Children's Home run by Holywell Children’s Services Limited in Lancashire

Inspection report for children’s home: 2663221 1 Registered provider: Holywell Children’s Services Limited

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This home is owned and operated by a private provider.

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Information about this children’s home

It is registered to provide care for up to two children with social and emotional needs.

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Information about this children’s home

One child is currently being cared for in this home. The inspector spoke with the child as part of the inspection.

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Information about this children’s home

There has been no registered manager since the 15 March 2024.

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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.

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inadequate

Date of last inspection: 15 November 2023

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inadequate

Overall judgement at last inspection: requires improvement to be good

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Enforcement action since last inspection:

A monitoring visit took place 22 August 2024 in response to whistleblowing concerns being made to Ofsted. These concerns relate to safeguarding practice, gaps in recording and reporting, and the working hours and well-being of staff. A compliance notice was Inspection report for children’s home: 2663221 2 issued under Regulation 12 of The Children’s Homes (England) Regulations 2015. A further monitoring visit took place on 26 September 2024. The compliance notice was deemed to have been met following this visit and no further enforcement action has been taken since this time. Inspection report for children’s home: 2663221 3

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Inspection date Inspection type Inspection judgement

15/11/2023 Full Requires improvement to be good 30/11/2022 Full Good Inspection report for children’s home: 2663221 4

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Overall experiences and progress of children and young people: inadequate

The child has lived in the home for over two years and has positive relationships with a stable staff team. However, their experiences and progress have been impacted by poor safeguarding practice and weak leadership and management of the home.

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Overall experiences and progress of children and young people: inadequate

Many areas of the home have been redecorated since the last inspection. Communal areas are fresh and well presented. However, these areas no longer contain any photographs of the child, their preferred wall hangings, or their artwork. The window restrictors in the bedrooms for children are burned and damaged. The child’s bedroom requires maintenance, such as a broken curtain pole and a faulty windowpane. Areas of the child’s bedroom are unclean. An area of the home is dedicated to the child pursuing their interests, but the child cannot complete artwork there because staff use it for storage.

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Overall experiences and progress of children and young people: inadequate

Another child came to live in the home for a short period. Staff could not meet the needs of the child. This resulted in immediate notice being served after a significant incident. The admission of this child was not carefully planned. The risks and needs of this child were either unknown or unrecognised by leaders and managers. The admission of another child had significant impact on the child who lives in the home and children in other local homes.

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Overall experiences and progress of children and young people: inadequate

Staff did not attend the child’s last statutory review. They do not have copies of the plans that were made following the meeting. Staff do not have copies of any of the personal education plans for the child. Internal plans are uninformed and cannot align with the wider plans for the child. Leaders and managers have not effectively challenged the placing authority for failing to provide the required documents.

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Overall experiences and progress of children and young people: inadequate

The child had a significant period out of education. Staff facilitated tutoring in the home whilst a school was identified. Following several complaints to the local council, the child now has a suitable school place. Staff take the child to and from school and liaise closely with school staff. The child attends regularly and will sit their GCSE examinations. The child’s predicated grades will allow them to study their preferred college course.

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Overall experiences and progress of children and young people: inadequate

Some aspects of the child’s health have improved. The child has had their overdue vaccinations and been able to have braces due to improved dental hygiene. Staff encourage a healthy diet and portion control. Staff provide a gym membership and take the child to the gym regularly. However, there are several health concerns now present, in relation to smoking and drug and alcohol misuse. A referral to drug and alcohol support services was significantly delayed, which meant the child was denied the opportunity of specialist support in a timely way.

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

Inspection report for children’s home: 2663221 5 Risks to children have either maintained or increased over the inspection period, except for self-harming risk for one child.

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

Safeguarding practice is poor. A bladed article was brought into the home and there was no assessment of this, or measures put into place to mitigate the risk. The child has been allowed to bring drugs into the home without challenge by staff. The child was seriously assaulted in the community and there was a lack of professional curiosity around this incident. The child removed high value items out of the home to sell and staff action was ineffective in preventing this. No room searches have been undertaken despite concerns about the child’s safety.

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

Risk assessments are clear, but do not consider some key or emerging risks. The assessments are updated whenever there is an incident, but the strategies to manage them remain the same and do not reflect any learning. Some strategies used by staff are not contained in the risk assessments, such as searching the child before school. Therefore, they are limited as tools to assist staff to effectively manage risk to children.

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

Staff do not record incidents in a timely way. Managers and leaders do not notify the regulator of all serious events. Serious events have been noted within the reports of the independent person and notifications have had to be requested for these matters. This limits the external scrutiny of concerns and does not allow the regulator to have effective oversight.

