Clare Lodge

Inspection report for secure children's home - monitoring visit: SC033362 1 Clare Lodge Peterborough City Council, Clare Lodge Secure Children’s Home, 8 Lincoln Road, Glinton, Peterborough PE6 7AW

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Inspected under the social care common inspection framework

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Information about this secure children’s home

This home is operated by a local authority and is approved by the Secretary of State to restrict children’s liberty.

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Information about this secure children’s home

The home provides care for up to 16 girls aged between 10 and 17 who are placed by local authorities, under section 25 of the Children Act 1989. At the time of this inspection, eight children were living at the home. One child was spoken to at this visit.

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Information about this secure children’s home

Admission of any child who is under 13 years old requires the approval of the Secretary of State, under section 25 of the Children Act 1989.

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Information about this secure children’s home

The commissioning of health services at this home is the statutory responsibility of NHS England under the Health and Social Care Act 2012. Education is provided on site in dedicated facilities. Inspectors only inspected the social care provision.

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Information about this secure children’s home

The registered manager has been in post since May 2013.

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Information about this secure children’s home

Inspection dates: 11 and 12 September 2024

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This monitoring visit

This visit was carried out to address specific concerns from a director of children’s services about the care of a child that the local authority has placed at the home.

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This monitoring visit

This child is receiving care that has, over time, developed into a reactive model. The multidisciplinary approach that includes the placing local authority’s input and oversight is not providing sufficient review, challenge, intervention or actions to improve the child’s care and well-being. As a result, there are a high number of Inspection report for secure children's home - monitoring visit: SC033362 2 incidents of physical restraint and limited routines. At times, over-restrictive and punitive practices are not reviewed or challenged effectively.

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This monitoring visit

The child has good relationships with some staff and said she has someone she trusts to talk to if she is worried or concerned. She said that she is bored.

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This monitoring visit

The incidents of physical restraint are justified to support children’s safety, however, middle managers tasked with reviewing incidents fail to identify concerns and/or learning. The registered manager samples their work. However, she fails to identify when there are concerns, or any learning following incidents. It is unclear whether all uses of physical restraint have been appropriate, due to the small number sampled by the manager from the significant overall number. The responsible individual agreed to conduct a full review of incidents of restraint.

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This monitoring visit

A significant number of physical restraints carried out by staff with this child follow a process that is informed by the multidisciplinary team. There have been opportunities to consider other strategies. However, there is a lack of insight and challenge from all involved, including the placing local authority, to come up with an appropriate plan to address the child’s complexities and meet their needs. Managers have failed to identify that the redesign of a child’s bedroom could have a positive impact and reduce incidents.

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This monitoring visit

In three physical restraint incidents, staff helped to keep the child safe but then failed to follow the child’s risk assessment and care plan in seeking medical advice. Managerial monitoring failed to identify that this action had not been taken. This did not affect the child’s health and well-being, as a health professional saw the child the next day and there were no concerns.

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This monitoring visit

In another incident, the child alleged that her arm was hurt intentionally by staff. The responsible individual confirmed that safeguarding procedures were not followed, and the matter was not identified in monitoring. Staff failed to recognise the concern as a safeguarding matter and did not follow the safeguarding procedures. The responsible individual acknowledged the inspectors’ findings and agreed to take action to review whether in other instances appropriate action had been taken.

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This monitoring visit

The child has contributed to her plan to include the range of activities that she likes. Inspectors observed that the child appeared bored. The child lacks a structured or interesting routine and is not engaged by staff. This has led to incidents. Records show that the child is offered limited activities. In some cases, activities have been withdrawn or delayed by staff due to a previous incident. The withholding of activities is not reasonable or justified and has led to the child’s increased frustration and caused further incidents. Another incident record shows that the child was not allowed outside for exercise and fresh air for 24 hours due to a previous event. This is despite the registered manager stating that fresh air and exercise were not Inspection report for secure children's home - monitoring visit: SC033362 3 restricted. The management and design of outside areas to reduce risks to the child

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This monitoring visit

could have been addressed to allow the child to safely access the outside space.

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This monitoring visit

Staff are doing their best to help keep this child safe and have not intentionally used inappropriate or concerning practice. They demonstrate admirable resilience and a will to do the best for this child. However, the level of the child’s needs means that staff require strong leadership and guidance, which is lacking. The lack of insight and direction by managers and the multidisciplinary team has failed to provide staff with enough guidance.

