Children's home run by Hexagon Care Services Limited in Preston

Assurance inspection report for children’s home: SC480854 1 SC480854

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Registered provider: Hexagon Care Services Limited

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Inspected under the social care common inspection framework

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Information about this children’s home

A private provider owns and operates this home. The home is registered to provide care for up to six children. Children may require support due to having learning, social and emotional difficulties.

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Information about this children’s home

At the time of the inspection, three children were living at the home.

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Information about this children’s home

The manager registered with Ofsted in May 2019.

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Inspection date: 26 March 2025

Date of last inspection: 2 September 2024

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Inspection date: 26 March 2025

Enforcement action since last inspection: none

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Information about this inspection

At this inspection, the inspector evaluated:

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Information about this inspection

 the care of children  the safety of children  the effectiveness of leaders and managers. The inspector has looked closely at the experiences and progress of children, using the social care common inspection framework. This assurance inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with The Children’s Homes (England) Regulations 2015 and the ‘Guide to the Children’s Homes Regulations, including the quality standards’. Assurance inspection report for children’s home: SC480854 2

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Findings from the inspection

Ofsted identified serious and widespread concerns in relation to safeguarding practice, care planning and the leadership and management of the home.

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Findings from the inspection

Since the previous inspection in September 2024, five children have moved into the home and four children have moved out of the home. One child experienced an unplanned move out of the home due to a serious incident and immediate notice was given on their placement. One child returned to live with their family as they did not feel safe living in the home and refused to return. One child currently living in the home has had notice served on their placement as staff cannot meet the child’s needs.

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Findings from the inspection

Before the children move into the home, leaders and managers do consider the individual needs of each child and evaluate how staff will meet their needs. However, five children moved into the home in a very short period. This did not allow adequate time for the staff to build effective relationships with children and fully understand their needs and vulnerabilities. This shortfall has contributed to staff being unable to keep children safe. The lack of robust care planning has contributed to children having poor experiences and not making consistent progress while living in the home.

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Findings from the inspection

Since the last inspection, several serious incidents have occurred. There have been incidents in relation to fire-setting. One serious incident led to the home being evacuated and the fire brigade attending due to smoke in the cellar. Poor staff supervision of children contributed to this incident. Other incidents have involved burn marks to a child’s rug in their bedroom and a burn mark on the bedroom wall.

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Findings from the inspection

There have been several incidents where children have verbally and physically assaulted other children living in the home. During one incident, a child was physically assaulted in a bedroom, which was observed and videoed on a phone by other children. Staff were not aware of this incident until another child showed the video to staff when she refused to remain living in the home due to feeling unsafe. The child told staff she had been intimidated and threatened by other children living in the home.

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Findings from the inspection

One child is having unsupervised contact with their parent despite this not being agreed as part of their plans. This has led to an increase in the risks posed to the child. Furthermore, the parent has made direct threats to staff and other children living in the home. The children were fearful of these threats. Leaders and managers have since implemented a safety plan.

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Findings from the inspection

Staff have not been able to manage children’s behaviours. This has led to an escalation in serious incidents in the home. Staff do not provide children with appropriate structures and routines. Staff have not been able to prevent children from having a negative impact on each other’s behaviours. This has led to an increase in serious incidents. Risk management plans do not consistently include Assurance inspection report for children’s home: SC480854 3 robust strategies for staff to follow to safeguard children in practice. These shortfalls leave children at potential risk of harm.

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Findings from the inspection

There have been several incidents when children have been held. One child complained about a hold used by staff. When this was investigated, it was deemed to be inappropriate. A further child made a complaint about a hold and when investigated it became apparent that staff had failed to record the incident. The lack of staff experience, skills and understanding of their roles and responsibilities does not ensure that effective action is taken to keep children safe.

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Findings from the inspection

The registered manager is suitably skilled and experienced. However, there was an escalation in incidents when the manager was off work. Managers from the company, a deputy manager and a responsible individual had oversight of the home. However, poor and ineffective management arrangements have had a negative impact on the children’s experiences and safety.

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Findings from the inspection

Although staff have received training in line with children’s needs, they have not been able to keep children safe. Staff completed training in restraint practice. However, staff were unable to apply what they had learned in the training to their practice with children.

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Findings from the inspection

There have been several allegations and complaints made by children in relation to staff practice. The responsible individual has ensured that the incidents have been investigated appropriately, information has been shared with the local authority designated officer and poor staff practice has been addressed.