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

Staff know the individual missing plans for children and follow these when they are absent from the home. However, one child was permitted to leave the home past their curfew without challenge by staff. Records of missing-from-care incidents lack detail, and there is no exploration with the child about their activity out of the home. The placing authorities have not completed return home interviews with the children, and this has not been effectively challenged. Staff have not actively tried to form relationships with the parents or guardians of other children the child has been missing with. Therefore, staff do not have the information to reduce the risks of children being missing in the future.

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

A child alleged they had been harmed by a member of staff. There was no immediate action taken by senior leaders. An internal investigation was not conducted, and the local authority designated officer was not informed. Children and staff were left unsupported and at potential risk of harm.

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

Staff only hold children when this is a last resort and proportionate to the risk faced by the child. However, staff do not speak to children about the hold following its use. This does not support children’s understanding or their feelings of security. Managers and leaders do not speak to involved staff following a hold. Therefore, there are missed opportunities to reflect on practice and support staff well-being.

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The effectiveness of leaders and managers: inadequate

Inspection report for children’s home: 2663221 6 The registered manager’s post has been vacant since 15 March 2024. The interim manager is registered at another home within the organisation and is also managing the adjacent sister home. There is a current application to convert the three homes into a single multi-build setting.

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The effectiveness of leaders and managers: inadequate

The statement of purpose for the home is inaccurate and has not been updated since May 2024. Managers and leaders have amalgamated the statement of purpose for the three homes contained within the multi-build application. Therefore, the home does not currently have an individual statement of purpose as required by regulation.

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The effectiveness of leaders and managers: inadequate

The acting manager is supported by a deputy manager who works solely at this home. The acting manager is present in the home and attends daily. Staff feel supported by managers and feel they benefit from an open door policy. Managers and leaders provide a comprehensive training programme for staff. However, staff do not complete refreshers in training in the required timescales.

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The effectiveness of leaders and managers: inadequate

Management oversight of the home is poor and does not recognise or address shortfalls in recording and practice. The manager has not completed an audit of the home for a significant period. Managers and leaders were unable to provide accurate information in relation to the home within the inspection. Management oversight of staff recordings does not evaluate staff practice. The manager does not complete a review of the quality of care in the required timescales and those completed lack evaluation. Leaders and managers do not have a firm grip of practice, and opportunities to consider the lived experiences of children are missed.

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The effectiveness of leaders and managers: inadequate

An independent person visits the home monthly. Their discussions with children do not cover key concerns in the home at the time. The reports lack analysis of serious incidents and staff practice in relation to those incidents. The independent person noted that one serious incident should have been notified to Ofsted, but did not recognise the pattern of failing to notify the regulator. The independent person has consistently stated that children are effectively safeguarded and their well-being is promoted, despite Ofsted having found significant shortfalls relating to the protection of children. Therefore, the independent person is not providing the additional layer of scrutiny and oversight they should.

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The effectiveness of leaders and managers: inadequate

Team meetings are held regularly. Staff discuss practice and areas for improvement. However, the meetings lack structure, and some lack actions or review of previous actions, or updates on individual children. Therefore, they are limited as tools for service improvement.

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The effectiveness of leaders and managers: inadequate

Staff appraisals are completed annually. The appraisals contain the views of staff, managers, and the child who lives in the home. However, they do not contain the views of other professionals who have worked with the staff member over the year. A recommendation in relation to this has been restated. Inspection report for children’s home: 2663221 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 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

take effective action whenever there is a serious concern about a child’s welfare; and

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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)(vi)(b))

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Requirement Due date

Specifically, the registered person should ensure that staff recognise and respond effectively to risk, and that all risks to children are adequately assessed with effective strategies to manage them in place. Immediate action should be taken in response to allegations of harm against staff, and thorough investigations undertaken to ensure the safety of those in the home.* 16 April 2025

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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— 16 April 2025 Inspection report for children’s home: 2663221 8 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

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

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

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

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Requirement Due date

Specifically, the registered person should ensure that staff complete relevant training in adequate timescales. Monitoring and review systems should be robust and allow the registered person to identify and address shortfalls in practice and recording.*

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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—

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Requirement Due date

that children are admitted to the home only if their needs are within the range of needs of children for whom it is intended that the home is to provide care and accommodation, as set out in the home’s statement of purpose;

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Requirement Due date

that arrangements are in place to— 16 April 2025 Inspection report for children’s home: 2663221 9 manage and review the placement of each child in the home. (Regulation 14 (1)(a)(b) (2)(a)(b)(ii))

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Requirement Due date

Specifically, the registered person should ensure that all necessary information to make decisions on whether children should move into the home is sought in a timely way, and robust assessments of whether staff can safely meet their needs are undertaken prior to them moving in. Children whose needs cannot be met should not be admitted to the home.