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This monitoring visit

The placing local authority is concerned that the home is hindering transition planning for the child, stating that the staff refuse to take her out of the home on mobility (time outside the home in the community) to assist with assessment and moving on. The child has complex needs and is a very high risk to herself. There is a high incidence of self-harm and regularly verbalised suicidal ideation. The child has told staff that if she is taken out of the home, she will run away and try to kill herself. The placing local authority’s view is therefore unfounded, and this raises the question of whether they fully understand and appreciate the level of risk that they are asking the home to manage.

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This monitoring visit

The home has engaged with the placing local authority, which, in July 2024, spoke positively about the care provided. Given the level of concern records show that social workers have only visited the child three times since her admission in February 2024. This does not reflect the level of concern expressed by the director of children’s services of the placing local authority. The last visit was on 9 July 2024. The records show that the placing local authority is not attending the regular meetings led by the home, including those held virtually. Inspectors sat in on one of these meetings attended by a manager, case manager, a clinical psychologist and education staff. Although the local authority was invited, they did not attend. On the evidence seen by inspectors, the placing local authority is not providing challenge to the home in relation to the concerns that they have about the child’s care. The

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This monitoring visit

director of children’s services of the host local authority, which oversees the running of the secure children’s home, was not aware of the concerns raised by the director of children’s services of the placing local authority until this inspection.

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This monitoring visit

The placing local authority is concerned that the home is not helping to improve assessment to inform care planning. Inspectors found that the home has conducted a detailed assessment of the child’s needs, which includes the views of the lead clinical psychologist. This assessment sets out what the staff think the child’s needs are for the next steps of their journey and includes the risks. This was shared with the placing local authority in July 2024. The home has agreed that, to support the child, it will arrange for its staff to take the child on visits to any new placement that is identified.

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This monitoring visit

The responsible individual told inspectors that she accepts all the findings from this inspection and will act on them quickly and decisively. Inspection report for secure children's home - monitoring visit: SC033362 4 Requirements made at the last inspection were outside of the scope of this visit. These will be reviewed at the next inspection.

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Inspection date Inspection type Inspection judgement

23/04/2024 Full Requires improvement to be good 25/07/2023 Full Good 29/11/2022 Full Requires improvement to be good 13/09/2022 Full Inadequate Inspection report for secure children's home - monitoring visit: SC033362 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 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

protect and promote each child’s welfare;

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Requirement Due date

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 develop resilience and skills that prepare the child to return home, to live in a new placement or to live independently as an adult;

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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. (Regulation 6 (1) (2)(b)(ii)(iv)(vi)(ix)) 30 September

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Requirement Due date

The enjoyment and achievement standard is that children take part in and benefit from a variety of activities that meet their needs and develop and reflect their creative, cultural, intellectual, physical and social interests and skills.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure— 30 September Inspection report for secure children's home - monitoring visit: SC033362 6 that staff help each child to—

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Requirement Due date

develop the child’s interests and hobbies;

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Requirement Due date

participate in activities that the child enjoys and which meet and expand the child’s interests and preferences; and

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Requirement Due date

that each child has access to a range of activities that enable the child to pursue the child’s interests and hobbies. (Regulation 9 (1) (2)(a)(i)(ii)(b))

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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.

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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

understand and develop skills to promote the child’s well- being. (Regulation 10 (1)(a)(b) (2)(a)(iv)) 30 September

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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

understand how children’s previous experiences and present emotions can be communicated through behaviour and have 30 October 2024 Inspection report for secure children's home - monitoring visit: SC033362 7 the competence and skills to interpret these and develop positive relationships with children;

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Requirement Due date

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

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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

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 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. (Regulation 12 (1) (2)(a)(v)(vi)(vii)(d))

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Requirement Due date

In particular, ensure that all managers and staff understand and implement the home’s safeguarding policies and procedures.

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Requirement Due date

Also, ensure that each child’s bedroom is designed to protect each child and assist staff in keeping children safe. 30 October 2024

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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— 24 November 2024 Inspection report for secure children's home - monitoring visit: SC033362 8 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

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)(a)(b) (2)(a)(f)(g)(i)(ii)(h))

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Information about this inspection

Inspectors visited the home following information shared with Ofsted about the care of a child placed at the home.

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Information about this inspection

This inspection was carried out under the Care Standards Act 2000. Inspection report for secure children's home - monitoring visit: SC033362 9

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Secure children’s home details

Registered provider: Peterborough City Council

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Secure children’s home details

Registered provider address: Sand Martin House, Bittern Way, Peterborough PE2 8TY

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Inspectors

Shaun Common, His Majesty’s Inspector Thirza Smith, Social Care Inspector Inspection report for secure children's home - monitoring visit: SC033362 10 to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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