices as entertainment for the older children.

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Overall experiences and progress of children and young people: inadequate

The home is clean, well maintained and presented. The children’s bedrooms are personalised and appropriately decorated. Photos of the children are displayed on the walls, which helps children to feel valued.

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

Children are not being kept safe. Risks, particularly in relation to self-harm and age- appropriate, child-specific restraint are not sufficiently identified to ensure that children receive consistent safe care. Information provided to staff is not specific enough to guide them effectively on how to prevent situations from escalating. At times, incidents have occurred when children have harmed one another and staff.

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

Staff use restraint and physical intervention techniques regularly. These are not always necessary or effective and, at times, have resulted in children becoming upset and distressed. Leaders and managers do not have a plan in place as to how this level of restraint can be reduced. Children have said that they have been hurt during physical interventions and have expressed emotional distress about its use. One child said ‘I do not like it when staff shout’. Children’s feelings have been minimised and not investigated by managers, despite them being recorded in incident reports. Children are offered debriefs following incidents so they can talk to staff about their wishes and feelings, but these are not carried out in a timely manner. In some situations, conversations have taken place a week later, which is not meaningful for young children. Leaders and managers cannot demonstrate learning from these conversations to inform

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

Leaders and managers do not provide robust oversight of incidents. Managers fail to highlight important issues, such as children being hurt, staff not being trained in using restraint, inappropriate responses from staff or learning from incidents. This has resulted in a culture in the home where physical intervention and punitive approaches to behaviour are used inappropriately and without consideration of the impact on children.

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

Managers fail to investigate when concerns, allegations and complaints are made by children or staff. They do not take robust or timely action to investigate and address these concerns. This has left children at risk.

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The effectiveness of leaders and managers: inadequate

The home has not had a registered manager since February 2024, with four changes of manager since the previous inspection. This has resulted in instability for the children and staff and a lack of effective oversight of the care that children have received. The new manager requires support to help their understanding of children’s homes regulations and how these are to be applied in practice. Inspection report for children’s home: 2717528 5 Supervision takes place regularly, and staff report feeling supported by the covering managers. However, issues and concerns raised during supervision sessions are often not followed up and effective action is not always taken.

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The effectiveness of leaders and managers: inadequate

Several staff are within their probationary period and, at times, work in the home overnight without an experienced staff member being present. Some staff are yet to receive appropriate training for using restraint, which leaves children and staff in a vulnerable position. Staff are injured on a regular basis when in the home but there is insufficient oversight, support or action to rectify this ongoing problem. This has resulted in some staff reporting that they feel unsafe.

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The effectiveness of leaders and managers: inadequate

Leaders and managers lack effective oversight of what medication children are prescribed and why, and whether some medication needs to be continued or changed. Processes for managing medication have not always been followed correctly by staff. This has resulted in three errors occurring, some of which were not discovered quickly. However, these mistakes did not cause harm to children. Managers have carried out comprehensive investigations with clear recommendations and have taken steps to improve medication administration arrangements.

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The effectiveness of leaders and managers: inadequate

Leaders and managers say that staff use a therapeutic and reparative approach; however, this is not sufficiently evident in practice.

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The effectiveness of leaders and managers: inadequate

Leaders and managers carry out the required checks on permanent staff to understand whether they are suitable to work with children. In contrast, managers do not verify the information they receive from agency providers to satisfy themselves that agency staff have the suitable experience, skills and training to care for children. Inspection report for children’s home: 2717528 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 ensure that—

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Requirement Due date

if they consider, 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.

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Requirement Due date

In particular, this relates to the registered person ensuring that they liaise effectively with other agencies to review the current education arrangements for children to ensure that they are suitable and meet their needs. 4 October 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

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

understand and apply the home’s statement of purpose;

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Requirement Due date

understand and apply the home’s statement of purpose;

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Requirement Due date

protect and promote each child’s welfare;

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Requirement Due date

treat each child with dignity and respect; 4 October 2024 Inspection report for children’s home: 2717528 7 provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background;

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Requirement Due date

help each child to understand and manage the impact of any experience of abuse or neglect;

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Requirement Due date

make decisions about the day-to-day arrangements for each child, in accordance with the child’s relevant plans, which give the child an appropriate degree of freedom and choice.