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Requirement Due date

In meeting the quality standards, the registered person must, and must ensure that staff—

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Requirement Due date

seek to secure the input and services required to meet each child’s needs;

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Requirement Due date

if the registered person considers, 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. (Regulation 5(b)(c))

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Requirement Due date

Specifically, the registered person must ensure that important documents, such as care plans and PEPs, are received from the placing authorities and children receive return home interviews when they have been missing. Failures to provide required documents and services in a timely way should be challenged and escalated. 16 April 2025

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if—

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Requirement Due date

an incident requiring police involvement occurs in relation to a child which the registered person considers to be serious;

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Requirement Due date

there is an allegation of abuse against the home or a person working there; or

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Requirement Due date

there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(b)(c)(e)) 16 April 2025

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Requirement Due date

The registered person must ensure that— 16 April 2025 Inspection report for children’s home: 2663221 10 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 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. (Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vii)(viii)(b)(i)(ii)(c))

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Requirement Due date

The registered person must maintain records (“case records”) for each child which— include the information and documents listed in Schedule 3 in relation to each child; and are kept up to date. (Regulation 36 (1)(a)(b)) 16 April 2025 Inspection report for children’s home: 2663221 11 Specifically, the registered person must ensure that care and education plans from the placing authority are current and reflect the decisions made about their care.

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Requirement Due date

The registered person must complete a review of the quality of care provided for children (“a quality of care review”) at least once every 6 months.

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Requirement Due date

In order to complete a quality of care review the registered person must establish and maintain a system for monitoring, reviewing and evaluating—

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Requirement Due date

the quality of care provided for children;

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Requirement Due date

the feedback and opinions of children about the children’s home, its facilities and the quality of care they receive in it; and any actions that the registered person considers necessary in order to improve or maintain the quality of care provided for children.

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Requirement Due date

After completing a quality of care review, the registered person must produce a written report about the quality of care review and the actions which the registered person intends to take as a result of the quality of care review (“the quality of care review report”).

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Requirement Due date

supply to HMCI a copy of the quality of care review report within 28 days of the date on which the quality of care review is completed; and

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Requirement Due date

make a copy of the quality of care review report available on request to a placing authority, if the placing authority is not the parent of a child accommodated in the home.

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Requirement Due date

The system referred to in paragraph (2) must provide for ascertaining and considering the opinions of children, their parents, placing authorities and staff. (Regulation 45 (1) (2)(a)(b)(c) (3) (4)(a)(b) (5)) 30 June 2025

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Requirement Due date

The registered person must compile in relation to the children’s home a statement (“the statement of purpose”) which covers the matters listed in Schedule 1. 16 April 2025 Inspection report for children’s home: 2663221 12 The registered person must provide a copy of the statement of purpose to HMCI and make a copy of it available upon request to—

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Requirement Due date

a child, or a child for whom accommodation in the home is being considered;

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Requirement Due date

a parent of a child, or a parent of a child for whom accommodation in the home is being considered;

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Requirement Due date

in the case of a qualifying school, the Secretary of State.

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Requirement Due date

keep the statement of purpose under review and, where appropriate, revise it; and notify HMCI of any revisions and send HMCI a copy of the revised statement within 28 days of the revision. (Regulation 16 (1) (2)(a)(b)(c)(d)(e) (3)(a)(b))

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 The registered person should provide a nurturing and supportive environment that meet the needs of their children. Specifically, that repairs should be undertaken in a timely way and space allocated for children to pursue their interests is usable. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 15, paragraph 3.9).  The registered provider should also ensure that the independent person they appoint has the skills and understanding necessary to assess all relevant information and form an impartial judgement about the quality of the home’s care. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 65, paragraph 15.8).  The registered person should ensure that staff appraisals take into account, where reasonable and practical, the views of other professionals who have worked with the staff member over the year and children in the home’s care. (‘Guide to the Children’s

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Recommendations

Homes Regulations, including the quality standards’, page 61, paragraph 13.5). This recommendation is restated.

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Information about this inspection

Inspection report for children’s home: 2663221 13 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: 2663221 14

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Children’s home details

Registered provider: Holywell Children’s Services Limited

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Children’s home details

Registered provider address: Scott & Wilkinson, Dalton House, 9 Dalton Square, Lancaster LA1 1WD

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Inspectors

Sarah Huntbatch, Social Care Inspector Angeline Clarke, Social Care Inspector Inspection report for children’s home: 2663221 15 regulates and inspects 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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