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Findings from the inspection

Leaders and managers use various monitoring and review tools. However, they have failed to identify the significant shortfalls found during the inspection.

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Findings from the inspection

The manager and responsible individual recognise that there are improvements that need to be made to ensure safe and positive care for children. They understand the seriousness of the incidents which have occurred. They have completed some reflections and lessons learned on how to address the shortfalls and how to improve practice.

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Findings from the inspection

Due to the serious and widespread concerns identified, Ofsted has issued compliance notices under 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. Assurance inspection report for children’s home: SC480854 4

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Inspection date Inspection type Inspection judgement

02/09/2024 Full Good 09/08/2023 Full Requires improvement to be good 21/09/2022 Full Good 24/05/2021 Full Good Assurance inspection report for children’s home: SC480854 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 he ‘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

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

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;

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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; and

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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.

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Requirement Due date

(Regulation 12 (1) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(b)(d)) 2 May 2025 Assurance inspection report for children’s home: SC480854 6 In particular, the registered provider must ensure that the children’s risk management plans contain sufficient information to support staff to safely manage risk and that staff understand the plans.

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Requirement Due date

The registered provider must ensure that staff have the skills to identify and act upon signs that children are at risk of harm and take action if there is a concern about children’s welfare.

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Requirement Due date

The registered provider must ensure that children are appropriately supervised by staff to prevent harm, and staff must take action to prevent children harming each other.

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Requirement Due date

The registered provider must ensure that broken furniture is replaced, and any identified maintenance issues are addressed in a timely manner.

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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—

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Requirement Due date

lead and manage the home in a way that is consistent with the approach and ethos, and

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Requirement Due date

delivers the outcomes, set out in the home’s statement of purpose;

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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

ensure that the home’s workforce provides continuity of care to 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; and 2 May 2025 Assurance inspection report for children’s home: SC480854 7 use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

(Regulation 13 (1)(a)(b) (2)(a)(c)(e)(f)(h))

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Requirement Due date

In particular, the registered provider must ensure that there is effective and consistent management oversight of the home.

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Requirement Due date

The registered provider must ensure that there are effective monitoring and review systems in place to help them review and evaluate the quality of care staff provide to children.

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Requirement Due date

Furthermore, the registered provider must ensure that the staff team has the necessary skills, knowledge, expertise, training and confidence to meet the assessed needs and risks of the children.

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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

ensure the effective induction of each child into the home;

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Requirement Due date

manage and review the placement of each child in the home; and

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Requirement Due date

plan for, and help, each child to prepare to leave the home or to move into adult care in a way that is consistent with arrangements agreed with the child’s placing authority.

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Requirement Due date

(Regulation 14 (1)(a)(b)(2)(a)(b)(i)(ii)(iii)) 2 May 2025 Assurance inspection report for children’s home: SC480854 8 In particular, the registered provider must ensure that they are able to meet all the needs of children who are moving into the home.

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Requirement Due date

Furthermore, The registered provider must consider the timing of children’s transitions into the home as part of the decision-making processes about when children should move into the home.

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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 2 May 2025 Assurance inspection report for children’s home: SC480854 9 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.

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Requirement Due date

(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 registered provider must ensure that there is a clear record in place of all incidents when it has been necessary to hold a child.

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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

help each child to develop and practise skills to resolve conflicts positively and without harm to anyone;

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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;

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Requirement Due date

understand and communicate to children that bullying is unacceptable; and

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Requirement Due date

have the skills to recognise incidents or indications of bullying and how to deal with them.

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Requirement Due date

(Regulation 11 (1)(a)(b)(c) (2)(a)(i)(iv)(xi)(xii)(xiii)) 2 May 2025 Assurance inspection report for children’s home: SC480854 10 In particular, the registered provider must ensure that children are supported to understand the impact of their behaviour on other children and manage relationships between children to prevent harm.

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Requirement Due date

*These requirements are subject to a compliance notice. Assurance inspection report for children’s home: SC480854 11

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Children’s home details

Registered provider: Hexagon Care Services Limited

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Children’s home details

Registered provider address: Unit 1 Tustin Court, Riversway, Preston, Lancashire PR2 2YQ

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Inspector

Suzanne Birchall, Social Care Inspector Assurance inspection report for children’s home: SC480854 12 to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for children looked after, safeguarding and child protection.

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Inspector

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Inspector

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Inspector

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