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Requirement Due date

(Regulation 6 (a)(b) (2)(a)(b)(i)(ii)(iii)(iv)(v) (ix))

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Requirement Due date

In particular, ensure that children’s wellbeing is effectively assessed and monitored, that children are provided with positive and purposeful experiences in the home and that care/support plans effectively guide staff. The education standard is that children make measurable progress towards achieving their educational potential and are helped to do so.

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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

help each child to achieve the child’s education and training targets, as recorded in the child’s relevant plans;

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Requirement Due date

support each child’s learning and development, including helping the child to develop independent study skills and, where appropriate, helping the child to complete independent study;

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Requirement Due date

understand the barriers to learning that each child may face and take appropriate action to help the child to overcome any such barriers;

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Requirement Due date

help each child to understand the importance and value of education, learning, training and employment;

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Requirement Due date

promote opportunities for each child to learn informally;

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Requirement Due date

maintain regular contact with each child’s education and training provider, including engaging with the provider and the placing authority to support the child’s education and training and to maximise the child’s achievement; Inspection report for children’s home: 2717528 8 raise any need for further assessment or specialist provision in relation to a child with the child’s education or training provider and the child’s placing authority;

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Requirement Due date

help a child who is excluded from school, or who is of compulsory school age but not attending school, to access educational and training support throughout the period of exclusion or non-attendance and to return to school as soon as possible.

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Requirement Due date

(Regulation 8 (1) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii))

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Requirement Due date

The health and well-being standard is that—

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Requirement Due date

the health and well-being needs of children are met;

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Requirement Due date

children receive advice, services and support in relation to their health and well-being; and

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Requirement Due date

children are helped to lead healthy lifestyles.

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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

achieve the health and well-being outcomes that are recorded in the child’s relevant plans;

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Requirement Due date

understand the child’s health and well-being needs and the options that are available in relation to the child’s health and well-being, in a way that is appropriate to the child’s age and understanding; and

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Requirement Due date

understand and develop skills to promote the child’s well-being.

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Requirement Due date

(Regulation 10 (1)(a)(b)(c) (2)(a)(i)(ii)(iv)) 4 October 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 4 October 2024 Inspection report for children’s home: 2717528 9 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

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

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;

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Requirement Due date

de-escalate confrontations with or between children, or potentially violent behaviour by children; and

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Requirement Due date

that each child is encouraged to build and maintain positive relationships with others.

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Requirement Due date

(Regulation 11 (1)(a)(b)(c) (2)(a)(i)(ii)(iii)(iv)(v)(viii)(ix)(x)(xi)(b))

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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. 4 October 2024 Inspection report for children’s home: 2717528 10 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

manage relationships between children to prevent them from harming each other;

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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

t hat the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (1) (2)(i)(ii)(iii)(iv)(vi)(vii)(b)(e))

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Requirement Due date

In particular, leaders and managers should carry out a full review of previous incidents and physical interventions. The punitive culture in the home should be addressed with immediate effect.

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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— 4 October 2024 Inspection report for children’s home: 2717528 11 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

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

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)(f)(g)(ii)(h))

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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

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Requirement Due date

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 is of integrity and good character;

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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; 4 October 2024 Inspection report for children’s home: 2717528 12 the individual is mentally and physically fit for the purposes of the work that the individual is to perform; and

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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

(Regulation 32 (1) (2)(a)(b) (3)(a)(b)(c)(d))

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Requirement Due date

In particular, leaders and managers should ensure that recruitment checks on agency members of staff are of the same standard as checks for permanent members of staff.

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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, 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: 2717528 13

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Children’s home details

Registered provider: Central and Southern Homes Limited

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Children’s home details

Registered provider address: Pitmaston House, Malvern Road, Worcester WR2 4LL

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Children’s home details

Responsible individual: Matthew Dangerfield

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Inspectors

Helen Cushnie, Social Care Inspector Sarah Canto, Social Care Inspector Inspection report for children’s home: 2717528 14 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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