Children's home run by Seashell Trust

Inspection report for children's home: SC035518 1 SC035518 Registered provider: Seashell Trust

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Inspected under the social care common inspection framework

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Information about this children’s home

The home provides care for up to 12 children with physical disabilities, learning disabilities and/or sensory impairment. Children live in five houses on a site that includes a school and college. Most children attend the on-site school. The inspectors only inspected the social care provision at this school.

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Information about this children’s home

The manager registered with Ofsted in August 2023.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

There are serious and/or widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded and the care and experiences of children and young people are poor and they are not making progress.

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inadequate

Overall judgement at last inspection: good

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Enforcement action since last inspection:

The home was judged inadequate at a full inspection carried out on 7, 8 and 9 May 2024. Compliance notices were issued under regulation 12, the protection of children standard, and regulation 13, the leadership and management standard. An urgent condition was placed on the home to reduce the number of children living at the home Inspection report for children's home: SC035518 2 to 12. At a monitoring visit on 13 June 2024, it was assessed that effective action had been taken and the compliance notices were met Inspection report for children's home: SC035518 3

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Inspection date Inspection type Inspection judgement

11/07/2023 Full Good 15/11/2022 Full Good 01/12/2021 Full Good 18/02/2020 Interim Sustained effectiveness Inspection report for children's home: SC035518 4

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Overall experiences and progress of children and young people: inadequate

At the time of the inspection, there were 11 children living in the home. Since the last inspection, one child has moved out of the home because staff were unable to meet his needs. Leaders and managers attempted to work with the placing authority to provide the child a more positive ending However, the child did not experience a positive ending, after living in the home for many years.

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Overall experiences and progress of children and young people: inadequate

Prior to the inspection, two whistle-blowing complaints had been made. These involved concerns about untrained staff, medication errors and children not being supported in line with their plans. During the inspection, further concerns about staff practice were raised. The concerns included night staff falling asleep and concerns about staff suffering bullying. Inspectors found that leaders had taken some action to address these concerns when they were aware of incidents.

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Overall experiences and progress of children and young people: inadequate

Each child has plans that include their health needs. The plans provide clear strategies for staff to follow to ensure that children’s complex health needs are met. However, two children’s physiotherapy needs are not consistently met. Records do not show that two children have received respiratory physiotherapy as outlined in their plan. This limits the child’s progress and puts them at increased risk of harm.

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Overall experiences and progress of children and young people: inadequate

Over the summer, some children have enjoyed activities such as trips to a museum, the park and animal farms. However, leaders, managers and staff do not consistently support all children to develop their interests or take part in activities that they enjoy. One parent said that their child has not had access to a range of on-site activities due to staff shortages. This is a missed opportunity to develop the child’s confidence and self- esteem.

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Overall experiences and progress of children and young people: inadequate

There are occasions when some children do not receive the care they need in line with their plans. Children are not consistently cared for by staff they know well and who understand their needs and plans. This is compromising children’s opportunities to build stable and secure relationships with staff.

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

Some children who live at this home have complex healthcare needs. Children require staff to carry out clinical procedures and daily personal care to ensure they remain healthy and safe. However, there are shortfalls in staff practice and management oversight of this area. This means children’s healthcare needs are not consistently being met.

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

Since the last inspection, there have been two occasions on waking night shifts when staff have fallen asleep when responsible for the care and support of children. This is a significant safeguarding concern. Following these incidents Leaders and managers have Inspection report for children's home: SC035518 5 introduced new monitoring systems to improve their oversight of staff practice. However, these systems are not embedded into practice.

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

When one child was recently discharged from hospital, medical advice was given to monitor the child throughout the night. However, the records available on inspection did not demonstrate that these required checks were completed. This leaves children at risk of further harm.

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

Safeguarding practice is often reactive. Since the last inspection, there have been several medication errors. Despite lessons learned exercises being carried out and additional training provided, errors continue to occur.

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

Recording in the home is poor and lacks accountability. Incident reports are not always completed in line with children’s risk management plans. For example, leaders and managers were unable to locate several reports regarding incidents when a child removed his tracheotomy tube and when a child had experienced seizures. Additionally, daily logs are not clear on actions taken by staff.

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

Restraint in the home is used as a last resort. When incidents do occur, records are poor and do not include all relevant information, including body maps, in line with the organisation’s own policy. Additionally, leaders and managers do not ensure that staff and children are spoken to individually about the incident, and there is only limited evaluation by the registered manager. This is a missed opportunity to fully understand any triggers for these incidents, to improve staff safeguarding practices.

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

Leaders and managers follow safer recruitment processes. This means that only suitable adults are employed to work with children.

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The effectiveness of leaders and managers: inadequate

Leaders and managers are not leading and managing the home in a manner that is consistent with the aims outlined in the home’s statement of purpose. The registered manager is currently absent from work.

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The effectiveness of leaders and managers: inadequate

The responsible individual has been overseeing the home. She has taken some action to address the requirements from the last inspection and some requirements are met. However, the absence of the manager has impacted on the overall management of the home.

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The effectiveness of leaders and managers: inadequate

Recording systems are poor. Records do not demonstrate that leaders and managers consistently review and monitor staff practice. Children’s plans and records do not include all relevant information. There is inconsistent review and monitoring by leaders and managers. Therefore, leaders and managers do not have consistent oversight of staff practice.

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The effectiveness of leaders and managers: inadequate

The registered manager does not demonstrate he has day-to-day oversight of care practice in the home. There is no evidence on records of managerial oversight, and some Inspection report for children's home: SC035518 6 staff say that the registered manager does not know the children or understand their needs.

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The effectiveness of leaders and managers: inadequate

Staff practice and knowledge are inconsistent, which impacts on children, who are not receiving support in line with their individual health needs. The failure to provide some children with required physiotherapy is because staff have not received the required training or are not confident to deliver this.

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The effectiveness of leaders and managers: inadequate

Handovers between staff are of poor quality. Information-sharing does not cover all the child’s needs, including any medical needs or treatment, and handovers do not demonstrate effective communication among staff.

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The effectiveness of leaders and managers: inadequate

Feedback from staff was mixed. One member of staff said that the situation regarding staffing has improved. However, another said, ‘Lots of staff do not know how best to support children and staff need to call on someone else for further assistance.’

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The effectiveness of leaders and managers: inadequate

Feedback from parents was varied. One parent said there was good communication. Another said, they were concerned as [name of child]’s communication was not developing as it should be, due to lots of new staff who are either not trained or competent.’

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The effectiveness of leaders and managers: inadequate

Supervision is not taking place in line with the organisation’s own policies and procedures. When supervision does take place, it does not include any reflection. Additionally, not all staff who are delivering supervision are suitably trained. There are missed opportunities to establish staff’s knowledge and understanding of their roles and responsibilities in meeting the needs of children and keeping them safe.

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The effectiveness of leaders and managers: inadequate

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

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The effectiveness of leaders and managers: inadequate

Due to the shortfalls, Ofsted has issued compliance notices under regulation 10, the health and well-being standard, regulation 12, the protection of children standard, and regulation 13, the leadership and management standard. Ofsted will monitor the provider’s compliance with these notices. Inspection report for children's home: SC035518 7

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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 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

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. (Regulation 10 (1)(a) (2)(a)(i)) 13 October 2024

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Requirement Due date

*The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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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

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

that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm. (Regulation 12 (1) (2)(a)(i)(iii)(v)(b)) 13 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— 13 October 2024 Inspection report for children's home: SC035518 8 helps children aspire to fulfil their potential; and

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

ensure that staff 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

use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b) (2)(a)(c)(f)(h))

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home.

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Requirement Due date

In particular the registered person must ensure that—

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Requirement Due date

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

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Requirement Due date

medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child; and

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Requirement Due date

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

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Requirement Due date

In particular, the registered provider must ensure that children receive all their medication, in line with the home’s policies and procedures, and that all staff are assessed as competent. 4 November 2024

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Requirement Due date

The registered person must ensure that all employees—

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Requirement Due date

undertake appropriate continuing professional development; 4 November 2024 Inspection report for children's home: SC035518 9 receive practice-related supervision by a person with appropriate experience; and

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Requirement Due date

have their performance and fitness to perform their roles appraised at least once every year. (Regulation 33 (4)(a)(b)(c))

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Requirement Due date

In particular, the registered provider must ensure that all staff receive regular reflective supervision and that those staff are suitably trained in delivering supervision.

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Requirement Due date

within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes—

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Requirement Due date

details of the child’s behaviour leading to the use of the measure;

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Requirement Due date

the date, time and location of the use of the measure;

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Requirement Due date

a description of the measure and its duration;

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Requirement Due date

details of any methods used or steps taken to avoid the need to use the measure;

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Requirement Due date

the name of the person who used the measure (“the user”), and of any other person present when the measure was used;

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Requirement Due date

the effectiveness and any consequences of the use of the measure; and

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Requirement Due date

a description of any injury to the child or any other person, and any medical treatment administered, as a result of the measure;

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Requirement Due date

within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (“the authorised person”)—

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Requirement Due date

has spoken to the user about the measure; and

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Requirement Due date

has signed the record to confirm it is accurate; and

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Requirement Due date

within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. 4 November 2024 Inspection report for children's home: SC035518 10 (Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c))

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Requirement Due date

In particular, the manager must ensure that body maps are completed in line with children’s plans and debriefs take place with staff who were not involved in the hold. The manager must ensure these records are fully evaluated.

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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: SC035518 11

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Children’s home details

Provision sub-type: Residential special school

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Children’s home details

Responsible individual: Bernadette White

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Inspectors

Judith Birchall, Social Care Inspector Jennifer Quest, Social Care Inspector Sarah Jackson, Social Care Inspector Inspection report for children's home: SC035518 12 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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